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time between the patients in a unit. A hospital has to manage resources and politi-
cal and legal regulations organize the allocation of ressources within the health care
system.
At first sight the four principles seem to be highly plausible normative guide-
lines for decision making in a medical context that are easy to apply. Beauchamp
and Childress argue that their four principles approach is more concrete and better
applicable than abstract ethical theories on the one hand side. On the other hand
side the four principles are open enough to be applied to different situations and
in different contexts and do not need to be too detailed like complex rule systems.
Another advantage of this approach can be seen in its simplicity. Ethical theory and
meta ethics provide a vast variety of approaches and theoretical starting points. This
leads to an ongoing debate about complex theoretical assumptions and ultimate jus-
tification of normative rules. It is unlikely that this plurality will dissolve in the near
future, the debate will go on and thus commonly share rules like those based on
human rights will not be derived from a commonly shared theoretical approach in
ethics. Similar to the plurality (and disagreement) on the level of theories there is a
plurality of positions on the level of evaluation of concrete actions such as abortion
or stem cell research. Here it is also difficult to find commonly shared positions. In
spite of the plurality on the level of theoretical approaches as well as concrete appli-
cable rules there is a level of commonly shared principles within certain contexts.
Beauchamp and Childress therefore suggest four principles of medical ethics that
can be seen as commonly shared positions despite differences with regard to theory
or concrete practice. On the intermediate level of mid-level norms they describe
a normative position that can be seen as a least common denominator and shared
starting point in medical ethics.
1
The four principles in between theoretical reasoning on the one hand side and
concrete rules on the other hand side also describe the position of ought to do rules
derived from those principles within a system of deontic rules. Ought to do rules
derived from the four principles provide ethical guidance and have a structure like
“You should not harm the patient”. The rules still need to be applied in concrete sit-
uations and principles can aim in different even conflicting directions when applied.
Cutting someone during surgery could be understood as an act of bodily violence
against the principle of non-maleficience while at the same time the surgery aims
at the beneficience of the patient. A patient might wish for an unsecure treatment
or refuse a necessary treatment and thus by following the principle of autonomy
and respecting the patient's wish a doctor may harm the patient and act against the
principle of non-maleficience. Providing care for one patient as good as possible
may lead to neglecting and thus harming other patients bringing the principles of
beneficience and justice into conflict. The examples show that the principles can
conflict with each other and thus cannot be applied in a mechanistic simple way.
The openness of the principlism, which is described as strength by Beauchamp and
Childress, can thus be also seen as a central problem of this approach. As Feuerstein
and Kollek point out, the principles are under-determined as well as over-determined
1
Besides the wide use the principles have also been criticized from different sides. For a
critique of the principles in different fields of application see the contributions in [8].
