“But I think the four principles should also be thought of as four moral nucleotides that constitute the moral DNA - capable alone or in combination, of explaining and justifying all the substantive and moral norms of health care ethics and I suspect of ethics in general”, p.308
There is no denying the impact and importance of the medical ethical principles in medical ethics, or the high esteem in which they are held - as the quote from Gillon illustrates. Since their introduction by Beauchamp and Childress they have been the dominant approach to the teaching and evaluation of medical ethical dilemmas in health care. Whilst they have received some criticism, predominantly from the casuists (the other main method adopted in bioethics)[3, 4] they are still widely used and discussed, even despite their limitations, both in practice and in the academic literature. However, given their dominance as an approach to medical ethics surprisingly little work has been conducted on the empirical importance and merit of the principles for individuals. Specifically, empirically establishing the worth of the principles as a descriptive and explanatory framework has received minimal academic attention. This may be because of the difficulty associated with the quantification of the principles and/or the focus on more practical and case specific goals. Whatever the case, the scope for further investigation is large, and given the importance of medical ethics and understanding ethical outcomes in the medical sphere, it is also of considerable academic and clinical importance. This study develops a measure of the medical ethical principles using the Analytic Hierarchy Process (AHP) as a methodological tool. It then tests whether the principles are predictive of ethical judgements.
Medical ethical principles
Research on the importance of medical ethical principles is generally one of three types. The first type, where most of the research has been focused, concerns the moral development and orientation of medical students throughout their medical training[6–9]. However, this body of literature is mainly focused on the developmental nature of morality rather than the specific principles valued, or their role in personal ethical decision making.
The second type of research has examined differences between groups of students with respect to the ethical principles they value[10, 11] and compares whether the same principles are important for different professions. These findings have shown that females value autonomy more than males and that medical students are generally more beneficent than lawyers.
The third kind of research investigates medical students’ evaluations of certain ethical principles[8, 12]. The study by Herbert had students read several ethical scenarios and identify as many ethical issues as they could in each scenario. The responses were evaluated post hoc against a “gold standard” marking scheme, where issues were classified as reflecting one of the three principles of autonomy, justice and beneficence. Results indicate that students were able to identify ethical issues in the cases consistent with the principles, however, the responses were often limited in range and tended to be of the same type. Price, Price, Williams and Hoffenberg examined changes in medical students’ attitudes as they progressed through their medical course, where attitudes were defined by the assessment of the ethical principles.
Westin and Nilstun discuss the principles and whether a certain type of ethical conflict (patient with ischemic heart disease) could be resolved by using “normative” reasoning with the ethical principles. This study was useful in identifying the conflicting nature of the principles for different stakeholders and the difficulties encountered with applying them in practice to a specific case, but it did not take an empirical approach to identifying the importance of the principles and their application. Moreover, it has been criticised for the manner in which the principles were applied or interpreted (principles examined in isolation) in the given case.
Landau and Osmo investigated the hierarchies of ethical principles among Israeli social workers. The ethical principle of “Protection of life” was the most important principle guiding the social workers’ decision making with 45% of respondents rating this principle as the most important. However, there was little consensus among the rankings of the ethical principles by the social workers and there was no consistent pattern of application across cases. Professional and personal hierarchies were not significantly different from each other. Social workers responded mainly to the case information and changed the importance of their ethical principles based on the situational information available in each case.
Twelve ethical principles were used in the Landau and Osmo study including “Autonomy & freedom”, “Truthfulness & full disclosure”, “Least harm” and “Public good”. The principles overlap considerably with the four principles but had a more specific social work focus. The 12 principles are also not conceptually distinct. The present study focuses only on six principles with an effort to prevent any conceptual overlap between principles. From a methodological point of view, the Landau and Osmo study was based only on the ranking of principles and simple Likert scales. The present study proposes an additional way to assess the importance of principles by computing the relative weight of principles for each individual. This has the advantage of being able to assess the importance of the principles when two very important principles conflict, which was not the case in the Landau and Osmo study.
Because of the novelty of this approach and the introduction of a new measure, no specific predictions can very clearly be extrapolated from past findings or empirical research. However, there is considerable theoretical discourse concerning the importance of the principles in medical ethics. Several arguments and pieces of evidence exist that may point to the possible empirical results.
First, the debate on medical principles can indicate which medical principles are the most important. In the Hippocratic Oath the principle of primary importance is Primum non nocere, above all do no harm. This principle has a long history of being very important in health care contexts. The Hippocratic injunction to do no harm has been an axiom central to the education of medical and graduate students.
In more recent times, the primary importance of this principle has been contested. In a reflection and discussion of the principles and their merits, Gillon argues for the principle of autonomy to ‘trump the rest’. He provides compelling reasons why respect for autonomy should be of primary importance in medical ethics and applied ethics in general. Different people argue for different hierarchies and yet others argue for no hierarchy at all, just the application of all the relevant principles to a case on a more relativistic basis. Prediction from the theoretical literature is therefore not straightforward.
In summary, this study examines the medical ethical principles and uses the AHP as a methodological tool to derive individual weightings for ethical principles. There are two aims of this study. First, to develop and evaluate a measure of the four principles from medical ethics, and second, to determine whether individuals’ rankings of these principles are used in decision-making in ethical scenarios where these principles conflict.
Analytic hierarchy process: an overview
The measure of the medical ethical principles developed here uses pairwise comparisons to elicit the weightings for the principles. This methodology is part of the AHP. The AHP is a multi-criteria decision making tool originally developed by Saaty that has been widely applied to many areas in the field of decision making including resource allocation, business performance evaluation, project selection, and auditing.
In the AHP, a judgement or a comparison is the numerical representation of a relationship between two elements that share a common parent. In this study there is only one parent (ethical principles) and a judgement consists of a rating of the relative importance of one principle over another. Through trade-offs the technique enables the explication of the advantages and disadvantages of options under circumstances of risk and uncertainty.
The AHP is used in this study as a pragmatic tool to assess the relative preferences that individuals have for the principles. The technique of weight computation for the principles can be considered an alternative way to assess the importance of the principles in the individual decision making process. Prior research has tended to only measure the importance of principles either in scenarios, in isolation (one principle at a time), or with post-hoc matching of responses to set criteria. The AHP methodology is a novel approach in this area.
It should be noted that no behavioural hypothesis about the way people cognitively use the principles is made in order to use the AHP. The numerical results must therefore be seen as an approximation and, to some extent, still qualitative, in spite of their quantitative nature.