Principlistic Equality: Understanding the Relative Importance of the Four Principles of Bioethics Among Primary and Urgent Care Clinicians

Christine Baugh – Center for Bioethics and Humanities – University of Colorado Anschutz School of Medicine; Matthew DeCamp – Center for Bioethics and Humanities – University of Colorado Anschutz School of Medicine; Lauren Taylor – Department of Population Health – New York University Grossman School of Medicine; Lindsey Fish – Department of General Internal Medicine – Denver Health and Hospital Authority; Susan Goold – Department of Internal Medicine – University of Michigan Medical School; Matthew Wynia – Center for Bioethics and Humanities – University of Colorado Anschutz School of Medicine; Eric Campbell – Center for Bioethics and Humanities – University of Colorado Anschutz School of Medicine

Abstract: Principlistic equality, the idea that the four principles of bioethics should be considered non-hierarchical in the abstract, is core to the original conception of principlism. Prior studies have explored how clinicians ultimately prioritize the principles in specified situations, but it is unclear whether clinicians start from a point of principlistic equality in their practice or if they consider some principles as weightier than others a priori. In a novel survey of primary and urgent care clinicians, we found just over half of respondents (51.9%) endorsed a hierarchy among the principles. Among these clinicians, non-maleficence was most often over-weighted (by 57.1% of these respondents), followed by autonomy (42.0%), justice (35.7%), and beneficence (34.8%). Several professional, personal and practice characteristics were associated with lower odds of endorsing principlistic equality, and several clinician characteristics were associated with giving additional weight to certain principles. Our findings provide insights into how clinicians conceptualize and value the four ethical principles and raise important questions about the teaching and use of principlism in practice.

Keywords: principlism, principlistic equality, theories of bioethics