Medical Ethics PHIL 148 @ Binghamton University, Sum 11


Lecture 06/03>Ethical Concepts and Principles

Today, we move on to general moral concepts and principles. Just like the ethical theories we looked at yesterday, these concepts and principles are tools for understanding the various issues we’ll be talking about this semester. The three general concepts are autonomy, beneficence, and justice. They each have various related principles which I’ll talk about in relation to each concept.

Autonomy is one of the major concepts we’ll be dealing with in the class. Autonomy, at its most basic, is an individual’s right to control and make decisions about their own life. It seems like a given, but it immediately becomes more complex once we start considering the embedded-ness of human life. All of us exist alongside and with other people. The result of this is that decisions about our own lives affect the lives of others. The questions, again, becomes “when is this effect morally relevant?”  Mandatory organ donation is one example where autonomy becomes problematic.  Think if everyone was required to be registered as a kidney donor and they could be called upon to donate that kidney at any time.

The harm principle is the first and most obvious autonomy-limiting principle. It seems to make intuitive sense that we should prevent one person’s exercise of autonomy to interfere with another’s exercise of autonomy. Yet, this is a matter of degrees. If one person will die without a kidney transplant, shouldn’t the healthy individual with two kidneys be forced to give up one kidney? After all, the option for one person is death, while the option for the other is simply recovery time. On the other hand, why should one individual suffer for the life of another? So, the harm principle becomes a question of what harms are allowable and what are not. What about forced blood donation? Such a small harm could benefit many.

It’s important to note that all of these justifications so far are consequentialist. It seems doubtful that a deontologist could allow forced donation of anything for the simple fact that it would treat the individual as a mere means. On the other hand, however, a deontologist likely could argue that an individual should donate a kidney if they are able. This is a difference between positive and negative duties. [Don’t confuse positive here to mean posited (as some of you may have heard it used in Phil 146).] A negative duty is something that one should avoid doing. In the consequentialist examples above, one should avoid harm. A positive duty is something one should do. In the deontologist example above, one should do good. If something is a negative duty, it would be immoral to perform the stigmatized action. If something is a positive duty, it would be immoral to not perform the action. Positive duties are usually considered to create a heavier burden than negative duties, but this is not always the case. For instance, if one argues that there is a duty not to abort a fetus, does this create a corresponding positive duty to adopt if one is able? And which of these duties is truly greater?

Paternalism points out a potentially important detail that underlies autonomy: autonomy to function fully has to fulfill a certain standard of information. If an individual is operating under false information or does not have enough information to make a proper decision, it is sometimes considered appropriate to make the decision for the individual.  What the text would say interferes with understanding. This kind of attitude was extremely pervasive in the medical field even a few decades ago. It was not uncommon for doctors to withhold information from cancer patients in order to prevent them from becoming depressed or for nurses to strap women in labor into their beds so that they couldn’t get up and move about--a violation of the condition of freedom from external restraint.  Today, paternalism still exists, but often in different, less explicit forms. For instance, is it paternalism to present information in a certain way that paints a more positive picture than if the information was presented in a different way? How many potential side effects should be listed to a patient for a new drug? Is there such a thing as too much information? In most cases, medical professionals have control of the information that a patient needs.  How should that information be presented? What ways of presenting information constitute paternalism (if any)? These are just a few questions that arise on this topic.

Alternatively, paternalism is sometimes (perhaps often) invoked in cases where a person is not considered rational. In these cases, the individual’s autonomy is thought to be appropriately limited because of a lack of rationality on that individual’s part. For instance, if a person attempts to commit suicide this is often taken to be a sign that they are irrational and they are committed for their own protection. Yet, some argue that there are circumstances where it is perfectly rational to commit suicide. Likewise, patients are free to refuse treatment. Yet, doctors and other third parties may seek a court order to force a certain course of action.  In this case, the external constraints are justified because there are supposed more problematic internal constraints.

The next two principles largely operate the same. Legal moralism and the offense principle both think that autonomy can be limited where an individual’s actions are immoral or offensive—the difference being that something can be offensive for more reasons than simply being immoral (think indecent or socially inappropriate). Interestingly, it is not always so simply to separate legal moralism and the offense principle from paternalism. Especially notorious is the history of the treatment of mental illness. It has largely been recognized that most historical treatment of mental illness was based more around the immorality or offensiveness of the patient’s behavior than any actual ailment—those with different religions, sexualities, opinions were the victims of this kind of thinking. Although the situation today is much better, it is difficult not to imagine that in the more difficult topics of medical ethics (still today including mental illness) the line between straight paternalism and legal moralism and the offense principle is blurred.

There are further concepts not covered in the text (but assumed by the text.  These are beneficence and nonmaleficence.  Nonmaleficence is a purely negative duty that demands simply that no harm be done. Beneficence is a positive duty of varying strength that demands that some action be done for the benefit of another. Of course, as with all these other principles, neither beneficence nor nonmaleficence is as straightforward as these simply statements make them out to be.

What complicates nonmaleficence is the same thing that complicates the harm principle: what do we consider to be relevantly harmful? Certainly some mental harm is done to an individual when they are told that they have only a limited time to live, but it is considered a necessary harm. Likewise, one is technically harmed when one is given a shot (there is pain involved), but it is, again, considered a necessary harm. Things become more complicated when risk becomes an issue. If a pharmaceutical trial is the last available possibility for a patient with chronic pain, but will involve a good possibility or failure and definite unpleasant side effect, should the doctor bring up the possibility? (Again, notice the problem of autonomy coming up in this problem.)

With beneficence, the question becomes to what degree a medical professional is obligated to others. Are they merely obligated to help prevent harm? What kind of harm? Are they obligated to actually help others as much as they can? Further, to whom are they obligated? How far does their obligation extend? Something like the social welfare principle is simply an extension of beneficience: how far can you go to help others?  Questions of extension (to whom they are obligated) and breadth (how great the obligation) are all integral to making sense of issues of beneficence.

The last major principle that you will need to be concerned with is justice. Justice can be characterized as what is considered as fairness and equality. But this alone (as with everything else so far) is not enough to really tell us enough to get us anywhere morally.  We need further specifications. The potential specifications are utilitarianism, egalitarianism, and libertarianism. Utilitarianism solves justice the exact way utilitarianism solves all problems: something is just so far as it maximizes utility. Egalitarianism (in its most basic form) claims something is just so far as there is an equal distribution of goods throughout the system. Egalitarianism runs a range of views. Lighter, more complicated versions of egalitarianism, such as John Rawls’, modify the degree to which everything must be equal--advocating some, but limited inequality--but are very careful to stray too far from the egalitarian ideal.

Libertarianism may be the most familiar and most popular view in society at large. It is famous for its small government rhetoric. In the matter of justice, libertarianism holds that inequality can be justified so far as that inequality is the result of nature. Redistributive schemes (which equalitarian schemes favor) are only just in cases where human constructs have caused the specified harm. This is particularly relevant in matters of medicine, as illness is largely taken to be a natural occurrence. According to libertarians, it would be unjust to take money from individuals who have earned it to help treat individuals who are suffering from a natural affliction.

We will talk more about these matters of justice when we get to Week 4: Health Care and Justice. For now, consider the different ways these various concepts and principles can be applied. Look at what you intuitively think and try and figure out what principles you incline towards naturally. Then, examine your own views and try and think up some potential objections to your own position.

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