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Title
Abstract
Introduction 1.1 Rationale
Objectives
Methods and Results
Summary of the Methods
Data Charting Process
Data Items and Variables
Synthesis of Results
Discussion
Summary of Evidence
Limitations
Conclusion
Data Availability
Underlying Data
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Philosophy
Ethics

Principlism in Bioethics: How to Consolidate Autonomy? A

Profile image of Michael J ReissMichael J Reiss

2025, Bioethics Open Research

https://doi.org/10.12688/BIOETHOPENRES.17704.1
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18 pages

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Abstract

Background The concept of autonomy in bioethics is subject to significant debate, with scholars describing it in contradictory terms-ranging from "fundamental" and "universal" to "blurry" and "flawed". Despite its central role in safeguarding patients' rights, informed choice, and personal integrity, the paradoxical nature of autonomy has led to conceptual fragmentation and academic disagreement. Objectives This study aims to reconcile autonomy with other core ethical principles—beneficence, non-maleficence, and justice—by considering it as a non-absolute principle that can be justifiably infringed upon in certain ethical circumstances. Additionally, it explores how emerging interdisciplinary approaches may refine or consolidate autonomy in bioethical discourse.

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This paper argues that the core principle of bioethics, autonomy, is rooted both in the 20 th century history of the development of new medical technologies as in political liberalism transferred to medical practices, rendering the medical decision-making of patients a centerpiece of medical interventions. The paper shows how the ambiguity in the interpretation of autonomy reflects the ambivalence of bioethics towards making normative claims on the moral agents insofar as these go beyond the respect for a patient’s autonomy. In the second part, the paper analyzes the alternative approach of care ethics, which intends to emphasize both the vulnerability and dependency of the patient and the medical professions’ responsibility to care for the patient. However, neither ‘autonomy’ nor ‘care’ ethics approaches can address the social and institutional mediations of today’s health care ethics; the paper therefore concludes with a proposal to embrace a critical social-ethical approach to bi...

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Principlism: Bioethics as Procedure?
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Clinical Responsibility in the Age of Patient Autonomy
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Personal Autonomy and Shared-Value in Bioethics
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Although the principle of "respect for personal autonomy" is largely conceptualized against the background of values of societies that espouse individual liberty, not all societies in the world place a high premium on the place of the individual person. This chapter examines the value of autonomy in bioethics and determines whether other values, such as "communal responsibility" dominant in African settings, are equally valuable in the context of healthcare and health research. It uses elderly care, as a case example, to explore the subtleties of personal autonomy and determine its valuableness in African contexts. In African settings, the care of elderly persons is binding on families and considered a responsibility of their communities. Elderly persons enjoy the privilege of being cared for, and families and communities are responsible for providing care. While some individual persons may choose not to provide the care and some elderly persons may reject care offered, the question remains whether the refusal is morally acceptable

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Compassionate Principlism: Towards a Novel Alternative to Standard Principlism in Bioethics
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Principlism appears to be the prevailing applied ethical framework in bioethics. Despite the view's various strengths, critics point out that since the principles are ad hoc, conflicts indubitably emerge leading to inconsistency. There is debate around whether principlism can provide definitive action-guiding moral prescriptions or only help structure intelligent analyses and justifications of moral choices. In this paper, I contend that applying concepts of moral symmetry and moral asymmetry allows us to modify one of principlism's principles-the principle of beneficence-into what I will call the principle of compassion. I argue that the principle of compassion can function as an arbitrating or primary principle within the principlist framework. The result is a view we might call compassionate principlism. Arguably, compassionate principlism leads to fewer inconsistencies and provides more acceptable action-guiding moral prescriptions than traditional principlism.

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Autonomy and Trust in Bioethics Onora O'Neill (2014)
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O'Neill's central concern is the paradox that recent discourse in bioethics has seen an increase in the protective measures of individual autonomy, and simultaneously an increasing public mistrust towards professionals and institutions concerned with bioethical issues. While O'Neill acknowledges the differences between those two areas, she believes that the basic oxymoron identified is illustrated in both. She is equally aware that explanations on that issue may have their moorings more in sociology than in moral philosophy, but still, she investigates whether there are sufficient normative grounds for an exchange between the protection of autonomy and a desirably high level of trust.

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The Need for Authenticity-Based Autonomy in Medical Ethics
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The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of " authenticity " ; the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to the concerns of medical ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires.

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'Consider the role of autonomy and whether it should rightly be regarded as the primary ethical principle in health care law'
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A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making: Part II: The Autonomy Model
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As part of a larger series addressing the intersection of law and medicine, this essay is the second of two introductory pieces. Beginning with the Hippocratic tradition and lasting for the next 2,400 years, the physician-patient relationship remained relatively unchanged under the benefi cence model, a paternalistic framework characterized by the authoritative physician being afforded maximum discretion by the trusting, obedient patient. Over the last 100 years or so, in response to certain changes taking place in both research and clinical practice, the bioethics movement ushered in the autonomy model, and with it, a profoundly different way of approaching decision making in medicine. The shift from the benefi cence model to the autonomy model is governed legally by the informed consent doctrine, which emphasizes disclosure to patients of information suffi cient to permit them to make intelligent choices regarding treatment alternatives. As this legal doctrine became established, philosophers identifi ed an inherent value in respecting patients as autonomous agents, even where patient choice seems to confl ict with the physician's duty to act in the patient's best interests. Whereas the benefi cence model presumed that the physician knew what was in the patient's best interests, the autonomy model starts from the premise that the patient knows what treatment decision is in line with his or her true sense of well-being, even where that decision is the refusal of treatment and the result is the patient's death.

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