Introduction to Principlism
Principlism is a theory of applied ethics developed to facilitate moral decision-making in biomedical contexts, such as healthcare and research involving human beings. In this text, I introduce the version of Principlism developed by Tom L. Beauchamp and James F. Childress in their book Principles of Biomedical Ethics.
Ethics and biomedicine
The earliest known moral precept in medical contexts, namely do good or do no harm is found in a book written by the the Greek physician Hippocrates of Cos (460–370 BC). However, Hippocrates is perhaps more famous for his Oath. Among other things, those who swear the Hippocratic Oath commit to keeping the sick “from harm and injustice,” and to work “for the benefit of the sick.” Even today, it is still common among many medical practitioners to refer to the Oath when making moral assessments.
The Oath, however, is very different from our contemporary medical ethics. For instance, the commitments of those who swear the Oath are unresponsive to the preferences of those who are treated. In contrast to modern medical practices in most Western liberal democracies, Hippocrates’s ethics is oriented around the care provider and not the care receiver. It focuses on the characteristics and virtues of a good care provider rather than the interests of the person they treat. In one sense, it is an authority-based ethics, i.e., oriented around a medical authority.
Historically, biomedical ethics has been authority-based, and included few or no constraints on what the care provider may do. In one case from the early 20th century, a physician named Dr. Pratt deceived a woman named Mrs. Davis to undergo surgery to treat her epilepsy; while Mrs. Davis was anesthetized, Dr. Pratt surgically removed her uterus and ovaries in the belief that he had the moral right to do whatever he thought was best for her.1
It was first in the 19th century that patients’ interest started to be taken into account, perhaps because of the development of legal institutions that enabled them to hold their physicians accountable.2 For instance, in Pratt v. Davis 1905, the court ruled that citizens under free governments have a ”right to the inviolability of his person” which ”forbids a physician or surgeon, however skillful or eminent … to violate without the permission the bodily integrity of his patient” (Katz 1984, p. 51).
In the 1970’s, partly in response to media coverage in connection to harmful medical experiments on unknowing subjects, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in the USA put together a report on ethical principles of biomedical research. It is commonly known as the Belmont Report. The report includes the first formulation of a theory of biomedical ethics called Principlism.
Principles of Biomedical Ethics
The most elaborate formulation of Principlism is found in a book titled Principles of Biomedical Ethics (2013), written by Tom L. Beauchamp and James F. Childress. It was first published in 1979; the 2013 edition of the book is the 7th.
In simple terms, Beauchamp and Childress’s version of Principlism is comprised of four principles intended to guide decision-making in biomedicine, and a method for applying the principles in practical contexts. The four principles are respect for autonomy, nonmaleficence, beneficence, and justice. The method for applying them in practice is based on reflective equilibrium as a theory of justification.3 I call it ”specificationism.” In what follows, I will account for the theory in more detail.
The principles in Principlism
The first principle in Principlism is respect for autonomy. To be autonomous is to be self-governing in a substantive sense, to be the master of one’s choices and of how one’s life goes.4 In biomedical contexts, clinicians or researchers respect a person’s autonomy by, for instance, informing her about how a certain medical intervention will affect her way of life, and by making sure that she is competent to make decisions concerning her own self.
The second principle is nonmaleficence. It obliges practitioners to abstain from causing harm to their patients or research subjects. Among other things, the principle includes an obligation to not kill, cause pain or suffering, incapacitate, cause offense, and deprive others of the goods of life.
The third principle is beneficence. While the two first principles mainly (but not exclusively) obliges practitioners to abstain from action, the principle of beneficence obliges them to act to contribute to other people’s welfare. The obligations include to protect and defend the rights of others, help persons with disabilities, and rescue persons in danger, among other things.
Finally, the fourth principle is justice. This principle concerns the socially just distribution of scarce resources, and focuses on healthcare institutions rather than particular healthcare decisions. Among other things, a just organization of healthcare provides equal measure of liberty and equal access to goods to all.
Principlism is a pluralist theory in the sense that it does not rest on one overarching principle; no principle takes precedence over another. Therefore, conflicts between the principles are expected. Consider this case, for instance, which builds from Lee (2010):
A 17-year-old has lost a lot of blood in an accident. The best chance of saving the teenager’s life is an urged blood transfusion and a surgical intervention to stop the bleeding. However, the teenager’s parents are Jehovah’s Witnesses. For religious reasons, they refuse to give permission for the blood transfusion. They request that surgery should be carried out anyway, although they understand that this will be much more dangerous than operating with blood transfusion.
In this case, the principle of respect for autonomy applies, as healthcare practitioners should respect the 17-year-old’s decisions (which the teenager’s parents represent as surrogate decision-makers).5 But, the principle of beneficence also applies, as practitioners are obliged to act to contribute to the teenager’s welfare. Thus, there is a conflict between the two principles, and it is not immediately clear which principle should be followed.
I think that the principle of beneficence should be followed in this case. The teenager’s own wishes are unknown to us; perhaps s/he is unconscious. Because it is a high-stake decision, I want to be sure that the parents really represent the teenager’s wishes. However, their decision is based on an extreme religious belief, which it is possible that the teenager does not share. And, even under the assumption that the teenager does in fact share those beliefs, s/he may not be sufficiently competent to make healthcare decisions on basis of them. Therefore, I hold that the treating clinicians should follow the principle of beneficence, override the parents’ decision, and proceed with the blood transfusion.
However, because Principlism is pluralist in the above sense, there may be conflicts between principles in which there is no right answer. Or, one other way to phrase this possibility is that there is then no wrong answer. Yet, when principles conflict, clinicians are obliged to try to find out whether one principle should take precedence over the other(s). This requires a method.
The four principles are underdetermined. By that, I mean that the formulations of the principles are not exhaustive; they do not include complete specifications of their various applications. There is no index of all possible moral dilemmas that practitioners can consult when conflicts between principles arise. Instead, they must engage in substantial moral deliberation and decide what should be done. Principlism includes a method for such deliberation, I call it ”specificationism.”
In its most simple form, specificationism is a three-step process. The first step is to decide tentatively which of the four principles that apply to a particular case. In most cases, there are no (serious) conflicts between principles. But in some cases, such as the hypothetical case discussed above, the conflict must be tentatively identified. With some training and experience, the first step is often relatively simple.
The second step is more difficult. It is interpretative, and aims to articulate in detail how the relevant principles apply to the particular case. In the hypothetical case above, for instance, one interpretation of the principle of beneficence is, “it is morally prohibited to risk the death of a patient if his or her life-threatening condition can be medically managed by suitable medical techniques” (Lee 2010, p. 525). One interpretation of the principle of respect for (surrogate) autonomy is, “it is morally prohibited to disrespect a parental refusal of treatment” (Ibid). Interpretation requires insight into the content and purpose of the moral principles, and an understanding of the relevant empirical facts associated with the case at hand.
Finally, the third step is to explain why the interpretation is correct, and to provide a balanced judgment with regard to the case. In the hypothetical case above, a balanced judgment may be that “it is morally prohibited to disrespect a parental refusal of treatment unless the refusal constitutes child abuse or child neglect or violates a right of the child,” and that the parents’ refusal constitutes that (Ibid, pp. 525–6).6
Thus, in steps one through three, the practitioner specifies how the underdetermined principles apply in the particular case, thus the name ”specificationism.” One other common method of application is casuistry, but I will not discuss it here. By specifying the principles, the practitioner creates some normative content that was not there before in the theoretical formulation of the principles. Therefore, Principlism also suggests that practitioners should be trained in practical moral decision-making.
To conclude, I have here called the precursor of our contemporary bioethical paradigm ”authority-based,” as it was oriented around a medical authority. I suggest that the currently prevailing ethical paradigm should be called ”individualist,” as it is oriented around decision-making individuals with rights and interests that are taken into account already in the theoretical outset.
The most influential theory of biomedical ethics in our time is commonly known as Principlism. I have introduced its main elements here, although only in brief. For a more elaborate discussion, see, e.g., Beauchamp and Rauprich’s entry ”Principlism” in the Encyclopedia of global bioethics (2016).
1 The case is discussed by, among others, Brennan (1991), Millenson (2011), and Strong (2013).
2 This overview is based on the development of medical ethics in northern America. I build here from Jonsen (2000) and Faden and Beauchamp (1986), in awareness of that the development in other parts of the world has been different from this brief overview.
5 In the original example in Lee (2010), the case is about a 2-year-old child. I discuss the case and how it is relevant to moral decision-making in my yet unpublished PhD thesis.
6 Note that while this judgment is balanced and supports the same decision that I argued in favor of above, it rests on a different justificatory base than my own argument; Principlism allows for different interpretations and explanations.
Beauchamp, T. L. and J. F. Childress. (2013). Principles of biomedical ethics. Oxford University Press.
Beauchamp, T. L., & Rauprich, O. (2016). Principlism. In H. ten Have (Ed.), Encyclopedia of global bioethics (pp. 2282–2293). Berlin: Springer.
Brennan, T. (1991). Just doctoring: medical ethics in the liberal state. University of California Press.
Faden, R. and T. Beauchamp. (1986). A History and Theory of Informed Consent. Oxford University Press.
Jonsen, A. R. (2000). A Short History of Medical Ethics. Oxford University Press.
Katz, J. (1984). The silent world of doctor and patient. The Johns Hopkins University Press.
Lee, M. J. H. (2010). The problem of ‘thick in status, thin in content’ in Beauchamp and Childress’ principlism. Journal of Medical Ethics 36:9, pp. 525–528.
Millenson, M. L. (2011). Spock, feminists, and the fight for participatory medicine: a history. Journal of Participatory Medicine 3:27.
Strong, C. (2013). Medicine and Philosophy: The Coming Together of an Odd Couple. In: The Development of Bioethics in the United States. Ed. by J. R Garret, F Jotterand, and D Ralston. Springer Netherlands.
Cite as: Ahlin, J. (2018). Introduction to Principlism. Retrieved (date) from: https://jesperahlin.com/for-students/introduction-to-principlism/