Principlism, medical individualism, and health promotion in resource-poor countries: can autonomy-based bioethics promote social justice and population health?

Respect for autonomy or respect for persons has tended to be the leading principle of biomedical ethics or research ethics, respectively. This principle historically has its roots in the liberal moral and political tradition of the Enlightenment in Western Europe. Within this tradition, the ethical justification of actions or practices strongly depends on the free decisions of individuals, i.e. an action or practice can only be ethically justified when undertaken without any coercive influence and entered by free and informed agreement. While there have always been disagreements on the details, all theories of autonomy agree on two essential conditions: the first is liberty, specifying the independence from controlling influences; the second is agency, referring to the capacity for intentional action[1]. Used in clinical ethics, autonomy functions primarily to examine decision-making in health care and serves to identify actions that are protected by the rules of informed consent, informed refusal, truth telling, and confidentiality[1]. Autonomy-based approaches are strongly expressed in Tom Beauchamp and James Childress' classic text Principles of Biomedical Ethics for clinical bioethics and, for research ethics, the influential Belmont Report[1,2].Many criticisms of autonomy-based bioethics have appeared over the past thirty years from a number of different angles, such as feminism, casuistry, disability rights, multiculturalism, cultural studies, and ethnography. In this article, we take a different approach by exploring what we will call the 'medical individualism' that autonomy-based bioethics largely assumes, and by raising questions about the relevance and impact of autonomy-based bioethics in developing countries (and communities within developed equitable ones), especially in light of initiatives to 'build capacity' in research sites and to ensure access to healthcare in resource-poor settings. This paper argues that the medical individualism underlying aut