A sociological account of the growth of principlism.

Bioethicists' attraction to principlism is rooted in a Western view of how matters that affect the public ought to be deliberated and decided: their resolution ought to be so structured and constrained that it can be understood and verified even by those at a remove from the circumstances of the problem. That view of deliberation, itself fostered by the Western view of government, has encouraged principlism to spread from its source in human subjects research into other areas of bioethics discourse. The three principles of respect for persons, beneficence, and justice first articulated in the Belmont Report and the four similar principles published in Beauchamp and Childress's Principles of Biomedical Ethics have structured decisionmaking in bioethics. [1] In this paper I do not address whether these principles are correct, or apply them to problems. Nor do I explain why certain principles have become institutionalized rather than others. Rather, I engage in an investigation of principlism from the perspective of the sociology of knowledge: Why has the use of a small set of principles--whichever they may be--become common in bioethics? The sociology of knowledge assumes that decisionmaking systems, such as principlism, do not become influential because they are "the best" or "correct," but rather because the social conditions are right for those promoting the system to defeat the the champions of competing ideas. That an idea is the "most coherent," for example, is important in this competition only if the people in authority to judge the legitimacy of the ideas agree that "coherence" is important. Everyone recognizes that to understand the dominance of principlism we must go back in history, perhaps to the Nuremberg trial. I propose that to understand the social determinants of principlism we must go back much farther, to 1494, when the first textbook for double-entry bookkeeping was written. This form of bookkeeping is the tabulation that any department chair is familiar with: What are our costs for the next year; what is our income? And more specifically, are the costs associated with this component of the business generating returns that justify the costs? This process is taken so much for granted it is hard to imagine an alternative. Before the invention of this system, however, accounts from businesses were basically a "rambling story with numbers" that served to "assist the memory of the businessman," but not help with evaluation of the businessman's actions. [2] For example, an account from early 14th century England stated: Account of Maurice Hunter and Fynlay Sutor, balies of the burgh of Stivelyn, given up at Dunbretan on the twenty-fifth day of January, . of the fermes of the said burgh for the two terms of this account. They charge themselves with . 36 [pounds sterling] received on the account of the fermes of the said burgh for the year of their account. Whereof, for their superexpenses made in the preceding account 40 s. 1 d halfpenny. And in the duties to the abbot of Cambuskyneth and Dunfermelyn, . during the time of the account, 23 [pounds sterling]. , 5 s. 4 d. And to the Friars Preachers of Stivelyn. (p. 40) Double-entry bookkeeping was a major innovation in economic history. Two changes in the accounts system also transformed it into a procedure that allowed for calculability, efficiency, and predictability in human action, paving the way for modern capitalism. The first change was that the new system was a means of discarding information deemed to be extraneous to decisionmaking. After all, does it matter to the calculation of profit that Hunter and Sutor live in the burgh of Stivelyn? This could be put in an address book. The new accounting just had numbers, with all other information removed. The second change was that these numbers took on a new degree of calculability. Instead of putting proceeds on one list (the account above) and costs on another, these two were translated into a common metric called "profit," making an evaluation of each action much more precise. …