What role, if any, should principlism—more precisely, the “four principles approach” popularized by Tom Beauchamp and Jim Childress's Principles of Biomedical Ethics (PBE)—play in bioethics today? In the wake of Tom Beauchamp’s death days ago (February 19, 2025) and the pivotal role principlism still plays in that field—and should play in the adjacent, if still emerging field of anti-poverty ethics—we have good reason to ask that well-worn question once again.
“A Knock at the Door: A Contractualist Approach to and Defense of Principlism” argues that a “contractualist-principlism,” one that weds the work of T. M. Scanlon to that of Beauchamp and Childress, preserves principlism’s best insights while addressing some of its most serious shortcomings. Because it has the power to take seriously the well-being and autonomy of the vulnerable, as well as the just distribution of life-saving resources, contractualist-principlism is well-suited not only to bioethics but also to anti-poverty ethics.
Debates about principlism are, admittedly, nothing new (see Toulmin 1981; Green 1990; Clouser and Gert 1990; Gudorf 1994; Dancy 2000; Arras 2017). Consequently, many turn their attention elsewhere: to the public health threats posed by pandemics, to the health inequities facing the poorest among us, and also to the role implementation science might play in helping us “implement ethical ideals in messy real-world contexts” (Taylor 2022). However important those subjects are, shoring up principlism is, I would argue, at least as important. Indeed, answering our questions about public health, poverty, and implementation often depends, whether explicitly or not, on principles.
As I aim to explain, we shore up principlism best with the help of Scanlonian contractualism, according to which, moral rightness is a function of what we can justify to others in relations of mutual recognition. In short, we should be ready at any point to answer the proverbial “knock at the door” and justify our actions to those we hurt or even fail to help. After a brief overview of contractualism and its affinities with principlism, I turn to a number of objections to principlism and the ways a “contractualist-principlism” might address each.
First, some say principlism suffers from moral blindness. According to critics (cf. McMillan 2018), principlism obscures morally relevant aspects of a situation, encouraging us to force its features into one of the four principles: respect for autonomy, nonmaleficence, beneficence, and justice. Contractualism, however, focuses, first and foremost, not on principles but on the more basic reasons we have to value or do something. Principles are, then, reasonable responses to the valuable aspects of human life, including the self-determination, well-being, and fundamental equality that undergird the four principles. And yet, because of its pluralistic bent and radical openness to value wherever it may surface, contractualism has the power to perceive any and all morally relevant aspects of a given case—not only self-determination, well-being, and equality, but also relationality, community, identity, and more.
Second, some say principlism suffers from want of a decision procedure. According to critics (cf. Toulmin 1994), principlism is incapable of adjudicating or balancing competing claims made by the four principles—at least, in any defensible way. Contractualism, however, has—better, contractualism virtually is—a decision procedure. Scanlon’s “greater burden principle” tells us that an act is wrong if it is reasonably rejectable: that is, if the burden imposed on someone by a general social arrangement can be relieved without imposing a worse burden on anyone else. While complex and contestable, that adjudication procedure clarifies what Beauchamp and Childress call “balancing,” offering an approach very much in keeping with the reflective equilibrium endorsed by principlists.
Third, some say principlism suffers from a lack of systematicity. According to critics (cf. Green 1990), the four principles are a hodgepodge of theories: consequentialism, Kantianism, and Rawlsian contractarianism. Contractualism, however, is a unified and unifying theory. In fact, it appeals to many of us because of its ability to unify utilitarianism’s concern for consequences, Kantian concerns for autonomy, and Rawlsian concerns for fundamental equality of regard or status.
To be clear, I aim to offer not only a contractualist approach—or, rather, complement—to principlism, but also a contractualist defense of it. Some complain that the four principles are an incomplete set of vague, exception-riddled, defeasible generalizations. In contrast, I agree with those (cf. Nussbaum 2000) who say that a list of principles, whatever its inadequacies, is a useful guide for the finite and imperfect creatures we are. More to my point, the lack of a list of heuristic short-cuts to moral perception is itself criticizable on contractualist grounds. The lack of a list would impose unjustifiable burdens on a number of people: the patient whose autonomy is ignored by a doctor hell-bent on beneficence is burdened, to be sure, but so is the health professional forced to navigate complex cases with either no list or a list so long it is impractical.
True, many may object that endorsing a particular moral theory—contractualist or not—violates the pragmatic pluralism characteristic of Beauchamp and Childress’s framework. However, as I conclude, contractualism is admirably open-ended and pluralistic. Consequently, it avoids the obsession with a “tight” theory which might “neglect or distort much of our moral experience” (Childress 1997). Unfortunately, Scanlonian contractualism (unlike Rawlsian contractarianism) was not yet available at the time Beauchamp and Childress developed their ideas. Scanlon’s “Contractualism and Utilitarianism” (1982) postdates PBE (1979) by three years. Furthermore, Scanlon's fuller account of contractualism, What We Owe to Each Other (1998), came out in the years after principlism’s key criticisms first appeared (early-mid 1990s). We have good reason, therefore, to consider the gains that might be had from a contractualist-principlism.
At the very least, given the ability that approach has to maintain principlism’s best insights and address its shortcomings, opponents should explain what is wrong with a contractualist-principlism. In short, they should make arguments. Such arguments--however they turn out--seem an especialy fitting way to honor the influential arguments of Jim Childress and the late Tom Beauchamp and also to usher in the second half-century since the creation of the Belmont Commission.
What role, if any, should principlism—the “four principles approach” popularized by Tom Beauchamp and Jim Childress—play in bioethics today? In the wake of Tom Beauchamp’s recent death (February 19, 2025), I argue that a “contractualist-principlism” has the power to preserve principlism’s best insights while addressing some of its most serious objections: 1) its constrained moral perception; 2) its want of a method for adjudicating conflicting claims; and 3) its lack of theoretical unity. Moreover, a “contractualist-principlism,” based on the work of T. M. Scanlon, suits the needs not only of bioethics but also of the emerging field of anti-poverty ethics, which also focuses on the well-being and autonomy of the vulnerable, and the just distribution of life-saving resources. Finally, to complement my contractualist approach to principlism, I conclude with a contractualist defense of principles—in particular, as helpful heuristics or shortcuts for both moral perception and judgment.