Contemporary clinical ethics was founded on principlism, and the four 
principles: respect for autonomy, nonmaleficence, beneficence and justice, 
remain dominant in medical ethics discourse and practice. These principles are 
held to be expansive enough to provide the basis for the ethical practice of 
medicine across cultures. Although principlism remains subject to critique and 
revision, the four-principle model continues to be taught and applied across the 
world. As the practice of medicine globalizes, it remains critical to examine 
the extent to which both the four-principle framework, and individual principles 
among the four, suffice patients and practitioners in different social and 
cultural contexts. Using the four-principle model we analyze two accounts of 
surrogate decision making - one from the developed and one from the developing 
world - in which the clinician undertakes medical decision-making with 
apparently little input from the patient and/or family. The purpose of this 
analysis is to highlight challenges in assessing ethical behaviour according to 
the principlist model. We next describe cultural expectations and mores that 
inform both patient and clinician behaviors in these scenarios in order to argue 
that the principle of respect for persons informed by culture-specific ideas of 
personhood may offer an improved ethical construct for analyzing and guiding 
medical practice in a globalized and plural world.