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9/3/2020 Principles of Biomedical Ethics
Principles of Biomedical Ethics

EIGHTH EDITION
Tom L. Beauchamp
James F. Childress
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We shift now from universal morality (the common morality) to particular moralities, which contain moral
norms that are not shared by all cultures, groups, and individuals who are committed to morality.
The Nature of Particular Moralities

Whereas the common morality contains moral norms that are abstract, universal, and content-thin (such as “Tell
the truth”), particular moralities present concrete, nonuniversal, and content-rich norms (such as “Make
conscientious oral disclosures to, and obtain a written informed consent from, all human research subjects”).
Particular moralities are distinguished by the specificity of their norms, but these norms are not morally justified
if they violate norms in the common morality. Specific moralities include the many responsibilities, aspirations,
ideals, sentiments, attitudes, and sensitivities found in diverse cultural traditions, religious traditions,
professional practice, and institutional guides. Explication of the values in these moralities sometimes requires a
special knowledge and may involve refinement by experts or scholars over centuries—as, for example, in the
body of Jewish religious, legal, and moral norms in the Talmudic tradition; well-structured moral systems to
provide methods for judgments and to adjudicate conflicts in Roman Catholic casuistry; and Islamic reliance on
Shari’ah-based principles. Each tradition continues today to elaborate its commitments through the development
of detailed, and hopefully coherent, systems of medical ethics. These elaborations are often derived from the
common morality, not merely from the scriptures of a particular religious tradition.
Professional moralities, which include moral codes and standards of practice, are also particular moralities.
They may legitimately vary from other moralities in the ways they handle certain conflicts of interest, research
protocol reviews, advance directives, and similar matters. (See the next section below on “Professional and
Public Moralities.”) Moral ideals such as charitable goals and aspirations to rescue suffering persons in
dangerous situations provide another instructive example of facets of particular moralities. By definition, moral
ideals such as charitable beneficence are not morally required of all persons; indeed, they are not required of any
person.11 Persons who fail to fulfill even their own personal ideals cannot be blamed or criticized by others.
These ideals may nonetheless be critically important features of personal or communal moralities. Examples are
found in physicians’ individual commitments or physician codes that call for assumption of a significant level of
risk in circumstances of communicable disease. It is reasonable to presume that all morally committed persons
share an admiration of and endorsement of moral ideals of generosity and service, and in this respect these ideals
are part of shared moral beliefs in the common morality; they are universally praiseworthy even though not
universally required or universally practiced. When such ideals are regarded by those who embrace them as
obligations (as they are, for example, in some monastic traditions), the obligations are still parts of a particular
morality, not of universal morality.
Persons who accept a particular morality sometimes presume that they can use this morality to speak with an
authoritative moral voice for all persons. They operate under the false belief that their particular convictions
have the authority of the common morality. These persons may have morally acceptable and even praiseworthy
beliefs, but their particular beliefs do not bind other persons or communities. For example, persons who believe
that scarce medical resources, such as transplantable organs, should be distributed by lottery rather than by
medical need may have good moral reasons for their views, but they cannot claim that their views are supported
by the common morality.
Professional and Public Moralities
Just as the common morality is accepted by all morally committed persons, most professions have, at least
implicitly, a professional morality with standards of conduct that are generally acknowledged and encouraged by
those in the profession who are serious about their moral responsibilities. In medicine, professional morality
specifies general moral norms for the institutions and practices of medicine. Special roles and relationships in
medicine derive from rules or traditions that other professions will likely not need or accept. As we argue in
Chapters 4 and 8, rules of informed consent and medical confidentiality may not be serviceable or appropriate
outside of medicine, nursing, biomedical research, and public health, but these rules are justified by general
moral requirements of respecting the autonomy of persons and protecting them from harm.
Members of professions often adhere to moral guidelines such as rules prohibiting discrimination against
colleagues on the basis of gender, race, religion, or national origin (some of these guidelines now have legal
backing). In recent years formal codifications of and instruction in professional morality have increased through
codes of medical and nursing ethics, codes of research ethics, corporate policies of bioethics, institutional
guidelines governing conflict of interest, and the reports and recommendations of public commissions. Before
we assess these guidelines, the nature of professions in general needs brief discussion.
In a classic work on the subject, Talcott Parsons defines a profession as “a cluster of occupational roles, that is,
roles in which the incumbents perform certain functions valued in the society in general, and, by these activities,
typically earn a living at a full-time job.”12 Under this definition, circus performers, exterminators, and garbage
collectors are professionals. It is not surprising to find all such activities characterized as professions, inasmuch
as the word profession has come, in common use, to mean almost any occupation by which a person earns a
living. The once honorific sense of profession is now better reflected in the term learned profession, which
assumes an extensive education in the arts, humanities, law, sciences, or technologies.
Professionals are usually distinguished by their specialized knowledge and training as well as by their
commitment to provide important services or information to patients, clients, students, or consumers.
Professions maintain self-regulating organizations that control entry into occupational roles by formally
certifying that candidates have acquired the necessary knowledge and skills. In learned professions such as
medicine, nursing, and public health, a professional’s background knowledge is partly acquired through closely
supervised training, and the professional is committed to providing a service to others.
Health care professions specify and enforce obligations for their members, thereby seeking to ensure that
persons who enter into relationships with these professionals will find them competent and trustworthy.13 The
obligations that professions attempt to enforce are determined by an accepted role. These obligations comprise
the “ethics” of the profession, although there may also be role-specific customs such as self-effacement that are
not obligatory. Problems of professional ethics commonly arise either from conflicts over appropriate
professional standards or conflicts between professional commitments and the commitments professionals have
outside the profession.
Because traditional standards of professional morality are often vague, some professions codify their standards
in detailed statements aimed at reducing vagueness and improving adherence. Their codes sometimes specify
rules of etiquette in addition to rules of ethics. For example, a historically significant version of the code of the
American Medical Association (AMA) dating from 1847 instructed physicians not to criticize fellow physicians
who had previously been in charge of a case.14 Such professional codes tend to foster and reinforce member
identification with the prevailing values of the profession. These codes are beneficial when they effectively
incorporate defensible moral norms, but some codes oversimplify moral requirements, make them indefensibly
rigid, or make excessive and unwarranted claims about their completeness and authoritativeness. As a
consequence, professionals may mistakenly suppose that they are satisfying all relevant moral requirements by
scrupulously following the rules of the code, just as some people believe that they fully discharge their moral
obligations when they meet all relevant legal requirements.
We can and should ask whether the codes specific to areas of science, medicine, nursing, health care, and public
health are coherent, defensible, and comprehensive within their domain. Historically, few codes had much to say
about the implications of several pivotal moral principles and rules such as veracity, respect for autonomy, and
social justice that have been the subjects of intense discussion in recent biomedical ethics. From ancient
medicine to the present, physicians have generated codes without determining their acceptability to patients and
the public. These codes have rarely appealed to general ethical standards or to a source of moral authority
beyond the traditions and judgments of physicians themselves.15 The articulation of such professional norms has
often served more to protect the profession’s interests than to offer a broad and impartial moral viewpoint or to
address issues of importance to patients and society.16
Psychiatrist Jay Katz poignantly expressed reservations about traditional principles and codes of medical ethics.
Initially inspired by his outrage over the fate of Holocaust victims at the hands of German physicians, Katz
became convinced that a professional ethics that reaches beyond traditional codes is indispensable:
As I became increasingly involved in the world of law, I learned much that was new to me from my
colleagues and students about such complex issues as the right to self-determination and privacy
and the extent of the authority of governmental, professional, and other institutions to intrude into
private life. … These issues … had rarely been discussed in my medical education. Instead it had
been all too uncritically assumed that they could be resolved by fidelity to such undefined principles
as primum non nocere [“First, do no harm”] or to visionary codes of ethics.17
The Regulation and Oversight of Professional Conduct

Additional moral direction for health professionals and scientists comes through the public policy process, which
includes regulations and guidelines promulgated by governmental bodies. The term public policy refers to a set
of normative, enforceable guidelines adopted by an official public body, such as an agency of government or a
legislature, to govern a particular area of conduct. The policies of corporations, hospitals, trade groups, and
professional societies are private, not public, even if these bodies are regulated to some degree by public policies
and sometimes have an impact on public policy.
A close connection exists between law and public policy: All laws constitute public policies, but not all public
policies are, in the conventional sense, laws. In contrast to laws, public policies need not be explicitly formulated
or codified. For example, an official who decides not to fund a newly recommended government program with
no prior history of funding is formulating a public policy. Decisions not to act, as well as decisions to act, can
constitute policies.
Policies such as those that fund health care for the indigent or that protect subjects of biomedical research
regularly incorporate moral considerations. Moral analysis is part of good policy formation, not merely a method
for evaluating existing policy. Efforts to protect the rights of patients and research subjects are instructive
examples. Over the past few decades many governments have created national commissions, national review
committees, advisory committees, and councils to formulate guidelines for research involving human subjects,
for the distribution of health care, and for addressing moral mistakes made in the health professions. Morally
informed policies have guided decision making about other areas of practice as well. The relevance of bioethics
to public policy is now recognized in most countries, some of which have influential standing bioethics
committees.18
Many courts have developed case law that sets standards for science, medicine, and health care. Legal decisions
often express communal moral norms and stimulate ethical reflection that over time alters those norms. For
example, the lines of court decisions in many countries about how dying patients may be or must be treated have
constituted nascent traditions of moral reflection that have been influenced by, and in turn have influenced,
literature in biomedical ethics on topics such as when artificial devices that sustain life may be withdrawn,
whether medically administered nutrition and hydration is a medical treatment that may be discontinued, and
whether physicians may be actively involved in hastening a patient’s death at the patient’s request.
Policy formation and criticism generally involve more specific moral judgments than the judgments found in
general ethical theories, principles, and rules.19 Public policy is often formulated in contexts that are marked by
profound social disagreements, uncertainties, and differing interpretations of history. No body of abstract moral
principles and rules can fix policy in such circumstances, because abstract norms do not contain enough specific
information to provide direct and discerning guidance. The implementation of moral principles and rules,
through specification and balancing, must take into account factors such as feasibility, efficiency, cultural
pluralism, political procedures, pertinent legal requirements, uncertainty about risk, and noncompliance by
patients. Moral principles and rules provide a normative structure for policy formation and evaluation, but
policies are also shaped by empirical data and information generated in fields such as medicine, nursing, public
health, veterinary science, economics, law, biotechnology, and psychology.
When using moral norms to formulate or criticize public policies, one cannot move with assurance from a
judgment that an act is morally right (or wrong) to a judgment that a corresponding law or policy is morally right
(or wrong). Considerations such as the symbolic value of law and the costs of a publicly funded program and its
enforcement often may have substantial importance for law and policy. The judgment that an act is morally
wrong does not entail the judgment that the government should prohibit it or refuse to allocate funds to support
it. For example, one can argue without any inconsistency that sterilization and abortion are morally wrong but
that the law should not prohibit them, because they are fundamentally matters of personal choice beyond the
legitimate reach of government—or, alternatively, because many persons would seek dangerous and unsanitary
procedures from unlicensed practitioners. Similarly, the judgment that an act is morally acceptable does not
imply that the law should permit it. For example, the belief that euthanasia is morally justified for some
terminally ill infants who face uncontrollable pain and suffering is consistent with the belief that the government
should legally prohibit such euthanasia on grounds that it would not be possible to control abuses if it were
legalized.
We are not defending any of these moral judgments. We are maintaining only that the connections between
moral norms and judgments about policy or law are complicated and that a judgment about the morality of
particular actions does not entail a comparable judgment about law or policy.
MORAL DILEMMAS
Common to all forms of practical ethics is reasoning through difficult cases, some of which constitute dilemmas.
This is a familiar feature of decision making in morality, law, and public policy. Consider a classic case20 in
which judges on the California Supreme Court had to reach a decision about the legal force and limits of medical
confidentiality. A man had killed a woman after confiding to a therapist his intention to do so. The therapist had
attempted unsuccessfully to have the man committed but, in accordance with his duty of medical confidentiality
to the patient, did not communicate the threat to the woman when the commitment attempt failed.
The majority opinion of the court held that “When a therapist determines, or pursuant to the standards of his
profession should determine, that his patient presents a serious danger of violence to another, he incurs an
obligation to use reasonable care to protect the intended victim against such danger.” This obligation extends to
notifying the police and also to warning the intended victim. The justices in the majority opinion argued that
therapists generally ought to observe the rule of medical confidentiality, but that the rule must yield in this case
to the “public interest in safety from violent assault.” These justices recognized that rules of professional ethics
have substantial public value, but they held that matters of greater importance, such as protecting persons against
violent assault, can override these rules.
In a minority opinion, a judge disagreed and argued that doctors violate patients’ rights if they fail to observe
standard rules of confidentiality. If it were to become common practice to break these rules, he reasoned, the
fiduciary nature of the relationship between physicians and patients would erode. Persons who are mentally ill
would refrain from seeking aid or divulging critical information because of the loss of trust that is essential for
effective treatment.
This case presents moral and legal dilemmas in which the judges cite relevant reasons to support their
conflicting judgments.21 Moral dilemmas are circumstances in which moral obligations demand or appear to
demand that a person adopt each of two (or more) alternative but incompatible actions, such that the person
cannot perform all the required actions. These dilemmas occur in at least two forms.22 (1) Some evidence or
argument indicates that an act is morally permissible and some evidence or argument indicates that it is morally
wrong, but the evidence or strength of argument on both sides is inconclusive. Abortion, for example, may
present a terrible dilemma for women who see the evidence in this way. (2) An agent believes that, on moral
grounds, he or she is obligated to perform two or more mutually exclusive actions. In a moral dilemma of this
form, one or more moral norms obligate an agent to do x and one or more moral norms obligate the agent to do
y, but the agent cannot do both in the circumstance. The reasons behind alternatives x and y are weighty and
neither set of reasons is overriding. If one acts on either set of reasons, one’s actions will be morally acceptable
in some respects and morally unacceptable in others. The withdrawal of life-prolonging therapies from patients
suffering from a wakeful unconscious state (formerly called a persistent, continuing, or continuous vegetative
state) is sometimes regarded as an instance of this second form of dilemma.
Popular literature, novels, and films often illustrate how conflicting moral principles and rules create difficult
dilemmas. For example, an impoverished person who steals from a grocery store to save a family from
starvation confronts such a dilemma. The only way to comply with one obligation is to contravene another
obligation. Some obligation must be overridden or compromised no matter which course is chosen. From the
perspective we defend, it is confusing to say that we are obligated to perform both actions in these dilemmatic
circumstances. Instead, we should discharge the obligation that we judge to override what we would have been
firmly obligated to perform were it not for the conflict.
Conflicts between moral requirements and self-interest sometimes create a practical dilemma, but not, strictly
speaking, a moral dilemma. If moral reasons compete with nonmoral reasons, such as self-interest, questions
about priority can still arise even though no moral dilemma is present. When a moral reason conflicts with a
personal reason, the moral reason is not always overriding. If, for example, a physician must choose between
saving his or her own life or that of a patient, in a situation of extreme scarcity of available drugs, the moral
obligation to take care of the patient may not be overriding.
Some moral philosophers and theologians have argued that although many practical dilemmas involving moral
reasons exist, no irresolvable moral dilemmas exist. They do not deny that agents experience moral perplexity or
conflict in difficult cases. However, they claim that the purpose of a moral theory is to provide a principled
procedure for resolving deep conflicts. Some philosophers have defended this conclusion because they accept
one supreme moral value as overriding all other conflicting values (moral and nonmoral) and because they
regard it as incoherent to allow contradictory obligations in a properly structured moral theory. The only ought,
they maintain, is the one generated by the supreme value.23 (We examine such theories, including both
utilitarian and Kantian theories, in Chapter 9.)
In contrast to the account of moral obligation offered by these theories, we maintain throughout this book that
various moral principles, rules, and rights can and do conflict in the moral life. These conflicts sometimes
produce irresolvable moral dilemmas. When forced to a choice, we may “resolve” the situation by choosing one
option over another, but we also may believe that neither option is morally preferable. A physician with a limited
supply of medicine may have to choose to save the life of one patient rather than another and still find his or her
moral dilemma irresolvable. Explicit acknowledgment of such dilemmas helps deflate unwarranted expectations
about what moral principles and theories can do. Although we find ways of reasoning about what we should do,
we may not be able to reach a reasoned resolution in many instances. In some cases the dilemma becomes more
difficult and remains unresolved even after the most careful reflection.
A FRAMEWORK OF MORAL PRINCIPLES

Moral norms central to biomedical ethics rely on the common morality, but they do not exhaust the common
morality. Some types of basic moral norms are treated in this section, especially principles, rules, and rights. The
virtues are the subject of Chapter 2, and the principles of primary importance for biomedical ethics are treated
individually in Part II of this book. Most classical ethical theories accept these norms in some form, and
traditional medical codes incorporate or presuppose at least some of them.
Principles
The set of pivotal moral principles defended in this book functions as an analytical framework of general norms
derived from the common morality that form a suitable starting point for reflection on moral problems in
biomedical ethics.24 These principles are general guidelines for the formulation of more specific rules. In
Chapters 4 through 7 we defend four clusters of moral principles: (1) respect for autonomy (a norm of respecting
and supporting autonomous decisions), (2) nonmaleficence (a norm of avoiding the causation of harm), (3)
beneficence (a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and
balancing benefits against risks and costs), and (4) justice (a cluster of norms for fairly distributing benefits,
risks, and costs).
Nonmaleficence and beneficence have played central roles in the history of medical ethics. By contrast, respect
for autonomy and justice were neglected in traditional medical ethics and have risen to prominence in this field
only recently. In 1803, British physician Thomas Percival published Medical Ethics, the first comprehensive
account of medical ethics in the long history of the subject. This book served as the backbone of British medical
ethics and as the prototype for the American Medical Association’s first code of ethics in 1847. Percival argued,
using somewhat different language, that nonmaleficence and beneficence fix the physician’s primary obligations
and triumph over the patient’s preferences and decision-making rights in circumstances of conflict.25 Percival
understated the critically important place of principles of respect for autonomy and distributive justice for
physician conduct, but, in fairness to him, these considerations are now prominent in discussions of ethics in
medicine in a way they were not when he wrote Medical Ethics.
That these four clusters of moral principles are central to biomedical ethics is a conclusion the authors of this
work have reached by examining considered moral judgments and the coherence of moral beliefs, two notions
analyzed in Chapter 10. The selection of these four principles, rather than some other clusters of principles, does
not receive an argued defense in Chapters 1 through 3. However, in Chapters 4 through 7, we defend the vital
role of each principle in biomedical ethics.
Rules
The framework of moral norms in this book encompasses several types of normative guidance, most notably
principles, rules, rights, and virtues. Principles are more comprehensive and less specific than rules, but we draw
only a loose distinction between them. Both are norms of obligation, but rules are more specific in content and
more restricted in scope. Principles do not function as precise guides in each circumstance in the way that more
detailed rules and judgments do. Principles and rules of obligation have correlative rights and often
corresponding virtues. (See the discussion of rights in Chapter 9 and of virtues in Chapter 2.)
We defend several types of rules, the most important being substantive rules, authority rules, and procedural
rules.
Substantive rules. Rules of truth telling, confidentiality, privacy, forgoing treatment, informed consent, and
rationing health care provide more specific guides to action than do abstract principles. An example of a rule that
sharpens the requirements of the principle of respect for autonomy in certain contexts is “Follow an incompetent
patient’s advance directive whenever it is clear and relevant.” To indicate how this rule specifies the principle of
respect for autonomy, it needs to be stated in full as “Respect the autonomy of incompetent patients by following
all clear and relevant formulations in their advance directives.” This specification shows how the initial norm of
respect for autonomy endures even while becoming specified. (See the subsection “Specifying Principles and
Rules” in the next section of this chapter.)
Authority rules. We also defend rules of decisional authority—that is, rules regarding who may and should
make decisions and perform actions. For example, rules of surrogate authority determine who should serve as
surrogate agents when making decisions for incompetent persons; rules of professional authority determine who
in professional ranks should make decisions to accept or to override a patient’s decisions; and rules of
distributional authority determine who should make decisions about allocating scarce medical resources such as
new and expensive medical technologies.
Authority rules do not delineate substantive standards or criteria for making decisions. However, authority rules
and substantive rules interact in some situations. For instance, authority rules are justified, in part, by how well
particular authorities can be expected to respect and comply with substantive rules and principles.
Procedural rules. We also defend rules that establish procedures to be followed. Procedures for determining
eligibility for organ transplantation and procedures for reporting grievances to higher authorities are typical
examples. We often resort to procedural rules when we run out of substantive rules and when authority rules are
incomplete or inconclusive. For example, if substantive or authority rules are inadequate to determine which
patients should receive scarce medical resources, a resort to procedural rules such as queuing and lottery may be
justifiable.26
CONFLICTING MORAL NORMS

Prima Facie Obligations and Rights
Principles, rules, obligations, and rights are not rigid or absolute standards that allow no compromise. Although
“a person of principle” is sometimes depicted as strict and unyielding, principles must be balanced and specified
so they can function practically. It is no objection to moral norms that, in some circumstances, they can be
justifiably overridden by other norms with which they conflict. All general moral norms are justifiably
overridden in some circumstances. For example, we might justifiably not tell the truth to prevent someone from
killing another person; and we might justifiably disclose confidential information about a person to protect the
rights of another person.
Actions that harm individuals, cause basic needs to go unmet, or limit liberties are often said to be either wrong
prima facie (i.e., wrongness is upheld unless the act is justifiable because of norms that are more stringent in the
circumstances) or wrong pro tanto (i.e., wrong to a certain extent or wrong unless there is a compelling
justification)—which is to say that the action is wrong in the absence of other moral considerations that supply a
compelling justification.27 Compelling justifications are sometimes available. For example, in circumstances of
a severe swine flu pandemic, the forced confinement of persons through isolation and quarantine orders might be
justified. Here a justifiable infringement of liberty rights occurs.
W. D. Ross’s distinction between prima facie and actual obligations clarifies this idea. A prima facie obligation
must be fulfilled unless it conflicts with an equal or stronger obligation. Likewise, a prima facie right (here we
extend Ross’s theory) must prevail unless it conflicts with an equal or stronger right (or conflicts with some
other morally compelling alternative). Obligations and rights always constrain us unless a competing moral
obligation or right can be shown to be overriding in a particular circumstance. As Ross put it, agents can
determine their actual obligations in situations of conflict by examining the respective weights of the competing
prima facie obligations. What agents ought to do is determined by what they ought to do all things considered.28
Imagine that a psychiatrist has confidential medical information about a patient who also happens to be an
employee in the hospital where the psychiatrist practices. The employee seeks advancement in a stress-filled
position, but the psychiatrist has good reason to believe that this advancement would be devastating for both the
employee and the hospital. The psychiatrist has several prima facie duties in these circumstances, including
those of confidentiality, nonmaleficence, beneficence, and respect for autonomy. Should the psychiatrist break
confidence in this circumstance to meet these other duties? Could the psychiatrist make “confidential”
disclosures to a hospital administrator and not to the personnel office? Addressing such questions through moral
deliberation and justification is required to establish an agent’s actual duty in the face of the conflicting prima
facie duties.
These matters are more complicated than Ross suggests, particularly when rights come into conflict. We may
need to develop a structured moral system or set of guidelines in which (1) some rights in a certain class of
rights (for example, rights of individuals while alive to decide whether to donate their tissues and organs after
death) have a fixed priority over others in another class of rights (for example, rights of family members to make
decisions about the donation of their deceased relatives’ tissues and organs) and (2) morally compelling social
objectives such as gathering information in biomedical research can generally be overridden by basic human
rights such as the right to give an informed consent or refusal.
No moral theory or professional code of ethics has successfully presented a system of moral rules free of
conflicts and exceptions, but this observation should not generate either skepticism or alarm about ethical
reflection, argument, and theory. The distinction between prima facie and actual obligations conforms closely to
our experience as moral agents and provides indispensable categories for biomedical ethics. Almost daily we
confront situations that force us to choose among conflicting values in our personal lives. For example, a
person’s financial situation might require that he or she choose between buying books for school and buying a
train ticket to see friends. Not having the books will be an inconvenience and a loss, whereas not visiting with
friends will disappoint the friends. Such choices do not come effortlessly, but we are usually able to think
through the alternatives, deliberate, and reach a conclusion.
Moral Regret and Residual Obligation

An agent who determines that a particular act is the best one to perform in a situation of conflicting obligations
may still not be able to discharge all aspects of moral obligation by performing that act. Even the morally best
action in the circumstances may still be regrettable and may leave a moral residue, also called a moral trace.29
Regret and residue over what is not done can arise even if the right action is clear and uncontested.
This point is about continuing obligation, not merely about feelings of regret and residue. Moral residue occurs
because a prima facie obligation does not simply disappear when overridden. Often we have residual obligations
because the obligations we were unable to discharge create new obligations. We may feel deep regret and a sting
of conscience, but we also realize that we have a duty to bring closure to the situation.30 We can sometimes
make up for not fulfilling an obligation in one or more of several ways. For example, we may be able to notify
persons in advance that we will not be able to keep a promise; we may be able to apologize in a way that heals a
relationship; we may be able to change circumstances so that the conflict does not occur again; and we may be
able to provide adequate compensation.
Specifying Principles and Rules
The four clusters of principles we present in this book do not by themselves constitute a general ethical theory.
They provide only a framework of norms with which to get started in biomedical ethics. These principles must
be specified in order to achieve more concrete guidance. Specification is a process of reducing the indeterminacy
of abstract norms and generating rules with action-guiding content.31 For example, without further specification,
“do no harm” is too bare for thinking through problems such as whether it is permissible to hasten the death of a
terminally ill patient.
Specification is not a process of producing or defending general norms such as those in the common morality; it
assumes that the relevant general norms are available. Specifying the norms with which one starts—whether
those in the common morality or norms previously specified—is accomplished by narrowing the scope of the
norms, not by explaining what the general norms mean. We narrow the scope, as Henry Richardson puts it, by
“spelling out where, when, why, how, by what means, to whom, or by whom the action is to be done or
avoided.”32 For example, the norm that we are obligated to “respect the autonomy of persons” cannot, unless
specified, handle complicated problems in clinical medicine and research involving human subjects. A definition
of “respect for autonomy” (e.g., as “allowing competent persons to exercise their liberty rights”) clarifies one’s
meaning in using the norm, but it does not narrow the scope of the general norm or render it more specific in
guiding actions.
Specification adds content. For example, as noted previously, one possible specification of “Respect the
autonomy of patients” is “Respect the autonomy of competent patients by following their advance directives
when they become incompetent.” This specification will work well in some medical contexts, but it will
confront limits in others, where additional specification will be needed. Progressive specification can continue
indefinitely, but to qualify all along the way as a specification some transparent connection must be maintained
to the initial general norm that gives moral authority to the resulting string of specifications. This process is a
prime way in which general principles become practical instruments for moral reasoning; and it also helps
explain why the four-principles approach is not merely an abstract theory limited to four general principles.33
An example of specification arises when psychiatrists conduct forensic evaluations of patients in a legal context.
Psychiatrists cannot always obtain an informed consent, but they then risk violating their obligations to respect
autonomy, a central imperative of medical ethics. A specification aimed at handling this problem is “Respect the
autonomy of persons who are the subjects of forensic evaluations, where consent is not legally required, by
disclosing to the evaluee the nature and purpose of the evaluation.” We do not claim that this formulation is the
best specification, but it approximates the provision recommended in the “Ethical Guidelines for the Practice of
Forensic Psychiatry” of the American Academy of Psychiatry and the Law.34 This specification attempts to
guide forensic psychiatrists in discharging their diverse moral obligations.
Another example of specification derives from the oft-cited rule “Doctors should put their patients’ interests
first.” In some countries patients are able to receive the best treatment available only if their physicians falsify
information on insurance forms. The rule of patient priority does not imply that a physician should act illegally
by lying or distorting the description of a patient’s problem on an insurance form. Rules against deception, on
the one hand, and for patient priority, on the other, are not categorical imperatives. When they conflict, we need
some form of specification to know what we can and cannot do.
A survey of practicing physicians’ attitudes toward deception illustrates how some physicians reconcile their
dual commitment to patients and to nondeception. Dennis H. Novack and several colleagues used a
questionnaire to obtain physicians’ responses to difficult ethical problems that potentially could be resolved by
use of deception. In one scenario, a physician recommends an annual screening mammography for a fifty-two-
year-old woman who protests that her insurance company will not cover the test. The insurance company will
cover the costs if the physician states (deceptively in this scenario) that the reason is “rule out cancer” rather
than “screening mammography.” The insurance company understands “rule out cancer” to apply only if there is
a breast mass or other objective clinical evidence of the possibility of cancer, neither of which is present in this
case. Almost 70% of the physicians responding to this survey indicated that they would state that they were
seeking to “rule out cancer,” and 85% of this group (85% of the 70%) insisted that their act would not involve
“deception.”35
These physicians’ decisions are rudimentary attempts to specify the rule that “Doctors should put their patients’
interests first.” Some doctors seem to think that it is properly specified as follows: “Doctors should put their
patients’ interests first by withholding information from or misleading someone who has no right to that
information, including an insurance company that, through unjust policies of coverage, forfeits its right to
accurate information.” In addition, most physicians in the study apparently did not operate with the definition of
“deception” favored by the researchers, which is “to deceive is to make another believe what is not true, to
mislead.” Some physicians apparently believed that “deception” occurs when one person unjustifiably misleads
another, and that it was justifiable to mislead the insurance company in these circumstances. It appears that these
physicians would not agree on how to specify rules against deception or rules assigning priority to patients’
interests.
All moral rules are, in principle, subject to specification. All will need additional content, because, as
Richardson puts it, “the complexity of the moral phenomena always outruns our ability to capture them in
general norms.”36 Many already specified rules will need further specification to handle new circumstances of
conflict. These conclusions are connected to our earlier discussion of particular moralities. Different persons and
groups will offer conflicting specifications, potentially creating multiple particular moralities. In any problematic
case, competing specifications are likely to be offered by reasonable and fair-minded parties, all of whom are
committed to the common morality.
To say that a problem or conflict is resolved or dissolved by specification is to say that norms have been made
sufficiently determinate in content that, when cases fall under them, we know what must be done. Obviously
some proposed specifications will fail to provide the most adequate or justified resolution. When competing
specifications emerge, the proposed specifications should be based on deliberative processes of reasoning.
Specification as a method can be connected to a model of justification that will support some specifications and
not others, as we argue in Chapter 10 (pp. 456–57).
Some specified norms are virtually absolute and need no further specification, though they are rare. Examples
include prohibitions of cruelty that involve unnecessary infliction of pain and suffering.37 “Do not rape” is a
comparable example. More interesting are norms that are intentionally formulated with the goal of including all
legitimate exceptions. An example is “Always obtain oral or written informed consent for medical interventions
with competent patients, except in emergencies, in forensic examinations, in low-risk situations, or when patients
have waived their right to adequate information.” This norm needs further interpretation, including an analysis
of what constitutes an informed consent, an emergency, a waiver, a forensic examination, and a low risk. This
rule would be absolute if all legitimate exceptions had been successfully incorporated into its formulation, but
such rules are rare. In light of the range of possibilities for contingent conflicts among rules, even the firmest and
most detailed rules are likely to encounter exceptive cases.
Weighing and Balancing

Principles, rules, obligations, and rights often must be balanced in circumstances of contingent conflict. Does
balancing differ from specification, or are they identical?
The process of weighing and balancing. Balancing occurs in the process of reasoning about which moral norms
should prevail when two or more of them come into conflict. Balancing is concerned with the relative weights
and strengths of different moral norms, whereas specification is concerned primarily with their range and scope,
that is, their reach when narrowing the scope of pre-existing general norms (while adding content). Balancing
consists of deliberation and judgment about these weights and strengths. It is well suited for reaching judgments
in particular cases, whereas specification is especially useful for developing more specific policies from already
accepted general norms.
The metaphor of larger and smaller weights moving a scale up and down has often been invoked to depict the
balancing process, but this metaphor can obscure what happens in balancing. Justified acts of balancing are
supported by good reasons. They need not rest merely on intuition or feeling, although intuitive balancing is one
form of balancing. Suppose a physician encounters an emergency case that would require her to extend an
already long day, making her unable to keep a promise to take her son to the local library. She engages in a
process of deliberation that leads her to consider how urgently her son needs to get to the library, whether they
could go to the library later, whether another physician could handle the emergency case, and the like. If she
determines to stay deep into the night with the patient, she has judged this obligation to be overriding because
she has found a good and sufficient reason for her action. The reason might be that a life hangs in the balance
and she alone may have the knowledge to deal adequately with the circumstances. Canceling her evening with
her son, distressing as it will be, could be justified by the significance of her reasons for doing what she does.
One way of approaching balancing merges it with specification. In our example, the physician’s reasons can be
generalized to similar cases: “If a patient’s life hangs in the balance and the attending physician alone has the
knowledge to deal adequately with the full array of the circumstances, then the physician’s conflicting domestic
obligations must yield.” Even if we do not always state the way we balance considerations in the form of a
specification, might not all deliberative judgments be made to conform to this model? If so, then deliberative
balancing would be nothing but deliberative specification.
The goal of merging specification and balancing is appealing, but it is not well-suited to handle all situations in
which balancing occurs. Specification requires that a moral agent extend norms by both narrowing their scope
and generalizing to relevantly similar circumstances. Accordingly, “Respect the autonomy of competent patients
when they become incompetent by following their advance directives” is a rule suited for all incompetent
patients with advance directives. However, the responses of caring moral agents, such as physicians and nurses,
are often highly specific to the needs of this patient or this family in this particular circumstance. Numerous
considerations must be weighed and balanced, and any generalizations that could be formed might not hold even
in remarkably similar cases.
Generalizations conceived as policies might even be dangerous. For example, cases in which risk of harm and
burden are involved for a patient are often circumstances unlikely to be decided by expressing, by a rule, how
much risk is allowable or how heavy the burden can be to secure a certain stated benefit. After levels of risk and
burden are determined, these considerations must be balanced with the likelihood of the success of a procedure,
the uncertainties involved, whether an adequately informed consent can be obtained, whether the family has a
role to play, and the like. In this way, balancing allows for a due consideration of all the factors bearing on a
complex particular circumstance, including all relevant moral norms.
Consider the following discussion with a young woman who has just been told that she is HIV-infected, as
recorded by physician Timothy Quill and nurse Penelope Townsend:38
PATIENT: Please don’t tell me that. Oh my God. Oh my children. Oh Lord have mercy. Oh God,
why did He do this to me? …
DR. QUILL: First thing we have to do is learn as much as we can about it, because right now you
are okay.
PATIENT: I don’t even have a future. Everything I know is that you gonna die anytime. What is
there to do? What if I’m a walking time bomb? People will be scared to even touch me or say
anything to me.
DR. QUILL: No, that’s not so.
PATIENT: Yes they will, ’cause I feel that way …
DR. QUILL: There is a future for you …
PATIENT: Okay, all right. I’m so scared. I don’t want to die. I don’t want to die, Dr. Quill, not yet. I
know I got to die, but I don’t want to die.
DR. QUILL: We’ve got to think about a couple of things.
Quill and Townsend work to calm down and reassure this patient, while engaging sympathetically with her
feelings and conveying the presence of knowledgeable medical authorities. Their emotional investment in the
patient’s feelings is joined with a detached evaluation of the patient. Too much compassion and emotional
investment may doom the task at hand; too much detachment will be cold and may destroy the patient’s trust and
hope. A balance in the sense of a right mixture between engagement and detachment must be found.
Quill and Townsend could try to specify norms of respect and beneficence to indicate how caring physicians and
nurses should respond to patients who are desperately upset. However, specification will ring hollow and will
not be sufficiently nuanced to provide practical guidance for this patient and certainly not for all desperately
upset patients. Each encounter calls for a response inadequately captured by general principles and rules and
their specifications. Behavior that is a caring response for one desperate patient may intrude on privacy or
irritate another desperate patient. A physician may, for example, find it appropriate to touch or caress a patient,
while appreciating that such behavior would be entirely inappropriate for another patient in a similar
circumstance.
How physicians and nurses balance different moral considerations often involves sympathetic insight, humane
responsiveness, and the practical wisdom of discerning a particular patient’s circumstance and needs.39
Balancing is often a more complex set of activities than those involved in a straightforward case of balancing
two conflicting principles or rules. Considerations of trust, compassion, objective assessment, caring
responsiveness, reassurance, and the like may all be involved in the process of balancing.
In many clinical contexts it may be hopelessly complicated and unproductive to engage in specification. For
example, in cases of balancing harms of treatment against the benefits of treatment for incompetent patients, the
cases are often so exceptional that it is perilous to generalize a conclusion that would reach out to other cases.
These problems are sometimes further complicated by disagreements among family members about what
constitutes a benefit, poor decisions and indecision by a marginally competent patient, limitations of time and
resources, and the like.40
We do not suggest that balancing is inescapably intuitive and unreflective. Instead, we propose a model of moral
judgment that focuses on how balancing and judgment occur through practical astuteness, discriminating
intelligence, and sympathetic responsiveness that are not reducible to the specification of norms. The capacity to
balance many moral considerations is connected to what we discuss in Chapter 2 as capacities of moral
character. Capacities in the form of virtues of compassion, attentiveness, discernment, caring, and kindness are
integral to the way wise moral agents balance diverse, sometimes competing, moral considerations.
Practicability supplies another reason to support the conclusion that the model of specification needs
supplementation by the model of balancing. Progressive specification covering all areas of the moral life would
eventually mushroom into a body of norms so bulky that the normative system would become unwieldy. A
scheme of comprehensive specification would constitute a package of potentially hundreds, thousands, or
millions of rules, each suited to a narrow range of conduct. In the model of specification, every type of action in
a circumstance of the contingent conflict of norms would be covered by a rule, but the formulation of rules for
every circumstance of contingent conflict would be a body of rules too cumbersome to be helpful.
Conditions that constrain balancing. To allay concerns that the model of balancing is too intuitive or too open-
ended and lacks a commitment to firm principles and rigorous reasoning, we propose six conditions that should
help reduce intuition, partiality, and arbitrariness. These conditions must be met to justify infringing one prima
facie norm in order to adhere to another.
1. 1. Good reasons are offered to act on the overriding norm rather than the infringed norm.
2. 2. The moral objective justifying the infringement has a realistic prospect of achievement.
3. 3. No morally preferable alternative actions are available.41
4. 4. The lowest level of infringement, commensurate with achieving the primary goal of the action, has been
selected.
5. 5. All negative effects of the infringement have been minimized.
6. 6. All affected parties have been treated impartially.
Although some of these conditions are obvious and noncontroversial, some are often overlooked in moral
deliberation and would lead to different conclusions were they observed. For example, some decisions to use
futile life-extending technologies over the objections of patients or their surrogates violate condition 2 by
endorsing actions in which no realistic prospect exists of achieving the goals of a proposed intervention.
Typically, these decisions are made when health professionals regard the intervention as legally required, but in
some cases the standard invoked is merely traditional or deeply entrenched.
Condition 3 is more commonly violated. Actions are regularly performed in some settings without serious
consideration of alternative actions that might be performed. As a result, agents fail to identify a morally
preferable alternative. For example, in animal care and use committees a common conflict involves the
obligation to approve a good scientific protocol and the obligation to protect animals against unnecessary
suffering. A protocol may be approved if it proposes a standard form of anesthesia. However, standard forms of
anesthesia are not always the best way to protect the animal, and further inquiry is needed to determine the best
anesthetic for the particular interventions proposed. In our schema of conditions, it is unjustifiable to approve the
protocol or to conduct the experiment without this additional inquiry, which affects conditions 4 and 5 as well as
3.
Finally, consider this example: The principle of respect for autonomy and the principle of beneficence (which
requires acts intended to prevent harm to others) sometimes come into contingent conflict when addressing
situations that arise in governmental and professional responses to serious infectious-disease outbreaks, such as
severe acquired respiratory syndrome (SARS). Persons exposed to SARS may put other persons at risk. The
government, under its public health responsibilities, and various health professionals have an obligation based
on beneficence and justice to protect unexposed persons whenever possible. However, respect for autonomy
often sets a prima facie barrier to infringements of liberty and privacy even in the context of public health
concerns. To justify overriding respect for autonomy, one must show that mandatory quarantine of exposed
individuals is necessary to prevent harm to others and has a reasonable prospect of preventing such harm. If it
meets these conditions, mandatory quarantine still must pass the least-infringement test (condition 4), and public
health officials should seek to minimize the negative effects of the quarantine, including the loss of income and
the inability to care for dependent family members (condition 5). Finally, impartial application of the quarantine
rules is essential for both fairness and public trust (condition 6).42
In our judgment, these six constraining conditions are morally demanding, at least in some circumstances. When
conjoined with requirements of coherence presented in Chapter 10 (pp. 439–44), these conditions provide
protections against purely intuitive, subjective, or biased balancing judgments. We could introduce further
criteria or safeguards, such as “rights override nonrights” and “liberty principles override nonliberty principles,”
but these provisions are certain to fail in circumstances in which rights claims and liberty interests are relatively
minor.
Moral Diversity and Moral Disagreement

Sometimes conscientious and reasonable moral agents understandably disagree over moral priorities in
circumstances of a contingent conflict of norms. Morally conscientious persons may disagree, for example,
about whether disclosure of a life-threatening condition to a fragile patient is appropriate, whether religious
values about brain death have a place in secular biomedical ethics, whether mature teenagers should be
permitted to refuse life-sustaining treatments, and other issues. Disagreement does not indicate moral ignorance
or moral defect. We simply lack a single, entirely reliable way to resolve many disagreements, despite methods
of specifying and balancing.
Moral disagreement can emerge because of (1) factual disagreements (e.g., about the level of suffering that an
intervention will cause), (2) disagreements resulting from insufficient information or evidence, (3)
disagreements about which norms are applicable or relevant in the circumstances, (4) disagreements about the
relative weights or rankings of the relevant norms, (5) disagreements about appropriate forms of specification or
balancing, (6) the presence of a genuine moral dilemma, (7) scope and moral status disagreements about who
should be protected by a moral norm (e.g., whether embryos, fetuses, and sentient animals are protected; see
Chapter 3), and (8) conceptual disagreements about a crucial moral concept such as whether removal of nutrition
and hydration from a dying patient at a family’s request constitutes killing.
Different parties may emphasize different principles or assign different weights to principles even when they
agree on which principles and concepts are relevant. Disagreement may persist among morally committed
persons who appropriately appreciate the basic demands that morality makes on them. If evidence is incomplete
and different items of evidence are available to different parties, one individual or group may be justified in
reaching a conclusion that another individual or group is justified in rejecting. Even if both parties have some
incorrect beliefs, each party may have good reasons for holding those beliefs. We cannot hold persons to a
higher practical standard than to make judgments conscientiously in light of the available norms and evidence.
When moral disagreements arise, a moral agent can—and usually should—defend his or her decision without
disparaging or reproaching others who reach different decisions. Recognition of legitimate diversity—by
contrast to moral violations that warrant criticism—is vital in the evaluation of the actions of others. One
person’s conscientious assessment of his or her obligations may differ from another’s when they confront the
same moral problem, and both evaluations may be appropriately grounded in the common morality. Similarly,
what one institution or government determines it should do may differ from what another institution or
government determines it should do. In such cases we can assess one position as morally preferable to another
only if we can show that the position rests on a more coherent set of specifications and interpretations of the
common morality.43
CONCLUSION
In this chapter we have presented what is sometimes called the four-principles approach to biomedical ethics,
now commonly called principlism.44 The four clusters of principles in our moral framework descend from the
common morality, but when specifying and balancing these principles in later chapters we will also call on
historical experience in formulating professional obligations and virtues in health care, public health, biomedical
research, and health policy. Although various assumptions in traditional medical ethics, current medical and
research codes, and other parts of contemporary bioethics need further reform, we are deeply indebted to their
insights and commitments. Our goal in later chapters is to develop, specify, and balance the normative content of
the four clusters of principles, and we will often seek to render our views consistent with professional traditions,
practices, and codes.
Principlism is not merely a list of four abstract principles. It is a theory about how these principles are linked to
and guide practice. In the nine chapters hereafter we show how principles and other moral norms are connected
to an array of understandings, practices, and transactions in health care settings, research institutions, and public
health policies.
NOTES
1. 1. See Albert Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998), pp. 3ff; Jonsen,
A Short History of Medical Ethics (New York: Oxford University Press, 2000); John-Stewart Gordon,
“Bioethics,” in the Internet Encyclopedia of Philosophy, especially section 2, available at
https://www.iep.utm.edu/bioethics/ (accessed March 23, 2018); and Edmund D. Pellegrino and David C.
Thomasma, The Virtues in Medical Practice (New York: Oxford University Press, 1993), pp. 184–89.
2. 2. A comprehensive treatment of this history that ranges worldwide is Robert B. Baker and Laurence
McCullough, eds., The Cambridge World History of Medical Ethics (Cambridge: Cambridge University
Press, 2009).
3. 3. The language of “applied ethics” can be misleading insofar as it suggests one-way traffic from ethical
theory and principles and rules to particular judgments about cases. In fact, particular case judgments
interact dialectically with and may lead to modifications of theories, principles, and rules. See our
discussion in Chapter 10, pp. 404–10.
4. 4. These distinctions should be used with caution. Metaethics frequently takes a turn toward the
normative, and normative ethics often relies on metaethics. Just as no sharp distinction should be drawn
between practical ethics and general normative ethics, no bright line should be drawn to distinguish
normative ethics and metaethics.
5. 5. Although there is only one universal common morality, there is more than one theory of the common
morality. For a diverse group of theories, see Alan Donagan, The Theory of Morality (Chicago: University
of Chicago Press, 1977); Bernard Gert, Common Morality: Deciding What to Do (New York: Oxford
University Press, 2007); Bernard Gert, Charles M. Culver, and K. Danner Clouser, Bioethics: A Return to
Fundamentals, 2nd ed. (New York: Oxford University Press, 2006); W. D. Ross, The Foundations of
Ethics (Oxford: Oxford University Press, 1939); and the special issue of the Kennedy Institute of Ethics
Journal 13 (2003), especially the introductory article by Robert Veatch, pp. 189–92.
For challenges to these theories and their place in bioethics, see John D. Arras, “The Hedgehog and the
Borg: Common Morality in Bioethics,” Theoretical Medicine and Bioethics 30 (2009): 11–30; Arras, “A
Common Morality for Hedgehogs: Bernard Gert’s Method,” in Arras, Methods in Bioethics: The Way We
Reason Now, ed. James F. Childress and Matthew Adams (New York: Oxford University Press, 2017), pp.
27–44; B. Bautz, “What Is the Common Morality, Really?” Kennedy Institute of Ethics Journal 26 (2016):
29–45; Carson Strong, “Is There No Common Morality?” Medical Humanities Review 11 (1997): 39–45;
and Andrew Alexandra and Seumas Miller, “Ethical Theory, ‘Common Morality,’ and Professional
Obligations,” Theoretical Medicine and Bioethics 30 (2009): 69–80.
6. 6. See Martha Nussbaum’s thesis that in Aristotle’s philosophy, certain “non-relative virtues” are objective
and universal. “Non-Relative Virtues: An Aristotelian Approach,” in Ethical Theory, Character, and
Virtue, ed. Peter French et al. (Notre Dame, IN: University of Notre Dame Press, 1988), pp. 32–53,
especially pp. 33–4, 46–50. In a classic work in philosophical ethics, David Hume presents a theory of the
virtues as objective and universal, though his theory is somewhat different from Aristotle’s. See Hume’s
An Enquiry concerning the Principles of Morals, ed. Tom L. Beauchamp, in the series “Oxford
Philosophical Texts Editions” (Oxford: Oxford University Press, 1998).
7. 7. For a broad and engaging account of common morality, see Rebecca Kukla, “Living with Pirates:
Common Morality and Embodied Practice,” Cambridge Quarterly of Healthcare Ethics 23 (2014): 75–85.
See also Bernard Gert’s insistence on the role of the whole moral system (not merely rules of obligation)
and the perils of neglecting it, an often overlooked point with which we agree. See Gert’s Morality: Its
Nature and Justification (New York: Oxford University Press, 2005), pp. 3, 159–61, 246–47; and see also
his “The Definition of Morality,” in The Stanford Encyclopedia of Philosophy; revision of February 8,
2016, available at https://plato.stanford.edu/entries/morality-definition/ (accessed February 9, 2018).
8. 8. This mistaken interpretation of our theory is found in Leigh Turner, “Zones of Consensus and Zones of
Conflict: Questioning the ‘Common Morality’ Presumption in Bioethics,” Kennedy Institute of Ethics
Journal 13 (2003): 193–218; and Turner, “An Anthropological Exploration of Contemporary Bioethics:
The Varieties of Common Sense,” Journal of Medical Ethics 24 (1998): 127–33.
9. 9. See David DeGrazia, “Common Morality, Coherence, and the Principles of Biomedical Ethics,”
Kennedy Institute of Ethics Journal 13 (2003): 219–30; Turner, “Zones of Consensus and Zones of
Conflict”; Donald C. Ainslee, “Bioethics and the Problem of Pluralism,” Social Philosophy and Policy 19
(2002): 1–28; Oliver Rauprich, “Common Morality: Comment on Beauchamp and Childress,” Theoretical
Medicine and Bioethics 29 (2008): 43–71; and Letícia Erig Osório de Azambuja and Volnei Garrafa, “The
Common Morality Theory in the Work of Beauchamp and Childress,” Revista Bioética 23 (2015),
available at http://www.scielo.br/scielo.php?pid=S1983-80422015000300634&script=sci_arttext&tlng=en
(accessed March 22, 2018). For a related, but distinguishable, criticism, see Anna E. Westra, Dick L.
Willems, and Bert J. Smit, “Communicating with Muslim Parents: ‘The Four Principles’ Are not as
Culturally Neutral as Suggested,” European Journal of Pediatrics 168 (2009): 1383–87; this article is
published together with a beautifully correct interpretation of our position by Voo Teck Chuan, “Editorial
Comment: The Four Principles and Cultural Specification,” European Journal of Pediatrics 168 (2009):
1389.
10. 10. Kukla reaches this conclusion in “Living with Pirates.” See, in response, Tom L. Beauchamp, “On
Common Morality as Embodied Practice: A Reply to Kukla,” Cambridge Quarterly of Healthcare Ethics
23 (2014): 86–93; Carson Strong, “Kukla’s Argument against Common Morality as a Set of Precepts: On
Stranger Tides,” Cambridge Quarterly of Healthcare Ethics 23 (2014): 93–99; and Kukla, “Response to
Strong and Beauchamp—at World’s End,” Cambridge Quarterly of Healthcare Ethics 23 (2014): 99–102.
11. 11. See Richard B. Brandt, “Morality and Its Critics,” in his Morality, Utilitarianism, and Rights
(Cambridge: Cambridge University Press, 1992), chap. 5; and Gregory Mellema, “Moral Ideals and Virtue
Ethics,” Journal of Ethics 14 (2010): 173–80. See also our discussion of moral ideals and supererogation
in Chapter 2, pp. 45–49.
12. 12. Talcott Parsons, Essays in Sociological Theory, rev. ed. (Glencoe, IL: Free Press, 1954), p. 372. See
further Jan Nolin, In Search of a New Theory of Professions (Borås, Sweden: University of Borås, 2008).
13. 13. See the excellent introduction to this subject in Edmund D. Pellegrino, “Codes, Virtues, and
Professionalism,” in Methods of Bioethics, ed. Daniel Sulmasy and Jeremy Sugarman, 2nd ed.
(Washington, DC: Georgetown University Press, 2010), pp. 91–108. For an overview of codes of medical
ethics, see Robert Baker, “Medical Codes and Oaths,” Bioethics [Formerly Encyclopedia of Bioethics], 4th
ed., ed. Bruce Jennings (Farmington Hills, MI: Gale, Cengage Learning, Macmillan Reference USA,
2014), vol. 4, pp. 1935–46. For a history and assessment of the Code of Ethics for Nurses of the American
Nurses Association, see Beth Epstein and Martha Turner, “The Nursing Code of Ethics: Its Value, Its
History,” Online Journal of Issues in Nursing 20, no. 2 (May 2015), available at
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofConte
nts/Vol-20-2015/No2-May-2015/The-Nursing-Code-of-Ethics-Its-Value-Its-History.html (accessed June 3,
2018).
14. 14. The American Medical Association Code of Ethics of 1847 was largely adapted from Thomas
Percival’s Medical Ethics; or a Code of Institutes and Precepts, Adapted to the Professional Conduct of
Physicians and Surgeons (Manchester, UK: S. Russell, 1803). See Donald E. Konold, A History of
American Medical Ethics 1847–1912 (Madison, WI: State Historical Society of Wisconsin, 1962), chaps.
1–3; Chester Burns, “Reciprocity in the Development of Anglo-American Medical Ethics,” in Legacies in
Medical Ethics, ed. Burns (New York: Science History Publications, 1977); and American Medical
Association, “History of the Code,” available at https://www.ama-assn.org/sites/default/files/media-
browser/public/ethics/ama-code-ethics-history.pdf (accessed March 23, 2018).
15. 15. For a related and rigorous critical analysis of Hippocratic and other medical codes, see Robert M.
Veatch’s influential views in his Hippocratic, Religious, and Secular Medical Ethics: The Points of
Conflict (Washington, DC: Georgetown University Press, 2012).
16. 16. Cf. the conclusions reached about medicine in N. D. Berkman, M. K. Wynia, and L. R. Churchill,
“Gaps, Conflicts, and Consensus in the Ethics Statements of Professional Associations, Medical Groups,
and Health Plans,” Journal of Medical Ethics 30 (2004): 395–401; Ryan M. Antiel, Farr A. Curlin, C.
Christopher Hook, and Jon C. Tilburt, “The Impact of Medical School Oaths and Other Professional
Codes of Ethics: Results of a National Physician Survey,” Archives of Internal Medicine 171 (2011): 469–
71; Robert D. Orr, Norman Pang, Edmund D. Pellegrino, and Mark Siegler, “Use of the Hippocratic Oath:
A Review of Twentieth Century Practice and a Content Analysis of Oaths Administered in Medical
Schools in the U.S. and Canada in 1993,” Journal of Clinical Ethics 8 (1997): 377–88; and A. C. Kao and
K. P. Parsi, “Content Analyses of Oaths Administered at U.S. Medical Schools in 2000,” Academic
Medicine 79 (2004): 882–87.
17. 17. Jay Katz, ed., Experimentation with Human Beings (New York: Russell Sage Foundation, 1972), pp.
ix–x.
18. 18. For an examination of different models of public bioethics, see James F. Childress, “Reflections on the
National Bioethics Advisory Commission and Models of Public Bioethics,” Goals and Practice of Public
Bioethics: Reflections on National Bioethics Commissions, special report, Hastings Center Report 47, no.
3 (2017): S20–S23, and several other essays in this special report. See also Society’s Choices: Social and
Ethical Decision Making in Biomedicine, ed. Ruth Ellen Bulger, Elizabeth Meyer Bobby, and Harvey V.
Fineberg, for the Committee on the Social and Ethical Impacts of Developments in Biomedicine, Division
of Health Sciences Policy, Institute of Medicine (Washington, DC: National Academies Press, 1995).
19. 19. See Allen Buchanan, “Philosophy and Public Policy: A Role for Social Moral Epistemology,” Journal
of Applied Philosophy 26 (2009): 276–90; Will Kymlicka, “Moral Philosophy and Public Policy: The
Case of New Reproductive Technologies,” in Philosophical Perspectives on Bioethics, ed. L. W. Sumner
and Joseph Boyle (Toronto: University of Toronto Press, 1996); Dennis Thompson, “Philosophy and
Policy,” Philosophy & Public Affairs 14 (Spring 1985): 205–18; Andrew I. Cohen, Philosophy, Ethics,
and Public Policy (London: Routledge, 2015); and a symposium on “The Role of Philosophers in the
Public Policy Process: A View from the President’s Commission,” with essays by Alan Weisbard and Dan
Brock, Ethics 97 (July 1987): 775–95.
20. 20. Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14
(Cal. 1976).
21. 21. On the interactions of ethical and legal judgments (and the reasons for their interactions) on bioethical
issues, see Stephen W. Smith, John Coggan, Clark Hobson, et al., eds., Ethical Judgments: Re-Writing
Medical Law (Oxford: Hart, 2016).
22. 22. See John Lemmon, “Moral Dilemmas,” Philosophical Review 71 (1962): 139–58; Daniel Statman,
“Hard Cases and Moral Dilemmas,” Law and Philosophy 15 (1996): 117–48; Terrance McConnell, “Moral
Dilemmas,” Stanford Encyclopedia of Philosophy (Fall 2014 edition), ed. Edward N. Zalta, available at
https://plato.stanford.edu/archives/fall2014/entries/moral-dilemmas/ (accessed March 23, 2018); H. E.
Mason, “Responsibilities and Principles: Reflections on the Sources of Moral Dilemmas,” in Moral
Dilemmas and Moral Theory, ed. H. E. Mason (New York: Oxford University Press, 1996).
23. 23. Christopher W. Gowans, ed., Moral Dilemmas (New York: Oxford University Press, 1987); Walter
Sinnott-Armstrong, Moral Dilemmas (Oxford: Basil Blackwell, 1988); Edmund N. Santurri, Perplexity in
the Moral Life: Philosophical and Theological Considerations (Charlottesville: University Press of
Virginia, 1987). For an approach to dilemmas offered as an addition to our account in this chapter, see
Joseph P. DeMarco, “Principlism and Moral Dilemmas: A New Principle,” Journal of Medical Ethics 31
(2005): 101–5.
24. 24. Some writers in biomedical ethics express reservations about the place of the particular principles we
propose in this book. See Pierre Mallia, The Nature of the Doctor–Patient Relationship: Health Care
Principles through the Phenomenology of Relationships with Patients (Springer Netherlands: Springer
Briefs in Ethics, 2013), esp. chap. 2, “Critical Overview of Principlist Theories”; K. Danner Clouser and
Bernard Gert, “A Critique of Principlism,” Journal of Medicine and Philosophy 15 (April 1990): 219–36;
Søren Holm, “Not Just Autonomy—The Principles of American Biomedical Ethics,” Journal of Medical
Ethics 21 (1994): 332–38; Peter Herissone-Kelly, “The Principlist Approach to Bioethics, and Its Stormy
Journey Overseas,” in Scratching the Surface of Bioethics, ed. Matti Häyry and Tuija Takala (Amsterdam:
Rodopi, 2003), pp. 65–77; and numerous essays in Principles of Health Care Ethics, ed. Raanan Gillon
and Ann Lloyd (London: Wiley, 1994); and Principles of Health Care Ethics, 2nd ed., ed. Richard E.
Ashcroft et al. (Chichester, UK: Wiley, 2007).
25. 25. Thomas Percival, Medical Ethics; or a Code of Institutes and Precepts, Adapted to the Professional
Interests of Physicians and Surgeons (Manchester: S. Russell, 1803 [and numerous later editions]). For
commentary on this classic work and its influence, see Edmund D. Pellegrino, “Percival’s Medical Ethics:
The Moral Philosophy of an 18th-Century English Gentleman,” Archives of Internal Medicine 146 (1986):
2265–69; Pellegrino, “Thomas Percival’s Ethics: The Ethics Beneath the Etiquette” (Washington DC:
Georgetown University, Kennedy Institute of Ethics, 1984), available at
https://repository.library.georgetown.edu/bitstream/handle/10822/712018/Pellegrino_M269.pdf?
sequence=1&isAllowed=n (accessed March 24, 2018); Robert B. Baker, Arthur L. Caplan, Linda L.
Emanuel, and Stephen R. Latham, eds., The American Medical Ethics Revolution: How the AMA’s Code of
Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society (Baltimore:
Johns Hopkins University Press, 1999).
26. 26. Procedural rules might also be interpreted as grounded in substantive rules of equality. If so
interpreted, the procedural rules could be said to have a justification in substantive rules.
27. 27. For a discussion of the distinction between pro tanto and prima facie, see Shelly Kagan, The Limits of
Morality (Oxford: Clarendon Press, 1989), p. 17. Kagan prefers pro tanto, rather than prima facie, and
notes that Ross used prima facie with effectively the same meaning, which some writers classify as a
mistake on Ross’s part. See further Andrew E. Reisner, “Prima Facie and Pro Tanto Oughts,” International
Encyclopedia of Ethics [online], first published February 1, 2013, available at
https://onlinelibrary.wiley.com/doi/full/10.1002/9781444367072.wbiee406 (accessed March 24, 2018).
28. 28. W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930), esp. pp. 19–36, 88. On
important cautions about both the meaning and use of the related notion of “prima facie rights,” see Joel
Feinberg, Rights, Justice, and the Bounds of Liberty (Princeton, NJ: Princeton University Press, 1980), pp.
226–29, 232; and Judith Jarvis Thomson, The Realm of Rights (Cambridge, MA: Harvard University
Press, 1990), pp. 118–29.
29. 29. Robert Nozick, “Moral Complications and Moral Structures,” Natural Law Forum 13 (1968): 1–50,
available at https://scholarship.law.nd.edu/cgi/viewcontent.cgi?article=1136...naturallaw_forum (accessed
March 26, 2018); James J. Brummer, “Ross and the Ambiguity of Prima Facie Duty,” History of
Philosophy Quarterly 19 (2002): 401–22. See also Thomas E. Hill, Jr., “Moral Dilemmas, Gaps, and
Residues: A Kantian Perspective”; Walter Sinnott-Armstrong, “Moral Dilemmas and Rights”; and
Terrance C. McConnell, “Moral Residue and Dilemmas”—all in Moral Dilemmas and Moral Theory, ed.
Mason.
30. 30. For a similar view, see Ross, The Right and the Good, p. 28.
31. 31. Henry S. Richardson, “Specifying Norms as a Way to Resolve Concrete Ethical Problems,”
Philosophy & Public Affairs 19 (Fall 1990): 279–310; and Richardson, “Specifying, Balancing, and
Interpreting Bioethical Principles,” Journal of Medicine and Philosophy 25 (2000): 285–307, also in
Belmont Revisited: Ethical Principles for Research with Human Subjects, ed. James F. Childress, Eric M.
Meslin, and Harold T. Shapiro (Washington, DC: Georgetown University Press, 2005), pp. 205–27. See
also David DeGrazia, “Moving Forward in Bioethical Theory: Theories, Cases, and Specified
Principlism,” Journal of Medicine and Philosophy 17 (1992): 511–39.
32. 32. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 289.
33. 33. For an excellent critical examination and case study of how the four-principles framework and
approach can and should be used as a practical instrument, see John-Stewart Gordon, Oliver Rauprich, and
Jochen Vollmann, “Applying the Four-Principle Approach,” Bioethics 25 (2011): 293–300, with a reply by
Tom Beauchamp, “Making Principlism Practical: A Commentary on Gordon, Rauprich, and Vollmann,”
Bioethics 25 (2011): 301–3.
34. 34. American Academy of Psychiatry and the Law, “Ethical Guidelines for the Practice of Forensic
Psychiatry,” as revised and adopted May 2005, section III: “The informed consent of the person
undergoing the forensic evaluation should be obtained when necessary and feasible. If the evaluee is not
competent to give consent, the evaluator should follow the appropriate laws of the jurisdiction. …
[P]sychiatrists should inform the evaluee that if the evaluee refuses to participate in the evaluation, this
fact may be included in any report or testimony. If the evaluee does not appear capable of understanding
the information provided regarding the evaluation, this impression should also be included in any report
and, when feasible, in testimony.” Available at http://www.aapl.org/ethics.htm (accessed February 19,
2018).
35. 35. Dennis H. Novack et al., “Physicians’ Attitudes toward Using Deception to Resolve Difficult Ethical
Problems,” Journal of the American Medical Association 261 (May 26, 1989): 2980–85. We return to
these problems in Chapter 8 (pp. 327–37).
36. 36. Richardson, “Specifying Norms,” p. 294. The word “always” in this formulation should be understood
to mean “in principle always.” Specification may, in some cases, reach a final form.
37. 37. Other prohibitions, such as rules against murder and rape, may be absolute only because of the
meaning of their terms. For example, to say “murder is categorically wrong” may be only to say
“unjustified killing is unjustified.”
38. 38. Timothy Quill and Penelope Townsend, “Bad News: Delivery, Dialogue, and Dilemmas,” Archives of
Internal Medicine 151 (March 1991): 463–68.
39. 39. See Alisa Carse, “Impartial Principle and Moral Context: Securing a Place for the Particular in Ethical
Theory,” Journal of Medicine and Philosophy 23 (1998): 153–69. For a defense of balancing as the best
method in such situations, see Joseph P. DeMarco and Paul J. Ford, “Balancing in Ethical Deliberations:
Superior to Specification and Casuistry,” Journal of Medicine and Philosophy 31 (2006): 483–97, esp.
491–93.
40. 40. See similar reflections in Lawrence Blum, Moral Perception and Particularity (New York:
Cambridge, 1994), p. 204.
41. 41. To the extent these six conditions incorporate moral norms, the norms are prima facie, not absolute.
Condition 3 is redundant if it cannot be violated when all of the other conditions are satisfied; but it is best
to be clear on this point, even if redundant.
42. 42. See James F. Childress and Ruth Gaare Bernheim, “Public Health Ethics: Public Justification and
Public Trust,” Bundesgundheitsblat: Gusundheitsforschung, Gesundheitsschutz 51, no. 2 (February 2008):
158–63; and Ruth Gaare Bernheim, James F. Childress, Richard J. Bonnie, and Alan L. Melnick,
Essentials of Public Health Ethics: Foundations, Tools, and Interventions (Boston: Jones and Bartlett,
2014), esp. chaps. 1, 2, and 8.
43. 43. For a criticism of our conclusion in this paragraph, see Marvin J. H. Lee, “The Problem of ‘Thick in
Status, Thin in Content,’ in Beauchamp and Childress’s Principlism,” Journal of Medical Ethics 36
(2010): 525–28. See further Angus Dawson and E. Garrard, “In Defence of Moral Imperialism: Four
Equal and Universal Prima Facie Principles,” Journal of Medical Ethics 32 (2006): 200–204; Walter
Sinnott-Armstrong, Moral Dilemmas, pp. 216–27; and D. D. Raphael, Moral Philosophy (Oxford: Oxford
University Press, 1981), pp. 64–65.
44. 44. See Bernard Gert, Charles M. Culver, and K. Danner Clouser, Bioethics: A Return to Fundamentals,
2nd ed., chap. 4; Clouser and Gert, “A Critique of Principlism,” pp. 219–36; Carson Strong, “Specified
Principlism,” Journal of Medicine and Philosophy 25 (2000): 285–307; John H. Evans, “A Sociological
Account of the Growth of Principlism,” Hastings Center Report 30 (September–October 2000): 31–38;
Evans, Playing God: Human Genetic Engineering and the Rationalization of Public Bioethical Debate
(Chicago: University of Chicago Press, 2002); and Evans, The History and Future of Bioethics: A
Sociological View (New York: Oxford University Press, 2011). For a critical analysis of Evans’s
arguments, particularly in Playing God, see James F. Childress, “Comments,” Journal of the Society of
Christian Ethics 24, no. 1 (2004): 195–204.
2
Moral Character
Chapter 1 concentrated on moral norms in the form of principles, rules, obligations, and rights. This chapter
focuses on moral character, especially moral virtues, moral ideals, and moral excellence. These categories
complement those in the previous chapter. The moral norms discussed in Chapter 1 chiefly govern right and
wrong action. By contrast, character ethics and virtue ethics concentrate on the agent who performs actions and
the virtues that make agents morally worthy persons.1
The goals and structure of medicine, health care, public health, and research call for a deep appreciation of moral
virtues. What often matters most in health care interactions and in the moral life generally is not adherence to
moral rules but having a reliable character, good moral sense, and appropriate emotional responsiveness. Even
carefully specified principles and rules do not convey what occurs when parents lovingly play with and nurture
their children or when physicians and nurses exhibit compassion, patience, and responsiveness in their
encounters with patients and families. The feelings and concerns for others that motivate us to take actions often
cannot be reduced to a sense of obligation to follow rules. Morality would be a cold and uninspiring practice
without appropriate sympathy, emotional responsiveness, excellence of character, and heartfelt ideals that reach
beyond principles and rules.
Some philosophers have questioned the place of virtues in moral theory. They see virtues as less central than
action-guiding norms and as difficult to unify in a systematic theory, in part because there are many independent
virtues to be considered. Utilitarian Jeremy Bentham famously complained that there is “no marshaling” the
virtues and vices because “they are susceptible of no arrangement; they are a disorderly body, whose members
are frequently in hostility with one another. … Most of them are characterized by that vagueness which is a
convenient instrument for the poetical, but dangerous or useless to the practical moralist.”2
Although principles and virtues are different and learned in different ways, virtues are no less important in the
moral life, and in some contexts are probably more important. In Chapter 9, we examine virtue ethics as a type
of moral theory and address challenges and criticisms such as Bentham’s. In the first few sections of the present
chapter, we analyze the concept of virtue; examine virtues in professional roles; treat the moral virtues of care,
caregiving, and caring in health care; and explicate five other focal virtues in both health care and research.
THE CONCEPT OF MORAL VIRTUE

A virtue is a dispositional trait of character that is socially valuable and reliably present in a person, and a moral
virtue is a dispositional trait of character that is morally valuable and reliably present. If cultures or social groups
approve a trait and regard it as moral, their approval is not sufficient to qualify the trait as a moral virtue. Moral
virtue is more than a personal, dispositional trait that is socially approved in a particular group or culture.3 This
approach to the moral virtues accords with our conclusion in Chapter 1 that the common morality excludes
provisions found only in so-called cultural moralities and individual moralities. The moral virtues, like moral
principles, are part of the common morality.
Some define the term moral virtue as a disposition to act or a habit of acting in accordance with, and with the
aim of following, moral principles, obligations, or ideals.4 For example, they understand the moral virtue of
nonmalevolence as the trait of abstaining from causing harm to others when it would be wrong to cause harm.
However, this definition unjustifiably views virtues as merely derivative from and dependent on principles and
fails to capture the importance of moral motives. We care morally about people’s motives, and we care
especially about their characteristic motives and dispositions, that is, the motivational structures embedded in
their character. Persons who are motivated through impartial sympathy and personal affection, for example, are
likely to meet our moral approval, whereas persons who act similarly, but are motivated merely by personal
ambition, do not.
Consider a person who discharges moral obligations only because they are moral requirements while intensely
disliking being obligated to place the interests of others above his or her personal interests and projects. This
person does not feel friendly toward or cherish others and respects their wishes only because moral obligation
requires it. If this person’s motive is deficient, a critical moral ingredient is missing even though he or she
consistently performs morally right actions and has a disposition to perform right actions. When a person
characteristically lacks an appropriate motivational structure, a necessary condition of virtuous character is
absent. The act may be right and the actor blameless, but neither the act nor the actor is virtuous. People may be
disposed to do what is right, intend to do it, and do it, while simultaneously yearning to avoid doing it. Persons
who characteristically perform morally right actions from such a motivational structure are not morally virtuous
even if they invariably perform the morally right action.
Such a person has a morally deficient character, and he or she performs morally right actions for reasons or
feelings disconnected from moral motivation. A philanthropist’s gift of a new wing of a hospital will be
recognized by hospital officials and by the general public as a generous gift, but if the philanthropist is
motivated only by a felt need for public praise and only makes the gift to gain such praise, there is a discordance
between those feelings and the performance of the praised action. Feelings, intentions, and motives are morally
important in a virtue theory in a way that may be lost or obscured in an obligation-based theory.5
VIRTUES IN PROFESSIONAL ROLES

Persons differ in their sets of character traits. Most individuals have some virtues and some vices while lacking
other virtues and vices. However, all persons with normal moral capacities can cultivate the character traits
centrally important to morality such as honesty, fairness, fidelity, truthfulness, and benevolence. In professional
life in health care and research, the traits that warrant encouragement and admiration often derive from role
responsibilities. Some virtues are essential for enacting these professional roles, and certain vices are intolerable
in professional life. Accordingly, we turn now to virtues that are critically important in professional and
institutional roles and practices in biomedical fields.
Virtues in Roles and Practices

Professional roles are grounded in institutional expectations and governed by established standards of
professional practice. Roles internalize conventions, customs, and procedures of teaching, nursing, doctoring,
and the like. Professional practice has traditions that require professionals to cultivate certain virtues. Standards
of virtue incorporate criteria of professional merit, and possession of these virtues disposes persons to act in
accordance with the objectives of the practices.
In the practice of medicine, several goods internal to the profession are appropriately associated with being a
good physician. These goods include specific moral and nonmoral skills in the care of patients, the application of
specific forms of knowledge, and the teaching of health behaviors. They are achievable only if one lives up to
the standards of the good physician, standards that in part define the practice. A practice is not merely a set of
technical skills. Practices should be understood in terms of the respect that practitioners have for the goods
internal to the practices. Although these practices sometimes need to be revised, the historical development of a
body of standards has established many practices now found at the heart of medicine, nursing, and public
health.6
Roles, practices, and virtues in medicine, nursing, and other health care and research professions reflect social
expectations as well as standards and ideals internal to these professions.7 The virtues we highlight in this
chapter are care—a fundamental virtue for health care relationships—along with five focal virtues found in all
health care professions: compassion, discernment, trustworthiness, integrity, and conscientiousness, all of which
support and promote caring and caregiving. Elsewhere in this chapter and in later chapters, we discuss other
virtues, including respectfulness, nonmalevolence, benevolence, justice, truthfulness, and fidelity.
To illustrate the difference between standards of moral character in a profession and standards of technical
performance in a profession, we begin with an instructive study of surgical error. Charles L. Bosk’s influential
Forgive and Remember: Managing Medical Failure presents an ethnographic study of the way two surgical
services handle medical failure, especially failures by surgical residents in “Pacific Hospital” (a name substituted
for the hospitals actually studied).8 Bosk found that both surgical services distinguish, at least implicitly,
between several different forms of error or mistake. The first form is technical: A professional discharges role
responsibilities conscientiously, but his or her technical training or information still falls short of what the task
requires. Every surgeon will occasionally make this sort of mistake. A second form of error is judgmental: A
conscientious professional develops and follows an incorrect strategy. These errors are also to be expected.
Attending surgeons forgive momentary technical and judgmental errors but remember them in case a pattern
develops indicating that a surgical resident lacks the technical and judgmental skills to be a competent surgeon.
A third form of error is normative: A physician violates a norm of conduct or fails to possess a moral skill,
particularly by failing to discharge moral obligations conscientiously or by failing to acquire and exercise critical
moral virtues such as conscientiousness. Bosk concludes that surgeons regard technical and judgmental errors as
less important than moral errors, because every conscientious person can be expected to make “honest errors” or
“good faith errors,” whereas moral errors such as failures of conscientiousness are considered profoundly serious
when a pattern indicates a defect of character.
Bosk’s study indicates that persons of high moral character acquire a reservoir of goodwill in assessments of
either the praiseworthiness or the blameworthiness of their actions. If a conscientious surgeon and another
surgeon who is not adequately conscientious make the same technical or judgmental errors, the conscientious
surgeon will not be subjected to moral blame to the same degree as the other surgeon.
Virtues in Different Professional Models

Professional virtues were historically integrated with professional obligations and ideals in codes of health care
ethics. Insisting that the medical profession’s “prime objective” is to render service to humanity, an American
Medical Association (AMA) code in effect from 1957 to 1980 urged the physician to be “upright” and “pure in
character and … diligent and conscientious in caring for the sick.” It endorsed the virtues that Hippocrates
commended: modesty, sobriety, patience, promptness, and piety. However, in contrast to its first code of 1847,
the AMA over the years has increasingly de-emphasized virtues in its codes. The 1980 version for the first time
eliminated all trace of the virtues except for the admonition to expose “those physicians deficient in character or
competence.” This pattern of de-emphasis regrettably still continues.
Thomas Percival’s 1803 book, Medical Ethics, is a classic example of an attempt to establish the proper set of
virtues in medicine. Starting from the assumption that the patient’s best medical interest is the proper goal of
medicine, Percival reached conclusions about the good physician’s traits of character, which were primarily tied
to responsibility for the patient’s medical welfare.9 This model of medical ethics supported medical paternalism
with effectively no attention paid to respect for patients’ autonomous choices.
In traditional nursing, where the nurse was often viewed as the “handmaiden” of the physician, the nurse was
counseled to cultivate the passive virtues of obedience and submission. In contemporary models in nursing, by
contrast, active virtues have become more prominent. For example, the nurse’s role is now often regarded as one
of advocacy for patients.10 Prominent virtues include respectfulness, considerateness, justice, persistence, and
courage.11 Attention to patients’ rights and preservation of the nurse’s integrity also have become increasingly
prominent in some contemporary models.
The conditions under which ordinarily praiseworthy virtues become morally unworthy present thorny ethical
issues. Virtues such as loyalty, courage, generosity, kindness, respectfulness, and benevolence at times lead
persons to act inappropriately and unacceptably. For instance, the physician or nurse who acts kindly and loyally
by not reporting the incompetence of a fellow physician or nurse acts unethically. This failure to report
misconduct does not suggest that loyalty and kindness are not virtues. It indicates only that the virtues need to be
accompanied by an understanding of what is right and good and of what deserves loyalty, kindness, generosity,
and the like.
THE CENTRAL VIRTUE OF CARING

As the language of health care, medical care, and nursing care suggests, the virtue of care, or caring, is
prominent in professional ethics. We treat this virtue as fundamental in relationships, practices, and actions in
health care. In explicating this family of virtues we draw on what has been called the ethics of care, which we
interpret as a form of virtue ethics.12 The ethics of care emphasizes traits valued in intimate personal
relationships such as sympathy, compassion, fidelity, and love. Caring refers to care for, emotional commitment
to, and willingness to act on behalf of persons with whom one has a significant relationship. Caring for is
expressed in actions of “caregiving,” “taking care of,” and “due care.” The nurse’s or physician’s trustworthiness
and quality of care and sensitivity in the face of patients’ problems, needs, and vulnerabilities are integral to
their professional moral lives.
The ethics of care emphasizes what physicians and nurses do—for example, whether they break or maintain
confidentiality—and how they perform those actions, which motives and feelings underlie them, and whether
their actions promote or thwart positive relationships.
The Origins of the Ethics of Care

The ethics of care, understood as a form of philosophical ethics, originated and continues to flourish in feminist
writings. The earliest works emphasized how women display an ethic of care, by contrast to men, who
predominantly exhibit an ethic of rights and obligations. Psychologist Carol Gilligan advanced the influential
hypothesis that “women speak in a different voice”—a voice that traditional ethical theory failed to appreciate.
She discovered “the voice of care” through empirical research involving interviews with girls and women. This
voice, she maintained, stresses empathic association with others, not based on “the primacy and universality of
individual rights, but rather on … a very strong sense of being responsible.”13
Gilligan identified two modes of moral thinking: an ethic of care and an ethic of rights and justice. She did not
claim that these two modes of thinking strictly correlate with gender or that all women or all men speak in the
same moral voice.14 She maintained only that men tend to embrace an ethic of rights and justice that uses quasi-
legal terminology and impartial principles, accompanied by dispassionate balancing and conflict resolution,
whereas women tend to affirm an ethic of care that centers on responsiveness in an interconnected network of
needs, care, and prevention of harm.15
Criticisms of Traditional Theories by Proponents of an Ethics of Care
Proponents of the care perspective often criticize traditional ethical theories that tend to de-emphasize virtues of
caring. Two criticisms merit consideration here.16
Challenging impartiality. Some proponents of the care perspective argue that theories of obligation unduly
telescope morality by overemphasizing detached fairness. This orientation is suitable for some moral
relationships, especially those in which persons interact as equals in a public context of impersonal justice and
institutional constraints, but moral detachment also may reflect a lack of caring responsiveness. In the extreme
case, detachment becomes uncaring indifference. Lost in the detachment of impartiality is an attachment to what
we care about most and is closest to us—for example, our loyalty to family, friends, and groups. Here partiality
toward others is morally permissible and is an expected form of interaction. This kind of partiality is a feature of
the human condition without which we might impair or sever our most important relationships.17
Proponents of a care ethics do not recommend complete abandonment of principles if principles are understood
to allow room for discretionary and contextual judgment. However, some defenders of the ethics of care find
principles largely irrelevant, ineffectual, or unduly constrictive in the moral life. A defender of principles could
hold that principles of care, compassion, and kindness tutor our responses in caring, compassionate, and kind
ways. But this attempt to rescue principles seems rather empty. Moral experience confirms that we often do rely
on our emotions, capacity for sympathy, sense of friendship, and sensitivity to find appropriate moral responses.
We could produce rough generalizations about how caring clinicians should respond to patients, but such
generalizations cannot provide adequate guidance for all interactions. Each situation calls for responses beyond
following rules, and actions that are caring in one context may be offensive or even harmful in another.
Relationships and emotion. The ethics of care places special emphasis on mutual interdependence and
emotional responsiveness. Many human relationships in health care and research involve persons who are
vulnerable, dependent, ill, and frail. Feeling for and being immersed in the other person are vital aspects of a
moral relationship with them.18 A person seems morally deficient if he or she acts according to norms of
obligation without appropriately aligned feelings, such as concern and sympathy for a patient who is suffering.
Good health care often involves insight into the needs of patients and considerate attentiveness to their
circumstances.19
In the history of human experimentation, those who first recognized that some subjects of research were
brutalized, subjected to misery, or placed at unjustifiable risk were persons able to feel sympathy, compassion,
disgust, and outrage about the situation of these research subjects. They exhibited perception of and sensitivity
to the feelings of subjects where others lacked comparable perceptions, sensitivities, and responses. This
emotional sensitivity does not reduce moral response to emotional response. Caring has a cognitive dimension
and requires a range of moral skills that involve insight into and understanding of another’s circumstances,
needs, and feelings.
One proponent of the ethics of care argues that action is sometimes appropriately principle-guided, but not
necessarily always governed by or derived from principles.20 This statement moves in the right direction for
construction of a comprehensive moral framework. We need not reject principles of obligation in favor of virtues
of caring, but moral judgment involves moral skills beyond those of specifying and balancing general principles.
An ethic that emphasizes the virtues of caring well serves health care because it is close to the relationships and
processes of decision making found in clinical contexts, and it provides insights into basic commitments of
caring and caretaking. It also liberates health professionals from the narrow conceptions of role responsibilities
that have been delineated in some professional codes of ethics.
FIVE FOCAL VIRTUES

We now turn to five focal virtues for health professionals: compassion, discernment, trustworthiness, integrity,
and conscientiousness. These virtues are important for the development and expression of caring, which we have
presented as a fundamental orienting virtue in health care. These five additional virtues provide a moral compass
of character for health professionals that builds on centuries of thought about health care ethics.21
Compassion
Compassion, says Edmund Pellegrino, is a “prelude to caring.”22 The virtue of compassion combines an attitude
of active regard for another’s welfare together with sympathy, tenderness, and discomfort at another’s
misfortune or suffering.23 Compassion presupposes sympathy, has affinities with mercy, and is expressed in acts
of beneficence that attempt to alleviate the misfortune or suffering of another person.
Nurses and physicians must understand the feelings and experiences of patients to respond appropriately to them
and their illnesses and injuries—hence the importance of empathy, which involves sensing or even
reconstructing another person’s mental experience, whether that experience is negative or positive.24 As
important as empathy is for compassion and other virtues, the two are different, and empathy does not always
lead to compassion. Some literature on professionalism in medicine and health care now focuses on empathy
rather than compassion, but this literature risks making the mistake of viewing empathy alone as sufficient for
humanizing medicine and health care while overlooking its potential dangers.25
Compassion generally focuses on others’ pain, suffering, disability, or misery—the typical occasions for
compassionate response in health care. Using the language of sympathy, eighteenth-century philosopher David
Hume pointed to a typical circumstance of compassion in surgery and explained how such feelings arise:
Were I present at any of the more terrible operations of surgery, ‘tis certain, that even before it
begun, the preparation of the instruments, the laying of the bandages in order, the heating of the
irons, with all the signs of anxiety and concern in the patient and assistants, wou’d have a great
effect upon my mind, and excite the strongest sentiments of pity and terror. No passion of another
discovers itself immediately to the mind. We are only sensible of its causes or effects. From these
we infer the passion: And consequently these give rise to our sympathy.26
Physicians and nurses who express little or no compassion in their behavior may fail to provide what patients
need most. The physician, nurse, or social worker altogether lacking in the appropriate display of compassion
has a moral weakness. However, compassion also can cloud judgment and preclude rational and effective
responses. In one reported case, a long-alienated son wanted to continue a futile and painful treatment for his
near-comatose father in an intensive care unit (ICU) to have time to “make his peace” with his father. Although
the son understood that his alienated father had no cognitive capacity, the son wanted to work through his sense
of regret and say a proper good-bye. Some hospital staff argued that the patient’s grim prognosis and pain,
combined with the needs of others waiting to receive care in the ICU, justified stopping the treatment, as had
been requested by the patient’s close cousin and informal guardian. Another group in the unit regarded continued
treatment as an appropriate act of compassion toward the son, who they thought should have time to express his
farewells and regrets to make himself feel better about his father’s death. The first group, by contrast, viewed
this expression of compassion as misplaced because of the patient’s prolonged agony and dying. In effect, those
in the first group believed that the second group’s compassion prevented clear thinking about primary
obligations to this patient.27
Numerous writers in the history of ethical theory have proposed a cautious approach to compassion. They argue
that a passionate, or even a compassionate, engagement with others can blind reason and prevent impartial
reflection. Health care professionals understand and appreciate this phenomenon. Constant contact with
suffering can overwhelm and even paralyze a compassionate physician or nurse. Impartial judgment sometimes
gives way to impassioned decisions, and emotional burnout can arise. To counteract this problem, medical
education and nursing education are well designed when they inculcate detachment alongside compassion. The
language of detached concern and compassionate detachment came to the fore in this context.
Discernment
The virtue of discernment brings sensitive insight, astute judgment, and understanding to bear on action.
Discernment involves the ability to make fitting judgments and reach decisions without being unduly influenced
by extraneous considerations, fears, personal attachments, and the like. Some writers closely associate
discernment with practical wisdom, or phronesis, to use Aristotle’s widely used term. A person of practical
wisdom knows which ends to choose, knows how to realize them in particular circumstances, and carefully
selects from among the range of possible actions, while keeping emotions within proper bounds. In Aristotle’s
model, the practically wise person understands how to act with the right intensity of feeling, in just the right
way, at just the right time, with a proper balance of reason and desire.28
A discerning person is disposed to understand and perceive what circumstances demand in the way of human
responsiveness. For example, a discerning physician will see when a despairing patient needs comfort rather
than privacy, and vice versa. If comfort is the right choice, the discerning physician will find the right type and
level of consolation to be helpful rather than intrusive. If a rule guides action in a particular case, seeing how to
best follow the rule involves a form of discernment that is independent of seeing that the rule applies.
Accordingly, the virtue of discernment involves understanding both that and how principles and rules apply.
Acts of respect for autonomy and beneficence therefore will vary in health care contexts, and the ways in which
clinicians discerningly implement these principles in the care of patients will be as different as the many ways in
which devoted parents care for their children.
Trustworthiness
Virtues, Annette Baier maintains, “are personal traits that contribute to a good climate of trust between people,
when trust is taken to be acceptance of being, to some degree and in some respects, in another’s power.”29 Trust
is a confident belief in and reliance on the moral character and competence of another person, often a person
with whom one has an intimate or established relationship. Trust entails a confidence that another will reliably
act with the right motives and feelings and in accordance with appropriate moral norms.30 To be trustworthy is
to warrant another’s confidence in one’s character and conduct.
Traditional ethical theories rarely mention either trust or trustworthiness. However, Aristotle took note of one
important aspect of trust and trustworthiness. He maintained that when relationships are voluntary and among
intimates, by contrast to legal relationships among strangers, it is appropriate for the law to forbid lawsuits for
harms that occur. Aristotle reasoned that intimate relationships involving “dealings with one another as good and
trustworthy” hold persons together more than “bonds of justice” do.31
Nothing is more valuable in health care organizations and contexts than the maintenance of a culture of trust.
Trust and trustworthiness are essential when patients are vulnerable and place their hope and their confidence in
health care professionals. A true climate of trust is endangered in contemporary health care institutions, as
evidenced by the number of medical malpractice suits and adversarial relations between health care
professionals and the public. Overt distrust has been engendered by mechanisms of managed care, because of
the incentives some health care organizations create for physicians to limit the amount and kinds of care they
provide to patients. Appeals have increased for ombudsmen, patient advocates, legally binding “directives” to
physicians, and the like. Among the contributing causes of the erosion of a climate of trust are the loss of
intimate contact between physicians and patients, the increased use of specialists, the lack of adequate access to
adequate health care insurance, and the growth of large, impersonal, and bureaucratic medical institutions.32
Integrity
Some writers in bioethics hold that the primary virtue in health care is integrity.33 People often justify their
actions or refusals to act on grounds that they would otherwise compromise or sacrifice their integrity. Later in
this chapter we discuss appeals to integrity as invocations of conscience, but we confine attention at present to
the virtue of integrity.
The central place of integrity in the moral life is beyond dispute, but what the term means is less clear. In its
most general sense, “moral integrity” means soundness, reliability, wholeness, and integration of moral
character. In a more restricted sense, the term refers to objectivity, impartiality, and fidelity in adherence to
moral norms. Accordingly, the virtue of integrity represents two aspects of a person’s character. The first is a
coherent integration of aspects of the self—emotions, aspirations, knowledge, and the like—so that each
complements and does not frustrate the others. The second is the character trait of being faithful to moral values
and standing up in their defense when necessary. A person can lack moral integrity in several respects—for
example, through hypocrisy, insincerity, bad faith, and self-deception. These vices represent breaks in the
connections among a person’s moral convictions, emotions, and actions. The most common deficiency is
probably a lack of sincerely and firmly held moral convictions, but no less important is the failure to act
consistently on the moral beliefs that one does hold.
Problems in maintaining integrity may also arise from a conflict of moral norms, or from moral demands that
require persons to halt or abandon personal goals and projects. Persons may experience a sense of loss of their
autonomy and feel violated by the demand to sacrifice their personal commitments and objectives.34 For
example, if a nurse is the only person in her family who can properly manage her mother’s health, health care,
prescription medications, nursing home arrangements, explanations to relatives, and negotiations with
physicians, little time may be left for her personal projects and commitments. Such situations can deprive
persons of the liberty to structure and integrate their lives as they choose. If a person has structured his or her life
around personal goals that are ripped away by the needs and agendas of others, a loss of personal integrity
occurs.
Problems of professional integrity often center on wrongful conduct in professional life. When breaches of
professional integrity involve violations of professional standards, they are viewed as violations of the rules of
professional associations, codes of medical ethics, or medical traditions,35 but this vision of integrity needs to be
broadened. Breaches of professional integrity also occur when a physician prescribes a drug that is no longer
recommended for the outcome needed, enters into a sexual relationship with a patient, or follows a living will
that calls for a medically inappropriate intervention.
Sometimes conflicts arise between a person’s sense of moral integrity and what is required for professional
integrity. Consider medical practitioners who, because of their religious commitments to the sanctity of life, find
it difficult to participate in decisions not to do everything possible to prolong life. To them, participating in
removing ventilators and intravenous fluids from patients, even from patients with a clear advance directive,
violates their moral integrity. Their commitments may create morally troublesome situations in which they must
either compromise their fundamental commitments or withdraw from the care of the patient. Yet compromise
seems what a person, or an organization, of integrity cannot do, because it involves the sacrifice of deep moral
commitments.36
Health care facilities cannot entirely eliminate these and similar problems of staff disagreement and conflicting
commitments, but persons with the virtues of patience, humility, and tolerance can help reduce the problems.
Situations that compromise integrity can be ameliorated if participants anticipate the problem before it arises and
recognize the limits and fallibility of their personal moral views. Participants in a dispute may also have recourse
to consultative institutional processes, such as hospital ethics committees. However, it would be ill-advised to
recommend that a person of integrity can and should always negotiate and compromise his or her values in an
intrainstitutional confrontation. There is something ennobling and admirable about the person or organization
that refuses to compromise beyond a certain carefully considered moral threshold. To compromise below the
threshold of integrity is simply to lose it.
Conscientiousness
The subject of integrity and compromise leads directly to a discussion of the virtue of conscientiousness and
accounts of conscience. An individual acts conscientiously if he or she is motivated to do what is right because it
is right, has worked with due diligence to determine what is right, intends to do what is right, and exerts
appropriate effort to do so. Conscientiousness is the character trait of acting in this way.
Conscience and conscientiousness. Conscience has often been viewed as a mental faculty of, and authority for,
moral decision making.37 Slogans such as “Let your conscience be your guide” suggest that conscience is the
final authority in moral justification. However, such a view fails to capture the nature of either conscience or
conscientiousness, as the following case presented by Bernard Williams helps us see: Having recently completed
his PhD in chemistry, George has not been able to find a job. His family has suffered from his failure. They are
short of money, his wife has had to take additional work, and their small children have been subjected to
considerable strain, uncertainty, and instability. An established chemist can get George a position in a laboratory
that pursues research on chemical and biological weapons. Despite his perilous financial and familial
circumstances, George concludes that he cannot accept this position because of his conscientious opposition to
chemical and biological warfare. The senior chemist notes that the research will continue no matter what George
decides. Furthermore, if George does not take this position, it will be offered to another young man who would
vigorously pursue the research. Indeed, the senior chemist confides, his concern about the other candidate’s
nationalistic fervor and uncritical zeal for research in chemical and biological warfare motivated him to
recommend George for the job. George’s wife is puzzled and hurt by George’s reaction. She sees nothing wrong
with the research. She is profoundly concerned about their children’s problems and the instability of their family.
Nonetheless, George forgoes this opportunity both to help his family and to prevent a destructive fanatic from
obtaining the position. He says his conscience stands in the way.38
Conscience, as this example suggests, is neither a special moral faculty nor a self-justifying moral authority. It is
a form of self-reflection about whether one’s acts are obligatory or prohibited, right or wrong, good or bad,
virtuous or vicious. It involves an internal sanction that comes into play through critical reflection. When
individuals recognize their acts as violations of an appropriate standard, this sanction often appears as a bad
conscience in the form of feelings of remorse, guilt, shame, disunity, or disharmony. A conscience that sanctions
conduct in this way does not signify bad moral character. To the contrary, this experience of conscience is most
likely to occur in persons of strong moral character and may even be a necessary condition of morally good
character.39 Kidney donors have been known to say, “I had to do it. I couldn’t have backed out, not that I had the
feeling of being trapped, because the doctors offered to get me out. I just had to do it.”40 Such judgments derive
from ethical standards that are sufficiently powerful that violating them would diminish integrity and result in
guilt or shame.41
When people claim that their actions are conscientious, they sometimes feel compelled by conscience to resist
others’ authoritative demands. Instructive examples are found in military physicians who believe they must
answer first to their consciences and cannot plead “superior orders” when commanded by a superior officer to
commit what they believe to be a moral wrong. Agents sometimes act out of character in order to perform what
they judge to be the morally appropriate action. For example, a normally cooperative and agreeable physician
may indignantly, but justifiably, protest an insurance company’s decision not to cover the costs of a patient’s
treatment. Such moral indignation and outrage can be appropriate and admirable.
Conscientious refusals. Conscientious objections and refusals by physicians, nurses, pharmacists, and other
health care professionals raise difficult issues for public policy, professional organizations, and health care
institutions. Examples are found in a physician’s refusal to honor a patient’s legally valid advance directive to
withdraw artificial nutrition and hydration, a nurse’s refusal to participate in an abortion or sterilization
procedure, and a pharmacist’s refusal to fill a prescription for an emergency contraception. There are good
reasons to promote conscientiousness and to respect such acts of conscience in many, though not all, cases.
Respecting conscientious refusals in health care is an important value, and these refusals should be
accommodated unless there are overriding conflicting values. Banning or greatly restricting conscientious
refusals in health care could have several negative consequences. It could, according to one analysis, negatively
affect the type of people who choose medicine as their vocation and how practicing physicians view and
discharge professional responsibilities. It could also foster “callousness” and encourage physicians’
“intolerance” of diverse moral beliefs among their patients (and perhaps among their colleagues as well).42
These possible negative effects are somewhat speculative, but they merit consideration in forming institutional
and public policies.
Also meriting consideration is that some conscientious refusals adversely affect patients’ and others’ legitimate
interests in (1) timely access, (2) safe and effective care, (3) respectful care, (4) nondiscriminatory treatment, (5)
care that is not unduly burdensome, and (6) privacy and confidentiality. Hence, public policy, professional
associations, and health care institutions should seek to recognize and accommodate conscientious refusals as
long as they can do so without seriously compromising patients’ rights and interests. The metaphor of balancing
professionals’ and patients’ rights and interests is commonly used to guide efforts to resolve such conflicts, but it
offers only limited guidance and no single model of appropriate response covers all cases.43
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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(eBook PDF) Principles of Biomedical

Ethics 8th Edition

Principles of Biomedical Ethics

The Nature of Particular Moralities

Professional and Public Moralities

The Regulation and Oversight of Professional Conduct

A FRAMEWORK OF MORAL PRINCIPLES

CONFLICTING MORAL NORMS

Moral Regret and Residual Obligation

Specifying Principles and Rules

Weighing and Balancing

DR. QUILL: No, that’s not so.

PATIENT: Yes they will, ’cause I feel that way …

DR. QUILL: There is a future for you …

DR. QUILL: We’ve got to think about a couple of things.

Moral Diversity and Moral Disagreement

THE CONCEPT OF MORAL VIRTUE

VIRTUES IN PROFESSIONAL ROLES

Virtues in Roles and Practices

Virtues in Different Professional Models

THE CENTRAL VIRTUE OF CARING

The Origins of the Ethics of Care

Criticisms of Traditional Theories by Proponents of an Ethics of Care

FIVE FOCAL VIRTUES

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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