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# The four principles of bioethics (principlism)

- Topic

Four principles help frame an ethical problem in medicine: respect autonomy, do good, do no harm and be fair.

Updated Nov 5, 2026

## Key points

- Autonomy: a capable, informed person decides about their own body and treatment.
- Beneficence: act for the patient's good; nonmaleficence: do not cause avoidable harm.
- Justice: treat like cases alike and share scarce resources fairly.
- They are prima facie: none always wins; in a conflict you must justify which weighs more in that case.
- The conflict exams ask most: autonomy versus beneficence (the capable patient who refuses treatment).

## What it is

Principlism organises clinical ethics around four principles: respect for autonomy, beneficence, nonmaleficence and justice. It arose in the United States in the late 1970s, after the Belmont Report (1978) proposed three principles for research with human subjects. The four principles are prima facie duties: they bind unless they clash with another duty of equal or greater weight. They do not hand out the answer; they help name the values in conflict and justify the decision.

## Key facts

- The Belmont Report (US National Commission, 1978) proposed three principles for research: respect for persons, beneficence and justice.
- In 1979 the clinical version with four principles appeared, separating nonmaleficence from beneficence.
- A prima facie duty binds «at first sight»: it gives way only to a stronger duty in that particular case.
- Principles are specified (turned into concrete rules, such as informed consent) and balanced (weighed against each other in the case).

## The four principles at a glance

| Principle | What it asks | Clinical example | Typical conflict |
| --- | --- | --- | --- |
| Respect for autonomy | Respect the decisions of a capable, informed person | Informed consent before surgery | A capable patient refuses a treatment that would help |
| Beneficence | Act for the patient's good | Offer the treatment with the best balance of benefit and risk | Doing good without imposing the doctor's idea of good (paternalism) |
| Nonmaleficence | Cause no avoidable harm and no unjustified risk | Order no unnecessary tests or treatments | Treatments with serious but necessary side effects |
| Justice | Treat equals equally and share resources fairly | Allocate intensive care beds by public clinical criteria | One patient's need against everyone else's |

## In clinical practice

- In a hard case, naming which principle supports each option shows where the real conflict lies.
- Respecting autonomy first requires checking that the person has decision-making capacity.
- Beneficence does not allow deciding for a capable patient: that is paternalism.
- Justice asks that age, ethnicity, religion or ability to pay do not change the quality of care.

## Legal framework in Colombia

- Colombia's Law 23 of 1981 (Code of Medical Ethics) sets out these ideas in its declaration of principles (art. 1) and in its rules: care for everyone who needs it (art. 3) and ask for the patient's consent (art. 15).
- The text of Law 23 was checked on 2026-11-05 in the Función Pública Gestor Normativo.

## Memory aid

«A-B-N-J»: Autonomy, Beneficence, Nonmaleficence, Justice; the middle two look at the patient, the J looks at everyone.

## Test yourself

Think of the answer, then tap the question to see it.

## What are the four principles of clinical bioethics?

Respect for autonomy, beneficence, nonmaleficence and justice.

## What does it mean that the principles are prima facie?

They bind unless they clash with a weightier duty in that case; none always wins, and the conflict is settled by justifying which weighs more.

## Which three principles did the Belmont Report propose for research with human subjects?

Respect for persons, beneficence and justice.

## A capable, informed patient refuses a blood transfusion. Which principles are in conflict?

The patient's autonomy against the doctor's beneficence; if the patient is capable and informed, their decision generally prevails.

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## Connections

## Related 4

- [Respect for autonomy](https://durgical.com/en/medical-ethics/respect-for-autonomy/)
- [Beneficence](https://durgical.com/en/medical-ethics/beneficence/)
- [Nonmaleficence: «first, do no harm»](https://durgical.com/en/medical-ethics/nonmaleficence-first-do-no-harm/)
- [Justice: fair distribution and equal treatment](https://durgical.com/en/medical-ethics/justice-fair-distribution-and-equal-treatment/)

[← All of medical ethics](https://durgical.com/en/medical-ethics/)

Educational content on ethics and health law; not legal advice. Laws and case law change: each page links the official text and says when it was last checked. For a real case, read the text in force and ask a lawyer or the medical ethics tribunal.

Sources: [The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research](https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html) (U.S. Department of Health and Human Services, Office for Human Research Protections, 1979); [WMA International Code of Medical Ethics](https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/) (World Medical Association, 2022); [Ley 23 de 1981, por la cual se dictan normas en materia de ética médica](https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=68760) (Función Pública, Gestor Normativo (Colombia), 1981).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/medical-ethics/the-four-principles-of-bioethics/