Welcome back to my Medical Ethics Series for the seventh installment. Unlike the loose fun of the last ones, where we explored what ethical theories might be best, here we will face very real situations, and ask the hardest questions of all… What is the right thing to do?
However, before we apply what we know, there is one last “theory” to go over.
Principalism
Introduced in 1979 by Beauchamp and Childress, this framework revolutionized the ethics of medicine. Principalism is not considered a normative theory as it lacks depth, but it isn’t truly just applied ethics, leaving it somewhere in the grey, sometimes called a “mid-level” theory. In fact, Beauchamp and Childress themselves deny it as a comprehensive moral theory, something they believe plays to its advantage. This is the framework that most bioethicists use, holding the four “pillars” of medical ethics: Autonomy, Justice, Beneficence, and Nonmaleficence.1
I will only give a brief reminder, as Dr. Beyda has covered this very well. Autonomy is respecting the patient’s decisions regarding their own health, Justice is distributing healthcare to all in a fair fashion, Beneficence is doing what is good for the patient(s), and Nonmaleficience is not doing harm to the patient(s). Given how much they are already discussed, there is little for me to teach. Instead, I am going to discuss the apparent pros, and more importantly, the strength of the cons, which I believe are sufficient to consider it a poor justificatory framework. That is not to say it doesn’t result in some good, or it isn’t a good starting point for medical ethics, but relying on it alone to guide decisions is insufficient and ethically inappropriate.
Pros
The biggest pro to this framework is that it is simple. Built from concepts we understand, Principalism allows us to distill deep philosophical moral thought into four pillars we can apply. When faced with the complexity of medicine, both of learning it and the complexities of moral decisions, there is something to be said for simplicity. This was the intent of the authors, as they found the other ethical systems complex and domineering without practical value. Secondly, although not the intent of the authors, Principlism can attempt to convey deeper theory (e.g. Deontology). This allows one to easily and quickly express their already existing moral theory. Third, Principalism is grounded from an assumption of common shared morality, and gives us the values that should be relevant to us. It identifies the (albeit limited) moral convergence we see across cultures and history, and leans on this to inform. In doing so, Principalism creates a shared moral language across these pluralistic views (e.g. moral variance). Fourth, there are some good constraints, namely it avoids one appealing openly to convenience, prejudice, or self-interest. Overall, it is simple, practical, broad-sweeping, and methodological.
Cons
There are a few deeply cutting problems with this framework as it was intended. First, it assumes a common morality without explaining it. Unlike our deep normative theories, Principalism simply decides what four values we should be weighing without a real argument as to why those values are the most important.2 Autonomy? This is increasingly sexy in the western world, but culturally this is something WE value, how can we assume it should be equal to the other three principles? Perhaps it is not subjective and you think objectively autonomy matters as much as the others, can you tell me why? Or when to weigh them?
That takes us seamlessly into the next problem. When do we apply what? It sounds nice to say “we should respect patient autonomy,” “we should use the principle of justice here,” but it doesn’t give much guidance. You essentially make decisions based on a preconceived ethical system that you use these words to describe. Ironically, Principalism cannot do what it claims without importing what it rejects.3 That is to say, you use Principalism to express a deeper system anyway, but now relying on your gut without the guidance of a well thought-out system (e.g. Utilitarianism). To be fair, Beauchamp and Childress deny that we should use our gut, and set out 6 conditions that need to be met to find a “good reason”1. However, I find these conditions a bit superficial, and they do not supply a normative (standardized) basis for prioritizing one principle over another when there are competing options.
This leads me to the final critique. Principalism gives us moral language, and authority, that we don’t deserve. It makes our authority and confidence come easy, without much moral labor, feeling as if we did enough by just thinking about which values matter. We avoid truly tussling with our deepest conceptions about what is right, because all along our preconceptions were going to “win out” in our mental argument. If my series so far has taught you anything, I hope it is this: we have far less ethical certainty than we often believe. But Principalism allows us to feel as if we can make correct decisions and say the right thing, without putting in that uncomfortable effort ahead of time to truly discover what that is.
In Summa
Principalism, as it was intended, is not a sufficient justificatory framework. It faces deep flaws that allow you to make decisions largely shaped by prior intuitions, bound only by loose limitations, with moral language to cover your conscience. That does not mean it cannot be used to express another system, or as a stopgap while learning deeper normative concepts. Rather, as it is presented by Beauchamp and Childress, it is not appropriate as a standalone justificatory framework. I know it seems easier, and given how busy we are, these deeper complicated theories I have talked about appear to be a lot of work and time we don’t always have. However, at the end of the day, we are privileged to have the power to make the decisions we do, and as such, have an obligation to explore those deeper theories and not solely rely on a weaker framework out of convenience. So, while using Principalism as a framework to express a deeper theory is unproblematic, using it alone is something that should be avoided.
References
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. New York, NY: Oxford University Press; 2019.
- Clouser KD, Gert B. A critique of principlism. J Med Philos. 1990;15(2):219-236.
- Shea M. Principlism’s balancing act: why the principles of biomedical ethics need a theory of the good. J Med Philos. 2020;45(4-5):441-470.
Travis Seideman
Travis Seideman is a member of the Class of 2026 at UACOM-P. He attended Northern Arizona University where he studied Exercise Science and Psychology. He is planning on practicing rural Family Medicine and pursuing a fellowship in Sports Medicine.