Foundations of Bioethics Ethical Theories Moral Principles and

Foundations of Bioethics: Ethical Theories, Moral Principles, and Medical Decisions

Introduction • The branch of philosophy concerned with principles that allow us to make decisions about what is right and wrong is called ethics or moral philosophy. • Bioethics is specifically concerned with moral principles and decisions in the context of medical practice, policy, and research. • Moral difficulties connected with medicine are so complex and important that they require special attention. Medical ethics gives them this attention, but it remains a part of the discipline of ethics. • Thus, if we are to answer the question as to whethere any rules or principles to use when making moral decisions in the medical context, we must turn to general ethical theories and to a consideration of moral principles that have been proposed to hold in all contexts of human action.

Introduction This chapter reviews several major ethical theories which attempt to supply basic principles that we can rely on in making moral decisions. Those theories are: • • • Utilitarianism Deontology – Kant’s version and Ross’s version Rawls’s Theory of Justice Natural law ethics Virtue ethics Care ethics

Introduction • • • The chapter also reviews several broad principles that cut across some or all of the ethical theories examined. These principles are: Non-maleficence Benevolence Utility Rules of distributive justice Autonomy

Utilitarianism • According to Utilitarianism, a person should perform those actions which conform to the Principle of Utility. • The Principle of Utility says: a person should choose that action which produce the greatest good for the greatest number of people affected by the alternatives open to him. • The rightness or wrongness of actions is determined by the goodness or badness of the actions’ consequences, not by the actions themselves.

Utilitarianism • Because the morality of an action, according to utilitarianism, rests on its consequences, utilitarianism is called a “consequentialist theory of ethics. ” • There are different views as to what make a consequence good or bad. • According to the “classical” or “hedonistic” version, what makes a consequence good or bad is its effect on people’s happiness.

Utilitarianism • Roughly, a consequence is bad if it reduces happiness, good if it increases happiness. • Happiness, in turn, is understood to mean: an increase in pleasure and/or decrease in pain. • Because of the emphasis on happiness, Utilitarianism is sometimes called “the greatest happiness principle”.

Application to bioethic • In August 2000, conjoined twins, named Mary and Jodie were born in a hospital in Manchester England. Their spines were fused, and they had one heart and one pair of lungs between them. Jodie, the stronger one, was providing blood for her sister. • The prognosis was that without intervention, both girls would die within six months. The only hope was an operation to separate them. This would save Jodie, but Mary would die immediately. • Thus, there were two options: (a) Not intervene and see both babies die Or (b) Intervene and save one life, Jodie.

Application to bioethics • What is the acceptable course of action? • According to utilitarian, we need to decide which course of action will produce the greatest good for the greatest number of people affected by the action. • It is plausible to interpret utilitarianism as supporting alternative (b). Surely it is better to save one life rather than not.

Deontology • As noted earlier, consequentialist theories of ethics find the basis for an action’s morality in the consequences produced by the action rather than in the action itself. • Deonological theories of ethics, argue that it is features of the action itself, apart from consequences, which determine its morality. • When an action has the relevant features then we can say it is our duty (or obligation) to perform it.

Deontology • It is this emphasis on duty that earns them the name “deontological”, which is derived from the Greek word for “duty” or “obligation”. • There are different versions of deontology. We examine two of them, those of Immanuel Kant and W. D. Ross.

Kant • According to Kant, we have an obligation to perform an action if it satisfies what he called “the categorical imperative”. • Kant formulated three versions of the imperative. Though differing in wording and emphasis, he understood them as three different “views” of the same overarching principle. They are:

Categorical imperative • Act only according to that maxim by which you can at the same time will that it should become universal law. • Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only. • Every rational being must so act as if he were through his maxim always a legislating member in the universal kingdom of ends. • We shall restrict ourselves to the first two versions, starting with the first.

First version • If you decide to have an abortion and go through with it, it is possible to view your action as involving a rule. • You can be thought of as endorsing a rule to the effect “Whenever I am in circumstances like these, then I will have an abortion. ” Kant calls such a rule a “maxim. ” • In his view, all reasoned and considered actions can be regarded as involving maxims.

First version • The maxims in such cases are personal or subjective, but they can be thought of as being candidates for moral rules. • If they pass the test imposed by the categorical imperative, then we can say that such actions are right. Furthermore, in passing the test, the maxims cease to be merely personal and subjective. They gain the status of objective rules of morality that hold for everyone.

First version • Kant calls the principle “categorical” to distinguish it from “hypothetical” imperatives. These tell us what to do if we want to bring about certain consequences— such as happiness. • A categorical imperative prescribes what we ought to do without reference to any consequences. The principle is an “imperative” because it is a command.

First version • The test imposed on maxims by the categorical imperative is one of generalization or “universalizability. ” The central idea of the test is that a moral maxim is one that can be generalized to apply to all cases of the same kind. • That is, you must be willing to see your rule adopted as a maxim by everyone who is in a situation similar to yours. You must be willing to see your maxim universalized, even though it may turn out on some other occasion to work to your disadvantage.

First version • The best way to illustrate the first version of the category imperative is to consider a possible instance where an action fails the test. • Suppose, for example, that I am a physician and I tell a patient that he has a serious illness, although I know that he doesn’t. This may be to my immediate advantage, for the treatment and the supposed cure will increase my income and reputation. • The maxim of my action might be phrased as, “Whenever I have a healthy patient, I will lie to him and say that he has an illness. ”

First version • Now suppose that I try to generalize my maxim (apply the first version of the categorical imperative). In doing so, I will discover that I am willing the existence of a practice that has contradictory properties. • If “Whenever any physician has a healthy patient, she will lie to him and say he has an illness” is made a universal law, then every patient will be told that he has an illness. Trust in the diagnostic pronouncements of physicians will be destroyed, while my scheme depends on my patients’ trusting me and accepting the truth of my lying diagnosis.

First version • It is as if I were saying, “Let there be a rule of truth telling such that people can assume that others are telling them the truth, but let there also be a rule that physicians may lie to their patients when it is in the interest of the physician to do so. ” • In willing both rules, I am willing something contradictory. Thus, I can will my action in a particular case, but I can’t will that my action be universal without generating a logical conflict.

First version • If we return to the Mary and Jodie example introduced earlier, we can see that Kant’s approach to evaluating the alternatives (allow both to die or save one but sacrifice the other) would be different from that of utilitarianism. Kant would reject the idea that we should look at the consequences of the two options. • Instead we should ask if something like the following rule could be universalized (that is, avoid “contradiction”): • Save one life in situations where failing to do so will result in the loss of life of two. • Can it be universalized? On the face of it, there is no obvious contradiction in trying to do. As a result, the Kantian and the Utilitarian could well agree on the morality of the action but for different reasons.

Second version • Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only. • This version illustrates Kant’s notion that every rational creature has a worth in itself. • This worth is not conferred by being born into a society with a certain political structure, nor even by belonging to a certain biological species.

Second version • The worth is inherent in the sheer possession of rationality. Rational creatures possess what Kant calls an “autonomous, self-legislating will. ” • That is, they are able to consider the consequences of their actions, make rules for themselves, and direct their actions by those self-imposed rules. Thus, rationality confers upon everyone an intrinsic worth and dignity. • So, we are treating a person (including ourselves) as an end (and not just a means to an end) when we act towards him in such a way that recognize his rationality or autonomy.

Second version • A non-bioethical example illustrates his meaning: • You need money and you want a loan but you know you can’t pay it back. It occurs to you to ask a friend for the money with the promise of paying it back. You are proposing to lie to the person and, in so doing, you are treating them merely as a means to one of your goals. • On the hand, imagine the same situation except this time you explain the situation to your friend, hoping still, of course, to get the money. But now you are allowing your friend to make his own free and fully-informed decision to give you the money or not. You have recognized and engaged the friend as a rational agent. You have respected his dignity.

Second version • Recall again the example of Mary and Jodie. How might we apply the second version of the categorical imperative to this case. Here is one possible way to phrase the question: • If we elect to save Jodie and allow Mary to die, have they both been treated as “ends”? One answer might be no because Mary has been “sacrificed” to allow Jodie to live – she is being treated merely as a means to Jodie’s survival. • If this is the correct conclusion then a question arises as to whether it is consistent with the apparently correct conclusion to the first version of the imperative, that there is no inconsistency in universalizing the rule: save one life when the alternative is to see two die.

W. D. Ross • W. D. Ross attempts to incorporate aspects of utilitarianism and aspects of Kantianism. • Ross rejected the utilitarian notion that an action is made right by its consequences alone, but he was also troubled by Kant’s view, if a rule passed the categorical imperative (and became a duty to follow), it could have no exceptions, it was absolute. • He saw not only that such rules fail to show sensitivity to the complexities of actual situations, but also that they sometimes conflict with one another.

Prima facie duties • Like Kant, Ross is a deontologist, but he believed (as Kant apparently did not) that moral duties can conflict, in which case their relative merits had to be weighed and the chosen action based on the outcome of that weighing. • Because duty A might be outweighed by another duty B in a situation where the two conflict, it might seem inappropriate to call A a duty in the first place. Aware of this concern, Ross describes A and B as prima facie duties. They are duties we have “all things being equal”. But in a situation only one of them will turn out (after weighing) to be our actual duty.

Prima facie duties • When is something our duty? Ross does not propose any general test of obligation like Kant’s categorical imperative. Instead, Ross falls within the tradition of “ethical intuitionism”. After a careful examination of the facts surrounding a case, he believes that we then are able to intuit the appropriate duty. • Ross claims that our experience with such cases puts us in a position to come to know our prima facie duties with the same degree of certainty as when we grasp the mathematical truth that a triangle has three angles. • Furthermore, according to Ross, our experience of many individual cases puts us in a position to recognize the validity of a general statement like “It is wrong to cause needless pain. ” We come to see such rules in much the same way that we come to recognize the letter A after having seen it written or printed in a variety of handwritings or typefaces.

Prima facie duties Ross offers a list of duties that he considers binding on all moral agents. (He did not claim that the list is exhaustive). 1. Duties of fidelity: telling the truth, keeping actual and implicit promises, and not representing fiction as history 2. Duties of reparation: righting the wrongs we have done to others 3. Duties of gratitude: recognizing the services others have done for us

Prima facie duties 4. Duties of justice: preventing a distribution of pleasure or happiness that is not in keeping with the merit of the people involved 5. Duties of beneficence: helping to better the condition of other beings with respect to virtue, intelligence, or pleasure 6. Duties of self-improvement: bettering ourselves with respect to virtue or intelligence 7. Duties of non-malfeasance: avoiding or preventing an injury to others

Bioethical example • Recalling the example of Mary and Jodie, Ross would answer the question of whether it is right or wrong to separate the twins by first seeing which of the prima facie duties are applicable and, in the event there is a conflict, examine the non-moral facts of the case, and with these facts as background, weigh the duties against one another. • In considering the case, the duties of non-malfeasance and beneficence seems relevant and it is plausible to read them as implying that there is an obligation to separate the twins.

Rawls’s theory of justice • The theory of justice formulated by the philosopher John Rawls can be understood as attempting to combine the strengths of utilitarianism and deontology while avoiding the weaknesses of each view. • For Rawls, the central task of government is to preserve and promote the liberty and welfare of individuals. Thus, principles of justice are needed to serve as standards for designing and evaluating social institutions and practices. • Rawls’ position has direct relevance to such bioethical issues as who should have access to health care, how donated organs should be distributed, and who should pay for society’s medical costs.

Principles of justice Rawls argues that there are two fundamental principles of justice: 1. Each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all. 2. Social and economic inequalities are to be arranged so that they are both a) to the greatest benefit of the least advantaged b) (b) attached to offices and positions open to all under conditions of fair equality of opportunity.

Principles of justice • For Rawls, these two principles are taken to govern the distribution of all social goods: liberty, property, wealth, and social privilege. • The first principle has priority. It guarantees a system of equal liberty for all. The second principle governs the distribution of social goods other than liberty. • Though Rawls’ overall position has relevance to individual medical decisions, it’s most important application is to the social institutions and practices of medical care and research.

Bioethical example: consent • According to Rawls’s principles it is wrong to exploit one group of people or even one person for the benefit of others. • Thus, experiments in which people are forced to be subjects or are tricked into participating are ruled out. • A person has a right to decide what risks she is willing to take with her own life and health. Thus, voluntary consent is required before someone can legitimately become a research subject.

Bioethical example: health care • The implication of Rawls position seems to be that everyone is entitled to health care. • First, it could be argued that health is among the “primary goods” that Rawls’s principles are designed to protect and promote. (“Primary goods” are the rights, opportunities, powers, wealth, and such that are both worth possessing in themselves and are necessary to securing the more specific goods people may want. ) • Second, it could be argued that the inequalities of the health care system can be justified only if those in most need can benefit from them. Since this is not obviously the case with the present system, Rawls’s principles seem to call for a reform that would provide health care to those who are unable to pay.

Natural law ethics • Natural law theories of ethics share the general idea that the rightness of actions is something determined by nature itself, rather than by the laws and customs of societies or the preferences of individuals. • The most well-known, and fully articulated, version of natural law is that formulated by St. Thomas Aquinas and endorsed by the Catholic Church. • Borrowing from Aristotle, the Thomistic version of natural law sees the universe organized in a teleological way. That is, the universe is structured in such a way that each thing in it has a goal or purpose. Thomism importantly add that this teleological structure was brought about by God so that the purposes found in the Universe are a reflection of God’s purposes.

Natural law ethics • For example, when conditions are right, a tadpole will develop into a frog. In its growth and change, the tadpole is following “the law of its nature. ” It is achieving its goal. • Humans have a material nature, just as a tadpole does, and in their own growth and development they, too, follow a law of their material nature. • But humans also possess a trait that no other creature does: reason. Thus, the full development of human potentialities—the fulfillment of human purposes or ends —requires that we follow the direction of the law of reason, as well as being subjected to the laws of material human nature.

Natural law ethics • We rely upon reason to determine what our ends are and how we can achieve them. In particular, reason directs us toward our good as the goal of our action, and what that good is, is discoverable within our nature. • The human good is “built into” human nature in the way that, in a sense, a frog is already “built into” a tadpole. Thus, the good is that to which we are directed by our natural inclinations as both physical and rational creatures.

Natural law ethics • These built-in inclinations are the basis for our moral duties. For example: • Like other creatures, we have a natural inclination to preserve our lives; consequently, reason imposes on us an obligation to care for our health, not to kill ourselves, and not to put ourselves in positions in which we might be killed. • We realize through reason that others have a rational nature like ours, and we see that we are bound to treat them with the same dignity and respect that we accord ourselves.

Natural law ethics • When we see that humans require a society to make their full development possible, we realize that we have an obligation to support laws and practices that make society possible. • We have a natural inclination to propagate our species (viewed as a “natural” good), so reason places on us an obligation not to thwart or pervert that inclination (by for example using condoms or masturbating). • As the examples illustrate, according to natural law ethics, through the application of reason, it should be possible to establish a body of moral principles and rules. These are the doctrines of natural law. • Following are two principles especially relevant to bioethics.

Principle of double effect • A particular kind of moral conflict arises when the performance of an action will produce both good and bad effects. On the basis of the good effect, it seems it is our duty to perform the action; but on the basis of the bad effect, it seems our duty not to perform it. • What are we obligated to do in this situation? The principle of double effect is intended to help in the resolution of these kinds of conflicts.

Principle of double effect The principle holds that such an action should be performed only if the intention is to bring about the good effect and the bad effect will be an unintended or indirect consequence. More specifically, four conditions must be satisfied: 1. The action itself must be morally indifferent or morally good. 2. The bad effect must not be the means by which the good effect is achieved. 3. The motive must be the achievement of the good effect only. 4. The good effect must be at least equivalent in importance to the bad effect.

Double effect example The principle might be illustrated by the example of Mary and Jodie: • The doctors wanted to save the life of Jodie, a morally good action. • The death of Mary was a bad consequence of saving Jodie but it was not the means; it was a foreseen but unintended by-product of saving Jodie. • The doctors intended to save the life of Jodie, it was not to kill Mary. • Saving the life of Jodie is morally as significant as the death of Mary.

Principle of totality • This principle says that an individual has a right to dispose of his or her organs or to destroy their capacity to function only to the extent that the general well-being of the whole body demands it. • Thus, it is clear that we have a natural obligation to preserve our lives, but, by the Roman Catholic view, we also have a duty to preserve the integrity of our bodies. • This duty is based on the belief that each of our organs was designed by God to play a role in maintaining the functional integrity of our bodies— that each has a place in the divine plan. As we are the custodians of our bodies, not their owners, it is our duty to care for them as a trust.

Principle of totality • The principle of totality has implications for a great number of medical procedures. • Strictly speaking, even cosmetic surgery is morally right only when it is required to maintain or ensure the normal functioning of the rest of the body. • More important, procedures that are typically employed for contraceptive purposes— vasectomies and tubal ligations—are ruled out since such procedures involve “mutilation” and the destruction of the capacity of the organs of reproduction to function properly.

Virtue ethics • Virtue ethics is ethics based on character. Its fundamental idea is that a person who has acquired the proper set of dispositions will do what is right when faced with a situation involving a moral choice. • Thus, virtue ethics doesn’t involve invoking principles or rules to guide actions. • The virtuous person is both the basic concept and the goal of virtue ethics. The virtuous person is one who acts right, because she is just that sort of person.

Virtue ethics • Right actions flow out of character, and the virtuous person has a disposition to do the right thing. Rules need not be consulted, calculations need not be performed, abstract duties need not be considered. • In medical contexts, virtue ethics calls attention to the central role which such virtues as courage, loyalty, integrity, compassion, and benevolence, along with determination and intelligence, should play in the practices of medical providers.

Care ethics • Care ethics is an outgrowth of feminist ethics or, perhaps more accurately, is a particular strand of feminist ethics. • Care ethics is not a unified doctrine that can be captured in a set of abstract statements. It is perhaps best characterized as a family of beliefs about the way values should be manifested in character and in behavior. • It is unified by a set of shared concerns and commitments, as well as by the rejection of the traditional philosophical view that ethics can be adequately represented by rules and principles. • As the name implies, the sentiment of caring is taken as a central consideration in deciding what to do. In medical ethical contexts this perspective is perhaps exemplified by how a doctor looks at his or her patient: is this a problem to fix or is this a person whose health I care about?

General moral principles relevant to bioethics • The following are thumbnail sketches of a number of principles which most, if not all, of the ethical theories considered endorse in one form or another. They all have relevance to bioethical issues.

Principle of Non-maleficence • “Above all, do no harm” is perhaps the most famous and most quoted of all moral maxims in medicine. It captures in a succinct way what is universally considered to be an overriding duty of anyone who undertakes the care of a patient.

Principle of beneficence • The principle of beneficence can be stated in various and different ways. Here is one formulation: We should act in ways that promote the welfare of other people. That is, we should help other people when we are able to do so.

Principle of utility • The principle of utility can be formulated in this way: We should act in such a way as to bring about the greatest benefit and the least harm. • The principle is the very foundation of the moral theory of utilitarianism. However, the principle need not be regarded as unique to utilitarianism. • It can be thought of as one moral principle among others that present us with a prima facie duty, and, as such, it need not be regarded as always taking precedence over others. • In particular, we would never think it was justified to deprive someone of a right, even if by doing so we could bring benefit to many others.

Rules of distributive justice • We expect (and can demand) to be treated justly in our dealings with other people and with institutions. The following rules reflect this basic sentiment. • They are best understood in terms of John Rawls’ position summarized earlier. • From a bioethical perspective, they have clear relevance to questions about, for example, access to health insurance, the distribution of organs, and who shoulder the burden of health care costs.

Rules of distributive justice Equality • According to the principle of equality, all benefits and burdens are to be distributed equally. Need • The principle of need is an extension of the egalitarian principle of equal distribution. • If goods are parceled out according to individual need, those who have greater needs will receive a greater share. However, the outcome will be one of equality. • Since the basic needs of everyone will be met, everyone will end up at the same level. The treatment of individuals will be equal, in this respect, even though the proportion of goods they receive will not be.

Rules of distributive justice Contribution • According to the principle of contribution, people should get back that proportion of social goods that is the result of their productive labor. Effort • According to the principle of effort, the degree of effort made by the individual should determine the proportion of goods received by the individual.

Principle of autonomy • The principle of autonomy can be stated this way: Rational individuals should be permitted to be selfdetermining. According to this formulation, we act autonomously when our actions are the result of our own choices and decisions. • Autonomy is significant not only because it is a condition for moral responsibility, but because it is through the exercise of autonomy that individuals shape their lives. Autonomy is a significant consideration when thinking about euthanasia and abortion.