Principlism Theory

Many credit Bjorn Ibsen, working in Copenhagen, Denmark in 1953, with the birth of modern Intensive Care Medicine. He used positive pressure ventilation, adapted from anaesthetic practice, to treat patients with respiratory failure secondary to a poliovirus epidemic.1 The early years of the new specialty were associated with great promise and innovation as critically unwell patients were treated with increasing levels of success. However, as the technology and clinical acumen advanced, previously unheralded ethical difficulties and limitations of this new discipline emerged. Unforeseen clinical scenarios of patients “being kept alive by machines” in various states of suspended physiological animation emerged as partial or virtual reality.

Firstly, I will criticise Principlism as a unifying theory of bioethics wholly applicable to ICU based on definition and specificity. Lack of definition of the four principles allows much scope for interpretation which reduces their applicability to some complex moral issues arising in ICU. I will also contend that attempts by some advocates to award an increased value to autonomy are at variance with the origins of principlism and suffer from a lack of clarity in their conception and application. Then, given the myriad of conflicting moral issues surrounding end-of-life affairs in ICU, I will argue that the proposed methodology suggested by proponents of principlism to resolve conflict is flawed and overly dependent on moral

Excessive power of autonomy changes a beneficent doctor-patient relationship to a client-consumer type relationship. I contend that this form of doctor-patient relationship will perpetuate the provision of inadvisable, harmful therapies. Without a beneficent objective, advances in technology and care provision of modern ICU would become ineffective for society. Care would be provided merely on request and provided excessively where it is unlikely to produce a meaningful benefit. I will argue that while the term “meaningful benefit” is open to discussion, it must consist of a significant component of medical judgement.

The principle of non-maleficence is often considered as a continuum of beneficence, as many therapies with beneficent aims have harmful side effects. I will contend that the avoidance of harm becomes a much greater moral concern if a clinician believes they are involved in a non-therapeutic relationship with a patient as that unilaterally demanded by excessive