BioethicsWalk addresses
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The Borg of Bioethics
Remember the Borg? Whenever their cube-shaped ship hovered over a helpless planet in Star Trek: The Next Generation, inhabitants were instructed to “prepare to be assimilated.” A moment later, all of their culture, their knowledge, their identity had become part of the now-stronger-than-ever Borg collective consciousness. Resistance was futile.
Bioethics has its own Borg: The Principles of Biomedical Ethics, by Thomas Beauchamp of Georgetown University and James Childress of the University of Virginia, first published in 1979. “Beauchamp and Childress,” now in its fifth edition, is the single most influential work in bioethics. Somewhere, someone is always giving a grand rounds on the famous, easily Power Pointed “four principles” – autonomy, nonmaleficence, beneficence, justice. So pervasive are these principles in clinical ethics that bioethics deliberation can seem to be reducible to a formula, the “Georgetown Mantra.” Know these (and only these) principles, goes this mantra, and you’ll know bioethics. Resistance is futile.
This is not what Beauchamp and Childress intended. In “Narratives vs. Norms: A Misplaced Debate in Bioethics,” an essay published in the collection Stories and their Limits: Narrative Approaches to Bioethics (1997), Childress points out that while he and Beauchamp are “normists,” the principles – any principles – are not the whole story of bioethics. Neither are stories, whether told through representative cases or through personal narratives, the whole story. He concludes: “If we start with either norms or narratives, we are driven to the other. We need both in any adequate ethics.” (268)
Within bioethics, an unreflective, cookbook application of the four principles may be described – affectionately – as “the Borg.” Reducing ethical deliberation to a matter of matching principles to situations may save a lot of time, but it doesn’t hint at the difficulty of defining these principles in different clinical and social contexts and at resolving dilemmas in which more than one principle applies: how do we honor the autonomy of a patient who is about to make a decision against her own interests? The power of the Borg is not Beauchamp and Childress’s fault: How many of us read the whole book before confidently asserting, citing, and Power Pointing those principles?
The four principles are perhaps best understood as a heuristic: a problem-solving tool. Because chaplains, and other health care professionals, are likely to work in institutions that use Beauchamp and Childress as the basis for clinical ethics, chaplains need to know how to use this tool. To resist the Borg, this means thinking critically about the principles we assert and apply.
What is an “adequate ethics” for the practice of health care chaplaincy? I invite your thoughts.
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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