Principlism This slide set is intended for inclusion in a lecture or other presentation.

Currently the dominant theory in clinical bioethics. Principlism Currently the dominant theory in clinical bioethics. Principlism is currently the dominant bioethical theory in clinical health care. It derives from the work of Thomas Beauchamp and James Childress who have developed this concept over the past 20 years. It has broad application in the approach to bedside dilemmas and clinical problem solving.

Principlism balances four principles: Beneficence Nonmaleficence Justice Autonomy Principlism, as a theory, suggests that the most acceptable course of action when met with an ethical dilemma in the clinical setting is the one that best balances (or least sufficiently addresses) four principles. These four principles are: beneficence, nonmaleficence, justice, and autonomy.

Principlism Beneficence All actions should be for the good of the patient Assumes the patient’s interest is the sole focus of any action Aligns with Kant’s Categorical Imperative Beneficience is the principle that all actions taken by a physician or other care giver should be for the good of the patient. This concept is deeply rooted in the Hippocratic tradition. It also resonates strongly with Emmanual Kant’s categorical imperative that all persons should be considered ends in themselves and never as means to an end. This principle fits well into our concepts of direct patient care but works less well under a public health framework.

Principlism Nonmaleficence No action should harm the patient Aligns well with the Hippocratic tradition "The physician must ... have two special objects in view with regard to disease, namely, to do good or to do no harm" (Hippocrates. Epidemics, book I, sect. 11, trans. Adams) More complex meaning in a modern context The principle of non-maleficence demands that our actions must not harm patients. Again, this principle has deep historic roots extending to the Hippocratic dictum to “at least, do no harm.” Meeting this burden in modern medicine can be challenging where treatments and interventions often have significant side-effects, and potential complications. The principles of beneficence and nonmaleficence are balanced each time a risk-benefit decision is made.

Principlism Justice Has both individual and collective dimensions All patients in like circumstances should be treated same way. The benefits and burdens of a society should be distributed with equity. Strongly supported in human-subjects research Variable expression in direct patient care Justice as a general philosophical concept leads to rich discussions of “fairness”, “equality”, “rights”, as well as political and economic theory. In the context of the physician-patient as care giver-patient relationship however, the principle of justice simply requires that individuals in like or similar circumstances should receive the same care. This requirement can be rapidly complicated both by internal forces such as biases or prejudices and by external forces such as payment and resource allocation.

Principlism Autonomy Recognizes the individual patient as an independent moral agent Supports the right of self-determination Highly-valued in American culture Expressed in health care as informed consent The concepts of individual rights and self-determination are well known in western democratic cultures underpin the principle of autonomy in clinical medicine. Individual patients are recognized as independent aware agents who can accept or refuse the treatments they are offered. The most tangible expression of autonomy is the practice of informed consent.

Principlism Beneficence Nonmaleficence Justice Autonomy Principlism recognizes the vagueries of the clinical world and that one or other principles may not be fully satisfied is a given clinical dilemma. This theory does, however, provide an excellent frame work with which to analyze a morally or ethically challenging situation.