As medical LLMs transition to clinical deployment, assessing their ethical reasoning capability becomes critical. While achieving high accuracy on knowledge benchmarks, LLMs lack validated assessment for navigating ethical trade-offs in clinical decision-making where multiple valid solutions exist. Existing benchmarks lack systematic approaches to incorporate recognized philosophical frameworks and expert validation for ethical reasoning assessment. We introduce PrinciplismQA, a philosophy-grounded approach to assessing LLM clinical medical ethics alignment. Grounded in Principlism, our approach provides a systematic methodology for incorporating clinical ethics philosophy into LLM assessment design. PrinciplismQA comprises 3,648 expert-validated questions spanning knowledge assessment and clinical reasoning. Our expert-calibrated pipeline enables reproducible evaluation and models ethical biases. Evaluating recent models reveals significant ethical reasoning gaps despite high knowledge accuracy, demonstrating that knowledge-oriented training does not ensure clinical ethical alignment. PrinciplismQA provides a validated tool for assessing clinical AI deployment readiness. Our data and test scripts are fully released on https://github.com/FreedomIntelligence/PrinciplismQA.

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