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Logo of jmedethJournal of Medical EthicsCurrent TOCInstructions to authors
J Med Ethics. Apr 2006; 32(4): 200–204.
PMCID: PMC2565782

In defence of moral imperialism: four equal and universal prima facie principles


Raanan Gillon is a noted defender of the four principles approach to healthcare ethics. His general position has always been that these principles are to be considered to be both universal and prima facie in nature. In recent work, however, he has made two claims that seem to present difficulties for this view. His first claim is that one of these four principles, respect for autonomy, has a special position in relation to the others: he holds that it is first among equals. We argue that this claim makes little sense if the principles are to retain their prima facie nature. His second claim is that cultural variation can play an independent normative role in the construction of our moral judgments. This, he argues, enables us to occupy a middle ground between what he sees as the twin pitfalls of moral relativism and (what he calls) moral imperialism. We argue that there is no such middle ground, and while Gillon ultimately seems committed to relativism, it is some form of moral imperialism (in the form of moral objectivism) that will provide the only satisfactory construal of the four principles as prima facie universal moral principles.

Keywords: four principles, autonomy, Gillon, moral objectivity, tolerance

In his paper, Ethics needs principles,1 Raanan Gillon (a noted subscriber to the four principles approach to healthcare ethics) makes two distinctive claims. Firstly, he argues in favour of a special role in healthcare ethics for the principle of respect for autonomy. In his view, each of the four principles is to be understood as a prima facie moral principle—that is, in a given case, which one we should actually conform to will depend on the details of that case, on the interplay of forces exerted by each of the moral principles applying to the case; nonetheless, respect for autonomy has a special position in this moral domain: it is first among equals.

Secondly, Gillon claims that this position in normative ethics will support a desirable view in meta‐ethics, one which avoids the twin pitfalls (as he sees it) of moral relativism and moral imperialism. He thinks on the one hand that the universality of the four principles approach precludes moral relativism, and on the other hand that the (allegedly) privileged position of respect for autonomy will enable, and indeed require, us to respect both individual and cultural moral variability, since such variability will affect people's autonomous beliefs, including their moral stances. Thus we will avoid an undesirable (as he sees it) commitment to moral imperialism.

This latter claim about the relationship between respect for autonomy and cultural variability, even if correct, may have considerably less scope than Gillon appears to think, since respect for autonomy does not seem to require us to respect cultural variations that undermine autonomy—for example, the oppression of women or minorities; lack of freedom of speech, and so forth. But these are, however, just the kind of variations about which people disagree very strongly, and which those who wish to avoid (so called) moral imperialism would want us to refrain from judging. But there are greater problems than that one with the meta‐ethical position he wants to endorse. We shall address those issues in the second part of our paper; first, however, we shall focus on his overall claim, that respect for autonomy is first among equals in the field of moral principles.

1. First among equals?

Gillon gives us two main reasons for thinking that respect for autonomy should have a privileged position among the other moral principles: (1) autonomy—that is, deliberated self rule—is morally precious, since without it there would be no morality, and (2) the other principles—beneficence, non‐maleficence, and justice—all require us to respect autonomy anyway. Hence respect for autonomy is more important than the other principles.

Neither of these arguments seems to us to be very convincing. Perhaps it is true that without autonomy there would be no morality. But our capacity for suffering is also very important, morally speaking, and without it morality, if it still existed, would be unrecognisably different. Indeed this thought may be what has given weight to the traditional claim that non‐maleficence is the most important moral principle: “Above all, do no harm”. We do not want to support the view that non‐maleficence is really the principle that comes first in the rank order, since we do not want to support the view that any principle comes first in the rank order. But if there were to be a first principle, it is not clear that the claims of respect for autonomy would outrank those of non‐maleficence.

Secondly, the claim that the other principles require us to respect autonomy is insufficient to show that respect for autonomy is first among equals. For a start, this claim might suggest that the reason we should respect autonomy is that this will promote beneficence, non‐maleficence, and justice; but that would tend to show that the other principles are more important, rather than less, as Gillon suggests. But also, it can plausibly be argued that in order to respect autonomy we must treat others justly, since otherwise we should be legitimised in respecting the autonomy of one person at the expense of respecting the autonomy of others. And the same is true with respect to beneficence and non‐maleficence. If so, that would suggest that justice, rather than respect for autonomy, should come first. And it is not clear, to say the least, how we should adjudicate between the claims of these two principles.

So Gillon's positive arguments are not as they stand very convincing. However, the difficulties with his first among equals view go much deeper than that. It is these deeper problems that we want to concentrate on.

There is general agreement that the four principles approach to healthcare ethics is a broadly Rossian one2—that is, each principle is to be thought of as a prima facie one, which indicates that the feature specified in the principle is a right making (or wrong making) feature of any act that possesses it. Whether an act possessing that feature is actually right (or wrong) will depend on the presence or otherwise of other right making (or wrong making) features. So there is no telling in advance that principle will be most important, since case by case it will depend on the array of morally significant features present there, which will of course vary from situation to situation. That is how prima facie principles are generally thought to work. (It might be argued that the four principles could be given a rule consequentialist construal, and hence need not be seen as part of the Rossian moral apparatus.3 But even on that construal, the problem of conflict between principles would still arise, and the difficulties that we mention below would still apply.) Against this background of principles interacting in ways peculiar to each particular situation, what sense are we to make of the idea of “first among equals”?

Here are some possible construals of that idea:

The principle that is first among equals:

a) always wins out in a conflict between two or more moral principles;


b) sometimes wins out in a conflict between two or more moral principles;


c) is an underpinning principle, in the sense that the other principles are in some way derived from it;


d) is an overarching principle, in the sense that it provides a goal such that conformity to the other principles is required because it will contribute to realising that goal.

On any of these construals, does the claim that respect for autonomy is first among equals come out looking at all plausible?

Perhaps the claim is to be understood as asserting that respect for autonomy always wins in situations of conflict with other principles, so that if we have to choose between respecting someone's autonomy and doing them some good, or treating others justly, then we should always go for respecting autonomy. But there are two things wrong with this claim: firstly, it is obviously false (resource allocation problems in health care cannot and should not be handled this way); and secondly, it would not be a case of first among equals. Any principle that always trumped the others would be first simpliciter, and the other principles would be not equal but subordinate.

Suppose we construe Gillon's claim as meaning that the principle of respect for autonomy sometimes wins out in a conflict with other principles. Would this make it first among equals? Just to raise this question is to answer it: obviously not. If respect for autonomy sometimes wins out, then other principles also sometimes wins out. So far, they are on an equal footing, and there is no reason given by this construal to privilege one of them.

Is it plausible to claim that respect for autonomy is a principle that underpins the other three, in the sense that they are derived from it? It is very hard indeed to see how the principle of non‐maleficence, say, can be derived from the principle of respect for autonomy, in the teeth of examples of agents autonomously choosing to do things that harm themselves (and there are also plenty of examples of autonomous choices to treat others unjustly, or to avoid that which is good for the agent). Sometimes people make harmful choices for shortsighted reasons, sometimes they make them for altruistic reasons. Either way, it does not look as if the principle of non‐maleficence, which seems to apply to these cases, is really a derivative of the principle of respect for autonomy; it looks much more as if these principles are genuinely in tension here. Perhaps on a Kantian construal of autonomy the derivation might go through. However, the kind of autonomy which demands our respect in the healthcare context is not Kantian autonomy, and that is just as well, since if we held out for Kantian autonomy then there would be remarkably few demands on our respect, since most reflective choices do not live up to the requirements of pure practical reason.4 The upshot of going down the Kantian road in healthcare ethics would be a sharp diminution of the role played in decision making by respect for autonomy, and it seems very unlikely that that is what Gillon is arguing for.

Finally, should we think of respect for autonomy, or perhaps autonomy itself, as providing an overarching goal, such that we ought to conform to the other three principles because doing so will contribute to the realisation of that goal? We think that this is not a persuasive claim. As a general point, deliberated self rule cannot be the only goal which we have, or should be aiming at. If we are to deliberate about what choices to make, and make our choices for ourselves, free from controlling influences, then there must be other things we legitimately want than just the freedom to decide for ourselves. There must be some substantive content to our choices other than just the exercise of our capacity to choose, since without such content—that is, reasons to act—our choices become vacuous. And why should we suppose that we ought to do others good, and refrain from harming them, and treat them justly, purely in order to foster their (or our) autonomy, their (or our) capacity to deliberate and choose, and their (or our) exercise of that capacity? The onus is on the one who claims that this is indeed the role of the other principles to explain how this is supposed to work, and why we should accept this claim, particularly since it seems equally possible to claim that the overarching principle is beneficence, and that the role of the other principles, including respect for autonomy, is to contribute to the realisation of the goal of beneficence, the maximum available good for others. (Indeed Gillon himself says that in the case of proposed compulsory medical treatment, he would regard respect for autonomy as trumping non‐maleficence, because a social system which permits compulsory medical treatment, even for the patient's own sake, would do far more harm than good.) It is not at all clear how we could adjudicate between these competing claims about which principle is to play this putatively overarching role.

In any case, there is no reason, within a general theory of prima facie duties and principles, to believe that any moral principle at all comes first, whether “among equals” or straightforwardly by itself. Part of the point of such a theory is to escape the straitjacket of moral absolutism and its demand that we regard some principles as exceptionless. The irresolvable conflicts of duty that such views of morality tend to generate, and the counterintuitive substantive judgments they force on us, are exactly what give the idea of prima facie duties its attraction. If we allow the existence of a First Principle we run the risk of resurrecting just those problems we sought to escape from by turning to the idea of prima facie duties. We should do better to acknowledge the importance of respect for autonomy, remind ourselves of the importance of the other principles too, and accept that there is no way of saying, at the theoretical level, which principle matters most. We cannot escape the need for particular judgments, case by case, at the particular level. The idea of prima facie principles introduces some structure into our moral deliberations, but it is quite possible that that is all the structure there is to be found in the domain of substantive moral issues. The rest is irreducibly a matter of judgment—here is where principles, and rules ordering them, run out.

2. The middle ground

We turn now to Gillon's second claim, that the four principles occupy a middle ground between moral relativism and (what he sees as) moral imperialism, and that this middle ground is a desirable place to inhabit.

Gillon believes that the four principles provide a clear route between what he sees as the twin dangers of moral relativism and moral imperialism. He defines moral relativism as “any ethics will do” and moral imperialism as a belief that there is “one and only one way of doing ethics” (Gillon, 1 p 309). But these definitions are not the standard ones, nor do they offer any advance in clarity or precision over more customary accounts. Moral relativism as standardly defined is not a view committed to “anything will do”; rather it is the view that moral claims are to be assessed internally, within the moral framework or perspective of a particular group, society, or culture. On this account, to be a participant in a society's morality requires the adoption of that society's moral framework. Relativism does not imply that “anything goes” in morality: moral relativists can easily justify the use of concepts such as “transgression” of moral rules, and practices such as punishment for those transgressions. A commitment to “anything goes” looks more like moral nihilism than moral relativism, and nihilism is, for well rehearsed reasons, a very unattractive position, and hence not one whose temptations we are likely to succumb to.

Moral imperialism, on the other hand, is not a standard ethical term at all. While its use here is clearly pejorative, it is not clear just what Gillon means by this charge. What is the commitment we are supposed to avoid? Objectivism? Realism? Cognitivism? Gillon does not specify his target for criticism; however, given his concern about views, which assume that there is only one way of doing ethics, it looks as though he may have moral objectivism in mind. In fact there are problems with supposing that objectivism (or realism or cognitivism, for that matter) is truly committed to the view that there is only one way of doing ethics. Teasing out the various possibilities and implications here would, however, take us too far away from Gillon's central concerns, and so for the purposes of this paper we will take Gillon's “twin dangers” to be relativism and objectivism (and we shall assume that the meanings of these two terms are reasonably clear).

Gillon claims that we should abjure both relativism and moral imperialism, and that we should seek, and can find, a middle way. We will argue, however, as follows:

(a) that Gillon is in fact committed to some form of moral relativism;

(b) that any plausible form of the four principles should in fact be committed to “moral imperialism”;

(c) that Gillon (and the rest of us) must decide which way to jump when faced by his putative two dangers, as there is no middle ground.

(a) Gillon's implicit relativism

In Gillon's account of the application of the four principles in different contexts, the idea of cultural differences plays a central role. But the only way in which this role, as he describes it, makes sense is within a moral relativistic framework.

Gillon's view is that one advantage of the four principles approach is that it allows a diverse range of responses to ethical issues by ensuring that different cultures can make diverse judgments about which principles take priority. His key example is that of the apparent priority given to autonomy in Western cultures versus its relative demotion in the use of the principles in Chinese culture. In other words, according to Gillon, different judgments are made in different cultures because those cultures choose to rank the principles in different ways. No doubt there is truth in this claim if it is treated as a descriptive one in the sociology of ethics. Gillon, however, needs it to be a normative claim, since he makes this point as a way of showing us the genuine ethical resources of the four principles approach. But as a normative claim it involves an implicit commitment to moral relativism, since it holds that culture plays an independent role in ranking moral principles prior to the making of particular judgments in particular circumstances. On this view, it is hard to see how the principles can be seen as being either universal or prima facie in nature.

The core of the problem here is that there are two broad ways in which differences in culture can be thought to lead to differences in moral judgment. One is the relativist way: since moral judgments (putatively) get their legitimacy from a culture's beliefs about morality, if we change to a different culture with different beliefs about morality we should expect different moral judgments to be legitimate. Gillon, given his China example, seems committed to such a view. However, the other way is the contextualist way: the non‐evaluative facts of the matter are likely to be different in different cultures—for example, different things will make people happy or sad; different economic systems will mean that the same action may have quite different consequences. Since moral properties are dependent on non‐moral ones, we can reasonably expect that significant changes to the non‐moral features of a situation, such as we might expect when we move from one culture to another, will lead to differences in the moral features of the situation.

This contextualist view does not involve any concessions to ethical relativism; this is in part because it allows for the retention of the idea that the four principles are universal in nature. On this approach responses might well differ between China and the UK. However, any such variation is the result of differences in the salient features of the situation that are relevant to the judgments in the two cases. Cultural facts will therefore play an indirect role in our judgments by allowing the principles to be combined in different ways because the situations are different: there is variation in the relevant non‐moral facts. Ranking of the principles at the level of culture plays no role; the fact (where it is a fact) that people in a given culture give priority to one principle rather than another does not by itself have any direct normative force.

Our suspicion that Gillon must be committed to the relativist treatment of cultural difference (rather than to the contextualist one) is supported by what he says about how the four principles are supposed to help to avoid moral imperialism. For example, he writes that the claim of moral imperialism is combated by:

the prima facie nature of the principles, along with morally legitimate difference in their interpretation, in their prioritisation in particular circumstances, and in decision making about their proper scope of application, as well as a principle that positively encourages respect for people's own deliberated thoughts for themselves… (Gillon,1 p 309) [our italics].

Although, on the account of prima facie moral principles given above, we can see how there will be different priorities to the ordering of the principles according to the situation, we need to ask what might count for Gillon as “morally legitimate difference[s] in their interpretation”. If judgments are to be made in response to the circumstances of particular situations why should there be room, or need, for any further “difference in interpretation”? Why think any two individuals that disagree on a response do so as a result of “morally legitimate” differences rather than, say, lack of clarity of vision, bias, ignorance etc—features quite common enough to account for any amount of moral disagreement? Surely if the non‐moral facts remain identical a correct judgment by two or more individuals of the moral facts must produce agreement? The only reason we might have for providing a negative answer to this question is a prior commitment to moral relativism.

Gillon also states that:

the actual use made of the four principles approach can legitimately vary from person to person, culture to culture (Gillon, 1 p 310).

Again the only plausible assumption here is that Gillon is leaving open a role for moral relativist (and even subjectivist) thoughts. (He seems to treat cultural disagreement and disagreement between individuals as parallel cases. But there are significant differences here that bear on the logic of the arguments.) Even if, as he claims, he does not want to embrace relativism, this is the position he is forced to adopt if he wishes to “respect” such disagreements. It looks as though Gillon thinks that the threat of moral imperialism forces him to accept moral relativism. As we shall see, however, this is a mistake.

(b) In defence of moral imperialism

Gillon suggests that the four principles express something about universal morality, but he does not want such a claim to commit him to “moral imperialism”. In this section we argue that if (as he claims) the principles are universal, then he is committed to moral imperialism and that, given his acceptance of the four principles, he should embrace this rather than moral relativism.

The prima facie construal of the principles as outlined in the first part of this paper means that we should order the principles in response to particular situations. Just because judgments are made in relation to particular situations does not mean such an approach is not universal; nor does it imply that different judgments can legitimately be made either by different individuals or from different cultures. The approach is universal in the sense that all can use the four principles: the morality of a situation will not track the moral views of those who are judging it, but rather the reverse—we should aim to align our moral views with the underlying moral nature of the situation which we are judging. On this view, there will be a correct answer in each situation. It will be the appropriate response to all of the morally relevant non‐moral features of the situation before us—as long as these remain fixed. A correct response is one that picks out the relevant features and weighs them appropriately. If these features change, then of course, so might the judgment.

This means that we do not need books containing separate chapters on, say, Islamic, Protestant, or Marxist use of the four principles. The four principles approach is a universal theory, and this entails a commitment to what Gillon calls “moral imperialism”, but which might be better styled moral objectivism. As we have seen above, judgments may legitimately differ from case to case, but they are tied to the factual differences between cases, not to cultural or subjective responses to those facts. However, once respect for “difference” in itself (as opposed to sensitivity to different situations) is allowed, then the theory collapses into relativism (and even subjectivism). Although some will be happy to accept such a result, Gillon should not be, since he wishes to retain the idea that the four principles (construed as prima facie ones) are a universal feature of morality.

Another reason for questioning Gillon's approach here arises from examples that involve either crossing different cultures or an explicit commitment to universal values. Both kinds of cases suggest that it is not clear that all moral judgments should, or can, be made from “within” a single culture. International infectious disease prevention through the World Health Organization's (WHO's) regulations—for example, involves a commitment to agreement across the world about the trade off between freedom of movement and the need to prevent the transmission of disease.5 In such a case there can be no room for cultural disagreement. In the second case, many would hold that a practice such as female genital mutilation is wrong whatever local custom may say about it. The grounds for such a judgment will be an appeal to universal norms such as non‐maleficence, or perhaps to the idea of a breach of an individual's human rights. Such commitments seem reasonable and are one of the attractions of a universal ethics. In the absence of strong reasons to reject such an approach, many would be loath to give it up: does Gillon imply we should?

Gillon seems moved to avoid the accusation of “moral imperialism” as a result of Campbell's arguments about respecting other points of view.6 He responds in two ways (Gillon, 1 p 311). Firstly, he argues that the role he gives to autonomy in the four principles—that is, that it is first among equals—means that nothing is imposed upon anyone else as a result of this approach. Secondly, he appeals to the fact of cultural variability as providing grounds for tolerance. Neither response is adequate. On the first response, it is not plausible to claim that acceptance of the view that certain things are morally right will result in a diminution of the individual's autonomy. Is our autonomy limited by the idea of moral truths? Surely not—the compulsion generated by moral imperatives is one of reasons, not of causes, and the reasons for action provided by moral truths are no more erosive of our autonomy than the reasons for action provided by overwhelming prudential considerations. We cannot suppose that overriding reasons are incompatible with autonomy in general. (Indeed we can autonomously choose to ignore moral truths, though that is a different and very complex story.) On the second response, the argument from cultural variability suffers from the traditional is/ought problem unless extra premises are added to the argument. Why should the sociological fact that different cultures have different moral views entail the normative claim that we should tolerate views different from those of our own culture? It looks as though the obvious premise to make the argument go through will just stipulate the “truth” of moral relativism. This is hardly a satisfactory position.

Gillon's response to Campbell should, in our view, be far more robust. He should ask what reasons there are for thinking that a commitment to objectivism implies a lack of tolerance. In fact, he could point out, such an attitude to other cultures can only be justified if we are committed to tolerance as an objective moral requirement (otherwise any culture, including our own, can just argue that tolerance is not part of “their” morality). A commitment to general tolerance (beyond one's own culture) necessarily involves a commitment to it as a universal feature of morality. This in turn is a judgment committing us to Gillon's moral imperialism. If this is right, then moral imperialism looks, at least to us, to be a good thing. Indeed, the world would be a better place if we were to have more of it.

(c) The middle ground collapses

We have argued above that Gillon seems to be committed to some form of moral relativism because of the role he assigns to cultural difference in the deliberations involving the four principles. His apparent worries about moral imperialism seem to support this. He also seems anxious, however, to invoke the idea that the four principles are universal. In addition, he is committed to the idea that it is legitimate to criticise what goes on in other societies (a perspective that strains at his apparent commitment to relativism). The clearest example of this is his critique of the US healthcare system. He argues that his disagreement with the US system does not:

show that the four principles approach is wrong; it is to argue against the way those principles are being prioritised within a particular social system (Gillon,1 p 310).

Here he invokes an external critical perspective upon a society he is not part of, and argues that that society has failed to prioritise the principles appropriately. It is hard to see how this criticism can have any force unless he is also committed to the idea that there are truths about how we ought to respond in making such judgments. It looks as though he is committed to moral imperialism after all.

We conclude that the position he wants to adopt “between” moral relativism and moral imperialism is inherently unstable. He needs either to accept moral relativism (and give up the critique of the US, and any other societies) or to accept moral imperialism (along with the view that culture as such is irrelevant to the application of the four principles). The “liberal chic” position of abjuring moral imperialism, but nonetheless condemning the US whilst being nice to the Chinese, is not a coherent option.


Gillon claims that respect for autonomy is the most important of the four principles, and, because of that, cultural variation can play an independent normative role in the construction of our moral judgments. This, he thinks, enables us to avoid both moral relativism and (what he calls) moral imperialism, and allows us to occupy a middle ground where we must respect some cultural differences simply because they are there, so to speak, although we still somehow retain enough in the way of moral universality to criticise other cultural differences.

We have argued that this position is not a tenable one. Firstly, there is no reason to accept that respect for autonomy is first among equals as a moral principle. Secondly, it does not generate an independent moral role for cultural variation, and if it did, that would amount to moral relativism. Thirdly, relativism will not simultaneously demand that we respect some cultural differences but reject others—this is just straightforwardly inconsistent. Fourthly, relativism does not provide a good basis for tolerance, of the kind Gillon wants to promote. Fifthly and finally, we have argued that the moral universality which Gillon also wants to endorse is at odds with his relativistic leanings, but that it offers a much more promising basis for tolerance, and in any case is needed for a satisfactory construal of the four principles as prima facie universal moral principles, which construal allows for all the flexibility that an adequate moral theory needs because of the context sensitivity of the way in which the principles interact. There is no middle ground: Gillon, and the rest of us, have to choose between moral relativism and some form of moral objectivism. We have suggested that the latter choice is the more attractive one, and that those who are particularly committed to tolerance as an important moral notion should accept that this will need to be grounded in a universal morality, and hence should accept the moral “imperialism” which that implies.


1. Gillon R. Ethics needs principles. J Med Ethics 2003. 29307–312.312. [PMC free article] [PubMed]
2. Ross W D. The right and the good. Oxford: Clarendon Press, 1967.
3. Beauchamp T, Childress J. Principles of biomedical ethics [5th ed]. Oxford: Oxford University Press, 2001. 12.
4. O'Neill O. Autonomy and trust in bioethics. New York, Cambridge: Cambridge University Press, 2002.
5. World Health Organization World Health Organization international health regulations[3rd ed]. Geneva: World Health Organization, www.who.int/csr/ihr/current/en/ (accessed 20 Apr 2005)
6. Campbell A V. The virtues (and vices) of the four principles. J Med Ethics 2003. 29292–296.296. [PMC free article] [PubMed]

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