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Abstract

The term “principlism” designates an approach to biomedical ethics that uses a framework of four universal and basic ethical principles: respect for autonomy, nonmaleﬁcence, beneﬁcence, and justice. It is presented and defended in Beauchamp and Childress’ Principles of Biomedical Ethics. The basic principles state prima facie (or non-absolute) moral obligations that are rendered practical by being speciﬁed for particular contexts. Moral problems arise when principles or their speciﬁcations come into conﬂict with each other. The conﬂicts are resolved by further speciﬁcation or balancing judgments. Principlism justiﬁes moral reasoning by appealing to the method of reﬂective equilibrium and to the common morality. Principlism is committed to a global bioethics because the principles are universally applicable, not merely local, customary, or cultural rules. They are correlative to basic human rights and set limits to what is ethically acceptable in all societies, but they are also sensitive to particular conditions in societies and cultures that may account for legitimate differences in the ethics of medical research and practice.

Introduction

The term “principlism” designates an approach to biomedical ethics that uses a framework of ethical principles that are both basic and global in application. Principlist theory concentrates on the philosophical and practical roles that these principles should play in bioethics. Principlist theory emerged in the 1970s, and the name “principlism” was bestowed in 1990 by K. Danner Clouser and Bernard Gert (Beauchamp and Childress 2013). A principlist theory is committed to a global bioethics because the principles are universally applicable, not merely local, customary, or cultural rules. This entry examines the origin of principlism, its basic framework of principles, and its application to concrete moral problems in biomedical research and practice. The nature of principlism as a global, cross-cultural, and context-sensitive biomedical ethics is emphasized.

The Historical Origin And Development Of Principlism

The objective of a theoretically sound and practical framework of basic moral principles in healthcare and biomedical research has a short history. Throughout the long history of Hippocratic medical ethics, a framework of basic principles never played a signiﬁcant role, despite its commitment to the maxim, “Above all [or ﬁrst] do no harm.”

Basic principles have often been attributed to the Nuremberg Code Trials of war criminals (1948–49) (1947) and the Declaration of Helsinki (1964), two documents that were established in response to inhuman medical experimentation of Nazi physicians using as their subjects inmates of concentration camps. However, neither document presents a framework of basic principles. The so-called Nuremberg Code was part of the verdict in trials against Nazi doctors, held by a US military tribunal in the city of Nuremberg, Germany, immediately after World War II. The code had no prior history and contained ten universal moral requirements for medical research, but no basic moral principles. In 1964, the World Medical Association (WMA) ﬁrst released the Declaration of Helsinki, which is set out in terms of “principles,” but not basic general moral principles. Instead, the Declaration offers an internationally applicable body of practical guidelines for clinical research ethics (Declaration of Helsinki 2015) . They have been correctly described by the WMA as “recommendations as a guide to every doctor in biomedical research involving human subjects (World Medical Association 2008).”

Basic ethical principles that can be understood with relative ease by a broad public ﬁrst came to prominence in bioethics in the 1970s. As scandals in biomedical research were accumulating, new government and international guidelines were needed, and frameworks of general principles were presented in a manner that allowed them to be readily understood by people with diverse forms of professional training. Two published works became the primary sources of interest in principles of bioethics.

The Belmont Report of the National Commission for the Protection of Human Subjects in the United States was published in the US Federal Register in 1979. The purpose of the Belmont Report was to ensure that basic ethical principles would become embedded in the US research oversight system so that meaningful protection was afforded to all research participants. This Commission advanced three principles as basic and universal, though the Commission did not address global issues or reach explicit conclusions about universality. The three principles are respect for persons, beneﬁcence, and justice (National Commission for the Protection of Human Subjects 1979).
Principles of Biomedical Ethics, also published in 1979, was written by Tom L. Beauchamp and James F. Childress at the same time the Belmont Report was being drafted. Whereas the goal of the National Commission was basic principles for research ethics, Principles of Biomedical Ethics presents a set of basic principles suitable for application to ethical problems in medical practice, research, public health, and the like. This book proposes that medicine’s traditional preoccupation with a beneﬁcence and care-based model of medical ethics be augmented by a principle of respect for the autonomy of patients and by wider concerns of social justice. It also has the objective of bringing order to various debates on bioethical issues that at the time the book was originally published lacked a systematic conceptual and moral framing, both in public discussions and in academic settings.

The moral framework in Principles of Biomedical Ethics Beauchamp and Childress (2013) has been under continuous discussion and modiﬁcation since 1980 and is still today, in its seventh edition, considered the main resource for principlist theory. The presentation here focuses on its framework of principles and supporting arguments.

The Framework Of Principles

Constitutive for principlism is the assumption that morally relevant aspects of many real-world situations cannot be reduced to a single, supreme moral principle but need to be captured by a plurality of irreducible principles. The principles in the principlist framework are grouped under four general categories: (1) respect for autonomy, (2) nonmaleﬁcence, (3) beneﬁcence, and (4) justice. Analysis of the meaning and moral demands of each of these principles is the core of principlism:

Respect For Autonomy

The two basic conditions of being autonomous are liberty (the absence of controlling inﬂuences) and agency (self-initiated intentional action). Personal autonomy is self-rule free from both controlling interference by others and from limitations that prevent meaningful choice, such as inadequate understanding. The autonomous individual acts freely in accordance with a self-chosen plan, analogous to the way an independent government manages its territories and sets its policies. The principle of respect for autonomy protects the rights of individuals to hold certain views and to make certain kinds of choices. It contains both a negative obligation and a positive obligation. As a negative obligation, autonomous actions must not be subjected to controlling constraints by others. As a positive obligation, autonomous actions must be treated respectfully, and individuals must be appropriately informed, educated, encouraged, and assisted if needed to foster their autonomous decision making. Respect for autonomy obligates professionals in healthcare and research to procure informed consent for signiﬁcant procedures by disclosing relevant information, ensuring understanding and voluntariness, protecting conﬁdentiality of personal information, and promoting autonomous decision making. True respect therefore requires more than mere noninterference. It includes, at least in some contexts, building up or maintaining others’ capacities for autonomous choice while helping to allay fears and other conditions that destroy or disrupt free agency.

Nonmaleficence

The second principle, nonmaleﬁcence, requires that actors abstain from causing harm or risk of harm to others. Not “harming” others means not thwarting, defeating, or setting back their interests. The term “interest” does not refer to what a particular individual seeks, desires, or happens to be interested in. Rather, it refers to that which is genuinely in an individual’s interest, which is a welfare condition or a welfare advantage. Typical welfare advantages are those of health, mental and physical ﬁtness, and social inclusion and opportunities.

Beneficence

The principle of nonmaleﬁcence requires not acting. By contrast, principles of beneﬁcence require acting – in particular acting to beneﬁt others. These principles are concerned with the wellbeing of individuals, but nonmaleﬁcence and beneﬁcence are notably different in their demands – the one requiring individuals to avoid taking actions and the other requiring that actions be taken. Principles of beneﬁcence require that we prevent harms from occurring, remove harming conditions that exist, and promote the good of others. Beneﬁcence in the care of patients has traditionally been the centerpiece of medical ethics. It is presented in principlism as a foundational value, but not the sole foundational value in healthcare and research ethics. Many speciﬁc duties in medicine, nursing, public health, and research are expressed in terms of a positive obligation of beneﬁcence to come to the assistance of those in need of treatment or in danger of injury.

Justice

Principles of justice make up the ﬁnal part of the framework. The broad term “justice” refers to fair and appropriate treatment in light of what is due or owed to individuals, whereas the narrower term “distributive justice” refers to fair and appropriate distribution of beneﬁts and burdens determined by norms that structure the terms of social cooperation. There is no single principle of justice in principlism, because no single principle is capable of expressing the diverse array of obligations of justice. Basic obligations in social justice are to provide each individual in society with the means necessary for the realization of core aspects of well-being, such as health. In principlism many issues of justice are about the distribution of primary social goods such as essential health beneﬁts and fundamental political rights and also about the distribution of burdens such as bearing the risks of participating in medical research. A basic ethical problem in every society, and certainly for principlism, is how to structure healthcare systems and research systems so that burdens and beneﬁts are fairly and efﬁciently distributed and a threshold condition of equitable levels of health and access to healthcare is in place.

This principlist framework is understood as part of (but not the whole of) a larger body of universal and basic moral requirements that all impartial, morally committed persons accept – what is called “the common morality” in principlism. The framework is regarded as complete in the sense that it is capable of covering all morally relevant aspects in medicine, public health, health policy, and related ﬁelds such as animal research, pharmaceutical research, and healthcare insurance.

Rendering Principles Practical Through Specification

The meaning and the general moral content of the basic principles in principlism are relatively straightforward, but it is often unclear how to bring them to bear on concrete cases and issues because the principles underdetermine their application. That is, there is too little content in abstract basic principles to determine many practical rules, judgments, and recommendations that are essential in particular contexts. Practical policies that guide action in healthcare and medical research do not follow directly from highly abstract concepts and principles such as “respect for autonomy” and “beneﬁcence.”

Principlism therefore holds that its principles must be speciﬁed to give concrete guidance about when and how to obtain an informed consent, how much information must be disclosed, how to maintain conﬁdentiality, and the like. Speciﬁcation is not a process of producing, explaining, or defending general principles, but of making them relevant and useful in speciﬁc contexts.

Specifying the norms with which one starts, whether the basic principles in the principlist framework or norms that were previously speciﬁed from those principles, is accomplished by adding context-speciﬁc clauses that enrich the content and narrow the scope of the norms. As Henry Richardson puts it, speciﬁcation occurs by “spelling out where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided (Richardson 1990, 2000).”

Speciﬁcation entails that every instance of a speciﬁed norm is also an instance of the general norm. For example, every instance of obtaining informed consent in healthcare is also an instance of respecting autonomy, but not vice versa. The speciﬁcation relations link the abstract four principles to concrete moral problems, cases, and issues of policy. Another example of a speciﬁcation of respect for autonomy is “respect the autonomy of competent patients when they become incompetent by following their advance directives.” Often, a string of progressive speciﬁcations is necessary to establish a transparent connection between a basic norm and a particular moral issue or case. The moral authority of the basic norm is transmitted step by step all along the way to the ﬁnal, speciﬁc judgment.

The formal requirements of speciﬁcation – adding clauses to and narrowing the scope of a norm – do not determine the substantive content of how norms are to be speciﬁed. The content is determined by a context-speciﬁc interpretation of the norm being speciﬁed, based on a judgment regarding adequate clauses for the particular context. Thus, the method of speciﬁcation requires the exercise of substantive moral deliberation, and therefore more than one line of speciﬁcation of principles is commonly available when confronting practical problems and moral disagreements. Different persons or groups may justiﬁably offer conﬂicting speciﬁcations. The variability in the particular moralities of different communities, cultures, and institutions can be seen, at least in part, as the result of differences in the speciﬁcation of basic principles that are themselves shared in each of the groups.

Principles As Statements Of Prima Facie Obligations

Oxford philosopher W. D. Ross developed a theory that has deeply inﬂuenced principlism. He contrasts prima facie obligations with actual obligations. All obligations are prima facie, which means that an obligation must be acted upon unless it conﬂicts with another obligation that is of overriding importance in the situation. One’s actual obligation is determined by an examination of the respective weights of the competing prima facie obligations. No obligation is overriding in all situations (Ross 1988).

Likewise, in principlism basic principles and their speciﬁcations claim universal validity in the sense that they constitute good moral reasons for or against certain acts in any case to which they apply. However, all moral norms can be justiﬁably overridden in some circumstances by other moral norms with which they come into contingent conﬂict. For example, a physician might withhold some diagnostic information from a rehabilitation patient in order to make the treatment regimen go maximally well and also might justiﬁably disclose conﬁdential medical information about a person in order to protect the rights of another person or the reputation of an institution. Principles, duties, and rights are not absolute (or unconditional or unbreachable) merely because they are universally valid, and there are justiﬁed exceptions to all basic principles.

Moral Conflicts And Their Resolution

In principlism, moral problems arise because of conﬂicts of prima facie duties. Classic examples are problems of paternalism where physicians seek to provide health beneﬁts by overriding a patient’s autonomous choice. These problems involve conﬂicts between prima facie duties of beneﬁcence (providing proper care) and prima facie duties of respecting autonomy when, for example, a patient refuses a lifesaving amputation of his/her leg.

Principlism proposes either dissolving moral conﬂicts by further speciﬁcation or deciding the conﬂicts through balancing judgments. The ﬁrst strategy consists in critically reviewing the conﬂicting norms and, upon due consideration, determining a need for a speciﬁcation that dissolves the seeming conﬂict. In the amputation case, imagine that the patient rejects amputation of his/her leg although he/she has been properly informed and understands that the intervention is the only way to save his/her life. This situation creates a conﬂict for the physician between the prima facie duty of beneﬁcence to save the patient’s life and the prima facie duty of respecting autonomy by respecting the patient’s informed refusal of the amputation. Imagine further that the patient suffers an acute depression that makes his/her focus, with a controlling emotional attachment, on his/her leg and blinds his/her to remaining life opportunities. This blindness is a reason for critically rethinking the speciﬁcation of the principle of respect for autonomy in this case. Arguably, the patient’s refusal is not adequately autonomous because his/her judgment is overwhelmed by an emotional distortion. Therefore, the appropriate speciﬁcation of the principle of respecting autonomy would be to respect the refusal of a patient who is adequately informed, adequately understands, and is not controlled by an emotional attachment. This speciﬁcation allows an overriding of the patients’ refusal because it would not violate the principle of respect for autonomy. Here the seeming conﬂict between the duties of respecting his/her refusal and saving his/her life dissolves.

In other cases, in which conﬂicts between prima facie duties cannot plausibly be dissolved, “balancing” the duties may be pursued effectively. No supreme principle or rule is available in principlist theory to balance conﬂicting obligations. Rather moral judgments have to be made that identify the best moral outcome, all things considered. For example, in the case above, a judgment is required to balance the risks of the amputation against the beneﬁts of saving the patient’s life. Only if the beneﬁts outweigh, all things considered, the harm can amputation be justiﬁed, and the moral conﬂict between harming and beneﬁtting can be decided in this manner.

Balancing judgments are not mere expressions of intuition. They are the result of careful reasoning that involves evaluation of evidence, assessment of consequences, a search for alternatives, consideration of possible biases and partialities, and other heuristic measures. In everyday life, thoughtful and impartial people agree on most balancing judgments. For instance, as in the case above, the risks of many surgical procedures are commonly judged to be outweighed by their expected beneﬁts. However, in some cases, thoughtful and impartial persons do disagree, even after thorough reﬂection, on the moral weight of conﬂicting prima facie obligations. In principlism these cases are not expected to have only one deﬁnite ethical solution, as there may be a (limited) plurality of acceptable solutions. The only question is how well one justiﬁes one’s solution, another issue principlism treats.

Justification In Principlism: Reflective Equilibrium And Common Morality

The selection of basic principles, their speciﬁcation in various contexts, and solutions of moral problems by further speciﬁcation or balancing are in need of justiﬁcation, given the potential for competing judgments. Thus, principlism is not complete without a theory of justiﬁcation, i.e., a systematic account of how to support one’s judgments.

Principlists argue that moral judgments are justiﬁed by the evidence and plausibility they gain in conjunction with related moral and nonmoral beliefs and ultimately by the coherence of the belief system as a whole. The coherence of a system of beliefs (whether in the form of a theory, the rules of institutions, or the beliefs of individuals) is established through a reﬂective testing, specifying, and revising of its elements with the goal of making them as consistent, mutual supporting, and uniﬁed as possible – a method of reﬂective equilibrium originally devised by John Rawls (1999) and extended in theoretical bioethics by Norman Daniels (1996). The goal of reﬂective equilibrium is not merely rendering particular views and theories coherent and plausible, but to seek a “broad” equilibrium, taking under consideration all relevant and plausible beliefs, whatever their source or level of abstraction. Accordingly, in the ideal a diverse array of particular judgments and views, rules, concepts, data, background theories, and the like are identiﬁed as relevant resources for moral reﬂection to be brought into equilibrium or rejected as being incapable of contributing to the coherence of the moral belief system. In principlism, the method of speciﬁcation is emphasized to achieve reﬂective equilibrium by producing coherent strings of norms that connect basic principles, derivative norms, and context-speciﬁc judgments.

The formation of reﬂective equilibrium requires that initial judgments – the starting points of deliberation and justiﬁcation – are available to be speciﬁed and rendered coherent. Rawls refers to these initial beliefs as considered judgments, i.e., judgments that are least likely affected by conﬂicts of interest and other distorting inﬂuences and, therefore, appear at least provisionally acceptable on their own. Principlists follow his lead and take its basic principles to be the main considered judgments at the roots of medical morality. These principles are considered as part of “the common morality,” which is a set of basic moral norms that, in the course of human history, have proved to be of fundamental importance for the prevention of harm to, and the general ﬂourishing of, communities and societies.

In contrast to Rawls, who does not refer to the concept of the common morality, principlism takes its basic considered judgments not only to be provisionally acceptable as starting points but as a solid moral base for the formation of reﬂective equilibrium. In principlism, a bare coherence of beliefs is not sufﬁcient for justiﬁcation, because the body of substantive judgments and principles that cohere could be merely a system of prejudices and ill-considered opinions. Normative views are often wrong not merely because they are incoherent, but because they irreparably conﬂict with basic moral principles. Therefore, in principlism, the principles function as the primary considered judgments and are justiﬁed by being basic to common morality. Particular judgments are justiﬁed by being shown to be both in accordance with the basic principles and to make a contribution to the coherence and plausibility of the overall structure of moral beliefs.

Because basic principles have a foundational place in the common morality in principlism, the theory of justiﬁcation is not purely coherentist, despite its clear commitment to coherentist methods of deepening a system of moral beliefs. In this way both foundationalist theory and coherentist theory are given appropriate places in the principlist theory of justiﬁcation.

There is no reason in principlist theory to expect that the process of rendering speciﬁed norms coherent will come to an end or be perfected. The process of reﬂective equilibrium is viewed as a continuous work in progress – a relentless process of creating and improving moral norms and increasing coherence. Medical morality, like all of morality, is not a ﬁnished product. Principlism also holds that moral systems such as research ethics and clinical ethics can be rendered coherent in more than one justiﬁable way, though not if basic principles are disregarded. Multiple particular moralities such as those found in medical institutions can be expected to present coherent ways to specify universal principles, but it is also expectable that some form of incoherence will be a ubiquitous problem in all such particular moralities. Normatively, principlists demand no more than that agents faithfully specify the universal principles with an attentive eye to overall coherence.

Using Principles In Practical Deliberation

Principlism approaches practical deliberations by embedding its framework of principles in a structured procedure of discussing cases and issues by what may be called a heuristic method for putting principles to work. The structure of the procedure may be adapted to different ﬁelds and types of moral problems in bioethics. The following ﬁve steps have proved useful in the context of clinical ethics in particular:

The ethical problem and the options for action are described as precisely as possible.
All facts and circumstances that seem morally relevant for the problem at stake are documented and explained. These involve medical aspects (e.g., diagnostic ﬁndings, treatment options, risks and side effects, etc.) as well as broader circumstances such as personal backgrounds of people involved, societal conditions, societal perceptions of unfairness, etc.
The basic principles are speciﬁed to become relevant for the circumstances of the case and the solution of the moral problem. This is the core work of principlism in practice and should be done in a detailed manner. Strings of speciﬁcation may be needed, with attention to the formal requirements of speciﬁcation as well as to the plausibility and coherence of the speciﬁed norms’ content. In clinical settings, it is useful to ﬁrst specify the principles of beneﬁcence and nonmaleﬁcence and to balance them with regard to the overall well-being of the patient. This deliberation is related to the determination of the “medical indication” for a particular treatment. Next, the patient’s choice and competence to choose are determined, and the principle of respect for autonomy is speciﬁed independently of considerations of well-being. Finally, it is speciﬁed how third parties such as physicians, relatives, and society are affected, including their preferences and well-being.
Once the proposed speciﬁcations are determined, the problems of the case or issues are worked out by examining any conﬂict of norms that may be present. For a solution of a prima facie conﬂict, the norms must be critically revised, further speciﬁed as appropriate, and balanced against each other, as described previously.
The resulting recommendations are critically assessed by addressing the strongest objections and the reasons favoring and disfavoring these objections.

Principlism As A Global Bioethics

Several features of principlism make it a global, cross-cultural biomedical ethics.

Global Acceptance Of Basic Moral Principles

Principlism claims that its basic principles (and other principles in the common morality) are acceptable in all cultures and communities around the world, despite profound differences in their particular speciﬁed moralities. Moral differences in communities usually descend from different speciﬁcations and balancing of the basic norms, which can be accounted for by different living circumstances, historical experiences, religious and secular beliefs, and other particular cultural and political sources of different communities and societies.

Although principlism was ﬁrst developed in the United States, its basic principles are not considered American or even Western products, but as drawn from the common morality that is shared globally among persons committed to morality. It has been claimed by some critics that principlism represents distinctly American values and that other basic moral principles are needed elsewhere – for example, European values such as dignity, precaution, subsidiarity, and solidarity are said by some to work better in Europe (Rendtorff 2002). Principlism does not deny that other moral norms such as solidarity are available that are useful in some contexts. But principlists argue that its basic principles are not parochial and are the best basis of an ethical framework for biomedicine in every society worldwide (cf. Gillon 1993).

The Convergence Of Moral Theories On Basic Principles

Principlism assesses its basic principles as acceptable for all major ethical theories that are committed to universal obligations and rights. Deep and perhaps irresolvable differences exist between types of ethical theory such as Kantian, utilitarian, and virtue ethics with regard to ethical reasoning and justiﬁcation, and they all converge to acceptance of a similar set of substantial moral norms that should govern conduct in particular contexts. Proponents of many ethical theories with different philosophical, cultural, and religious backgrounds have accepted the principles featured in principlism, even if they sometimes prefer another terminology and support them for different reasons. They may to some extent interpret, specify, and balance the principles differently with regard to particular cases and issues, but they share with principlism a commitment to similarly formulated universal moral norms.

The Principlist Framework As A Basis For Cross-cultural Moral Judgments

The acceptability of the basic principles across cultures and theories will not, of course, eliminate all substantive moral disagreement. Principlism serves only as a common basis for cross-cultural and cross-theoretical controversies in biomedicine. Medical practices and opinions from all cultures and societies are to be judged within the framework of the basic moral norms. No healthcare professional from any culture or community can plausibly deny that avoiding causing pain or other harms to patients, providing them with health-related beneﬁts, respecting their freedom of choice, and treating every patient and patient population fairly are of central moral importance. Therefore, the principlist framework is a legitimate basis for judging – and, as appropriate, criticizing – morally relevant features of healthcare and research with human subjects in foreign cultures as well as in one’s own culture.

Research Ethics As An Example Of Global Standards

Principlists share the goal of developing globally accepted standards of bioethics that are justiﬁed within the principlism framework. A good example is the research ethics that govern human subjects research in biomedical research centers. Research ethics is today a body of worldwide standards that are no longer in serious dispute in any country in which research with human subjects is conducted. Even if the rules vary to some extent from one country to the next, every community in which scientiﬁc research with human subjects occurs has accepted a body of universally valid rules. Examples are requirements to disclose all material information to subjects; requirements to obtain individual, voluntary, and informed consent; requirements to protect subjects in research against excessive and unnecessary risk; and requirements that ethics review committees criticize and approve research protocols. These rules grounded in general moral obligations of not harming other people, helping them in need, respecting their freedom of choice, and giving what is owed to them. The Declaration of Helsinki is one of many examples of the formulations of such rules (though, in contrast to principlism, it contains no arguments about how the rules are grounded).

The Place Of Context Sensitivity

The prima facie status of moral norms and their potential to be speciﬁed allow for precise and subtle judgments in different contexts, appreciating all morally relevant differences between societies that may account for their different practices and moralities. It would be false and inappropriate for a global bioethics to claim to be able to locate the same particular obligations for every community regardless of their environments. As examples, legitimate claims of people in need of care may well be different in nomadic tribes and highly developed cities, and the demands of rules of informed consent will need to be adjusted for illiterate and literate societies. Speciﬁc moral requirements are the result of speciﬁc natural, economic, historical, social, and cultural conditions, including religious beliefs and conceptions of healthy environments.

The Rejection Of Relativism

However, there are limits to what is to be tolerated and what constitutes reasonable judgments and justiﬁcations. The bare fact that a particular medical practice has a long tradition behind it in some societies is not by itself a sufﬁcient justiﬁcation for the practice. Principlism rejects the claim of moral relativism, according to which every society (or even every person) has its own morality that cannot be judged and criticized from outside. Medical practices that cannot reasonably be justiﬁed by and made coherent with the principlist framework of universal norms are to be rejected. For instance, female genital mutilation cannot be justiﬁed in principlism, irrespective of cultural practices and despite its presence in several countries. Injuring and hurting children severely for no medical beneﬁt by using physical force are serious violations of basic principles that cannot reasonably be outweighed by culturally speciﬁc ideas of chastity, aesthetics, or family honor. This form of relativism is entirely unacceptable.

Acceptance Of A Moderate Pluralism

Principlism does not reject all forms of moral pluralism. Many responsibilities, ideals, attitudes, and sensitivities found in, for example, cultural, religious, and professional guidelines can be justiﬁed. In some situations, different practices are morally justiﬁed, fulﬁlling moral requirements equally well. For instance, healthcare systems may be organized differently but perform equally well with regard to health outcome, fair ﬁnancing, and general service quality. Moreover, conﬂicting prima facie principles might be of equal or incomparable moral weight in particular situations such that each alternative is acceptable from a principlist point of view. Many difﬁcult decisions in clinical practice can be interpreted in this way, e.g., when the chances and the risks or the opportunity costs and the beneﬁts of a particular treatment are judged as having equal moral weight. Well-informed, impartial, and morally committed persons may well disagree, upon due consideration, about morally relevant facts (e.g., chances and risks of therapies, presumed preferences of patients, and societal consequences of particular practices) or about how to specify and balance moral obligations in particular situations.

Principlists expect a pluralism of theories and moral positions in bioethics, but they draw a threshold line at what is tolerated: All justiﬁed particular moralities share the general norms of the common morality with all other justiﬁed particular moralities. These norms are universal, not local, and so can only be speciﬁed, not abandoned.

The Relation Between Universal Principles And Human Rights

A human rights approach has in recent years become the most widely used way to express foundational moral norms that cross national boundaries and that support the statements of international law and policy made by international agencies and associations. Assuming that they have this status, how are the basic principles of obligation in principlism related to human rights? And how might they jointly constitute a global bioethics of universal norms?

A human rights approach, like principlism, provides standards that transcend morally problematic norms and practices in particular cultures. These rights are interpreted in principlism as prima facie rights that must be speciﬁed in order to become practical moral, political, and legal norms, just as in the principlist account of basic, universal norms of obligation. Without careful speciﬁcation(s), a human right such as the right to be told the truth will leave us uncertain what the right does and does not cover. Even such fundamental human rights as the rights to life, freedom of religion, and property can be justiﬁably overridden in particular situations if they come into conﬂict with other human rights or important public interests. For example, some cases of self-defense, bans of extremist religious groups, or expropriation of private land for important public purposes may be justiﬁed.

Principlists regard the grounding of human rights as in one respect identical to that of the basic principles of obligation. Both are basic norms (basic considered judgments) of the common morality. Principlists also see basic principles (and the norms that specify those principles) as uniformly translatable into correlative rights; likewise, basic rights are always translatable into correlative basic principles of obligation. For example, the basic principle that one should not cause pain or suffering to others (the principle of nonmaleﬁcence) directly translates to the right to not be caused pain or suffering by others. Likewise the principle of respect for autonomy directly translates into the human right to have one’s autonomy respected.

This thesis of the correlativity of rights and obligations does not hold that universal rights are identical in meaning to universal principles. Rights in general are justiﬁed moral claims to something that individuals or groups can legitimately assert against other individuals or groups. Human rights in particular are those that all humans possess. What rights language adds to the language of principles of obligation is the part about “justiﬁed moral claims.” A right gives its holder a justiﬁed claim to something (an entitlement) and a justiﬁed claim against another party. The latter party is the holder of the correlative obligation. Claiming is a mode of action that appeals to moral norms that permit persons to demand, afﬁrm, or insist upon what is due to them because a correlative obligation requires that the claim be honored. “Rights,” then, are justiﬁed claims that can legitimately be asserted against persons or institutions who are the bearers of obligation to these individuals or groups. The right to receive an adequate level of healthcare, for example, is correlative to a communal obligation to provide the necessary resources. If this right is a human right, then all humans are owed a proper distribution of available resources, a demand of justice.

Conclusion

Principlism presents a global bioethics. It has basic moral norms that are acknowledged by morally committed persons across all cultures and societies, and it offers a moral framework that is universally binding and that allows for a systematic assessment of moral issues in biomedicine. It both sets limits to what is ethically acceptable in all societies and is sensitive to particular cultural, economic, and natural conditions in societies that may account for legitimate differences in medical research and practice.

This approach requires tolerance and mutual respect in global bioethics, without spreading moral indifference. If there is no one deﬁnite ethical solution to every moral problem, but a limited plurality of acceptable solutions to some moral problems, then conﬂicting opinions and practices in different cultures need not be based on partiality, ignorance, or irrationality.

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