A Summary of Biomedical Ethical Theory

Except as indicated otherwise, this is an

Abridgement of General Introduction of Mappes, Thomas A. and David DeGrazia (eds). Biomedical Ethics, 4th edition, 1996. McGraw-Hill.

Pages:

1 [I.] THE NATURE OF BIOMEDICAL ETHICS

[It is] a subdiscipline within the more general discipline of ethics [which] as a philosophical discipline [is] the "philosophical study of morality" [as] distinguished from the scientific study of morality, often called "descriptive ethics" [seeking] causal origin.

2 (1) normative ethics and (2) metaethics, although the precise relationship of these two branches is a matter of some dispute. In normative ethics, philosophers attempt to determine what is morally right and what is morally wrong with regard to human action. In metaethics, philosophers are concerned with tasks such as analyzing the nature of moral judgments and specifying appropriate methods for the justification of particular moral judgments and theoretical systems.

[General N]ormative ethics attempts to establish which moral views are justifiable and thus ought to be accepted . . . what is morally right and what is morally wrong? In applied normative ethics . . . the task is to resolve particular moral problems . . . [B]iomedical ethics [is] one branch of applied (normative) ethics. [Business ethics is another example.]

2 Only since about 1970 [has biomedical ethics become] a relatively autonomous discipline . . . [3] (1) the awesome advance of biomedical research [and] biomedical technology and (2) the practice of medicine in an increasingly complicated institutional setting.

3 [B]iomedical ethics is an interdisciplinary field [1] within philosophy [in relation to general normative ethics, social-political philosophy, and philosophy of law] [2, in relation to] moral theology and [3, in relation to] medicine and biology.

4 [C]onceptual, factual, and [especially] normative issues [are involved in biomedical ethics].

4 [II.] ETHICAL THEORIES

4 The Critical Assessment of Competing Ethical Theories

(1) consistency

(2) completeness

(3) reconcilability with our experience of the moral life (common sense?) Be in accordance with the facts of moral life. [p. 8: Among the "commonsense rules of morality" are . . .: "do not kill," "do not injure," "do not steal," "do not lie," "do not break promises[.]"

(4) effective guidance in disputed situations. Function heuristically (stimulating further investigation, learning [Gk.to find out, discover] by guiding us when confronted with moral perplexity.)


5 Teleological [consequentialist] versus Deontological [limiting the importance of outcome] Theories

6 Any ethical theory that claims the rightness and wrongness of human action is exclusively a function of the goodness and badness of the consequences resulting directly or indirectly from that action is a teleological theory. . . . A deontological theory maintains, in contrast, that the rightness and wrongness of human action is not exclusively (in the extreme case, not at all) a function of the goodness or badness of consequences.

6 The most prominent teleological ethical theory is the theory known as "utilitarianism." . . . [M]uch argumentation in biomedical ethics is based on utilitarian reasoning . . .

6 Ethical egoism [p. 7: directs a person always to act so as to produce the greatest balance of good over evil for oneself (i.e., the agent)] . . . [seems to be] at odds with our ordinary moral thinking . . . is flatly antisocial in nature [as in loving to set fires, and in being inconsistent if one advocates it, as that wouldn't be in one's own self-interest]. In "collapsing" morality into prudence, ethical egoism does not accord with a commonly experienced phe[7]nomenon of the moral life, the tension between self-interest and morality, between "what would be best for me" and "what is the morally right thing." [It is] a notable instance of a teleological yet nonutilitarian theory.

7 Act-Utilitarianism

A person ought to act so as to produce balance the greatest balance of good over evil, everyone considered.

7 [A]ny system of utilitarian calculation must ultimately be [8] anchored in some conception of intrinsic value (i.e., that which is good or desirable in and of itself). [What is "good" in] classical utilitarianism [is] a so-called hedonistic theory of intrinsic value. According to Bentham, only pleasure (understood broadly to include any type of satisfaction or enjoyment) has intrinsic value; only pain (understood broadly to include any dissatisfaction, frustration, or displeasure) has intrinsic disvalue. According to Mill, only happiness has intrinsic value; only unhappiness has intrinsic disvalue. . . . [M]any contemporary utilitarian thinkers have embraced more elaborate and nonhedonistic theories of intrinsic value.

9 Examples of Act-Utilitarian Reasoning in a Biomedical Context

10 Critical Assessment of Act-Utilitarianism

(1) Act-Utilitarianism Confronts Individuals with an Overly Demanding Moral Standard. Whereas ethical egoism seems to wrongly "collapse" morality into prudence [here seemingly meaning convenience or advantage, whereas prudent normally means wise, judicious in practical affairs, discreet or circumspect, cautious, provident: showing or having foresight, mindful in making provision, frugal], it would seem that act-utilitarianism "expands" morality so as to destroy the [nonmoral] realm of prudence [inasmuch as] a person is continually under a moral obligation to produce the greatest balance of good over evil, everyone considered.

11 [There is nothing left "above and beyond the call of duty."

(2) Act-Utilitarianism Does Not Accord with Our Experience of Particular, Morally Significant Relationships. [It ignores special relationships, such as parent and child, physician and patient, with] special obligations . . . that function to restrict the effort to maximize utility. . . . For a physician to damage the interests of an individual patient in an effort to maximize utility surely seems wrong. W. D. Ross . . . asserts that the "essential defect of the . . . theory is that it ignores, or at least does not do full justice to, the highly personal character of duty."

11 (3) Act-Utilitarianism Does Not Accord with Our Conviction That Individuals Have Rights. . . . Certain means of achieving a desirable social end are simply wrongful because they entail the violation of a person's right. Contra act-utilitarianism, such means cannot be justified by the ends.

[Two responses:] [1] "so much the worse for our ordinary moral

12 thinking." [2] [W]when all the significant long-term, indirect consequences are taken into account, the theory does not give rise to conclusions that seem so patently objectionable.

[However, act-utilitarianism does] provide effective guidance where it is most needed. . . . [I]n contemporary times, most utilitarian thinkers have rejected act-utilitarianism in favor of a theory known as rule-utilitarianism.

12 Rule-Utilitarianism

A person ought to act in accordance with the rule that if generally followed, would produce balance of good over evil, everyone considered.

14 Examples of Rule-Utilitarian Reasoning in a Biomedical Context

Problems, all of them relating to the general tendencies produced by certain activities, if engaged in: (1) lying to a patient

(2) morality of mercy killing (justification of exceptions to rule against killing; for self-defense, OK, but most issues can be argued on both sides by rule utilitarians.

(3) medical confidentiality.

15 Critical Assessment of Rule-Utilitarianism

Rule utilitarianism fares better than act-utilitarianism with regard to "ordinary moral thinking." But it can't "provide an adequate theoretical foundation for individual rights," although some think that it can by considering individual rights to be special cases of a utilitarian-based moral code.

More broadly, rule-utilitarianism may fail to provide grounds for obligations of justice.

16 Kantian Deontology

continues to command substantial attention in contemporary discussions of ethical theory and, importantly, is the underlying framework of much argumentation in biomedical ethics.

The "supreme principle of morality," the principle from which all of our various duties derive, Kant calls the "categorical imperative."

17 Kantian deontology is an ethics of respect for persons. In Kant's view, every person, by virtue of his or her humanity (i.e., rational nature) has an inherent dignity. All persons, as rational creatures, are entitled to respect, not only from others but also from themselves as well.

17 First formulation of categorical imperative: "Act only on that maxim through which you can at the same time will that it should become a universal law."

Second formulation of categorical imperative: "Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end." Kant considered the first to be more basic, but commentators have emphasized the second as the more promising, since (a) it embodies the central notion of respect for persons (b) this is the form in which Kantianism almost always is encountered in biomedical ethics. "Kantian deontology is an ethics of respect for persons." Everyone has inherent dignity by virtue of higher rational nature. From this. particular duties are derived, including to both self and others:

17 Perfect duties: require that we do or abstain from certain acts without exceptions, binding in all circumstances. AND

Imperfect duties require us to pursue or promote certain goals (e.g., the welfare of others), but never at the expense of a perfect duty. There is no duty to perform any specific beneficent action, but we do have the duty "to formulate a plan of life that embodies a commitment to the goal of personal development" including (19) promoting the wellbeing of others. "We transgress imperfect duties by failing to treat a person as an end, even though we do not actively treat him as a means."

18 "The most notable of our perfect duties to others are: (1) the duty not to kill an innocent person, (2) the duty not to lie, and (3) the duty to keep promises."

19 Beneficence (considered in connection with imperfect duties to others) is contrasted with nonmaleficence, which is "the noninfliction of harm on others." Beneficence is actively (1) preventing evil or harm from befalling someone, (2) removing an evil that is presently afflicting someone, and (3) providing benefits ("doing good") for someone. The imperfect duty to oneself of beneficence requires no specific actions.

19 The Kantian Framework in a Biomedical Context

It's particularly relevant to the question of a physician's lying to a patient. Kant's claim that everyone has a perfect duty not to lie, would prevent it. Beneficence, which would allow lying in some circumstances, is an imperfect duty, so subordinate to a perfect duty.

Kantianism would prohibit using people for experimentation, since they would be used as means, rather than ends.

20 Critical Assessment of Kantian Deontology

Pro: (1) The wrongfulness of some actions, such as murder, stealing, hurting, lying, and breaking promises can be understood as flowing from the categorical imperative.

(2) Kantian deontology provides a firm foundation for the notion of individual rights, understood as correlates of our perfect duties to others. (Imperfect duties do not generate rights.)

It supports the ideas that individual rights cannot be overridden by "utilitarian" considerations and that the end does not justify the means.

Con: (1) It runs afoul of our feeling that there should be exceptions to never lying and always keeping promises.

21 "One is tempted to say that even if the theory provides reasonably clear guidance, it sometimes fails to provide correct guidance."

21 W[illiam]. D[avid]. Ross[1871-1971]'s Theory of Prima Facie Duties

Reese: "that obligation with a presumptive right to be considered the most important obligation in a given situation."

The Right and the Good (1930): Provides for conflicting duties.

22 "A prima facie duty is a conditional duty [that] can be overridden by a more stringent duty." Ross denies that there are any absolute, or unconditional, duties; there are only prima facie duties, which have no unitary basis (whereas the utilitarian find a unitary basis in the principle of utility, and the Kantian in the categorical imperative). Prima facie duties "emerge out of our numerous 'morally significant relations,' relations such as promisee to promiser, creditor to debtor, spouse to spouse, child to parent, friend to friend, citizen to state, fellow human being to fellow human being. 'Each of these relations is the foundation of a prima facie duty, which is more or less incumbent on me according to the circumstances of the case.'"

Where there is no conflict of duty, the prima facie duty is the actual duty. Where there is conflict, one must make a "considered decision" as to which duty has priority.

The 7 prima facie duties: duties of:

(1) fidelity

(2) reparation

(3) gratitude

(4) beneficence

(5) nonmaleficence

(6) justice

(7) self-improvement

23 Prima Facie Duties in a Biomedical Context

24 Critical Assessment of Ross's Theory

The theory "provides us with virtually no substantive guidance for resolving" moral dilemmas. It lacks any "coherence-based decision procedure" "for mediating among conflicting duties."

24 [III.] RELEVANT CONCEPTS AND PRINCIPLES

25 Autonomy

defined as "self-governance or self-determination"

"Several senses of autonomy . . . to clarify some of the issues raised when questions are asked about justified infringements or limitations of individual autonomy":

The Concept of Autonomy

1 Autonomy as Liberty in Action refers to external restraint

2 Autonomy as Freedom of Choice also refers to external restraint

26 3 Autonomy as Effective Deliberation refers to internal restraint, in not having sufficient abilities or sufficient development of them, or inability to express them.

28 The Value of Autonomy

"For Kant, 'Autonomy of the will is the property the will has of being a law unto itself,'" governing themselves in accordance with rules of their own choosing. A kantian position, "describes autonomy in terms of self-control, self-direction, or self-governance. The individual capable of acting on the basis of effective deliberation, guided by reason, and neither driven by emotions or compulsions nor manipulated or coerced by others, is, on a Kantian position, the model of autonomy."

29 Liberty-limiting Principles

Some say that one's liberty may be justifiably restricted in order to:

(1) prevent that one's harming others (the harm principle).

(2) prevent that one's offending others (the offense principle).

(3) prevent that one from harming himself or herself (the principle of paternalism).

(4) benefit that one (the principle of extreme paternalism).

(5) prevent that one from acting immorally (the principle of legal moralism).

(6) benefit others (the social welfare principle).

30 Paternalism

Gerald Dworkin: "the interference with a person's liberty justified by reasons referring exclusively to the welfare,

31 good, happiness, needs, interests, or values of the person being coerced." But it needn't involve coercion. It can be any "limitation of, or usurpation of individual autonomy justified by reasons referring exclusively to the welfare or needs of the person whose autonomy is being interfered with, limited, or usurped."

A Kantian approach always denies the legitimacy of paternalism, as it calls for treating people as less than ends in their own right.

J. S. Mill upholds it.

35 The Principles of Biomedical Ethics

The 4 principles proposed by Beauchamp and Childress:

(1) respect for autonomy of patients

(2) nonmaleficence (don't harm patients)

(3) beneficence (promote the welfare of patients)

(4) justice (social benefits and burdens--taxes--be distributed justly)

36 [IV.] ALTERNATIVE DIRECTIONS AND METHODS

Criticism recently has been directed at two broad approaches to ethical reasoning:

(1) deductivism: (such as utilitarianism or Kantianism) "features a single foundational principle that supposedly provides a basis for all ethical justification. According to this approach, correct ethical judgments ca, in principle, be derived from the foundation, given relevant factual information (e.g., concerning the consequences of possible actions, in utilitarianism)."

(2) principle-based ethics (also called "principlism"), featuring "a framework of several principles, rules, or duties, none of which takes absolute priority over any other," applying "whatever principles, rules, or duties are relevant in the circumstances, settling conflicts by determining which seems more weighty."

36 Virtue Ethics

37 Virtues (for our purposes): "character traits that are morally valued, such as truthfulness, courage, compassion, and sincerity." Agents are the focus, what kind of person one is, one's character rather than the right thing to do.

Arguments for virtue ethics:

(1) We judge people's motivations and character, as in on's giving to a charity when he is running for office.

(2) Principles, rules, and codes are of are of little use in actual decision making, since they are to abstract to provide practical guidance, and there is great dispute over which theory is correct. "A more effective approach, according to this argument, is to cultivate enduring traits (such as competence, attentiveness, honesty, compassion, and loyalty) through education, the influence of role models, and habitual exercise of those traits. Such virtues, it is claimed, are a more reliable basis, in practice, for morally correct action than is knowledge of principles, rules, or codes."

Yet ethics is most centrally concerned with what people should DO (but virtues are "generally reliable means for doing the right thing"), so "virtue partly constitutes right action."

39 The Ethics of Care and Feminist Ethics

"As originally characterized by [Carol] Gilligan and now generally understood, the ethics of care downplays rights and allegedly universal principles and rules in favor of an emphasis on caring, interpersonal relationships, and contexts.

41 Casuistry: Case-Based Reasoning in Historical Context

The "top-down" reasoning inherent in deductivism and principle-based ethics is inadequate for the resolution of concrete problems.

42 (1) "no simple, unified ethical theory can capture the great diversity of our moral ideas [which] helps to account for the fact that there is such extensive disagreement about ethical theories."

(2) "our actual moral thinking does not typically consist of straightforward deductive reasoning (deriving an ethical judgment from a supreme principle). Practical wisdom is required to determine which of various norms (principles or rules) applies in a complicated or ambiguous case."

(3) Traditional theories such as utilitarianism or Kantianism "miss the fact that moral certainty, where it exists, concerns particular cases" so cannot be so certain as judgment on what a particular person does.

"Casuists assert the priority of practice over theory. Moral norms are to be found in practice; practice is not to be justified (or condemned) by absolute moral principles, because there are none." NOTE THAT THIS IS ETHICAL RELATIVISM. Casuists have allies in such pragmatists as James and Dewey.

44 Reflective Equilibrium and Appeals to Coherence

John Rawls's model of reflective equilibrium: no level of ethical conviction deserves exclusive priority. Justification occurs at all levels of generality: (1) theories; (2) principles and rules of differing degrees of specificity, and (3) judgments about cases. Judgments made at any level can be used to revise judgments at any other level.

45 Revisions are never considered final. Even considered judgments may require later modification.


Philosophical and Other Resources

Making Ethical Decisions, Josephson Institute of Ethics

Josephson Institute of Ethics links

Entered Feb 10, 2000, by Alan Anderson, Contact Info.