Читать книгу This Is Bioethics - Udo Schüklenk, Ruth F. Chadwick - Страница 25

2.31 The last principle is primarily concerned with fairness in the allocation of scarce resources, that is distributive justice²⁰. This obviously is an important principle given the resource constraints faced by most health care systems. Initially we can reduce the idea of justice to a formal principle often ascribed to Aristotle: ‘Equals must be treated equally, and unequals must be treated unequally’ (Beauchamp 2019, 268). While uncontroversial, this formal principle doesn’t realistically help us when we are faced with distributive justice questions. We need to complement the formal principle with a material principle of justice, in other words, we need to move beyond the formal structure, and add substance to the principle. Once we do that though we are faced with a plethora of competing ideas about what justice entails, ranging from traditional communist, utilitarian to libertarian ideals as well as more recent ones such as those introduced by defenders of what is called the capabilities approach.

2.32 Justice then seems to be a thing that is very much in the eyes of the beholder, subject to the vagaries of one’s personal ideological convictions. A Marxist will hold a quite different view on resource allocation justice then a libertarian or a utilitarian (Takala 2001, 73). Finnish philosopher Tuija Takala quite nicely illustrates the problems with this principle by means of describing the political arguments political parties in Finland had during an election campaign:

In the spring of 1999, there was again in Finland the time for parliamentary elections. During the campaigns it became obvious that there was an overwhelming consensus among the rival parties that justice is important and that we should aim for a more just society. The only small difference between the parties was in the understanding of what justice is and what measures should be taken that justice would prevail. The right wing thought that by lowering the taxation of property and high salaries we would be able to do this. Meanwhile, the suggested solution from the left wing was to lower the taxation of the lower income groups and reaffirm the welfare rights, such as free education, free healthcare, and reasonable unemployment benefits. The political middle, representing the interests of agricultural Finland, reckoned that above all the government should fund the farmers. Same word, but different interpretations of what justly belongs to whom. Is it to everyone according to their need? An egalitarian principle to be found in Marxist thought as well. Or should we follow the libertarian idea of everyone owning their natural properties in good and in bad. If you happen to be faster, better, and smarter than the rest, you should have the benefits.

And equally, if you get a raw deal in the natural lottery, it is your own problem. Should we in principle guarantee that everyone has equal opportunities, or should we go further and give fair equal opportunities for all? Within the sphere of bioethics, these questions arise especially in an age of scarcity. If we cannot help all patients, by which criteria are we able to say that X is to be treated whereas Y is to be left on his own?

Political philosophy has struggled throughout its history with the question of what justice is. How can it suddenly become a non‐question in bioethics?

2.33 Similar arguments can be advanced with regard to each of the other principles. It is doubtful that there is actually an uncontroversial cross‐cultural consensus on the relevance and meaning of these principles, as Beauchamp and Childress claim there is. Coming to their aid, one of their colleagues at Georgetown University, philosopher Robert M. Veatch, has offered an eloquent defense of the idea that such a ‘common morality’ exists among all humans (Veatch 2003).

2.34 A further critical point is worth noting: the absence of a hierarchy among the principles has the potential to leave, for instance, patients subjected to more or less arbitrary and unpredictable decisions by health care professionals, simply because health care professionals could always pick the principle most suited to support their already formed intuitive response to a particular ethical problem. Say, a doctor is willing to respect the patient’s do‐not‐resuscitate advance directive, hence the autonomy principle will be deployed. Another doctor, facing the same situation, might have decided to override the patient’s choice, hence the principle of beneficence could be deployed in order to justify a paternalistic course of action. In the absence of an overarching ethical theory that arbitrates conflicts between principles, decisions with regard to what ought to be done might be somewhat arbitrary. If, on the other hand, an overarching theory of this kind was utilized – something not supported by Beauchamp and Childress – it would be unclear why we should not adopt the theory itself and forget about the principles altogether.

2.35 However, the Georgetown Mantra has proven to be of enduring staying‐power in bioethical analyses and debates, hence its inclusion among the concepts this book will make reference to throughout. If nothing else, the principles flag issues that are important to many people and that ought to be considered in ethical analyses.