Principlistic Equality: The Relative Importance of the Four Principles Among Primary and Urgent Care Clinicians

Principlistic equality, the idea that the four principles of bioethics should be considered as nonhierarchical in the abstract, is core to the original conception of principlism, but it is unclear whether clinicians endorse principlistic equality in practice. We surveyed 227 primary and urgent care clinicians (62.8% response rate), finding just over half of respondents (51.9%) endorsed a hierarchy among the principles. Among this group, non-maleficence was most often over-weighted (by 57.1% of these respondents), followed by autonomy (42.0%), justice (35.7%), and beneficence (34.8%). Practicing in a safety net setting (OR = 0.51, 95% CI = 0.27-0.96) and spending less than half of one's time in direct patient care (OR = 0.23, 95% CI = 0.09-0.58) were associated with significantly lower odds of endorsing principlistic equality. Several clinician characteristics were associated with giving additional weight to certain principles. Our findings provide insight into how clinicians value the four ethical principles, which could inform education and training initiatives in bioethics.