is approach has been dominated by what has come to be known as "principalism", which is an approach to reasoning about ethical problems that, for the most part, proceeds neither deductively from higher-order theory, nor inductively from a detailed attention toward the situation presented, but, rather, "from middle-level principles down to the case presented" (Wolf, 1994, p. 396). The four principles involved in the bioethical process are (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. Principalism and the four principles dominated the practice of bioethics until the early- to mid-1990s. A paradigm shift appears to have begun, however, around the mid-1990s.
Fundamental modifications are evolving in the method of reasoning downward from middle-level principles, to the content of those principles, and to the failure of bioethics to address differences associated with gender, race, ethnicity, and insurance status (Lowes & Laufer, 1994). There is a proliferation of alternatives to principlism. Suggested changes include a demand for even more abstract moral theory deductively applied, advocacy of specified principlism, a revival of causality, a call for an inductivism based on empirical information or ethnography, interest in narrative bioethics, and the articulation of care-based ethics. There are also challenges from a variety of perspectives to the content of the four principles (Wolf, 1994).
In addition, there is in progress a rise of empiricism in bioethics, as illustrated by an increased level of attention to differences in race, ethnicity, and gender. Empirical studies increasingly look for differences by race or ethnicity and in relation to medical decision-making (Blechner, 1994; Montoya, Trevino, & Kreitz, 1999).
The politics of providing mental health care services to (1) minority and poor families and (2) groups of people degraded by society, such as HIV/AIDS patients, in the United States have ...