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When four principles are too many: bloodgate, integrity and an action-guiding model of ethical decision making in clinical practice
  1. William Muirhead
  1. Correspondence to Dr William Muirhead, Foundation Office, Post Graduate Medical Education Centre, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire LN2 5QY, UK;will.muirhead{at}


Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken in clinical practice. Two kinds of medical ethical decisions are distinguished: biosocial ethics and clinical ethics. It is argued that principlism is an inappropriate model for clinical ethics as it is neither sufficiently action-guiding nor does it emphasise the professional integrity of the clinician. An alternative model is proposed for decision making in the realm of clinical ethics.

  • Medical ethics
  • clinical ethics
  • principle-based ethics
  • applied and professional ethics
  • surgery
  • codes of/position statements on professional ethics
  • philosophical ethics

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  • Funding This work received no specific funding, but an earlier draft was awarded two prizes by the Institute of Medical Ethics.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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