Principlism on a pedestal: Rethinking priorities in ethics education

As I begin my career as a medical student at the University of British Columbia, I find myself in a unique position. Having already studied, worked, and researched in the field of bioethics, I have had the privilege of being exposed to a wide array of literature and perspectives that have helped me form my ethics toolkit. Now that I have an equal privilege of being educated in medical ethics from the perspective of a medical student, I find myself reflecting on the nature of ethics education in medical school and wondering whether we ought to have a more varied, and perhaps different approach. 

I have not ventured far into medical school; as a first-year student I have not been exposed to the entirety of the ethics education that lies ahead. However, my experiences thus far have caused me to reflect on the dangers of prioritizing principlism in a medical-ethics education. From being asked to choose between “correct” principles on a multiple-choice exam, to being given lectures and assignments focused on the four principles, I wonder to what extent medical students are being taught to approach ethical dilemmas in a framework rooted in principlism.

For many working in the space of bioethics, this would not come as much of a surprise. Beauchamp and Childress’s four principles of biomedical ethics (autonomy, beneficence, nonmaleficence, and justice) have been hailed as an integral theoretical framework from which to approach and address ethical dilemmas in medicine for decades. A quick Google search of “medical ethics” confirms this, with the four principles cited and discussed in almost every search result on the first page. However, while principlism can be important in helping students approach ethical dilemmas from a structured approach, I argue that it is not sufficient in addressing the many ethical dilemmas faced in clinical practice.

The purpose of a medical-ethics education in medical school should be to adequately equip students to unpack the various morally significant factors in an ethical dilemma, to weigh the morally acceptable options, and to choose one that is most justifiable within the narratives of the concerned parties. Principlism is insufficient to meet these criteria. In fact, I think that no single moral theory can sufficiently meets these criteria; rather, one must use several of them concurrently to appropriately tease out moral wrinkles. 

One such approach is narrative ethics, which teaches us to explore the time and setting of the environment—to contextualize how an ethical dilemma came to be. This approach equips the ethicist to find a deeper understanding of what truly matters to relevant players at hand. Similarly, it is important to understand how to develop certain values or characteristics that can guide actions toward morally appropriate outcomes, which can be learned through Aristotelian-inspired virtue ethics. An understanding of utilitarianism gives us the framework to view ends and outcomes in quantifiable ways, and an understanding of deontology helps us understand if the means to these ends are inherently right or wrong. Taken together, these different approaches amount to a toolkit, which goes beyond reducing a dilemma into four principles and weighing them against one another.

As future physicians we have an obligation to give our best to our patients and communities. Our best includes having the ability to appropriately handle emotionally charged and ethically complex situations. By no means should we demonize principlism, but we should ask, can an ethics education steeped in principlism adequately prepare medical students for the challenges that lie ahead?
—Farhad R. Udwadia, MBE
UBC Faculty of Medicine, Class of 2022

This posting has not been peer reviewed by the BCMJ Editorial Board.

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