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Epi Wit & Wisdom Articles
Moral Reasoning in Epidemiology
By Steven S. Coughlin
Methods of moral reasoning have
been discussed in relation to ethics curricula for graduate training
programs in epidemiology and as part of continuing professional
education for epidemiologists. Methods of moral reasoning have also
been applied to the analysis of ethical issues in the design of
epidemiologic studies, both in the literature and in presentations at
professional meetings in epidemiology. Two approaches have figured
prominently in these discussions, namely, the principle-based approach
to moral reasoning explicated in successive editions of Principles of
Biomedical Ethics by Beauchamp and Childress, and the case-based
method of casuistry, which has been championed in its modern form by
Jonsen and Toulmin.
The principle-based approach to
moral reasoning has been applied in analyses of ethical issues in the
design of randomized controlled trials, preventive trials and
observational studies in epidemiology. The four principles of
beneficence, nonmaleficence, justice and respect for the autonomy of
persons are also mentioned in ethics guidelines drafted for
epidemiologists, although the guidelines do not provide a detailed
account of how the principles can be used as a framework for ethical
decision-making in epidemiology. Methods of analogical reasoning such
as casuistry have been discussed in relation to case-based ethical
decision-making in epidemiology.
Other approaches to moral
reasoning such as right-based theories, duty-based theories, and more
recent approaches such as contractarianism, the ethics of care,
narrative ethics, and communitarianism or community-based theories
have not been widely applied in epidemiology. The moral-rule-based
system of Gert and Clouser, however, is discussed as a potential
alternative to other leading approaches to moral reasoning in a new
book on Case Studies in Public Health Ethics. Virtue ethics have also
been recently discussed in relation to professional ethics in
epidemiology.
Thus, it is reasonable to
consider leading approaches to moral reasoning in relation to ethical
decision-making in epidemiology. Epidemiologists should be acquainted
with methods of moral reasoning so that they can appropriately make
and justify ethical decisions in epidemiologic research and practice;
deliberations about applied moral problems in epidemiology should not
be left up to those unacquainted with core values and ethical precepts
in the field. Nevertheless, there has been extensive recent discussion
and debate in the bioethics literature on fundamental methods of moral
reasoning. The question arises, therefore, what methods of moral
reasoning should be highlighted in epidemiology? There are at least
three possible responses to this question.
First Proposal
One proposed approach, advocated
by Goodman and Prineas in a recent book chapter on ethics instruction
in epidemiology, is for epidemiologists to be familiar with major
ethical theories (for example, utilitarianism and Kantianism) and a
number of currently prominent approaches to ethical decision-making:
the principle-based approach of Beauchamp and Childress, the impartial
rule theory of Gert and Clouser, casuistry, and rights-based theories.
This “cover all the bases”
approach to methods of ethical decision-making in epidemiology has the
questionable advantage of not requiring epidemiologists to choose
between alternative approaches to moral reasoning. Most
epidemiologists have not had formal training in moral philosophy and
bioethics, however, and it is unreasonable to expect most
epidemiologists to master such diverse theoretical frameworks in order
to identify and solve ethical problems in their own research and
practice.
But how essential is it for
epidemiologists to be well-acquainted with such theoretical
foundations? Members of other professions (medicine and nursing, for
example) often are not trained in moral philosophy even when they
receive formal instruction in professional ethics. Epidemiologists can
be well informed about their professional obligations to research
subjects, to society, to employers and funding sources, and to
professional colleagues without being formally trained in moral
philosophy.
Second Proposal
A second approach is for
epidemiologists to be well-versed in practical approaches to the
resolution of moral problems in epidemiologic research and practice
which are far removed from ethical theory. As Beauchamp pointed out,
moral problems can sometimes be reduced or eliminated by getting the
disputing parties to agree to the adoption of a new policy or code
such as recently proposed ethics guidelines for epidemiologists. In
other instances, moral disagreements can be resolved by obtaining
further factual information about matters at the center of the moral
controversy or by providing definitional clarity and reaching
agreement over the meaning of the language used by the disputing
parties. Other steps that can be taken to resolve moral controversies
include the use of examples and counter examples and the analysis of
arguments to expose the inadequacies, gaps and fallacies in an
argument.
Despite the value of
epidemiologists being well-acquainted with such steps that can be
taken to resolve moral problems, this approach has the drawback of not
providing epidemiologists with a conceptual or analytical framework
for ethical analysis and practical decision-making. Further
specification and interpretation of general norms and principles, as
discussed by Beauchamp and Childress, is an important approach to the
resolution of ethical problems. In dealing with difficult cases, the
first step is to specify general norms and to reduce or resolve
conflicts through this process of further specification and reform.
Progressive specification is then needed on an ongoing basis as new
problems arise. An understanding of practical steps that can be taken
to resolve moral problems in epidemiology seems incomplete without a
consideration of more powerful analytic tools such as recent
refinements of the four principles approach.
Third Proposal
A third approach, which is
really a hybrid of the other two, is for epidemiologists to be
acquainted with both non-theoretical approaches to the resolution of
moral problems and one or two carefully selected methods of ethical
decision making. Decisions about which method or methods of moral
reasoning to employ can be made on the basis of practicality and
applicability to actual moral problems in epidemiology, as well as on
the basis of theoretical considerations.
It is beyond the scope of this
paper to provide theoretical arguments for or against the use of
particular methods of moral reasoning. Interested readers may wish to
refer to articles featured in a recent issue of the Kennedy Institute
of Ethics Journal, and to Beauchamp and Childress’ response to
criticisms of their principle-based approach to moral reasoning.
It is important to point out
that methods of moral reasoning suitable for medical ethics may or may
not be optimal for resolving moral problems in epidemiology. Much of
the recent debate over alternative methods of ethical decision-making
has focused on moral reasoning in clinical medicine. Moral obligations
in medicine have traditionally been conceived in terms of principles,
rules, rights, virtues and the like. The ethical principles of
nonmaleficence and beneficence are expressions of the centuries-old
professional commitments of physicians to protect patients from harm
and to provide medical care. In recent decades, however, physicians’
moral responsibilities have been understood more in terms of
autonomy-based patient rights to truthfulness, confidentiality,
privacy, disclosure and consent, and in terms of rights to welfare,
which are grounded in principles of justice.
Principles of beneficence and
justice figure even more prominently in public health ethics. Thus, an
approach to moral reasoning that focuses on the principle of
nonmaleficence, such as the impartial rule theory of Gert and Clouser
may not be as intuitively appealing or compelling in epidemiology. A
further issue is that epidemiology and other public health disciplines
often have ethical precepts and traditions quite different from those
of clinical medicine. Concepts and methods from environmental ethics,
for example, may be useful for ethical decision-making in
environmental epidemiology.
Although there has been ongoing
interest in the development and refinement of ethics guidelines for
epidemiologists, such guidelines do not provide specific answers to
many of the complex ethical questions encountered in epidemiologic
research and practice. It is important, therefore, for epidemiologists
to be skilled at ethical decision-making so that they can
appropriately make and justify ethical decisions. Epidemiologists need
to be in a position to identify and solve moral problems in their own
epidemiologic research and practice, and they should have some
understanding of the concepts and language of ethics. Decisions
between alternative conceptual or analytical frameworks for ethical
analysis ought to take into account practicality and applicability to
actual moral problems in epidemiology as well as theoretical
considerations.
References:
1. Beauchamp, T. L., Childress,
J. F. Principles of Biomedical Ethics, 4th Ed. New York: Oxford
University Press, 1994.
2. Beauchamp, T. L., Coughlin S.
S., Eds. Moral Foundations In: Ethics and Epidemiology, New York:
Oxford University Press, 1996; 24-52.
3. Clouser K. D., Gert, B. A
critique of principlism. J Med Philos 1990; 15:219-36
4. Coughlin, S. S., Soskolne, C.
L., Goodman, K. W. Case analysis and moral reasoning. In: Case Studies
in Public Health Ethics. Washington, DC: American Public Health
Association 1997, in press.
5. Gert, B. Morality: A New
Justification of the Moral Rules. New York: Oxford University Press,
1988.
6. Goodman, K. W., Prineas, R.
J. Toward an ethics curriculum in epidemiology. In: Coughlin SS,
Beauchamp TL, eds. Ethics and Epidemiology, New York: Oxford
University Press, 1996; 290-303.
7. Jonsen, A. R., Toulmin, S. E.
The Abuse of Casuistry. Berkeley, CA: University of California Press,
1988.
Published January 1998 v
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