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Moral Theory

John McMillan, PhD


Introduction

The RCPSC recommends “Knowledge of major ethical theories” as an educational objective for Canadian physicians.1 Given that this primer is an introduction to the major philosophical moral theories, it is important to explain why it is important that physicians think about these ideas.

Most physicians deliberate and make effective decisions about hard moral problems without knowing much or anything about moral theory. However, moral theories can help physicians to justify and reflect upon the ethical decisions that they make. Often physicians will explain a decision on the basis of their clinical experience: “I just know that in a case like this you should this.” However, while clinical experience is often a good guide to the right thing to do, it is fallible. Un-picking the reasoning that is implicit in good decision-making can help us to discover why it is that we think something is right, as well as testing whether we have done the right thing. One of the main reasons for learning something about moral theory is that this knowledge can shed light on the way that we reason about ethical problems.

It is also important to bear in mind that moral theories are different from many of the other theories that physicians use. Many theories in medicine are useful because they predict what is going to happen and can tell us what we should do. For example, a theory about the function of serotonin re-uptake inhibitors might tell us that particular drugs are likely to increase the amount of serotonin in a patient’s brain. Combined with other clinical judgments about a person suffering from moderate depression and whether this might be helped by appropriate medication, this theory can play a role in predicting what we should do. Moral theories are different from other theories: while they can help us to justify the ethical decisions that we make, they are often not predictive in the same way. There are a number of reasons for this.

Moral theories attempt to explain what it is that makes some actions right and others wrong. They operate at a more general level than moral or legal principles and rules. For example, if a physician is faced with a difficult decision about whether he/she is ethically bound by a patient’s refusal of treatment, an ethical rule about the right of patients to refuse treatment is more relevant and immediate than more general theoretical considerations about autonomy or the maximization of happiness. Moral theories play an important role in justifying our moral principles and rules, but sometimes they are only indirectly relevant to a specific problem.

Clinical ethical problems are usually complicated: often if a question about clinical ethics is not complicated then there is not a problem! When there is a significant doubt about what would be best for a patient, how a patient’s or family’s wishes should be balanced against physicians’ judgments about what is best or other complicated decisions, introducing moral theory might not provide the magic answer.

Moral theories are more complicated than they initially appear and they do not usually produce the straightforward predictions that many people expect. This is partly because moral theories are often refined and developed so that they can accommodate counterintuitive implications. (The next section on utilitarianism will discuss a number of theory refinements like this.) However, it is also because all moral theories are controversial, while theories in medicine are often not. Given that physicians face clinical decisions and problems it is reasonable for them to look for theories that will help. While this is fine for other areas of medicine, moral theories are controversial and will often imply different things about the same case. The following sections will consider a number of cases where moral theories and their variants imply that a particular, sometimes counterintuitive, action should be performed. This is an important point, because it would be worrying if a physician did something that was morally unwise because it followed from a particular moral theory.

While there are some reasons for being cautious about moral theories, these theories also hold great potential for enriching critical reflection upon our decisions. To bring this kind of critical reflection into sharp relief, it is important to introduce moral theory in a way that conveys the complexity of, and controversy about, the major moral theories. The following sections explain the three main major theories— utilitarianism, Kantian deontology and virtue theory—along with some of their variants and problems. All of these theories have something going for them and illuminate at least some of the important features of morality. All of them also have some serious problems, and we should not treat any of them as being completely correct. Nonetheless, knowledge of these theories can help us to understand, reflect upon and improve our moral deliberation.

While moral theory might not always tell us the right answer, it can provide us with powerful critical tools for un-picking our moral decision making. The final two sections describe influential methods for moral reasoning in medical ethics. The first describes some of the features, strengths and weaknesses of the “four principles” approach to biomedical ethics. The second discusses a number of other important accounts of medical morality.


Utilitarianism

You are an intensive care physician responsible for admissions to a busy intensive care unit (ICU). You have just been called to see patient A in the emergency room, who requires an urgent admission to ICU. All of the beds on your unit are full, and while this patient might survive transport to the nearest ICU with a spare bed, in your clinical judgment there would be a significant risk of patient A dying in transit.

While all of the patients in your ICU still need to be there, patient B is making an excellent recovery and will be ready to be moved from the ICU in a day or so. In your clinical judgment it would be feasible to move patient B to another ward without a significant risk to his medical welfare. Moving patient B to another hospital would not be in patient B’s best interests, but you wonder whether it might be justified in this case.

What is utilitarianism? The principle of utility

There are, of course, a number of issues that are relevant to making a decision in this case. Some of them are legal, but there are also important moral questions about your obligations to these particular patients. One initially attractive option is to argue that the most good can be done by moving patient B and treating patient A, and that this is ultimately the most important thing. Appealing to what will produce the most good is the kind of argument that would appeal to a utilitarian. In general, utilitarians think that the point of morality is to maximize the amount of happiness that we produce from every action. Utilitarianism is not the only moral theory that says that we should try to maximize the length and quality of life. All plausible moral theories should say something about the importance of improving the lives of human beings. The crucial thing that distinguishes utilitarianism from other moral theories is the claim that maximizing human welfare is the only thing that determines the rightness of actions.

John Stuart Mill is, perhaps, the most famous utilitarian. He claimed the following: “…actions are right in the proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain and the privation of pleasure.”2

Mill insisted that there is a strict relationship between the rightness of an action and the amount of pleasure it promotes and pain it prevents. He also said that the only thing that is relevant for determining the morality of an action is whether it produces the greatest happiness. Other moral considerations, such as keeping promises, only have moral value insofar as they produce happiness: if keeping a promise means that happiness is not maximized then, according to utilitarianism, this promise should not be kept.

Intuitively, there is at least something right about the utilitarian viewpoint. Mill was a radical social reformer who worked to promote the rights of women and slaves and argued for the importance of free speech.3,4 Focusing upon the importance of maximizing pleasure can provide an important moral scalpel for criticizing moral rules or conventional practices that harm people.

At first, utilitarianism looks like an attractive theory for dealing with some moral problems in medicine. Suppose you are responsible for a public health care budget. Suppose also that you only have enough money left in your budget to provide either new radon gas remediation measures or pneumococcal vaccinations for elderly people. Ideally you would like to provide both of these services, but for the next year you can only afford one of them. A study in the UK has estimated the radon gas measures to cost £6143–10,323 per quality-adjusted life year (QALY),5 whereas the pneumococcal vaccination is likely to cost £273 per QALY.6 You are likely to be able to produce more QALYs, or happiness, if you fund the vaccination program. While we should be concerned about whether QALYs accurately represent quality of life and the fact that we cannot provide the radon treatment too, it does seem right that if we must choose then we should choose the vaccination program. The rationale implicit in this decision seems defensible and is clearly a utilitarian rationale.

Utilitarianism might also appear to have some plausibility in an emergency setting. Suppose that you are in a triage situation where two people urgently need your care. You would do anything within your ability to save both of these people, but it is only possible for you to save one of them. Suppose that one of the people is a girl of 6 years and the other a man of 72 years. You know nothing about these individuals apart from these facts: what should you do? An option that some would take is to refuse to assess the worth of other human beings in this way and to save the nearest person or decide who to treat on the basis of some other random, arbitrary factor. However, another possibility is to take the decision to treat the 6-year-old child because, potentially, this child has a greater amount of life ahead of her. This is a decision that many would rather not take, but it does seem an instance where there is at least something to the utilitarian view.

While utilitarianism might appear to have some appeal, it does have implications that most would find unpalatable. Before considering these, it is worth thinking more carefully about Mill’s claim that happiness is the most and only important thing.

Hedonism, preference satisfaction and ideal accounts of human welfare

The core idea common to most versions of utilitarianism is that maximizing human welfare is what makes actions right. There are a number of philosophical accounts of what human welfare consists of and these can be plugged into the principle of utility, thereby generating different versions of utilitarianism.

Hedonism
Mill thought that happiness, understood as the presence of pleasure and the absence of pain, is what makes people’s lives go well. So, not only did he think that the point of morality is to maximize human quality of life, he also gave us an account of what quality of life consists of. Hedonism is the view that the only thing that contributes to a person’s life going well is pleasure, so we can consider Mill to be in favour of what we might call “hedonistic utilitarianism.”

Given that the greatest happiness principle requires that we maximize happiness, this raises the question of whether we can sum pleasure: unless we can know that something produces more pleasure, how, on this account, can we know that it is right? Mill’s predecessor, Jeremy Bentham, claimed that the value of pleasures and pains should be measured by their intensity and duration.7 Suppose that a patient asks you whether she should opt for treatment A or treatment B, both of which are equally effective at treating the relevant medical condition. Treatment A is significantly more unpleasant than treatment B; based on your clinical experience, you think it is about twice as unpleasant. However, the unpleasantness of treatment A generally only lasts one third as long as treatment B. If, on this basis, you advised your patient to get it over with and go for treatment A, this is likely to be because once intensity and duration have been taken into account, treatment A is the least unpleasant treatment.

While this might make some sense when trading off discomforts, it becomes a much more complicated matter when we start thinking about all of the things that can we count as “pleasures.” A person who regains their mobility after hip replacement surgery and is able to take their dog for a decent walk might count this as a pleasure. They might also count the experience of being able to sit through a performance of Twelfth Night as a pleasure. While it does seem possible to compare the duration of the walk with that of Twelfth Night, is it really possible to compare the intensity of the resulting happiness? This difficulty becomes even more apparent when you consider the difference between pleasures such as being mildly intoxicated, playing pinball, reading the Bible, or watching your children play. While these may all be pleasures, is it really possible to compare their intensity, thereby providing a way for us to say that one of them contributes more to our happiness? These pleasures do all seem to be pleasurable, but they are not necessarily the same kind of pleasure. Rather than maximizing any one of these, most of us would rather have a number of these experiences.

Hedonism might appear to be a shallow and implausible view for another reason, too. When Sigmund Freud was terminally ill he refused all pain relief except aspirin because he wanted to be able to think clearly even though it would mean that he was in extreme pain.8 Freud had this preference even though it was not “hedonistically” the best thing for him: unless the pleasure of his work was more intense than his extreme pain, hedonism appears to imply that Freud was wrong about what was best for him.

Preference satisfaction
The possibility that people might prefer things that do not necessarily maximize their happiness is one of the reasons why some people believe in “preference or desire satisfaction” accounts of human welfare. The idea is that because people have preferences for particular things or experiences, they must think that these things or experiences are of value to them. Freud’s preference about how he wanted to spend his final days is surely a better account of what was in fact better for him. The most attractive feature of a preference satisfaction account is that it makes what is best for a person depend upon what that person judges to be best for him/herself. Intuitively, most of us think that, at least to some extent, what is best for us as individuals depends upon our own judgment—certainly, most of us object to having someone else’s view of what is best for us enforced upon us without regard to our desires or preferences. Perhaps the major strength of preference satisfaction accounts of welfare is that they capture the “subjectivity” of human well-being in an appropriate way.

Utilitarians who opt for this account of human welfare are usually known as “preference utilitarians.” This means that the right action is the action that would lead to the satisfaction of the most significant or strongly held preferences. While this might appear to imply even worse measurement problems than those that bedevil hedonistic utilitarianism, in fact, this is very close to the position adopted by many welfare and health economists. I mentioned in the previous section the QALY, which attempts to sum improvements in the quality of life produced by medical interventions. QALYs are usually produced by asking people how much more they would prefer to be in one health state than another. For example, health economists wanting to find out how many QALYs coronary artery bypass surgery produces might ask a group of people how much they would prefer to be in good health as opposed to a particular state of ill health. These preferences are used to produce a quality of life score for different illness states. The implicit assumption in QALYs and preference satisfaction theory is that there is a strict relationship between something being preferred and it is being good for or valuable to a person.

While the subjectivity of preference satisfaction is attractive in some ways, it can also result in some counterintuitive implications. Suppose that you discover that one of your patients, an 18-year-old woman, has been hoarding sleeping pills with the thought that she might take her own life. When a person attempts suicide, they have a strong desire or preference for their life to end. It might be argued that there are some cases of “rational suicide” (i.e., when a person has sound reasons for wanting to end their life). However, in this case you are convinced that the 18-year-old is making a mistake and that her life is of value to her. According to preference satisfaction theory, her suicide is good for her. The preference satisfaction theorist might respond by saying that only rational, properly informed preferences are relevant to welfare. This will go some way to answering this worry, but there may still be some difficult cases.

Consider the following: Andrew has been injured in a car accident and requires surgery to correct a fracture to his skull. He refuses to consent to surgery because he is concerned that it might damage his appearance. When you point out to him that there are significant risks to not having the surgery, including a significant risk of mortality, he says that he is prepared to run this risk because, to him, his appearance is crucially important. He would rather risk death than have surgery that alters his appearance. Of course, there is no question about what should be done in this case: if Andrew continues to refuse the surgery and is competent there is no question that he has the right to make that decision. On the other hand, it is possible to doubt that he is making the best decision for him. Even though he is informed, rational and therefore doing what is best on a preference satisfaction account, is there something to the thought that this is not really the best thing for him? It might be that if Andrew does have the surgery and is scarred then his life will not turn out to be as bad for him as he thinks it will.

Ideal theory
The third main kind of welfare theory that generates another version of utilitarianism is what is referred to “ideal” or “objective list” theory. The main idea is that rather than making welfare depend upon the preferences of a person, there is a range of goods that, when present in a person’s life, make that person’s life go better. Of course it is very hard to determine which items should go on such a list, but plausible candidates might include friendship, virtue, happiness, wisdom and intelligence.

A heroin addict might argue that his drug use gives him a great amount of pleasure or that his desire for heroin is so strong that its satisfaction contributes greatly to his welfare. If the addict funds his drug use through petty crime then it seems plausible to infer that this might be at the expense of things like friendship and virtue. Even though the addict does not think that the omission of these things from his life means that his life does not go as well as it could, there is at least some plausibility to the thought that he is making a mistake. Even if he experiences a great deal of pleasure or desire satisfaction from his heroin use, things like friendship and virtue play an important role in making a life go well, even if the person concerned does not realise it.

This version of welfare theory is one that might be thought to have some alarming implications for medical ethics. “Ideal” theory opens up the possibility that people can be wrong about what it is that makes their life go well, and this suggests that it is possible for other people to know is best for them. This sounds like an open invitation for paternalism and is ethically a little alarming. Nonetheless, there are some plausible responses that the “ideal” theorist can make. While it might be true that the addict is making a mistake about what will make his life go best, it does not follow that forcing him to stop taking heroin will mean that he experiences the goods of friendship and virtue. It is likely that this degree of compulsion would be counterproductive: we can not force friendship or virtue upon people; unless they are freely chosen and developed they are unlikely to be the real thing.

The ideal theorist can also appeal to the importance of autonomy rights—it does not follow that someone who is making a mistake about what is best for them loses their right to decide what happens to them. In some respects, this is similar to a medical situation where a physician is convinced that a treatment will be medically better for a patient: even if that patient disagrees with the physician and is making mistake about their medical welfare, they still have the right to refuse the treatment.

�Ideal� or �objective list� theories of welfare generate a third variant of utilitarianism: �ideal utilitarianism.� This version implies that we should maximize the total amount of human welfare, understood as being comprised of a number of possible intrinsic goods in a person�s life. This version of utilitarianism is much more difficult to apply than the hedonist or preference satisfaction variants. Rather than maximizing one thing, an ideal utilitarian has a number of different kinds of good. This generates a number of difficult questions: what should be done when a choice has to be made between maximizing different goods? Should good of different kinds be weighted differently�for example, is friendship more important than happiness? In such cases, the ideal utilitarian may not be able to provide any moral guidance.

Preference utilitarianism and hedonist utilitarianism are the two most common variants but, as I will show in the next section, there are serious objections to all three versions. It is worth emphasizing that you might think that one of the theories of welfare is right (e.g., that happiness really is the only thing that makes a person’s life go well) while also disagreeing with utilitarianism.


The impartiality assumption

While there are problems with all of the welfare theories, there are core features of utilitarianism that are likely to make it a difficult creed for most people. The decision to move patient B in the ICU case involves a second defining feature of utilitarianism: the impartiality assumption. Most forms of utilitarianism claim that we should maximize human welfare. The impartiality assumption is the closely related idea that we should not be concerned about whose welfare it is that is maximized—maximizing welfare is the only thing that matters.

One objection to moving patient B is that you have already undertaken to treat B and you therefore have a duty of care to him. While patient A desperately needs your care, they are not “your patient” yet. This is a far from uncontroversial response. It might be objected that the mere fact that a patient is in an ambulance as opposed to being in the ICU is not a relevant moral difference. Nonetheless, this does appear to be an example of “partiality,” or moral obligations that are based upon the nature of a specific relationship. Other partial obligations are much less controversial. For example, parents are very strongly motivated to do all that they can to care for their children. While they have a moral concern for all children, they think that they have special obligations to their own children because they are their own children. This kind of obligation is not, from a utilitarian point of view, easily justified.

The impartiality assumption is at the root of an important problem for utilitarianism that is known as the integrity objection.

The integrity objection

Bernard Williams argued that a plausible moral theory should not require us to perform actions that are a poor fit with our psychology.9 By this, he means that if a moral theory obliges us to do things that are radically at odds with the kind of moral commitments that we ordinarily think we have then something is wrong with that moral theory.

Suppose that you are working in a country where there is a civil war and you are kidnapped by guerrillas. They say that unless you assist them in extracting information from a captive, a high-ranking officer in the military, they will start executing other prisoners. Of course, you cannot be certain that the guerrillas will not execute the prisoners if you do help to torture the officer. However, from what you have seen of the guerrillas so far you are convinced that they are serious about the promise to execute the prisoners and it seems overwhelmingly likely that if you do not help to torture the officer then many prisoners will die.

For all of the versions of utilitarianism that we have considered so far, assisting in the torture is morally the right thing to do. The torture will inflict appalling suffering upon the officer, and the knowledge that you have taken part in torture is something that you will always have to bear. However, if morality requires you to maximize utility, then avoiding the deaths of many prisoners outweighs the harms caused by the torture.

According to Williams, the point of the integrity objection is not so much that utilitarianism says that torturing the officer is right, but that the moral choice is so straightforward. When the pain and suffering of one individual can lead to saving a number of lives, the utilitarianism equation appears very simple. One thing that is missing from this picture is respect for your integrity as a person. Because utilitarianism implies that you will be partly responsible for the deaths of the prisoners if you do not torture the officer, your integrity as a person or moral agent is missing from the picture. The fact that you might have particularly strong moral objections to physicians ever being involved in torture or that acting on principle is morally important count for nothing in this scenario.

The demandingness objection

Another way of framing these problems about the fit between our psychology and utilitarianism is by pointing out how demanding being a utilitarian would be. Most of us could do more to aid those in the developing world. Physicians are in a unique position to improve the quality of other people’s lives: there are few things that have a greater impact upon human happiness (or whatever account of human welfare you favour) than treating disease. Physicians practicing medicine in Canada or another country in North America or Europe can improve the quality of patients’ lives while also maintaining a high standard of living. However, the developing world has a shortage of skilled physicians and it seems likely that most physicians in the Western world could make a comparatively larger contribution to the lives of their patients if they worked in a developing country.

Many physicians do choose, via organizations such as Médecins Sans Frontières, to work in areas where there is a shortage of physicians. Suppose that you and your family live in a comfortable Canadian town where you work at the local hospital as a general surgeon. An organization looking for volunteer physicians to work in a war-torn developing country contacts you. You know that if you leave your comfortable Canadian town then the hospital will be able to find a replacement general surgeon, and you also learn that the developing country is desperately short of physicians. In short, if you resign from your job in Canada and sacrifice your excellent quality of life for the sake of saving more people in the developing country then you will maximize the amount of utility you can produce.

While doing this might be a morally excellent thing to do, expecting you to act with this degree of self-sacrifice makes morality very demanding. Most of us will put our interests aside for the sake of other people; parents do this on a daily basis. However, utilitarianism obliges us to sacrifice our most important interests for the sake of people we do not know, if this is what will maximize utility. This is even more demanding than it first appears. According to utilitarianism, if you do not resign your job and move to the developing country, and you know that a number of people are likely to die as a result of there being nobody to save them, then you are responsible for their deaths.

The principle of utility says that acts are right or wrong in accordance with their propensity to produce utility or disutility respectively. If you act in a way that does not produce the greatest amount of utility possible then you have done something wrong and are morally responsibility for that disutility. If you respond by pointing out that you manage to produce a significant amount of utility by being a general surgeon in Canada, the utilitarian will reply that you are morally obliged to produce the most utility that you can and that you are morally responsible for disutility that results from not doing so.

If we take Bernard Williams’ remark seriously and insist that moral theories must fit our psychology and not require a radical rethink of what we take ourselves to be, then the demandingness of utilitarianism makes it an unattractive and perhaps impossible moral ideal. However, there are variants of utilitarianism that attempt to sidestep the demandingness and integrity objections.

Act versus rule utilitarianism

Thus far, we have considered variants of act utilitarianism. Simply put, act utilitarians, like Mill, think that the moral rightness of an action depends upon the extent to which it promotes utility. This means that the rightness of every action depends only upon the utility that results from it. If this action involves a lie or some other kind of action that we would ordinarily think of as wrong, this does not make a moral difference to the act utilitarian. If lying or murder would lead to greater utility then this is not only permitted, it is morally required. The reason why it is so straightforward for the act utilitarian to say that you must torture the captured officer is because this is likely to lead to the greatest utility—the fact that this involves torture counts for nothing. (There is a subtle point here. Utilitarians care about the consequences of actions, and it might be that bad consequences follow from the fact that a physician has lied or tortured. Even in this kind of case, the fact that this is a lie or an act of torture does not matter morally.)

This is very counterintuitive. Most of us think that there are moral rules that prohibit some actions and that breaking those rules is morally important. Even though torture and murder might lead to maximizing utility on some occasions, it is a mistake to think that it is right to partake in such actions. Rule utilitarians take the importance of moral rules seriously and think that actions are morally right when they conform to a moral rule:

�Rule-consequentialism makes the rightness and wrongness of particular acts, not a matter of the consequences of those individual acts, but rather a matter of conformity with that set of fairly general rules whose acceptance by (more or less) everyone would have the best consequences.�10

The requirement that physicians keep sensitive information about their patients secret is a moral rule. Furthermore, the preservation of patient confidentiality is crucial for maintaining patient trust and ensuring that physicians have the information that they need for diagnosis and treatment. Without a general rule to keep patient information confidential, many of the central aims of medicine would become far more difficult.

There is a general prohibition on physician involvement in torture11 and this, too, makes sense from a rule utilitarian point of view. There is something intuitively wrong about any physician being involved in torture, and if all physicians follow this rule it is likely to lead to the best consequences.

Rule utilitarianism appears to make much better sense of some important moral concerns in medicine than act utilitarianism. However, it is subject to the criticism that it collapses into a form of “rule worship.”

The central feature of all forms of utilitarianism is that morality has, at its core, the promotion of utility or human welfare and that the more of this the better. It is hard to dispute that having moral rules of some sort is important for the promotion of utility. Medical confidentiality is a good example—if patients do not think that their physician will always keep their information secret and will rather decide confidentiality on the basis of whether it maximizes utility on each occasion, patients are unlikely to trust physicians with sensitive information.

The problem of “rule worship” occurs when the consequences of following a moral rule on a particular occasion do not promote overall utility. While the physician who refuses to help torture the captured officer might appeal to the general rule against physicians participating in torture, it is not obvious why this is a utilitarian justification. Even though the rule tends to maximize utility in general, on this occasion it does not. Maximizing utility is at the core of all forms of utility, so if a rule utilitarian says that on this occasion utility need not be maximized, they can be accused of “rule worship.” To escape this conclusion, rule utilitarians can attempt to modify the rule so that there is an exception in this case; then, however, rule utilitarianism collapses back into act utilitarianism—whether we follow a rule in a particular case depends upon whether it maximizes utility in that case.

Of course, you might wonder what is bad about worshipping some moral rules; general rules that always prohibit torture and murder might be considered attractive moral ideals. Rule worship is only a problem if you want to use a strictly utilitarian justification for moral rules. As we will see in the next section on Immanuel Kant and Kantian approaches to ethics, there are other ways that we can justify general moral rules.

Direct versus indirect utilitarianism

There is another option open to utilitarianism that helps to reconcile the principle of utility with general moral rules. Imagine how hard it would be to always act so that your actions maximize utility. Remember that utilitarianism is impartial, so the fact that a person is your patient, spouse or child makes no difference to your moral obligations to them. However, patients, spouses and children expect us to prioritize their interests over those of unknown people. Living in a utilitarian world where we cannot maintain the relationships that are an integral part of life would be intolerable and perhaps impossible for us. This observation has led many act utilitarians, including Mill, to argue that we should not directly aim at maximizing utility. Instead, we should follow the rules and conventions of customary morality. Mill argued that conventional morality, which includes things like a general rules against torture and murder, has developed so that it guides us to acts that are likely to promote utility.

Mill clarified this idea by drawing an analogy with the tables and guides that sailors use for navigation.

�Nobody argues that the art of navigation is not founded on astronomy, because sailors cannot wait to calculate the National Almanac. Being rational creatures, they go to sea with it already calculated; and all rational creatures go out upon the sea of life with their minds made up on the common questions of right and wrong, as well as on many of the far more difficult questions of wise and foolish.�2

Mill goes on to argue that conventional morality guides us about right and wrong and that we should follow this rather than attempting to always apply the principle of utility. Nonetheless, the reason why some actions are right and others are wrong is explained by the principle of utility.

Consider patient confidentiality again. Patients expect that sensitive information will be kept confidential and that physicians who are conforming to conventional medical morality, at least in a Canadian context, will take all reasonable measures to ensure that this happens. There are good reasons for thinking that keeping patient confidences tends to maximize utility: it helps to facilitate trust between physicians and their patients, makes it possible for physicians to find out important prognostic information and has other functions that are ultimately important for patient welfare. An indirect act utilitarian like Mill would say that this makes perfect sense. The presumption that patient information is kept confidential has developed because of its tendency to maximize utility. An indirect utilitarian could also make sense of the abhorrence that a physician would have at being compelled to take part in torture. In general, torture has the most appalling effects upon human welfare so it makes perfect sense that conventional medical morality has a strong prohibition of it. While torturing the officer might in this case maximize utility and, strictly speaking, be the right thing to do, the physician who refuses because it is contrary to conventional moral thinking is not necessarily doing the wrong thing (even though they are doing the wrong thing).

Indirect utilitarianism sounds like a much more plausible view. It does seem right that the reason why we have at least some of the conventional medical morality that we do is because it aims at maximizing human welfare. However, there are still some serious problems with this more refined view. One question is, does creating different levels in moral thinking risk creating a moral dissociation in us?

Indirect utilitarians say that we should follow conventional moral rules when deliberating about moral choices—but, at the same time, there is another level of moral thinking that does not need to enter into our deliberations, even though it is really the level at which things are right and wrong. This creates a schism in our moral thinking. When we believe we are thinking through the solution to a moral problem, in fact we are only indirectly appealing to what matters morally. This naturally leads to the thought that there might be a better way to make sense of our moral reasons that does not involve appealing to considerations that are not part of our moral deliberation. In other words, perhaps there is structure within our moral thinking that provides the key to its justification. The idea that moral thinking has its justificatory structure built into it is at the core of Immanuel Kant’s moral theory. This is the topic of the next section.

Learning points

  • At the core of utilitarianism is the idea that morality derives from one principle: we should always act so as to maximize good consequences.
  • If the QALY is used to allocate medical resources, this involves a form of utilitarian reasoning.
  • While utilitarianism aims at maximizing human welfare, there are principally three welfare theories that generate three versions of utilitarianism: hedonistic (or classical) utilitarianism, preference satisfaction utilitarianism and ideal (or object list) utilitarianism.
  • Utilitarianism claims that our moral obligations are impartial: we do not have special reasons to prioritize the welfare of any particular person, including ourselves.
  • An important objection to utilitarianism is that it fails to respect the integrity of human beings and alienates us from our fundamental nature as moral agents.
  • Utilitarianism can be accused of being too morally demanding, requiring more than we would ordinarily consider to be morally required.
  • Rule utilitarianism attempts to answer these objections by claiming that actions are right when they conform to moral rules that would maximize utility if everyone followed them.
  • Rule utilitarianism can be criticized for resulting in rule worship or collapsing into act utilitarianism.
  • Indirect utilitarianism says that we should follow the guidance that conventional morality gives us and directly attempt to maximize utility.
  • Indirect utilitarianism makes our ordinary moral deliberations appear disconnected or dissociated: when we think we are deliberating about morality we are not really deliberating about what matters morally.


Kantian Ethics and Deontology

The Tuskegee syphilis study, which started in 1932, attempted to describe the natural progression of syphilis in black American males. Subjects were offered the heavy metals therapy that was thought to be effective at that time. The experiment continued until 1972, well beyond the 1940s when it became clear that penicillin is an effective treatment for syphilis. Subjects were recruited with “Misleading promises of ‘special free treatment’ (actually spinal taps done without anaesthesia to study the neurological effects of syphilis), and were enrolled without their informed consent.”12

There are a number of reasons why the Tuskegee syphilis study was wrong. The absence of consent and the failure to provide effective treatment when it became available are obvious moral failings. Tuskegee has also had a disastrous effect upon the relationship between many black Americans and researchers. We might also say that Tuskegee was wrong because of the way that it “instrumentalized” experimental subjects and used them simply as a way of finding out about the natural progression of syphilis.

The wrongness of instrumentalizing human beings is one of the important moral requirements that follows from the moral theory of the philosopher Immanuel Kant (1724–1804). Before reaching Kant’s statement of that principle, it is important to consider the first steps in Kant’s analysis of morality and its requirements.

Utilitarians claim that the consequences of actions determine their rightness. Indirect and rule utilitarians attempt to soften some of the implications of this view by emphasizing the importance of acting in ways that are consistent with moral rules or conventional morality. While this goes some way to making utilitarianism more palatable, it does raise the question of whether there is another way of thinking about morality that makes more sense of moral rules. Kant’s moral theory is, at least on this criterion, a more plausible moral theory. Instead of stressing the importance of the consequences of actions, Kant says that it is the “maxim” guiding that action that is important for determining its rightness. A “maxim” is a description of the reason why someone is doing something (i.e., what they are trying to achieve and a description of what they are doing to bring this about). The most straightforward way to think about this is to think of a maxim as specifying the “means” and “ends” of a particular action. This is an idea that can be best explained with an example.

Suppose that an oncologist talks to one of her patients about the possibility of entering a clinical trial. It is a randomized, double-blind trial where a new medication that looks very promising is compared to a standard frontline treatment for that condition. The oncologist cannot be sure, but she thinks that this new medication is likely to be the best thing for this patient and the trial is the only chance that this patient has of receiving it. The trial is sponsored by a drug company and the oncologist will receive a significant payment for every patient she recruits (although this plays no part in her decision to recommend the trial). In this case, the oncologist’s maxim might be “Recommend the clinical trial to this patient because it is likely to be best for him.” The end is “doing what is best for the patient” and the means is “recommending the trial.”

Suppose that a second oncologist recommends the same clinical trial to a different patient, but acts on a different maxim. Instead of acting to further the interests of his patient, the second oncologist thinks only of the money to be made by recruiting patients to this trial. His maxim might be “Recommend the clinical trial to this patient because it will help maximize my income.” Both cases share the same means, but the second oncologist has a different end. Suppose also that both patients are appropriate candidates for inclusion in the trial and that the second oncologist’s motivation has not clouded his judgment. Intuitively, it seems like the first oncologist has done a good thing while the second oncologist has done something that is at least shady, if not straightforwardly wrong.

Utilitarians think that consequences are the only relevant consideration when determining the rightness of an action. Because what has actually been done and the consequences of these two cases appear identical, a utilitarian will have to tell a complicated and perhaps implausible story to say why the second oncologist did something less moral than the first.

For Kant, the rightness of an action depends upon its maxim. In this case, the first oncologist is acting on a morally praiseworthy maxim, while the second oncologist’s maxim is morally dubious. Even though the two actions are likely to have a nearly identical effect, the different reasons make a significant difference to the morality of the acts. This is a plausible and intuitive idea: when we find out that someone only appeared to be doing the right thing, but in fact had ulterior or wicked motives, we reappraise the morality of what they did. However, more is needed to explain the idea that maxims are the only things that are morally relevant, and how we know that some maxims are right while others are not.

Good will

Because Kant wants to derive morality from maxims, he needs to show why they are the only thing that could generate moral requirements. He argues that a “good will” or a will that intends to do the right thing is the only thing that is always morally good.

�It is impossible to think of anything at all in the world, or indeed even beyond it, that could be considered good without limitation except a good will � Power, riches, honor, even health and that complete well-being and satisfaction with one�s condition called happiness, produce boldness and thereby often arrogance as well unless a good will is present which corrects the influence of these on the mind��13, p. 7

Kant’s phrase “good without limitation” is important because he is not saying that the good will is the only thing that’s good—clearly there are many other things, such as health, power, happiness and money, that we can think of as valuable for their own sakes. His point is that for all of these valuable things, there are instances where they are not morally good. So when he says there is nothing that is “good without limitation,” he means that there are conditions under which we do not think these things morally good.

It is not hard to think of examples where power and wealth are not good: this is familiar idea. A more interesting example, which is highly relevant to the previous sections, is that Kant also mentions happiness. Classical utilitarians think that the maximization of happiness is the only thing that matters; yet, according to Kant, happiness is not always good. Suppose that a senior physician is particularly happy with his status and position in life, even though he has achieved this by being dishonest and ruthless in his dealings with his colleagues and juniors. According to utilitarianism his happiness is morally significant, even though be has achieved it by doing bad things. If his happiness in life had been tempered by a will that acted on morally correct maxims then his happiness would (according to Kant) be morally good.

Why does Kant think that a good will is always good? Suppose that a physician provides a patient with a blood transfusion under emergency conditions and does so with the express purpose of saving that person’s life. Suppose also that the patient is a Jehovah’s Witness and that because of the emergency there was no time for the physician to find this out. This patient might feel wronged or harmed by the fact that they were given blood products, but it still seems that the physician did the right thing. The maxim that the physician acted might have been “I will save this patient’s life by giving him a transfusion.” This is a morally good maxim if the physician does not know that this way of saving a life is not what this patient would want. According to Kant, is morally good even though that action may have resulted in a bad consequence for the patient.

If good will is the only thing that is always good and this involves acting on morally correct maxims, how does Kant identify maxims that demonstrate a good will? The arguments that Kant uses for this part of his moral theory are quite complicated and it is not possible to explain them fully in a brief way. Nonetheless, the most important point to grasp is that, for Kant, for something to be a moral requirement it must be possible for it to apply to all agents who are contemplating the same action in the same situation. A physician who is trying to decide whether it is right to breach confidentiality because they are concerned about the fitness of a particular patient to drive will weigh a number factors before determining the best course of action. If they decide that, in this case, it is right to break the implicit promise to keep medical information confidential, Kant would say that if this decision really is morally right then it should be morally right for all physicians, when faced with the same situation, to do the same thing.

You can think of this by using an analogy with the law. If a situation is such that a particular course of action is legally permitted, then in all other situations that are exactly the same, that action should again be permitted. As we will see, Kant says that moral requirements must take the form of moral laws—if the relevant conditions exist for that moral requirement then that is what we must do. Kant develops this idea and uses to it argue for a supreme principle of morality: the categorical imperative.

The categorical imperative

�� Act only in accordance with that maxim through which you can at the same time will that it become a universal law.�13, p..31

For Kant, the maxim of an action determines its morality. What now requires explanation is what it is to “will your maxim as a universal law.” The central idea is very close to the way in which we often think through moral problems.

Suppose that a medical researcher desperately needs to replicate a laboratory result, but is simply unable to make the experiment work. If she contemplates fudging her data because of her need, she might reason along the following lines: “If I fudge my data it is not likely to be very significant. I know that eventually my experiment will work and this is one isolated fabrication. However, if I think about what the world would be like if every researcher in my predicament fudged their data then it is clear that I would not want the world to be this way. If every researcher did this then progress in my area might grind to halt. Kant would say that I cannot will this maxim to be a universal law because fudging my data would not be an effective way to claim that I had produced a useful result. In other words, if everyone who wanted to claim an experimental effect when they couldn’t produce it falsified their data, falsifying data wouldn’t be a good way to claim that I had produced an experimental effect people wouldn’t have any reason to believe that I had produced that effect.”

This example is similar to one that Kant gives when he explains the categorical imperative. He imagines a man who decides to borrow money, even though he does not intend to pay the money back.

�� his maxim of action would go as follows: when I believe myself to be in need of money I shall borrow money and promise to repay it, even though I know that this will never happen � how would it be if my maxim became a universal law? I then see at once that it could never hold as a universal law of nature and be consistent with itself, but must necessarily contradict itself. For the universality of a law that everyone, when he believes himself to be in need, could promise whatever he please with the intention of not keeping it would make the promise and the end one might have in it itself impossible, since no one would believe what was promised him but would laugh at all such expressions as vain pretenses.�13, p. 32

In this example, a false promise cannot be an effective means of attaining the end that this action aims at (money). For Kant, we cannot will that the world is organized in this way because we cannot conceive of the world that works in this way. The failure of universalization in this example is a “failure in conception.”

Kant thinks that there is a second way in which maxims can fail to be universalizable: if they involve a contradiction in what we would will or really want. Suppose that a physician working on a fee-for-service basis is approached by someone in need who cannot pay. If the physician turns the patient away even though it would not have been a significant burden on her to treat this patient, her maxim might be “Do not treat those in need unless they can pay so that my wealth is increased.” This maxim could be conceived of as a universal law. If all physicians who wanted to maximize their wealth refused to treat anyone who could not pay, this would be an effective way for physicians to maximize their wealth. While we can conceive of the world working in this way, Kant says that we would not will (or want) the world to be organized in this way. If physicians who want to increase their wealth never treat people who could not pay but needed care then the world would be a far worse place. Helping those in need is part of the function of medicine, and we should not want the world to be organized in this way.

Kant thought that all of our moral obligations ultimately derive from the categorical imperative. However, he produced different formulations of the categorical imperative that demonstrate particular moral obligations. He is one of the great defenders of “respect for persons” and he states this in his “formula of humanity.”

Formula of humanity

After describing the categorical imperative and some of its applications, Kant defines the formula of humanity:

�So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means.�13, p. 38

He derives this principle from the categorical imperative by emphasizing the kind of rationality that the categorical imperative generates. A good or rational will is one that acts upon maxims that could become universal laws of action. Humanity or, perhaps more accurately, rational persons, embody this kind of rationality. Given that good will is the only thing that is good without exception, rational human beings are likewise of unconditional moral worth. Something that is of unconditional moral worth should not be treated or used in a way that is inconsistent with this moral status.

We are all familiar with the wrongness of using people as mere means or instruments. One of the reasons that Tuskegee was glaringly wrong is because of the way in which researchers failed to offer or inform research subjects about antibiotics, and used the subjects as mere means to find out about the natural progressions of syphilis. Kant’s explanation of this wrongness is that the researchers failed to recognize the status of human beings as creatures capable of rational, universalizable and moral action. Turning human beings into instruments or means for furthering knowledge wrongs them in a profound way.

While the wrongness of turning other people into mere means for our own purposes is familiar, the idea that we should always treat people as “ends” is not immediately obvious. It is useful to think again about what a maxim is. A maxim always involves doing something so that something else happens: a maxim always involves adopting a “means” to bring about an “end” that is valuable. In the Tuskegee case, the researchers thought that knowing about the natural progression of syphilis was a valuable end, and they used the research participants as means to reach that desirable end.

So far so good, but does Kant’s formula of humanity say too much? All medical research uses research participants for the sake of furthering knowledge: does Kant imply that all medical research is wrong? Note that the formula of humanity says that we should treat people “as ends, never merely as a means.” In daily life, we frequently use other people as a means. The checkout operator totalling your bill, the taxi driver taking you to the airport and the nurse handing a scalpel to a surgeon are being treated as a means to an end. These are all morally acceptable ways in which to interact with other people, as long as they are consistent with them also being treated as ends or rational agents.

What is it for someone to be treated as a “mere” means? There are many historical examples in which research subjects have not known that were being experimented upon and have suffered greatly. In these cases people were treated as mere means—no regard was paid to their status as rational agents and they were used as mere instruments for medical knowledge. In a research context, informed consent is the primary way in which we can ensure that people are not used as “mere” means, but are used in ways that are consistent with their humanity. Perhaps it is for this reason that the “voluntary consent” of the research subject is given such prominence in the Nuremberg Code. (The Nuremberg Code list 10 principles of research ethics, but consent is the first and longest paragraph.14)

Sometimes when we think about moral requirements, we think of them as being requirements only to other people. The formula of humanity says that we also have a duty to respect our own humanity:

�� someone who has suicide in mind will ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from a trying condition, he makes use of a person merely as a means to maintain a tolerable condition up to the end of life. A human being is not a thing and hence not something that can be used merely as a means, but must in all his actions always be regarded as an end in itself.�13, p. 38

Some of us are likely to reject Kant’s view about the impermissibility of suicide. Many of us would argue that there are instances in which a person’s life might become so intolerable that they should not be stopped from ending it if it is clear that this is what they really want. Nonetheless, Kant’s argument is important and worth examining. You might argue with Kant and say that some cases in which a person contemplates suicide are consistent with respecting humanity: why does suicide involve treating your self as a mere means? Pro-euthanasia campaigners often stress the importance of autonomy and claim that allowing people to make these decisions is respecting them as autonomous persons, able to make important decisions for themselves. Kant thinks that persons are ends because of their capacity for rationality. Suicide involves terminating your own capacity for rationality so that you no longer suffer. Given that the rational (good) will is the only thing that is unconditionally good, you should not destroy something like this for the sake of some other end, such as the avoidance of suffering. For Kant, suicide is an intrinsically irrational act: you cannot use the extinction of your rationality as a way of bringing about a better state because your rationality is a precondition of any state having value.

Kant’s moral theory is in many respects a more attractive option than utilitarianism. Kant does explain why it is that we think some actions or reasons for acting are immoral, even when they might lead to better consequences. However, there are consequences of Kant’s view that make it less attractive that it might initially appear.

Absolutism

While utilitarianism has the problem that it appears to justify the most appalling actions if they are likely to lead to good consequences, Kant’s moral theory has almost the reverse of this problem. An absolutist about ethics believes that there are some things that we should never do, even when the consequences of not doing so are very serious. An important 20th century moral philosopher and absolutist is Elizabeth Anscombe, who argued that murder can never be morally justified.15 Anscombe’s work continues to be relevant: she wrote about the intentional targeting of civilians during war and sadly, as has been demonstrated in recent conflicts in the Middle East, this continues to be a pressing moral problem. In a medical context, many physicians are convinced that they should never intentionally take life, even when a patient is in intolerable suffering and this is what he/she wants. Absolutism about the taking of human life has some strong arguments in its favour and is a moral prohibition that many of us would find plausible.

However, the problem with Kant is that he thinks that we should be absolutists in cases where many of us are likely to make an exception. Kant thinks that we should never lie, even when we think that lying is necessary to avoid a serious harm. Suppose that a colleague calls at your door and begs you to let her into the basement of your house so that she can hide from someone who is trying to murder her. When the murderer calls at your door and asks whether you have seen her, according to Kant you are morally obliged to not lie.16 Kant attempts to justify this position by pointing out that if you lie then something worse may happen, and in that case you will share some of the blame for what the murderer does next. Most of us will agree that, in general, lying is likely to be the wrong thing to do; however, many of us would, in this case, consider it morally permissible to make an exception. After all, the murderer is exploiting your morality so that he can do something evil; surely in this kind of case a lie is justified.17 Whereas absolutism may be plausible for some actions, Kant’s absolutism about lying means that most of us could not be consistent, thorough-going Kantians.

The integrity objection (again)

One of the problems facing the utilitarian is the way in which maximizing utility might alienate us from our normal and natural commitments. Versions of the integrity objection can be directed at Kant. Suppose that you make a home visit to one of your patients, an elderly woman with osteoporosis who has broken her leg. When you arrive at her house, it is on fire and you can hear her cries from her first floor bedroom. You quickly dial the fire brigade and then rush into the burning house and carry her to safety. Once you are safely outside of the house, she thanks you profusely for saving her life. You are a good Kantian and explain that you realized that you could will your maxim as universal law and it was therefore consistent with your duty to help your patients. This explanation of why you saved her seems to involve an artificial kind of reason and is a bit emotionally “cold.” It seems more natural to describe this as a heroic action motivated by a concern for your patient’s well-being. Kant’s insistence that we must act on maxims that could be universal laws and out of a sense of duty alienates us from our ordinary moral reactions to situations.18

Other deontological theories

Kant’s moral theory is probably the most famous “deontological” moral theory. All versions of deontology embody the idea that actions are morally right when they are consistent with and motivated by moral duty. Kant’s categorical imperative is a way of specifying what our duties are, but there are other versions of deontology that differ in some important respects.

W. D. Ross argued that we have many moral duties that derive from the importance of doing good for other people, as well as other duties that derive from more Kantian obligations such as promise-keeping.19 Ross said that we have a number of prima facie moral obligations, each of which can be relevant to what is right in a particular situation. One reason that his moral theory is relevant to medical ethics is because this idea that morality involves the weighing up and interpretation of moral requirements is important for understand the influential “four principles of biomedical ethics” (see later).

Summary and conclusions

Perhaps the most attractive feature of Kant’s moral theory is the explanation that it gives for why the instrumentalization of human beings is so wrong. This in turn provides a strong justification for informed consent and the other ways in which autonomy should be respected in medical practice. However, Kant’s theory is complex and might not provide us with guidance that is useful for a range of important questions about medical ethics. It also seems to miss something important from what really matters when people are morally motivated in the right kind of way. The next section will consider virtue theory, which attempts to solve these problems.

Learning points

  • The instrumentalization of human beings is a serious wrong.
  • For Kant, a maxim is a description of what a person is trying to achieve by a particular action and the action employed to achieve this.
  • A good will is the only unconditional good.
  • The categorical imperative states that one should “Act only in accordance with that maxim through which you can at the same time will that it become a universal law.”
  • The formula of humanity states: “So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means.”
  • The formula of humanity does not rule out using people as a means if this use is consistent with respecting them as an end.
  • Kant thinks that lying is absolutely prohibited.
  • Kant’s moral theory is absolutist and may be too demanding for many.
  • Kant’s moral theory seems to miss some of the important aspects of moral motivation.


Virtue Theory

Suppose that avian flu mutates and there is a human pandemic. The general population have been advised to stay indoors and to avoid all human contact unless it is absolutely necessary. Medical services are stretched to the limit and you have been working very long hours at significant risk to yourself. You are worried about the risk, but can see that it is the right thing to do. If you are asked to explain your motivation for doing this, there are a number of moral reasons that you might give.

As we have seen, utilitarians think that actions are right when they maximize human welfare, so a utilitarian answer to this question is likely to mention helping those with avian flu as a good way to maximize welfare, even though it means putting yourself at risk.

Kantians think that actions are right when they are based on maxims that could be willed to be universal laws, so a Kantian might say that helping those with avian flu is in accordance with a universal maxim about the importance of helping those in need so, in effect, helping these patients is your duty.

There is a third kind of moral motivation that may have moved you to act: you might say “I put myself at risk to help others because that’s what a good physician does in this kind of situation.” Instead of appealing to what maximizes utility or explaining that it is your duty, you are in effect appealing to what a good person would do in this situation. In other words, a virtue ethic says that the right thing to do in a given situation is what a good or virtuous person would do. Intuitively, this is an appealing idea: most, perhaps all, of us want to be good people, so doing what a good person would do does seem to capture what we aim for when faced with a moral decision.

Moral motivation

Perhaps the major strength of a virtue theory is that it provides us with an answer to the question “Why should I be moral?” In Plato’s Republic, Glaucon asks what reason we would have to do the right thing if the external constraints upon our behaviour were removed.20 He imagines what would happen if a shepherd discovered the Ring of Gyges, a golden ring that can make its wearer invisible and immune from the usual sanctions that go along with acting badly. Glaucon claims that if the external punishments that usually accompany wrongdoing are removed, even apparently good people would end up doing bad things. If the only reason that people do the right thing is because of adverse consequences otherwise, then morality, in the sense of doing the right thing for a moral reason as opposed to a purely self-interested reason, is a fiction. Glaucon’s challenge is a severe test for any moral theory, and there seems to be a deep truth behind the thought that often those who appear to be the most moral are also those who have the most to lose by being thought immoral.

Utilitarianism and Kantianism are very demanding moral theories. Always acting to maximize utility or out of respect for one’s duty can conflict with our own interests. Perhaps, then, when people act in an apparently utilitarian or Kantian way their moral motivation is not what it appears and, likewise, given the demand of these theories, perhaps people will simply not follow their commands. This observation is one of the key reasons for the re-emergence of virtue theories in the 20th century. Although Anscombe herself was a Catholic and absolutist, she argued that for people who do not believe in God or a divine enforcer of morality, moral theories such as utilitarianism and Kantianism will simply not work.21 Unless there is a good reason for people to follow a moral code then it is unlikely that they will. Anscombe suggested that we need to rethink morality so that the connection between being moral and living well is re-established.

Likewise, Glaucon’s challenge addresses a philosophical question that was fundamental to the Ancient Greeks: “How should one live?” Perhaps the most influential answer to that question is given by Aristotle in the Nichomachean Ethics.22

All of us have an interest in living a good life, and it is plausible that a central aspect of whether our lives are of value to us is how happy we are. Aristotle argues that there is a special and complete form of human happiness, eudaimonia, that can only be obtained by living a virtuous life and flourishing as a human being. It is important to emphasize that eudaimonia is state of well-being that involves living a reasoned and reflective life: if someone thinks that they are happy, but fails to live in accordance with reason and reflection, they cannot be in a state of eudaimonia. According to Aristotle, all things can be described as having their own distinctive functions, and performing these functions well makes that thing into an excellent example of its kind.

For Aristotle:

�� what is proper to each thing is by nature best and pleasantest for it; for a human being, therefore, the life in accordance with intellect is best and pleasantest, since this, more than anything else constitutes humanity. So this life will be the happiest.�22, p. 196

For Aristotle, something is good when it fulfils its function well. For example, we might describe a scalpel as a good scalpel when it does what a scalpel should do well. Scalpels need to be sharp, sterile, easy to grip and manipulate and so on. If we came up with a list of all of the features that a good scalpel has we would, in effect, have a list of virtues for a good scalpel. This is a general feature of all of the tools and aids that a physician might use: whether they are good instruments depends upon how well they perform the functions that we want these instruments to perform.

Aristotle proceeds to consider the function, or true and distinctive nature, of a human being, so as to arrive at an account of what a “good human being” is. He claims that what is distinctive about human beings is our ability to reason and to live in accordance with reason. So good human beings live and act in accordance with reason and can be described as existing in a state of eudaimonia. Aristotle solves the problem of moral motivation by showing how being virtuous and living in accordance with reason is essential for our happiness.

Does this provide a solution to Glaucon’s challenge? If people are genuinely motivated to do the right thing then they should be able to resist, at least to some extent, the temptations resulting from the Ring of Gyges. A virtue ethicist could insist that unless a person is still moved to do the right thing, even when wearing the ring, then virtue or reason are not what actually motivates their actions and they are not in fact virtuous. If they fail to do the right thing when the external sanctions for acting badly are removed then they will know that they are not in fact virtuous and that, at least according to Aristotle, they cannot be in a state of eudaimonia.

The ideal of living in accordance with reason and virtue intuitively sounds right, but more can be said to make this relevant to medicine. Aristotle mentions not only that tools have proper functions, but also some professions. He says

�� the good�the doing well�of a flute player, a sculptor or any practitioner of a skill, or generally whatever has some characteristic activity or action, is thought to lie in its characteristic activity ��22, p. 11

It is natural to extend this idea to medicine to see whether the activity of practicing medicine can generate a list of virtues for the good physician (i.e., the physician who performs these characteristic activities well). This is the task that Pellegrino and Thomasma undertake in For The Patient’s Good.23 They argue that the core function of medicine is to improve the well-being of patients. Working toward the patient’s good requires a broad range of skills as well as concern for the autonomy and welfare of the patient. Good physicians are physicians who do this well. The function of medicine therefore implies a number of virtues and skills that will be mastered by a good physician.

A major advantage of a virtue-based approach to medical ethics is that it provides a powerful reason for physicians to do the right thing. In general, all professionals or crafts people want to be good at what they do. While there are some people who do not appear to take much pride in their work, usually even these people would like to think of themselves as being capable of doing their job well. Medicine is a demanding profession and physicians are usually highly motivated and strive to be as good at their job as they can. If doing the right thing forms part of what it is to be a good physician, then physicians have a powerful, self-interested reason to do what is right.

How to know what is right?

Virtue theory does seem to have an advantage over other moral theories in that it provides a plausible answer to the question: why be moral? However, a moral theory not only needs to give an account of moral motivation, but also needs to say something useful about how we can determine the right thing to do. Aristotle argued that the right action is the action that would be performed in that particular situation by a virtuous person. (Aristotle thinks that part of acting virtuously is having the right kind of emotional reaction and to the right kind level at a particular kind of situation.) So, because the virtuous physician would continue to work during an epidemic, this is the right thing for a physician to do.

However, an important question remains: how does a virtuous physician know the right thing to do? The virtue theorist’s response will be that virtuous physicians have, via a process of education and habituation, developed a character that enables them to judge that this is the kind of situation in which they should help. This might at first seem like an unusual idea: instead of relying only upon a moral theory or rule to tell us what is right, the virtuous person knows what is right partly because of how they perceive and are motivated by a situation.

Suppose you are consulting a radiologist who is an expert at interpreting MRI scans of the knee. This colleague might be able to diagnose the problem with a knee joint far more quickly than you can. This is not just because she has seen many scans like this before and knows a great deal about anatomy and possible pathologies, it is also because she has developed her clinical skills and has sensitized herself to this particular kind of phenomenon. The virtue theorist is, in effect, making a similar kind of claim about the morality of a situation. As the result of past experiences, modelling the behaviour of others and reflecting upon how one should act, it is possible for a physician’s character to be such that he/she just knows the right thing to do given the situation at hand.

While this might fit with the way in which we model the moral behaviour of those that we admire, how can we know that their habituated judgments and predispositions are right? After all, your radiologist colleague, although experienced, may have incorporated a small mistake about the physiology of the knee into her diagnosis of knee problems.

There is a further problem in that utilitarianism and Kantianism do seem capable of saying something about how we should reason morally difficult cases. While utilitarianism does lead to some unpalatable conclusions, it does at least give us moral guidance in many cases where we would otherwise not know what to do. While we might balk at a utilitarian recommendation to assist in torture, at least that theory does imply a course of action. A virtue theorist might respond that in this kind of case the virtuous physician could reflect upon the importance of maximizing overall utility and whether assisting in torture would violate a duty. In other words, there is no reason why the virtuous person or physician could not consider the importance of the same factors as the utilitarian or Kantian. However, this will mean that to offer an account of why a particular action is right, a virtue theorist will end up arguing in the same way that a Kantian or utilitarian might.

Conclusions

When philosophers defend their moral theory of choice they often try to show how their theory converges with common-sense moral judgments. There are exceptions to this tendency: some utilitarians think that when common-sense morality conflicts with maximizing utility then common-sense morality should be revised. (A clear example is J. Harris’ “The survival lottery,” which argues that we should sacrifice some members of society so that their organs can be used to save the lives of those needing donor organs.24)

Nonetheless, there is a significant amount of convergence in moral theories and it would be a mistake to think that they will always yield different conclusions about what we should do. Virtue theory does have a significant advantage over Kantianism and utilitarianism in providing a plausible account of moral motivation. Where it falls down is that in many cases it does not tell us much about how to act, apart from “Think of what a virtuous person would do in this situation.” Determining what is right in a morally difficult situation may mean adopting the same arguments that a utilitarian or Kantian would use.

Learning points

  • Virtue theory emphasizes the importance of a virtuous character for determining the right action.
  • Virtue theory offers a plausible account of moral motivation.
  • Virtue theory’s weakness is that it does not offer a distinctive method for determining what is right.


The Four Principles Approach

Arguably, Tom Beauchamp and James Childress’ The Principles of Biomedical Ethics25 is the most influential book on medical ethics ever written. The four principles of justice, autonomy, beneficence and non-maleficence provide a theoretical framework for thinking through moral problems in medicine.

The principle of justice implies that we ought to aim for fair access to or the equitable distribution of health care resources. Autonomy is interpreted as “self rule” or legislation, and implies that patients should be able to make important decisions for themselves and to have confidential information protected. Beneficence captures the moral obligation that health care workers have to benefit their patients. Non-maleficence describes the Hippocratic injunction to “First of all, do no harm.”

Given that this primer has just outlined some key features of the most influential moral theories, this raises a question about how the four principles fit with moral theory. If the four principles approach provides an adequate method for thinking through moral problems in medicine, is knowledge of moral theory important?

Justification for each of the principles can be derived from the three major moral theories. In his essays On Liberty and Utilitarianism,2,4 John Stuart Mill gives utilitarian defences of the importance of freedom, promoting human welfare and justice, which appear to map onto at least three of the four principles. Kant’s formula of humanity is one of the classic defences of respect for persons and provides a compelling argument for the principle of autonomy. Kant’s moral theory also implies that we have an imperfect moral obligation to work towards the welfare of fellow human beings, which is an argument in favour of a principle of beneficence. In the Metaphysics of Morals, Kant develops his account of our justice-based obligations.26 Matters are slightly more complicated when considering Aristotle’s virtue theory: for him, the “just man” and the “good man” are used interchangeably. Nonetheless, it is not unreasonable to extrapolate that the virtuous physician is one who acts on considerations of autonomy, beneficence, non-maleficence and justice.

One of the primary motivations behind the four principles approach is to distill the main moral requirements of biomedicine. Beauchamp and Childress describe the four principles as capturing the essential features of our “common morality,” and by this they mean the central moral requirements that all of us would agree are essential for moral medicine.25 One of the big arguments in favour of principles based on a common or shared morality is that there will be broad-based agreement about the appropriate moral rules for biomedicine and a common language for discussing moral problems. If two people have different moral beliefs but can agree upon essential principles then these principles can form the basis from which moral disagreements can be discussed and resolved.

The four principles approach has been the subject of great deal of academic discussion in the last 30 years, and it is not possible to do justice to all of the objections and rival accounts. Nonetheless, there are some significant objections to principlism that make it important to have some knowledge of moral theory.

Which principle?

Many moral problems in medicine involve tensions between conflicting moral obligations, such as what a person wants and what is good for them, or what we could do for another person if we do not treat a particular patient. These tensions can be described as instances where autonomy, beneficence and justice appear to imply that contradictory things are right.

Beauchamp and Childress follow W D. Ross19 and think that the principles of justice, autonomy, beneficence and non-maleficence are prima facie (“on the face of it”) obligations. Suppose that one of your patients requests a referral to an allergy specialist because he is convinced that his problems in controlling his weight and general feelings of malaise are the result of food allergies. You have already tested him for likely allergens and are not convinced that this referral is in your patient’s best interests. This case involves an apparent tension between autonomy and beneficence. What the patient wants conflicts with what you think beneficence requires in this case. While there is no doubt about the principles that are relevant here, there is a question regarding how you can do the right thing—if you write the referral you will not be doing what you think is required by beneficence, but if you do not do what the patient wants then you will not (in one sense at least) be respecting his autonomy.

This is where the concept of the principles being prima facie obligations comes in. If you decide to write the referral and reason that while it might not be what is best for your patient, it is not likely to be harmful and is what they want, then you can still be doing the right thing even though you have not done what would be implied by beneficence if it were the only relevant principle. In other words, the obligation to be beneficent is only an obligation if there is no other stronger conflicting obligation—in this case, respect for autonomy.

In simple cases such as this it will usually be a relatively easy matter to think through the significance of the conflicting demands of principles, and clinical experience is likely to be an adequate guide. However, in many cases it will be more difficult to determine how the principles should be applied. There are a number of ways that we can think through more complicated problems. We can simply weigh how important the competing moral demands appear, but we can also think more closely about the theoretical justification for a principle in a particular case.

Suppose that you are providing emergency care to a 16-year-old who has been injured in a road accident. She has lost a significant amount of blood and in your view needs a blood transfusion. When you explain this to her she becomes anxious and repeatedly says that she cannot be given blood products because of her religion. She is in a distressed state, but nonetheless appears sufficiently rational to be considered competent to refuse treatment. Again, the principles of beneficence and autonomy appear to be in tension: from your perspective, a transfusion would be best for her. However, giving a transfusion, perhaps if she loses consciousness, would appear to violate her autonomy.

A full exploration of this kind of case can involve going further than considering the respective weights of principles: it can be important to go to the level of moral theory so as to consider different justifications and ways of understanding beneficence and autonomy. This primer has discussed some of the different ways that we can understand human welfare: hedonism, preference satisfaction and ideal accounts. While these theories are themselves in tension, reflecting upon the different theoretical accounts of what beneficence might entail for this young woman can yield a fuller understanding of what this principle implies. If we do not move to the level of moral theory then there is a risk that we will not reflect carefully enough about whether this treatment would be best for this woman. If the satisfaction of important preferences is an essential component of a person’s well-being then satisfying her preference to live and, if necessary, die in a way that is consistent with the teachings of her religion may be what is best for her. On this understanding of beneficence, what is best could end up being the same as that which she has autonomously chosen.

While there are three principal accounts of human welfare, the theoretical basis of autonomy is more complex. For utilitarians such as Mill, freedom is an important precondition of human beings learning to lead happy lives (in addition to being able to live the life that makes us happiest). From this view, there will be occasions when it is right to give people the freedom to make their own mistakes, even when there are good reasons for supposing that this will not be what is best for them. In this case it could be argued that, although it is very risky for her not to have a blood transfusion, our general interest in being able to make our own mistakes is so important that her autonomy should be respected.

For Kant, autonomy is important because of its grounding in rationality and as a source of value (see the earlier section on good will). Whether this request is autonomous depends upon the rationality of the will that it embodies. (The pre-eminent Kant scholar Onora O’Neill has described this idea as a defence of “principled autonomy.”27 Mere preferences or wishes are not necessarily autonomous: autonomy requires a genuine act of self-legislation—an agent must determine rationally the maxim that is to be their will.) Whether willing to risk death because of a religious belief is the preference of a Kantian rational will is open to argument. Nonetheless, the important point is that on a Kantian defence of autonomy, merely expressing a preference is not necessarily an expression of an agent’s autonomy.

The principle of autonomy can imply different things for the same case depending on whether a Kantian or a utilitarian justification of autonomy is emphasized. Given that the four principles are intended to help physicians resolve moral dilemmas and that the principles attempt to amalgamate moral ideas that might imply different things about the same case, they are themselves not sufficient to reason through what should be done in a complicated case. To provide useful guidance for moral deliberation and difficult cases, the principles need to be augmented by some knowledge of moral theory. In fact, the situation is more complicated than is suggested by this case. While Kantian and utilitarian defences of autonomy can have significantly different implications, there are numerous accounts of what autonomy is and how it can be understood that could have different implications for a specific case.The same problems arise for justice which is a highly contested concept.

Clarity at the risk of superficiality?

The four principles appear to be a great advance in that they group together in a particularly concise way the main moral considerations of biomedicine. For physicians and medical students who are thinking about ethics seriously for the first time, this can provide a way to make moral deliberations more systematic and accessible. While it is clear that the principles can provide a moral vocabulary, there is a risk that the apparent clarity that they bring to a moral problem can hide the complexity of many moral problems. When the principles are applied to a case there can be a temptation to use them to merely identify the relevant features of a clinical scenario and to then simply make a decision about which of the principles you think should hold sway. Doing this might neglect the subtleties and different ways of understanding the morality of a situation.

Of course, moving to the level of moral theory makes medical morality even more complicated in difficult cases. As well as deciding which principle to apply, you must also think about different ways in which that principle can be understood. Nonetheless, the reason why it is hard to know what to do in some cases is because it is hard to know what the right thing to do is. Reasoning in a deeper way may make moral reflection more difficult, but ultimately it should lead to more reflective and better justified decisions.

Beauchamp and Childress did not intend the principles to be used in a deductive manner as a general theory about genetics or microbiology might. Instead, they thought that the principles could play a justificatory role when we are formulating moral rules or about specific cases: we refer back to the principles when testing our intuitions or require an argument for what we think is right. They would probably agree that in certain cases it may be necessary to delve more deeply into different theoretical accounts of justice, autonomy or beneficence. While this is a reasonable claim it is a fairly subtle distinction, and if the four principles are the only moral concepts used then there is a risk that they will be used in a superficial way.

A common morality?

When you move to a theoretical level of morality you can see that although the principles appear to be a set of common moral requirements, there is in fact significant disagreement among philosophers. This is clearly the case with autonomy and beneficence, but is even more acute for the principle of justice. Although theories of autonomy emphasize different aspects of freedom, self-determination and other similar concepts, theories of justice can reach radically different, often contradictory accounts of what is just.

The two most influential theories of justice written in the 20th century are by Robert Nozick in Anarchy, State and Utopia28 and John Rawls in A Theory of Justice.29 While neither of these philosophers says exactly what their theories imply for health care (their theories are general accounts of justice within a political community), it is clear that they have radically different implications for justice and health care. Briefly, Nozick states that justice requires us to have only a minimal state, one where taxation is only justified if it is necessary for self-defence. On this view, health care should not be delivered by a publicly funded system, but instead should be an individual matter between a citizen or insurance company and a physician. On the other hand, Rawls states that we need to redistribute resources within society so that the position of the least well off is maximized. It is not a straightforward matter to apply this idea to health care, but it does seem to support a system of health care that is publicly funded and provides universal access to a minimum level of care.30 Although both of these philosophers use the same term, “justice,” the accounts of what justice is are so divergent that it is hard to see how a principle of justice can articulate a common morality.

There are even more serious problems for the idea of a common morality. According to Beauchamp and Childress, moral theories are not the only relevant sources of justification.25,31 The four principles attempt to articulate the moral principles that all of us think should apply to biomedical ethics. Beauchamp and Childress think that biomedicine needs to move toward an ethic that pays due respect to autonomy and justice. It is simply not the case that everybody agrees that these principles are part of medical morality (e.g., Pellegrino and Thomasma think that biomedical ethics can be built upon beneficence23). In many countries, a paternalist ethic is expected by patients and physicians alike. Of course, this might not be right, but the justification for a system of ethics cannot be based upon the things that people really value if these values differ between individuals and countries .

Conclusions

There is no question that the four principles approach has revolutionized medical ethics and provided a solid foundation from which to begin moral reasoning. However, it is important not to take the clarity and simplicity that they seem to imply to show that moral deliberation is a straightforward matter: the four principles are not magical keys for unlocking the solutions to moral problems. There is no question that they provide a useful moral common vocabulary, but moral deliberation about difficult cases requires more than this. In addition to clinical experience and knowledge about what is likely to happen in a particular clinical context, considering the justifications and concepts that underpin moral principles can enrich moral deliberation.

Learning points

  • Principles-based approaches provide a useful common vocabulary for biomedical ethics.
  • Principlism can encourage shallow moral deliberation.
  • The resolution of moral problems involves moving to moral theory.
  • The “common morality” provided by the principles may be illusory.


Other approaches to moral reasoning

While utilitarianism, Kantianism and virtue theory are the major moral theories, they have inspired many other moral theories that borrow elements from them. As earlier sections have explained, there is a distinction between moral theory, which aims to provide us with a foundational account of what makes actions right, and bioethics theories that are intended to provide us with tools for thinking through and justifying solutions to moral problems in biomedicine. Just as there are many moral theories, there are also many approaches to bioethics. It is indicative of bioethics’ rapid development that in the years following the first publication of The Principles of Biomedical Ethics so many distinctive approaches have been developed. This section will outline some of the more influential approaches.

Casuistry

While principlism emerged as the dominant approach to moral reasoning in bioethics during the 1980s, a rival account, casuistry, also had many supporters. The most significant book in this debate is Jonsen and Toulmin’s The Abuse of Casuistry.32 They describe the history of casuistry’s rise and fall as an account of moral reasoning, and argue for the importance of its reinvention and application to moral problems in medicine.

One of the distinctive features of casuistry is that it emphasizes the importance of prior experience and how this bears upon new moral problems. This is similar to the account of right action argued for by virtue ethicists. Earlier, I considered how a radiologist might be particularly good at interpreting MRI scans of the knee. Judgments such as these involve synthesizing past knowledge and experience in a new situation to arrive at an interpretation of the new situation. Note that this is quite different to reasoning about an abstract question in ethics such as “Is lying always wrong?” or a general scientific principle such as “Light has a constant velocity of 1,079,252,849 km/hr.” Clinical judgment involves pulling together past experience and present clinical observation. In essence, casuists think that this is also how we should reason about moral problems in clinical medicine.

Casuistry is often described as case-based reasoning: using our experience of what we decided about morally problematic cases in the past to determine what we should do in a new situation. Casuists such as Jonsen argue that it is a more sophisticated doctrine than this, and that there are three important steps in casuistical reasoning.33

�Determination of topics� is the first step. This involves an assessment and classification of the considerations that are relevant to the decision at hand. Suppose that you are presented with a sexually active, 15-year-old girl who requests contraceptive help. She says that she does not want you to tell her mother because she thinks that she will �fly off the handle� at this news. When thinking through what you should do, you might sort through a number of relevant considerations. There are medical considerations around what form of contraception is likely to be most appropriate and whether there are any other issues to be considered, such as sexually transmitted diseases. There are considerations around what she wants and the extent to which she is able to form a rational view about this. There are also a number of �contextual features� that have a bearing on this case: the legal situation, the health care setting where this takes place and other background social features. For a casuist, determining the relevant considerations and sorting them into appropriate categories of relevance is the first step in reaching a sound decision about what to do.

The “interpretation of principles and maxims” is the second step in casuistical reasoning. This involves thinking through how moral principles or maxims might apply in a relevant way to a case. Although casuistry is a case-by-case form of moral reasoning, it does involve interpreting and applying more general moral considerations to specific cases. For the 15-year-old girl, general considerations about the importance of autonomy, promoting the patient’s welfare, respecting medical confidentiality and the significance of parental preferences all need to be interpreted and applied to the case at hand. A casuist is likely to demand that careful thought is given to whether and how these considerations apply to the case. For example, taken at face value, it appears that the 15-year-old girl has a strong autonomy right for her confidentiality to be respected. However, it is important to inquire further about the nature of her understanding so as to determine how significant an expression of her autonomy this really is. This feature of casuistry means that it can be consistent with a number of moral theories or accounts of moral principles. It is consistent not only with a four principles approach, but also takes seriously the importance of promoting human welfare or acting on moral maxims that could be applied in all cases.

This third step is the one that most people think of as the identifying feature of casuistry: “argument by analogy.” When the casuist has identified the relevant considerations and determined how moral principles and maxims are likely to apply in this case, they must then think through whether their decision is consistent with the way in which they have weighed other similar but distinct situations. Suppose that you had seen a 12-year-old girl the week before about whom you had more serious concerns: it was clear to you that she was associating with a group of older youths who appeared to be taking advantage of her sexually. In this case, you might have classified similar relevant issues and applied the same moral principles and maxims and decided that you could not straightforwardly respect her confidentiality and needed to act to protect her welfare. When comparing these two cases, you could reason by analogy to see whether there are relevant similar or dissimilar features between the cases. If you arrive at a morally relevant reason for why the two cases are different, perhaps because the 15-year-old girl does not appear to be at risk of exploitation and is making a more informed and rational decision, then you might be clear that it is right to honour the 15-year-old’s request.

There are casuistic moral theories that attempt to generate an account of right action, but Jonsen and Toulmin’s influential explication of casuistry for medical ethics is an account of moral deliberation that can borrow different but appropriate elements from the moral theories.

Narrative ethics

Narrative-based medicine is well established as an approach in primary or family care.34 Patient stories and narratives can be useful ways in which to help promote patient-centred care. Given the obvious links between the objectives of patient-centred care and biomedical ethics, it is not surprising that a number of people have advocated narrative-based approaches to clinical ethics.35–37

In some ways, narrative ethics builds on features of casuistry. Both approaches are methods for reaching an ethically sound decision about a particular case. Like casuistry, narrative ethics draws on moral principles and maxims when they are relevant and integral to the narrative or case, as well as grounding the ethical considerations firmly in the particulars of that narrative. While casuists are careful to emphasize the importance of categorizing and being aware of considerations that are relevant to the case, a narrative-based approach goes beyond this and insists that the patient descriptions must be detailed and rich. Patient stories must be complete narratives or “thick” descriptions that can represent the full significance of an illness experience in a person’s life.38 While patients will often develop a narrative that describes the history of an illness and its development into their current condition if given the opportunity to do so, they can also construct higher-order narratives that situate the illness narrative within other frames of reference.

According to Howard Brody, there are a number of different levels of patient narrative that can be relevant to ethics.39 In addition to a narrative about a patient’s illness, they might also tell a “story of a patient’s life,” “grand narratives about society/culture” and “sacred narratives (people and cosmos).”

I earlier illustrated preference utilitarianism with the case of Andrew, who needs surgery fix a fracture in his skull. Andrew refuses to consent to surgery because he is concerned that it might damage his appearance. Andrew’s “illness narrative” might involve a description of his accident, his experience of recovery and an account of how his injury is impacting him now. When he explains to you that, for him, keeping his appearance is worth the risk of death, this might form part of an extended narrative about his life and why it is that his appearance matters to him. This “story of a patient’s life” might make sense within a broader “grand” narrative about the kind of society/culture he lives in. A cultural context in which it can make sense to place a very high priority upon one’s appearance, even when this might places a person’s existence in jeopardy, is likely to have a number of related grand narratives about the importance of beauty or appearing young. These grand narratives might make sense within a higher order “sacred” narrative about the pursuit of material possessions being the only thing of value.

Advocates for narrative ethics describe a number of other ways in which the narratives of physicians and patients intersect to demonstrate the utility of this approach. It is arguable whether a narrative ethic improves upon methods such as casuistry in moral deliberations. Perhaps it should not be considered as a stand-alone method, but rather as a useful standpoint from which to reach a deeper understanding of the patient’s experience and the background conditions on which it makes sense.

An ethic of care

The principal idea behind an ethic of care is that women’s moral deliberation is importantly different from that of men. The key idea is that women’s moral experience is more oriented toward attitudes and caring relationships than toward acting out of respect for abstract moral rules, which is thought to be more typical of men’s moral thinking. Different authors have stressed different aspects of a care ethic, but undoubtedly the most significant work is Carol Gilligan’s groundbreaking book In a Different Voice.40 Gilligan found that when faced with hypothetical moral scenarios, women tended not to act in ways that were in accordance with what an abstract moral rule or principle required, unlike their male counterparts. Instead, women tended to make decisions that would maintain relationships and ensure that other people were cared for. Gilligan also used the phrase “ethics of responsibility” because women’s moral decision-making emphasized the obligations that women felt they had to the people around them.

Gilligan is a psychologist, so her work is an factual account of the way that women reason about morality. In other words, she does not produce a moral theory in the sense of giving an account of what it is that makes actions wrong. Nonetheless, the central observations in her empirical work have been developed into distinctive moral theories by a number of authors,41–43 and attempts have been made to apply these ideas to applied ethics, particularly within nursing.44 Care-based ethics have been popular in nursing, partly because this profession has tended to have more female than male members, but also because caring is often considered a central role of the profession. Because care-based ethics focuses upon the specific needs of the individuals in a situation and stresses the importance of sensitivity to the particulars of a moral situation, it also looks like a promising approach for clinical bioethics.

The literature on these theories is large and a number of important objections to care ethics have been developed. One of the most important is a worry about the nature of the relationship that these theories tend to imply. Nelson has argued that the ideal image of a female care relationship is that of a mother and child.45,46 This model of caring might reinforce roles that promote an unequal status of women in relationships. Therefore, while a care ethic can distinguish important aspects of women’s moral experiences, using this to justify moral requirements might reinforce existing inequalities in women’s relationships. What appears to be a distinctive voice for women’s moral experiences runs the risk of perpetuating patriarchal structures.

Learning points

  • Theories about moral reasoning in bioethics emphasize the importance of particulars.
  • Paying attention to the particulars of cases is essential for sound moral deliberation about complex clinical cases.
  • Moral theory can have a role to play, but it must be carefully interpreted and applied so that it is relevant to clinical cases.


References

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Further Reading and Resources

For more on the way that moral theory can get in the way of sensible moral deliberation: McMillan J. Ethics and clinical ethics committee education. Health Ethics Committee Forum 2002; 14(1): 45–52.

Utilitarianism

For an introduction to QALYs and their problems: McMillan J. Allocation of resources. The Foundation Years 1996; 2(3): 102–5.

For more on how QALYs are generated and some of the problems that this presents: Nord E. Cost-value analysis in health care: making sense out of QALYs. Cambridge: Cambridge University Press; 1999.

Hedonistic utilitarianism such as that promoted by Mill and Bentham is often referred to as “Classical utilitarianism.” For a very useful introduction to hedonism and the other theories of welfare described in this section: Crisp R. Mill on utilitarianism. London: Routledge; 1997.

For a discussion of the demandingness objection and an attempt to answer it: Glover J. Causing death and saving lives. Penguin: London; 1977.

Kantian ethics and deontology

Immanuel Kant’s ideas about morality are developed in three books: The Metaphysics of Morals, The Groundwork of the Metaphysics of Morals and the Critique of Practical Judgment.

Virtue theory

For an excellent critical discussion of the concept of eudaimonia and its importance in the Nichomachean ethics: McDowell J. The role of eudaimonia in Aristotle’s ethics. In: Rorty A, editor. Essays on Aristotle’s ethics. California: University of California Press; 1980: 359–76.

For discussion of the “mean in respect of the passions”: Urmson J. Aristotle’s doctrine of the mean. In: Rorty A, editor. Essays on Aristotle’s ethics. California: University of California Press; 1980: 157–70.

Four principles

For an interestingly and scholarly overview of other principles that could be used for biomedical ethics: Veatch R. How many principles for bioethics? In: Ashcroft R, Dawson A, Draper H, McMillan J, editors. Principles of healthcare ethics, 2nd edn. Chichester: John Wiley and Sons; 2007: 43–50.

For excellent accounts of the different ways of understanding autonomy: Dworkin G. The theory and practice of autonomy. New York: Cambridge University Press; 1988 and Stoljar N. Theories of autonomy. In: Ashcroft R, Dawson A, Draper H, McMillan J, editors. Principles of healthcare ethics, 2nd edn. Chichester: John Wiley and Sons; 2007: 11–8.

Casuistry

For more of how casuistry can be applied to clinical ethics: Jonsen A, Siegler M, Winslade W. Clinical ethics: a practical approach to ethical decisions in clinical medicine. New York: McGraw-Hill; 1998.

Author Information

John McMillan, PhD, is Associate Professor in Medical Ethics, Law and Professionalism, School of Medicine, Flinders University, Adelaide, Australia.