Ethical Theory - MU School of Medicine

Morally wrong acts are activities such as murder, theft, rape, lying, and breaking promises. Other descriptions would be that they are morally prohibited, ... Skiptomaincontent Close COVID-19VaccinationandTesting Learnhowtoscheduleanappointmentforvaccinationortesting. ReadMore DynamicMainMenu ClinicalEthicsCommittee EthicsConsultService EthicsFAQ MeettheTeam CenterforHealthEthics DynamicMainMenu ClinicalEthicsCommittee EthicsConsultService EthicsFAQ MeettheTeam EthicalTheory Breadcrumb Home  /   Centers,Institutes&Labs  /   CenterforHealthEthics  /   EthicsFAQ  /   EthicalTheory SectionMenu SectionMenu Abortion AdvanceDirectivesandSurrogateDecisionMaking AnimalUse ConceptofPersonhood Confidentiality EthicalTheory EthicsandtheLaw Euthanasia GeneTherapyandGeneticEngineering GeneticTestingandScreening HealthCareAccess HumanResearch InformedConsent MulticulturalMedicine OrganAcquisition OrganTransplantation PhysicianandNurseRelationships Provider-PatientRelationship TreatingMinors TruthTelling WhatisMorality? Moralitydirectspeopletobehaveincertainwaysandavoidbehavinginotherways.Itevaluatesbehaviorasrightorwrongandmayinvolvemeasuringtheconformityofaperson’sactionstoacodeofconductorsetofprinciples.Moralityis“normative,”itisconcernedwithhowpeopleshouldbehave,notjusthowtheyactuallydobehave. Somepeopleusetheterm“ethics”forthesystematicstudyofmorality.Butreallythereissuchloosenessintheuseofthetermsthatinthemindsofmanymoralityandethicsarethesame.Thus,“Whatisyourethics?”isusuallytakentomeanthesameas“Whatisyourmorality?” Controversyexistsinthestudyofmoralityaboutsuchquestionsaswhetherthereisasinglestandardofmoralityforallpeopleandhowwecanknowwhatthatstandardis. TypesofActs Thoughmoralityusesthecategoriesofrightandwrong,thosetwotermsarenotenoughtocaptureallthatwewanttosayaboutdifferenttypesofbehavior.Toseethis,notethatwhiletosaythatanactionismorallywrongmeansweoughtnottodoit,toclaimthatanactionismorallyrightfailstoclarifywhetherweshoulddoitoraremerelyallowedtodoit(thatis,whetheritisobligatoryormerelypermissible).Andwhatofactsthatgoaboveandbeyondthecallofduty?Theyaremorallyright,butperhapsweneedatermtoseparatethemfromotheractsthatarerightinthesenseofmerelypermissible. Expandingthecategoryof“morallyright”toincludethreedifferentsubcategoriesbettercapturesthedistinctionswewant: morallywrong morallyright morallyneutral morallyobligatory morallysupererogatory Morallywrongactsareactivitiessuchasmurder,theft,rape,lying,andbreakingpromises.Otherdescriptionswouldbethattheyaremorallyprohibited,morallyimpermissible,actsoneoughtnottodo,andactsonehasadutytorefrainfromdoing. Morallyrightactsareactivitiesthatareallowed.Theyincludethemorallyneutral,themorallyobligatory,andthemorallysupererogatory. Morallyneutralactsaremorallyrightactivitiesthatareallowedbutnotrequired.Oneisneitherobligatednorprohibitedfromdoingthem.Onemightcallthemthe"merelymorallypermissible."Examplesofsuchactsincludewatchingtheeveningnewsontelevision,eatinganappleinsteadofanorange,choosingvanillaoverchocolate,whistlingwhileyouwork,thoroughlychewingyourfoodbeforeswallowing,brushingbeforeflossinginsteadofafter,etc. Morallyobligatoryactsaremorallyrightactsoneoughttodo,oneismorallyprohibitedfromnotdoingthem,theyaremoralduties,theyareactsthatarerequired.Suchactsmightbekeepingone'spromisesandprovidingguidanceandsupportforone'schildren. Morallysupererogatoryactsarethosemorallyrightactivitiesthatareespeciallypraiseworthyandevenheroic.Theygobeyondwhatdutyrequires.Theyaren'trequired,morally,butiftheyaredoneitisanespeciallygoodthing.Examplesincludegeneroussupportforworthwhilecharities,volunteerworkforalocalnursinghome,andriskingone'slifetosavesomeonefromaburningbuilding. Thesefourcategoriesofactsarenotalwaysexplicitlydistinguishedbypeoplebuttheyseemimplicitlyincorporatedintoourmoraldistinctionsanddecisions.Thereis,however,somedisagreementaboutexactlywhattypesofactfitintowhichcategories.Thus,forexample,whileeveryonethinksmurdertobemorallywrong,thereiscontroversyaboutwhetherabortioniswrong;somepeoplebelieveabortiontobewrongandothersbelieveittobemorallypermissible. KindsofEthics Wesaidthatmoralitywasconcernedwithnormativestandardsofrightandwrongbehavior.Actuallythatisonetypeofethicscalled“normativeethics.”Besidesnormativeethics,ethicistsalsotalkofdescriptiveethicsandmetaethics.Descriptiveethicsdescribesexistingacceptedstandardsofmorality,normativeethicspromotesorarguesforthe“correct”standardofmorality,andmetaethicsanalyzessuchthingsasthemeaningandjustificationofmoraljudgments. Biomedicalethicists,medicalethicists,healthcareethicists,nursingethicists,bioethicists,etc.aremainlydoingnormativeethics,thoughrestrictedtoaparticularareaordomain(healthcare).Healthcareisthusengagedinwhatsomeconsiderafourthkindofethics,appliedethics.Butreallyitcouldbearguedthatanynormativeethicsthatgetsawayfromgeneralprinciplesanddiscussestheirapplicationtoparticularsituationsmightberightfullyconsideredappliedethics.Andsosomethinkersconsiderappliedethicsjustatypeofnormativeethics,notaseparatekindofethics. NormativeEthicalTraditions Onewaytodonormativeethicsistofocusonanalyzinghumanacts;anotherwayistofocusonhumancharacter.Thislatterapproachoccursthrough“virtue”ethics.Virtueethicsseekstoascertainthecorrectvirtuesthatshouldbepossessedbypeopleofstrongmoralcharacter.Perhapsvirtueethicshasabetterchanceofgettingpeopletodotherightthing,butact-basednormativeethicsseemstostandabetterchanceofdeterminingwhatthatrightthingisinanygivensituation.Inhealthethicsdiscussionstheact-basedapproachhasbeenmostimportantsowewilldiscussitinmoredetail. Forourpurposestherearetwobasicapproachestodeterminingtherightnessofacts,twobasicapproachestonormativeethics.Tounderstandthedifference,considerthatwhenyoudosomething,undertakeanyaction,thereisgoingtobe(1)whatyouactuallydo,andthentherearegoingtobe(2)theconsequencesofwhatyoudo.Forexample,ifIstealanotherperson’scar,thereistheactofstealingthecar,andthentherearetheconsequencesofthattheft–theownerwon’thaveawaytogettowork,itwillencouragehimandotherstolockthingsupbetter,Imightgetcaughtandthrowninjail,etc. Sowhenlookingatanactwecanfocusonthenatureoftheactitselforontheconsequences.Wecansaytheactisrightorwrongbecauseitisacertainkindofact,itfitsinwithcertainprinciplesorrules,orwecansaytheactisrightorwrongbecauseitresultsingoodorbadconsequences. Tosimplifythematterwe’llcallthefirstkindofapproach“deontology”andthesecondkind“utilitarianism.”Othernamesfordeontologyorthingslikethemare“nonconsequentialism”and“path-dependenttheories.”Othernamesforutilitarianismorthingslikethemare“consequentialism”and“cost-benefitapproaches.” Totakeuputilitarianismfirst,asimplewaytoputthebasicperspectiveistosaythatwhenfacedwithalternativecoursesofpossibleaction,moralityrequiresustochoosetheactorchoiceorcourseofactionthatbringsaboutthegreatestgood(usuallythoughtofashappiness)forthegreatestnumberofpeople.Thekeyisthattoconsideronlytheconsequencesoftheact,bothshort-termandlong-termconsequences.Sointhecaseofcartheft,howmuchhappinessisproducedforeveryonebystealingthecarversusthehappinessfromnotstealingthecar?Chancesaremorehappinessforeveryonewouldoccurfromnotstealingthecar,sothatistherightthingtodo. Thedeontologicalapproachsaysthatconsequencesareimportanttoconsiderbuttheyarenottheonlything.The“path”totheconsequencesshouldbetakenintoaccountalso;somekindsofactarejustwrongregardlessofwhethertheybringaboutthegreatestamountofhappinessoverall.Forexample,ifbymurderinganinnocentpersonIsomehowwouldmakemanypeoplehappythatdoesn’tmakeitright–murderingwouldbewrongevenso,soIshouldn’tdoit.Whatkindsofactsarerightorwrongbecauseofthepathtotheconsequences?Opinionsvary,buttherearecertainprinciplesorrulessuggestedthattelluswhatkindsofactsarerightorwrong. Deontologystressesthatwehavecertain“duties”orobligationsapartfromconsequences,thoughoftendoingtherightkindofactwillinfactleadtogoodconsequencesforthemostpeople.Forexample,thephilosopherW.D.Rosslistedanumberofapparentdutiesweallhave;theymaybeparaphrasedas: Fidelity:dutytokeeppromisesandcontractsandnotbedeceptive Reparation:dutytomakeupforinjuryonecausedtoanother Gratitude:dutytobegratefulforfavorsandifpossiblereturnthem Non-maleficence:dutynottoharmothers Beneficence:dutytodogoodtoothers Self-improvement:dutytoimproveoneself Justice:dutytoseethatpleasureorhappinessisnotdistributedoutofproportiontowhatpeoplemerit TheaveragepersonintheUnitedStateshasnotheardRossbutheorshehasheardofanothersetofrulesorprinciplesfromtheBible,morepreciselytheOldTestamentorHebrewscriptures(inthebooksofExodusandDeuteronomy);theseprinciplesorrulesareknownasthe“TenCommandments.”Insofarasanyoftheseprovidemoralrulesthattellushowtoactandthusdistinguishbetweenrightandwrongacts,theyrepresentanonconsequentialist,deontologicalapproach.Hereisaparaphrase: WorshiponlytheonetrueGod. Donotworshipidols. DonotmakewrongfuluseofthenameofGod. OntheseventhdayoftheweektakeaSabbath. Honoryoufatherandmother. Donotmurder. Donotcommitadultery. Donotsteal. Donotbearfalsewitnessagainstyourneighbor. Donotcovetyourneighbor’swifeorpossessions. Certainoftheserulesarereligiousratherthanmoral,butcommonmoralrulesspecifiedaretorespectyourparentsandtorefrainfrommurder,adultery,theft,falselyaccusingortestifyingagainstanotherperson,andbeingjealousofanddesiringanotherperson’sspouseandpossessions. PrinciplesofBiomedicalEthics Utilitarianreasoningoccasionallysurfacesinhealthcareethics,particularlywhenthediscussionisabouttheallocationofscarceresourcesandacost/benefitorcost/effectivenessapproachisbeingused.ButthemostwidelyknownapproachisadeontologicalapproachemphasizingfourprinciplesstemmingfromtheBelmontreportastweakedbytheethicistsBeauchampandChildress: Respectforautonomy(respectforthefreedomofpersons) Non-maleficence(donoharm) Beneficence(dogood) Justice(fairness) Autonomyisthefreedomofapersontomakedecisionsthatcontrolhisorherlife.Inhealthcare,patientsdeservetohavetheirautonomyrespectedinthattheyshouldbepresentedwiththemedicalsituation,advisedoftheoptionsandtheirexpectedoutcomesandrisks,andhavethefreedomtomaketheirowndecisionsabouttheirtreatmentratherthanbeingmisledorcoerced. Non-maleficenceisaprincipleofethicswidelyheldoutsideofhealthcareinthateachofushastheobligationtorefrainfromharminganotherpersonunlessthereexistextraordinarycircumstancessuchastheneedforself-defenseagainstimmanentharm.Inhealthcarethisprinciplemeansclinicianshaveanobligationnottoharmpatients.Temporarypainanddiscomfortduetotests,procedures,orothertreatmentinterventionsshouldbebalancedbythelong-termbenefittheywillbring. Theprincipleofbeneficenceisalsorecognizedoutsideofhealthcareinthateachofushasageneralmoralobligationtodogoodforoneanother.Butthisprinciplehasalimitedextentinthatnootherpersonhasarighttodemandmycharitytowardthem.Inhealthcareitbecomesaprincipleofspecificbeneficencethataproviderowestohisorherpatient.Thepatientdoesexpecttheproviderwillworkforthebenefitofthespecificpatientandprovidethebestpossiblecare.Thisisbasedonthefiduciarynature(trust)thatcharacterizestheprovider-patientrelationship. Thefourthprincipleisthathealthcareshouldbeprovidedwithjusticeinallocationofresourcesandintheproviderallocatinghisorhertimetopatients.Theusualunderstandingofjusticeinsuchcontextsis“distributive”justicehavingtodowithfairdistribution.Theapplicationofthisprincipleisnotclearcut,however,sincetherearedifferinginterpretationsofwhatfairnessmeans–equality,basedonmerit,basedonneed,etc. Inhealthcareethicsweconsiderparticularsituationsandwonderwhetheraproposedcourseofactionorinactionismorallyobligatory,merelymorallypermissible(morallyneutral),ormorallyimpermissible.Weaskquestionsaboutwhatprovidersandcliniciansshoulddoincertainsituations.Controversiesoccurinhealthcareethicsandinethicsingeneraloverthecorrectnormativeethicalapproach,overwhetherprinciples,rights,ordutiesareinvolvedatall,overwhichprinciplesapplyinparticularsituationsandhowtheyapply,andoverwhichprinciplesshouldprevailifdifferentprinciplesseemtodirectdifferentcoursesofaction. Some“casuistic”approachespurporttoeschewprinciplesalltogetherandclaimweshoulddecideonacase-by-casebasisusingsimilaritieswithaccepteddecisionsfromearliercases.However,criticswouldquestionhowthoseearlierdecisionscouldbejustifiedordistinguishedfrommereprejudiceunlessonehadprinciplesorrulestodrawuponinmakingthoseinitialjudgments. Metaethics Metaethicsasksquestionssuchas: Domoralprinciplesandjudgments(“stealingiswrong,”“yououghtnottostealthat,”)representknowledge,mereopinion,orexpressionsofemotionthathavenocognitivecontent? Howdoweknowwhatthecorrectmoralprinciplesare? Ismoralityuniversalforallpeopleorinsteadrelativetoculture? Metaethicsrarelyentersintohealthcareethicsdiscussions.Providersandpatientsgenerallyacceptthattherearerightandwrongbehaviorsandprinciplesorrulesthatmakethemso,almostalwayswithoutaskinghowweknowofsuchprinciplesatall. Itisnotclearwhattheimplicationsareofthislackofmetaethicsdiscussion.Insistenceonmetaethicsdiscussioninhealthethicscertainlywouldtremendouslycomplicatemattersandperhapsevenparalyzeneededethicaldiscussioninhealthcare.However,onatheoreticallevelandinanacademiccontext,discussionofmetaethicswouldseemtobeveryimportantincreatingdialogueamongpeopleofdifferentviewpointsaboutwheretogettherightethicalprinciples. 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