Medical Ethics PHIL 148 @ Binghamton University, Sum 11

26Jun/1126

Lecture 06/27>Abortion

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There are two central moral concerns in abortion: the moral status of the fetus and the rights of the mother. The moral status of the fetus can best be understood in terms of personhood. For some reason, Marquis seems to think he is not talking about personhood when he is talking about “the category of having a valuable future like ours” . Yet, it is difficult to see why he thinks this. In philosophy, person is a term that signifies an individual that satisfies certain criteria that allow them to be categorized as morally relevant. For Kant, a person is a rational being. For Peter Singer, a person is a being that is able to feel pain. For Warren, a person is a being that is part of the proper moral community. Likewise, for Marquis, it would make sense to say that a person is a being that has “a valuable future like ours.” [This definition has a bunch of other problems (like how similar does the valuable future have to be and how does the degree of similarity affect our obligations to these beings?), but that is something that we can get into in discussion, if anyone is interested.] Given that Marquis’ distinction between the category of personhood and his category of a valuable future seems to be meaningless, I think it makes sense to talk about personhood as one of the central moral concerns in abortion.

As you can see above, personhood can be satisfied by many different criteria. What is important, however, is that personhood bears with it the stamp of moral status. If someone is a person, then they have moral relevance. This is most easily understood in terms of obligation, but it also applies to consequentialist theories. As is pointed out in several of the essays for this week, the most common form of argument for and against abortion relies on the question of whether an embryo/fetus is a person. If a fetus is a person, then they have moral status and abortion is immoral. As Thomson points out, this is not as steadfast a conclusion as it is usually taken to be, as even in everyday life we recognize that there are situations where killing a person is not only not immoral, but right. Further, Thomson points out, one of the central tenets of western thought is the right to bodily integrity. Even if a fetus is a person, it does not follow that the rights of a fetus trump the mother’s right to bodily integrity.

The debate on abortion then is a debate about the balance of the rights of a person (where the fetus satisfies the criteria of personhood—it may satisfy it as a fetus, but not as an embryo—or where there is a sufficient argument from potential personhood) and the rights of bodily integrity. Notice that most debates about abortion that we are familiar with (from taking place very publically and vocally) are predicated on one of these sides in absolute terms: either the fetus’ personhood trumps the mother’s bodily integrity or the mother’s bodily integrity trumps the fetus’ personhood. It is likely that the moral situation is nowhere near as clear cut as this, as can be seen by the various arguments put forward by the writers in your text. The mere possibility of rape and the death of the mother speak to these complications, and it is only the most extreme supporters of abortion that allow that the death of the mother is preferable to the death of the fetus (after all, that situation makes the debate about identical situations: dying person versus dying person). The abortion debate becomes about the point where the mere rights of personhood do or do not trump the rights of bodily integrity.

This debate is impacted by many different details. As I pointed out above, an embryo may not count as a person, while a fetus might. Likewise, the mother’s involvement in the creation of the embryo might impact the strength of her right to bodily integrity (the status of a child resulting from failed birth control might be morally different than a child resulting from rape). For instance, while bodily integrity may be a prima facie right, that right might be overcome if the woman’s own actions led to the creation of the fetus—in other words, the woman may end up with a positive duty to support the child that overcomes the woman’s other right to bodily integrity.

An additional detail that strongly influences the position of those who support the legalization of abortion is the fundamental vulnerability of a woman’s position in reproduction. After all, if a woman has a positive duty to support even an unwanted child, then it follows naturally that so does the father of the child. Practically, however, forcing a father to provide for a child is much more difficult than preventing a woman from obtaining an abortion. A system that makes abortion illegal contributes to this the naturally more difficult position of the woman in such a situation. In talking about the balance of the rights of the fetus as a person and the rights of the mother to bodily integrity, we have been talking about the balance between duties of beneficence and duties of autonomy. Vulnerability, however, introduces an additional duty of justice. If the natural vulnerability of pregnancy (based solely on biological factors) is compounded by social circumstances (both systemic and non-systemic), does this bolster the woman’s right to bodily integrity or does it have no impact? What kind of system would have to be in place to make abortion morally unacceptable? Or does justice play no role in abortion?

Some Questions to Consider:

  • Do the rights of personhood trump rights of bodily integrity? Or vice versa?
  • What makes a being a person? What details make a being morally relevant?
  • What role should justice play in the abortion debate?
  • What relevance do biological differences make to how abortion should be treated?
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19Jun/1134

Lecture 06/20>Health Care and Justice

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There are two main issues in the question of justice and health: access and right to health care and health care rationing. Within each of these issues, we are searching for the appropriate balance between moral issues.

Today’s week is focused on justice. But justice varies depending on how one chooses to balance the various ethical concepts and perspective. If autonomy is the most important of the ethical concepts, then justice would be the schema that best preserves everyone’s autonomy. If equality is the most important of the ethical concepts, then justice would be the schema that best preserves everyone’s equality. Of course, all of these schemes ask further questions: What kind of autonomy matters (physical, economic)?  What should be the basis of equality? What efforts can be made to achieve the baseline of justice?

There are two main issues in the matter of health care and justice: access and rationing. Access asks what right all individuals have to health care, if any, and what measures can be morally justified to guarantee that right. Rationing concerns the limited health care resources and how those resources should be distributed. Rationing is related to access because if resources are not available, then there is a question of how access can be granted. Rationing might act as a constraint on what kind of access is available to each individual, whether that lack of access is moral or not.

Take the libertarian position as a starting point. Libertarians take autonomy to be the highest good. Specifically, they define autonomy in terms of an individual’s economic activity. So, for libertarians, economic autonomy should be preserved for all individuals. This means something very specific: individuals have the sole right to the products of their labor. Depending on the severity of this position, this can range from no taxation to minimal taxation. Regardless of the severity, the libertarian position on health care access is that it should be dependent entirely on an individual’s economic goods. Even if an individual had a right to health care access, this access could not be provided by any of the means society has established because it would mean unfairly taking the fruits of another person’s labor. This matters because social redistribution should only take place when the wrong is caused by a social system itself. So, redistribution for health care access cannot be provided by the system unless the health harm is caused by the system. If the harm is caused by an individual it should be rectified by the individual and if it is caused by nature, then there is no one’s responsibility to rectify the situation. [This does not rule out donations and charity by private individuals, but this should never be forced. It might be moral for a libertarian to help another, but it is always immoral for the government to force individuals to help one another.]

The egalitarian position is very different. It favors equality in a wider sense than the libertarian conception. While the libertarian speaks of equality in moral terms, but claims that difference comes from economic status, the egalitarian thinks that equality is defined in terms of social goods. The most common egalitarian position is that individuals should be guaranteed a basic minimum—this is usually spoken of in terms of human rights. According to some egalitarians, access to basic health care is a moral right that all humans have. Depending on the form of egalitarianism (cosmopolitanism or state-centered), one’s individual moral duty to help attain this basic level of health care may extend to those in one’s community or to those on the other side of the world. [Those who support the latter argue that our way of life is based on exploitation of other’s on the other side of the world. Because we play a part in causing suffering there, we have a moral duty to help guarantee basic health care.] Because economic goods are not the sole good, it makes sense for egalitarians to have some level of redistribution of wealth to guarantee these certain goods.

As you might note, however, these two positions do not necessarily speak to the obligations of individuals. Libertarianism states that it is immoral for governments to take individual goods and egalitarianism states that this redistribution can be moral, but this does not speak to the matter of individual moral responsibility. The question now comes, then, regardless of government involvement, what moral obligation does an individual have to provide access to health care? And, if there is a moral obligation to help others, then does it make sense to have a government system that assists individuals in helping others? Of course the major problem with the last point for libertarians is that such a system would involve taxation, a necessary evil in all government programs.

Further, even if we can establish the need and morality of a minimum of health care, what does this minimum constitute? Is a minimum simply general checkups, vaccinations, and routine treatments, with no further help beyond that? Is a minimum full access to any needed health care procedures on top of regular checkups (which might serve to identify needed treatment)? The answers to these questions depend on what moral standpoint one takes and what one takes to be morally relevant (libertarianism and egalitarianism serving as two examples of what is morally relevant or justifiable).

Rationing makes the question of access even more difficult. Society does have a limited amount of resources which can be put towards health care, be this supplies, time, or personnel.  It seems that none of the options that are available seem to provide a best case solution. For example, eliminating insurance may ultimately cut down on unnecessary costs, but, on the other hand, it may also be extremely unfair to those who are in bad economic straits. Still,  insurance—and at a greater level government sponsored health care—put a greater financial burden on society as a whole. Presently, if poorer individuals do not have access to medical treatment, their treatment tends to be delayed until they are in the emergency room. At which point, the cost ends up on society anyway and the cost is much higher than it would have been had society been providing basic medical care from the start.

From all of these reasons, utilitarianism would generally seem to lean towards providing at least some form of minimal health care. On the other hand, we might take the hardnosed approach that what is better is allowing the sick to die off without treatment and prevent and burden on the system. Deontology may say that we have a duty to provide for our fellow human beings. Yet, it might also claim that forcing an individual to help is immoral. Virtue ethics might say that individuals have a moral duty to maintain their own health and that if they are unable to do this then they should be allowed to die (as mixing with such individuals would be damaging to other’s character). Alternatively, virtue ethics might hold that it is the job of society to educate and properly raise individuals to be able to care for themselves. Finally, care ethics might say that we each have duties of care to those around us and that we should care for and provide for those with which we have a relationship. Yet, it is not clear that care ethics would have anything to say about government’s role or those who are unfortunately outside of healthy, appropriate human relations.

Given all of this, the question of what is just in health care is not always attached to what is moral for the individual. Many of the moral theories we have worked with do not provide any clear cut answers on what role justice should play in health care (but then, when do they provide a clear cut answer?). To find an answer, you must be able to decide what you take to be morally relevant, what you take to be the correct ethical perspective, and determine how to balance the ethical concepts.

Key Concepts:

  • Egalitarianism
  • Libertarianism
  • Justice
  • Equality

Some Questions to Consider:

  • What do you think utilitarianism would have to say about access to health care? Deontology? Virtue ethics? Care ethics? What would they each have to say about rationing?
  • Which of this week's readings tend towards libertarianism?  Which towards egalitarianism?
  • Why is economic status considered so important for many? Should economic status impact our moral duties?
  • Is morality an individual action or can/should it be societal? Who bears moral responsibility?
12Jun/1126

Lecture 06/13>Euthanasia and Assisted Suicide

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The main moral question for this week is: Is it ever morally right to take a life?

As with any of the questions in this course, the devil is in the details and this single question is complicated by a host of distinctions.  First, we are, as is appropriate to medical ethics, focusing on this question within the medical field, so this question is narrowed to the question: what medical circumstances justify taking a life?  Is terminal illness all?  Or severe chronic pain? Or life-altering disability?  Euthanasia comes from the Greek and means (literally) "good death."  The main idea behind euthanasia is that control over the circumstances and time of one's death are critical no only to having a good death, but having a good life.

There are different sorts of "taking a life."  And these distinctions are taken to be morally relevant.  I want to concentrate on these distinctions in this week's lecture.

Voluntary, Non-Voluntary, and Involuntary Euthanasia.  These three terms refer to three distinct relations of the patient to their death.  Voluntary euthanasia is purposeful death where the patient has consented to die.  Non-voluntary euthanasia is purposeful death where the patient is unable to consent to die (think persistent vegetative state or other forms of lower functioning).  Involuntary euthanasia is purposeful death where the patient has expressed a desire not to die.  The focus of arguments will not be on this last one, as it is extremely problematic.  Where voluntary and non-voluntary euthanasia both have vocal proponents, involuntary euthanasia has very little support (for reasons you can fill in on your own).  However, see Hardwig's article for one line of thought that could lead to involuntary euthanasia, although this is not what Hardwig is arguing for.

Active and Passive Euthanasia. The distinction drawn between active and passive euthanasia is the form of dying.  In active euthanasia, drugs or another direct form are applied in order to directly bring about the patients death.  In contrast, passive euthanasia involves the removal of life support or other forms of care and allowing a disease, injury, or other damage to the body to take its course.  In passive euthanasia, it is argued that the actions of those involved only indirectly cause the death of the patient.

Physician-Assisted Suicide. This is simply a subclass of euthanasia that refers to the assistance of medical staff in the death of an individual.  The term euthanasia is generally used to refer to any form of purposeful death to end pain or suffering.  Thus, euthanasia can be performed by anyone: the patient, a family member, a friend, a stranger.  What is important about physician-assisted suicide (PAS) is the role of the medical professional in the death.  It does not have to be a direct role.  While directly injecting drugs into a patient's system or unhooking life support fall under PAS, so does writing a prescription for the patient to take on their own.  The main concern in PAS is the particular moral issues that arise from a medical professional taking part in ending a life.

Over the course of your readings, these distinctions are given different emphasis--largely focused on active versus passive euthanasia and PAS.  The active/passive distinction is controversial because the end and intention are the same.  Refusal of hydration and nutrition further complicates matters.  One of the main arguments in favor of passive over active euthanasia is that passive is simply "letting nature take its course."  Yet, one could argue that starvation is equally "natural."  Is refusal of hydration and nutrition passive or active?  And if it is passive, is it as equally justified as a patient going off life support?

PAS is controversial because there is a question of the proper role of medical professionals.  Are they meant to preserve life at all cost?  Are medical professionals supposed to do no harm?  What constitutes doing harm?  Some argue that euthanasia is fine, but physician-assisted suicide is extremely problematic because of the role of medical professionals.

Key Concepts:

  • Voluntary Euthanasia
  • Involuntary Euthanasia
  • Non-voluntary Euthanasia
  • Active Euthanasia
  • Passive Euthanasia
  • Physician-Assisted Suicide

Some Questions to Consider:

  • Are active and passive euthanasia different?
  • What is the proper role of medical professionals?
  • How could involuntary euthanasia be justified?
  • How much does control over one's own body impact discussions of euthanasia?
5Jun/1129

Lecture 06/06>The Patient-Professional Relationship

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The question we are faced with today, and will be faced with throughout the semester, is “what is the object of medicine?” The answer to this question severely impacts what the answer to the various ethical questions we ask will be. Is the purpose of medicine merely to heal physical injury and disease? Or is it meant to aim at something more. Notice the language that all of the articles you read for today use in discussing the various bioethical issues: their main concern is the balance between patient health and patient autonomy. Notice as well that when they discuss health, they are not merely discussing physical well-being, but also mental well-being.  There is an important distinction underlying all of these articles: that between disease and illness.

Disease, injury, whatever word best expresses the point, refers to the underlying physical cause of trouble for an individual. This is the broken bone or the clogged arteries; the damage to the brain, the loss of sight. These are all problems that fall under the category of disease. Illness, on the other hand, refers to the impact of disease on the individual. Illness is a subjective category closely tied to the individual life of the patient and the way they approach their disease or injury.  The readings for today are largely concerned not simply with disease, but with illness--a concern largely represented through the concept of patient autonomy.

These readings frame the object of medicine as restoring the patient to an autonomous state or, where not possible, carrying out the patient’s autonomous wishes. These might be called illness concerns. On the other side of the equation are the disease concerns—the drive to solve the physical malady. The object of medicine might be to solve the illness concerns, but this might only be done by solving the disease concerns. Yet, these two kinds of concerns can conflict and it is not a simple resolution where these conflicts take place.

If the world was absolutely certain and we understood one another perfectly, it is likely that there would be little conflict between illness and disease concerns. However, the world in general and the medical world in particular both operate under the burden of mere probability. Complicating matters, individuals are not transparent to one another.  As Childress and Seigler point out, we have varying different values and these values might not be shared by both the patient and the health care professional.

Autonomy is often treated as if it is an all or nothing concept, but this seems wrong. An individual might be diminished in their autonomy capacity, yet still be able to make certain kinds of decisions. If illness simply robbed an individual of their capacity to act autonomously, then there would be very little to discuss in medical ethics—medical professionals would have the freedom to treat patients in whatever way would best suit the problem. Precisely the fact that medicine does not work in this way demonstrates that autonomy is a continuum on which we all operate at various levels depending on our circumstances. This is true even in our day to day lives. In some situations, we feel completely in control. In others, we feel powerless. In these situations out capacity for autonomous action is operating at different levels. Of course, in these situations medicine does not interfere. Medicine only deals with autonomy problems related to physical ills.

Consider the flu. If you have ever been sick with the flu, you know that it weakens you physically; it drains you of energy; and it makes it difficult to function properly. In a certain sense, you have lost control of your life through the interference of this malady. But the flu is (generally) minor. You are bedridden for a few days and you make a slow recovery. Within a week, you are almost back to normal functioning. The impact of the flu is minimal. It may have some drastic effects immediately, but it’s overall impact on one’s autonomy competency is slim. This is because the flu is a blip on the radar of your life. It is (usually) easily dealt with. Some medication, bed rest, and it passes. The treatment is simple and easy to grasp. The whole medical element of the flu is minimal.

There are, however, two ways in which disease or injury might rob one of autonomy in a more serious way. The first is directly related to the disease. The more pervasive a disease or injury is, the more it dominates one’s identity. The loss of a leg might throw a person of balance, not merely physically, but mentally. Imagine an individual whose identity was closely wrapped up with their physical ability. The loss of a leg would deal a large blow to their ability to make sense of themselves and, through that, their world. The self might be considered a kind of faux stationary point from which one may move the world. It is the strength of one’s self that gives one the competency to be autonomous. This autonomy can be eliminated by a disease that robs an individual of their identity, their stationary point, or which forces them to reconceive of themselves as weak and dependent in some sense.

The second more serious impact of disease on autonomy is only indirectly related to the disease but directly related to the treatment of the disease. Just as disease can throw an individual off balance and so rob them of autonomy competency, being admitted into the medical system can have just as damaging an effect. The medical system operates under the idea that the patient is weak and dependent and, as they serve to overcome this, they reinforce that perception--this is what Ackerman calls the "sick role.' Further, the medical system is alien to the patient in many ways (at least most patients) and this feeling of alienation further reinforces the loss of control. Thus, a patient who was already struggling with autonomy becomes further undermined in their treatment.

Yet, if this diminishing of autonomy can later serve to strengthen and repair autonomy, shouldn’t such a diminishing be allowed?

It is this balancing between diminishing and balancing autonomy that is at stake in the conflict between illness and disease concerns. In order to treat the illness, the disease must be treated. Sometimes treating disease requires taking actions that the patient might not want to consent to. Sometimes treating the disease requires taking actions that the patient is not able to understand. Both of these cases raise issues of competency and to decide them a balance needs to be struck between the patient’s present level of autonomy competency, the potential diminishing of autonomy competency by the treatment, and the desire to increase the patient’s autonomy competency.

Key Concepts:

  • Autonomy
  • Disease
  • Illness
  • Paternalism

Some Questions to Consider:

  • Is the object of medicine really to treat illness and not merely disease?
  • Can we adequately talk about medicine in terms of autonomy? Or is this a misleading conversation?
  • What obligation does the health care professional have to the patient?
  • What obligation does the patient have to herself?

 

3Jun/1121

Lecture 06/03>Ethical Concepts and Principles

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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.

1Jun/118

Lecture 06/01>Ethical Theories

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The ethical theories that you learned about today (combined with the concepts you will learn on Friday) form the basic tool set you will use to explore ethical issues in medicine.  Before we even start discussing issues in bioethics, everyone needs to have a basic foundation in the different kinds of existing ethical theories.  These are: Utilitarianism, Deontology, Virtue Ethics, and Care Ethics. [Although Feminist Ethics is an equally good theory, it is also deeply complex.  We are only going to focus on the first four in this class.]

To understand each of these ethical theories, consider these three questions:

  1. What does the theory take to be morally relevant details of the world?
  2. What is the standard by which the theory judges those morally relevant details right or wrong?

The different ethical theories are going to give various different answers to these questions, but they will also overlap in different respects.  All five ethical theories offer different strengths and weaknesses in approaching questions in bioethics. You must be able to understand different ethical issues from different ethical perspectives; therefore, you must understand each of these ethical theories as a potentially useful way of looking at the moral world. Try on different ethical perspectives and see which fits your own intuitions about what is morally correct. Test your own moral stances against each ethical theory. Use these different theories to challenge your preconceptions and the preconceptions of others.

To clarify the importance of questions (1) - (2),  let's take a look at each individual theory.

Utilitarianism is a form of consequentialism. Consequentialism answers question (1) by pointing to consequences.  Consequentialism takes the consequences of an action to be all that are morally relevant. Utilitarianism answers question (2) by establishing a standard by which to judge consequences of actions.  For utilitarianism, consequences are good or bad based on whether they maximize utility. There are  debates about what constitutes utility.  Our text gives two examples:  Jeremy Bentham defines utility as pleasure and the absence of pain; John Stuart Mill defines utility as happiness.  The significant difference is that Bentham thinks all pleasures are of an equal kind.  So, eating a steak will provide the same kind of pleasure as reading a book.  Even if reading a book tends to create greater pleasure, eating enough steak can equal that amount of pleasure.  In contrast, Mill thinks that there are two kinds of pleasures: higher and lower.  For Mill, eating steak is a lower, sensual pleasure, while reading a book is a higher, intellectual pleasure.  No amount of eating steak can equal the pleasure brought about by reading a book because they are qualitatively different.  Higher pleasures always provide greater utility than lower pleasure.  This distinction is central to Mill's definition of happiness.

All utilitarianism further stipulates that what matters is overall utility.   What is morally relevant about an action is not simply that its consequences create happiness or pleasure, but that it maximizes the happiness of the greatest number. The most moral actions will be those that cause great happiness for a large number of people. The most immoral actions will be those that cause great unhappiness for a large number of people.

However, as the readings point out, there is a further distinction to make because there are two basic forms of utilitarianism: act and rule.  Act-utilitarians believe that what matters is what particular action will actually bring about best consequences at the moment.  Rule-utilitarians believe that what matters most is what rule tends to produce the best consequences, even if that rule does not produce the best consequences in these particular circumstances.  So, if an act-utilitarian were faced with the accidental killing of a child by car, the act-utilitarian would ask: did the action create greater happiness or unhappiness? If the answer is unhappiness, then the action is immoral. If the answer is happiness, then the action is moral.  In contrast, there is no choice for rule-utilitarians because killing is recognized to generally create pain and decrease pleasure.  Thus, regardless of the particular details of this accident, the killing of the child is immoral.

Key Concepts:

  • Consequentialism
  • Rule-Utilitarianism
  • Act-Utilitarianism
  • Utility
  • Pleasure
  • Lower Pleasures
  • Higher Pleasures

Deontology takes a very different tact from utilitarianism.  For deontology, the answer to question (1) (what is morally relevant?) is duty or intentions. If you act for the right reasons, then you acted morally regardless of the consequences.  More importantly, deontology (specifically Kantian deonotology) has a radically different answer to question (2) (by what moral standard?).  The standard of moral worth for Kantian deontology is respect for persons.  What Kant calls the categorical imperative. If your intention conforms with the categorical imperative, then your action is moral.  The categorical imperative can be simply stated as the following: "Treat other persons as end, not as mere means."  Put another way, never treat others simply as tools to your own ends; treat them as capable of having and endorsing their own ends.  The clearest example is lying.  If I wanted to buy an iPod, but didn't have any money.  I might ask you if I could borrow $200.  I tell you why and then I tell you that I will pay you back next week.  I have no intention of paying you back.  I have lied to you because I want you to lend me the money.  In other words, I am using you as a mere means (or a tool) to achieving my end of getting an iPod.  By lying to you about paying you back, I am not allowing you to take my end of getting an iPod as your own.  By not allowing you this option, I am not respecting you as a person.  To do so, I would have to tell you the truth: that I cannot pay you back, but I would like you to give me the money anyway.  Only then am I respecting you as a person.

One problem with Kantian deontology is that it is sometimes obscure when it comes down to deciding between different duties.  While utilitarianism is uncertain because of the very nature of the future (there are so many uncontrollable influences, that you never can be certain what consequences your actions will bring about, Kantian deontology is uncertain because it seems that conflicting duties can hold equally. Rossian deontology attempts to fix this by introducing the concept of prima facie duties.  Prima facie duties are duties that are completely conditional.  Kant makes a distinction between duties that hold absolutely (perfect duties) and duties that hold conditionally (imperfect duties).  Ross collapses all duties into the conditional category and holds that our natural moral intuitions will help us determine what duty to follow when we have multiple duties, but can only fulfill one.  This, however, does not strictly fix the obscurity of the decision making process, as intuitions are often inscrutable--it simply makes the decision making process more transparent.

Key Concepts:

  • Kantian deontology
  • Rossian deontology
  • Categorical imperative
  • Respect
  • Perfect duties
  • Imperfect duties
  • Prima facie duties

While utilitarianism takes consequences to be the most important aspect of a moral theory and deontology takes intentions to be the most important aspect of a moral theory, virtue ethics focuses on something different: character.  In answer to question (1) (what is morally relevant), virtue ethics answers that it is the temperament and orientation of one's personality towards the world that matters. This takes some unpacking.

Character is displayed in different ways.  First, it is displayed through one's actions.  According to Aristotle, the father of virtue ethics, one does not have complete control over the meaning and success of one's actions.  In this way, virtue ethics adopts the insight of consequentialism that responsibility can outrun control--we can cause things we did not mean to cause.  So, what actions you perform are linked to the successful consequences of those actions.

Second, character is displayed through one's intentions.  It is not enough that you act and cause good consequences.  You must also intend to act in the way you acted and cause the consequences you did.  Thus, the morality of an act is not confined to consequences, but also your control over those consequences.  In this way, virtue ethics adopts the insight of deontology that what matters is what you can control.

Finally, character is displayed through the "naturalness" of one's behavior.  This is a critical aspect of virtue ethics.  You only have the right character if you innately act the right way.  Or, perhaps a better way to put it, you only have the right character if acting in the right way is second nature to you.  This is not a claim about being born a certain way.  Rather, it is a claim about habituation.  A way of acting becomes second nature by consistently acting that way.  So, when you are little you are forced to brush your teeth.  You might not want to, but you do it because your parents/guardians tell you to.  If you continue to do it because you feel obligated, but not because you want to, then brushing your teeth is not part of your character.  If, on the other hand, you internalize the habit of brushing your teeth and approve of the habit, then brushing your teeth does become part of your character.  In the same way, if you act to save someone's life, according to virtue ethics this is only a moral action if it is an organic outgrowth of who you are.  This is in deep contrast to deontology and utilitarianism, which could care less whether you act from some deep, important sense of self or not.  Virtue ethics holds that acting from who you are (your actual character) is precisely what is morally relevant.  Because the success of our actions directly impacts whether we can actually be said to have a certain kind of character (you wouldn't say a person who constantly crashes a car is a good driver, even if the crashes are never actually their fault), who we are is not entirely under our control, but open to luck caused by our circumstances.

Of course, it is not enough that we know what is morally relevant, we must also answer what makes this aspect right or wrong (question (2)).  For Aristotle, this was what he called "the mean."  The right character is a moderate character--the mean between two extremes. To understand this, we have to actually categorize different aspects of character, called virtues.  These are some examples of virtues: courage, temperance (in food and drink), generosity, charity, pride, and patience.  Each of these as corresponding extremes.  Courage, for example, is the mean between cowardice and foolhardiness.  Some of the virtues Aristotle gave do not always match up with out modern day intuitions.  For instance, it might seem odd to see pride in the list above.  Aristotle saw pride as the mean between humility (which today is often preached as a virtue) and vanity.  Pride is knowing and acting in accordance with one's own worth.  You can think of this in terms of respecting yourself.  Aristotle would say that being humble when you deserve praise is actually disrespecting yourself.  In this way, this can be thought of as a facet of honesty.

Clearly, virtue ethics is complicated.  However, it can be reduced to a simple phrase: Act in the right way, at the right time, for the right reason.  Thus, virtue ethics requires knowledge and wisdom: knowledge to analyze a situation and wisdom to know how to act appropriately.  After all, if you had no knowledge of the mean, you would have little idea what the right way to act would be!  It is because of this that Aristotle thinks how and where you are raised will greatly impact your ability to be virtuous (i.e. moral).  If you are raised poorly, then there is much less of a chance that you will be able to navigate moral situations.  Using virtue ethics requires knowing what virtue is being exercised and what moderation requires in these particular circumstances.

Key Concepts:

  • Virtue
  • Character
  • The mean
  • The virtues

Care ethics is similar to virtue ethics in that it focuses on the actual particular circumstances in lieu of universal principles.  However, care ethics is more specifically focused on relationships than virtue ethics.  Care ethics takes relationships to be the morally relevant aspect of the world (in answer to question (1)).  Utilitarianism and deontology focus on pushing away from personal relationships by abstracting to a point of fairness and detachment. Thus, for those ethical theories, precisely what is not morally relevant are individual attachments. Care ethics turns this on its head by claiming that precisely these individual attachments are what is morally relevant (at least in everyday ethics). Care ethicists argue that the detachment that utilitarianism and deontology foster is actually morally harmful because it denies certain realities of life. Central among these ignored realities is that every individual is cared for at some point in their life. Without this basic level of care, there would be no human race. In fact, there is good reason to think that the detached autonomous individual that is held up by utilitarianism and deontology is only realizable on the backs of those who care for others.

Of course, care ethics must define what it means for personal relationships to be morally good (question (2)) and it does this largely by defining what healthy relationships involve. One way to think of this, as noted above, is as a narrow set of virtues focused on relationships: “sympathy, compassion, fidelity, love, friendship.” But a simple way to think of care ethics is to emphasize a primary element of care: the ability to put another before one’s self. To do this, one needs to know and understand the other person and put aside one’s own opinions on an issue. Care ethics is built on the closeness of relationships that can develop in an atmosphere of trust--this is the ideal of care ethics.  To determine what is morally right or wrong in a given situation, care ethics must identify what relationships are involved, whether these relationships are healthy, and what kind of obligations these relationships produce.  In the example first mentioned in the utilitarianism section, a child is accidentally killed by a driver.  Care ethics could say that the action is wrong, but it would be less concerned with punishment than with the kinds of relationships of obligation the accident produces.  For instance, what kind of relationship does this produce for the driver to the child's family and what kind of actions are obligated by this relationship?

Key Concepts:

  • Care
  • Relationships
  • Health
  • Relationship virtues

All of these theories are fairly worthless if you do not know how to apply them. So, I leave you with a few ways to approach various questions from these different ethical perspectives.

Some Questions to Consider (for use with readings):

Utilitarianism

  • What examples of maximum utility are there in the reading?  Are there any?
  • How can utility be maximized?
  • What does it mean for utility to be maximized?
  • What good and bad consequences are there in the reading?  Do they balance out?

Deontology

  • What are the intentions of the individual actors?
  • Do these intentions treat others as mere means?  How?
  • Could the actors have acted in another way that would have been moral?

Virtue Ethics

  • What character virtues might be involved in this reading?
  • What is involved in these virtues?
  • Have certain circumstances made it impossible to be moral?
  • Whose virtue matters here?

Care Ethics

  • What are the relevant relationships?  If there are multiple, what kind of conflict does this create?
  • What responsibility does each person have to the other?
  • Are all of the relationships healthy?  If yes, how?  If no, which are not and why are they not?
  • What impact does this have morally?
utilitarianism and deontology focus on pushing away from personal relationships by abstracting to a point of fairness and detachment. Thus, for those ethical theories, precisely what is not morally relevant are individual attachments. Care ethics turns this on its head by claiming that precisely these individual attachments are what is morally relevant (at least in everyday ethics). Care ethicists argue that the detachment that utilitarianism and deontology foster is actually morally harmful because it denies certain realities of life. Central among these ignored realities is that every individual is cared for at some point in their life. Without this basic level of care, there would be no human race. In fact, there is good reason to think that the detached autonomous individual that is held up by utilitarianism and deontology is only realizable on the backs of those who care for others.