Adding the fourth principle

It would also explicitly add the fourth of those four prima facie moral commitments, increasingly widely accepted by doctors internationally. Two of them—benefiting our patients (beneficence) and doing so with as little harm as possible (non-maleficence)—have been an integral part of medical ethics since Hippocratic times. Respect for autonomy and justice are very much more recent additions to medical ethics. The WMA, having added respect for autonomy to the Declaration of Geneva, should, I proposed, complete the quartet by adding the ‘balancing’ principle of fairness and justice.

Since the Declaration is unlikely to be revised for several years, it seems likely that the proposal to add to it an explicit commitment to practise fairly and justly will have to wait. However, an explicit commitment to justice and fairness has, at the BMA’s request, been added to the draft of the International Code of Medical Ethics and it seems reasonable to hope and expect that it will remain in the final document.

Adding a commitment to fairness and justice is the easy part! Few doctors would on reflection deny that they ought to try to practise fairly and justly. It is far more difficult to say what is actually meant by this. Two additional components of my Presidential project—the essay competition and a conference (which with luck will have been held, virtually, shortly before publication of this editorial)—sought to help elucidate just what is meant by practising fairly and justly.

One of the most striking features of the essay competition was the readiness of many writers to point to injustices in the context of medical practice and policy and describe ways of remedying them, but without giving a specific account of justice and fairness on the basis of which the diagnosis of injustice was made and the remedy offered.

Wardrope’s winning essay comes close to such an approach by challenging the implied premise that an account of justice and fairness must provide some such formal theory. In preference, he points to the evident injustice and unsustainability of humans’ degradation of ‘the Land’ and its atmosphere and its inhabitants and then challenges some assumptions of contemporary philosophy and ethics, especially what he sees as their anthropocentric and individualistic focus. Instead, he invokes Leopold Aldo’s ‘Land Ethic’ (as well as drawing in aid Isabelle Stenger’s focus on ‘the intrusion of Gaia’). In his thoughtful and challenging paper, he seeks to refocus our ethics—including our medical ethics and our sense of justice and fairness—on mankind’s exploitative threat, during this contemporary ‘anthropocene’ stage of evolution, to the continuing existence of humans and of all forms of life in our ‘biotic community’. As remedy, the author, allying his approach to those of contemporary virtue ethics, recommends the beneficial outcomes that would be brought about by a sense of fairness and justice—a developed and sensitive ‘ecological conscience’ as he calls it—that embraces the interests of the entire biotic community of which we humans are but a part.

Fritz and Cox pursue a very different and philosophically more conventional approach to the essay competition’s question and offer a combination and development of two established philosophical theories, those of John Rawls and Thomas Scanlon, to provide a philosophically robust and practically beneficial methodology for justice and fairness in medical practice and policy. Briefly summarised, they recommend a two-stage approach for healthcare justice. First, those faced with a problem of fairness or justice in healthcare or policy should use Thomas Scanlon’s proposed contractualist approach whereby reasonable people seek solutions that they and others could not ‘reasonably reject’. This stage would involve committees of decision-makers and representatives of relevant stakeholders looking at the immediate and longer term impact on existing stakeholders of proposed solutions. They would then check those solutions against substantive criteria of justice derived from Rawls’ theory (which, via his theoretical device of the ‘veil of ignorance’, Rawls and the authors argue that all reasonable people can be expected to accept!). The Rawlsian criteria relied on by Fritz and Cox are equity of access to healthcare; the ‘difference principle’ whereby avoidable inequalities of primary goods can only be justified if they benefit the most disadvantaged; the just savings principle, of particular importance for ensuring intergenerational justice and sustainability; and a criterion of increased openness, transparency and accountability.

It would of course be naïve to expect a single universalisable solution to the question ‘what do we mean by fairness and justice in health care?’ As the papers by Wardrope1 and Fritz and Cox2 demonstrate, there can be very wide differences of approach in well-defended accounts. My own hope for my project is to emphasise the importance first of committing ourselves within medicine to practising fairly and justly in whatever branch we practise; and then to think carefully about what we do mean by that and act accordingly.

Following Aristotle

For my own part, over 40 years of looking, I have not yet found a single substantive theory of justice that is plausibly universalisable and have had to content myself with Aristotle’s formal, almost content-free but probably universalisable theory, according to which equals should be treated equally and unequals unequally in proportion to the relevant inequalities—what some health economists refer to as horizontal and vertical justice or equity.6

Beauchamp and Childress in their recent eighth and ‘perhaps final’ edition of their foundational ‘Principles of biomedical ethics’¹ acknowledge that ‘[t]he construction of a unified theory of justice that captures our diverse conceptions and principles of justice in biomedical ethics continues to be controversial and difficult to pin down’.

They still cite Aristotle’s formal principle (though with less explanation than in their first edition back in 1979) and they still believe that this formal principle requires substantive or ‘material’ content if it is to be useful in practice. They then describe six different theories of justice—four ‘traditional’ (utilitarian, libertarian, communitarian and egalitarian) and two newer theories, which they suggest may be more helpful in the context of health justice, one based on capabilities and the other on actual well-being.

They again end their discussion of justice with their reminder that ‘Policies of just access to health care, strategies of efficiencies in health care institutions, and global needs for the reduction of health-impairing conditions dwarf in social importance every other issue considered in this book’ ……. ‘every society must ration its resources but many societies can close gaps in fair rationing more conscientiously than they have to date’ [emphasis added]. And they go on to stress their own support for ‘recognition of global rights to health and enforceable rights to health care in nation-states’.

For my own part I recommend, perhaps less ambitiously, that across the globe we extract from Aristotle’s formal theory of justice a starting point that ethically requires us to focus on equality and always to treat others as equals and treat them equally unless there are moral justifications for not doing so. Where such justifications exist we should say what they are, explain the moral assumptions that justify them and, to the extent possible, seek the agreement of those affected.