ETHICS AT A GLANCE

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ETHICS AT A GLANCE
Author: Dr. Deb Bennett-Woods
May not be duplicated without permission.
Copyright © Regis University 2005
Table of Contents
Foundational Concepts in Ethics..................................................................................... 2
Ethics and Morality Defined............................................................................................ 2
Moral Objectivism and Ethical Relativism.................................................................... 3
Deontological and Teleological Assumptions in Normative Ethics.............................. 5
Principlism and the Moral Principles.............................................................................6
Principle of Respect for Persons.............................................................................. 7
Nonmaleficence ......................................................................................................... 9
Beneficence .............................................................................................................. 10
Veracity.................................................................................................................... 11
Fidelity ..................................................................................................................... 12
Principles of Justice ................................................................................................ 13
Virtue Ethics.................................................................................................................... 15
Catholic Moral Tradition............................................................................................... 17
Kantian Ethics................................................................................................................. 20
Utilitarianism................................................................................................................... 22
Rawlsian Ethics............................................................................................................... 24
Feminist Ethics................................................................................................................ 26
Ethic of Care.................................................................................................................... 28
Rights and Rights-Based Ethics..................................................................................... 30
Communitarian Ethics................................................................................................... 32
2
Foundational Concepts in Ethics
Ethics at a Glance provides a brief introduction to a range of ethical concepts,
principles and theory that can be applied in the analysis of cases and topics in
health care ethics. Various ethical concepts and traditions provide individual
lenses through which ethical questions can be posed and considered. Each
perspective brings a slightly or, in some cases, radically unique viewpoint to the
examination of particular issues raised in health care ethics.
Ethics and Morality Defined
Although the words ethics and morality are often used interchangeably, morality
is more precisely used to refer to the customs, principles of conduct and moral
codes of an individual, group or society. Ethics, also termed moral philosophy or
the science of morals, is the branch of philosophy that studies morality through
the critical examination of right and wrong in human action.
The study of ethics falls into three main areas of focus: metaethics, normative
ethics and applied ethics. Metaethics is concerned with the very nature of right
and wrong, where and how ethical judgments originate, and what they mean in
relation to human nature and conduct. For example, questions posed in
metaethics include how to define the nature of a good act and whether or not
morality exists independently of human beings.
Normative ethics seeks to define specific standards or principles to guide
ethical conduct in answer to questions such as what is valuable and how are
actions morally assessed and justified. Various normative ethical theories
attempt to systematically formulate guidelines to answer the basic question of
how one ideally ought to behave in a particular situation. A central challenge of
normative ethics is that various theories disagree on the fundamental basis and
criteria for ethical analysis and conduct.
Just as the conceptual assumptions of metaethics contribute to the formulation of
normative ethics, normative ethics provide a basis for applied ethics when
employed in the analysis of specific, practical issues. Finally, descriptive
ethics simply describes the ethical beliefs, norms and behaviors of an individual
or group as they actually exist, as opposed to how they ought to exist.
For more on definitions of ethics and morality see:
Internet Encylopedia of Philosophy. Ethics.
http://www.iep.utm.edu/e/ethics.htm
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3
Moral Objectivism and Ethical Relativism
A central question in ethics is whether there are one or many valid ethical
viewpoints. Attempts to answer this question reveal two fundamentally different
assumptions from which moral reflection begins.
Moral objectivism holds that at least some moral principles and rules are
objectively knowable on the basis of observation and human reasoning. The
term universalism suggests that basic right and wrong is the same for everyone,
while also allowing for some variation in individual circumstances and context.
On the other hand, ethical absolutism is “the view that there exists an eternal
and unchanging moral law that transcends the physical world and is the same for
all people at all times and places” (Holmes, 1993). In this view, moral rightness
and wrongness exist independent of human beings and unrelated to human
emotions and thought. There is an absolute source of truth that transcends
human rationality and choice.
Critics of this view point to human diversity and the difficulty of deriving a single,
“true” morality that everyone would hold in common at all times and in all
circumstances. The fact that beliefs and behaviors have changed over time in
relation to individual preference and social approval suggests that an absolutist
approach may ultimately conflict with observed human nature and behavior.
In sharp contrast with objectivism, subjective approaches deny the validity of
objective moral principles and standards that can be applied universally. For
example, ethical relativism holds that judgments about the rightness or
wrongness of an act can legitimately vary between persons or cultures based on
individual feelings (subjectivism) and specific social and cultural circumstances
(cultural relativism). This view assumes that morality depends on a dual
consideration of human nature and the human condition with specific social and
cultural circumstances playing a role in determining moral beliefs and practices.
In extreme forms, subjectivist and relativist positions can be applied to conclude
that what is true for others may not be true for me, rendering it impossible to
evaluate the moral weight of even radically different actions. Critics of relativistic
positions point to the failure of relativism to provide a workable means for
resolving ethical issues since every action can be judged differently, depending
on the actor’s point of view.
For more on moral objectivism and relativism see:
Ethics Update. Internet Philosophical Resources on Moral Relativism.
http://ethics.sandiego.edu/theories/Relativism/
Stanford Encyclopedia of Philosophy. Moral Relativism.
http://plato.stanford.edu/entries/moral-relativism/
4
Wikipedia. Moral Relativism. http://en.wikipedia.org/wiki/Moral_relativism
Wikipedia. Objectivism. http://en.wikipedia.org/wiki/Objective_morality
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5
Deontological and Teleological
Assumptions in Normative Ethics
When examining various normative theories, a distinction is often made between
deontological and teleological perspectives. Deontology (from the Greek deon,
meaning “duty”) refers to an ethical theory or perspective based on duty or
obligation. A deontological, or duty-based, theory is one in which specific moral
duties or obligations are seen as self-evident, having intrinsic value in and of
themselves and needing no further justification. Moral actions are evaluated on
the basis of inherent rightness or wrongness rather than goodness or a primary
consideration of consequences. Holmes (1993) distinguishes between strong
deontological theories, in which goodness is irrelevant to the rightness of an act,
and weak deontological theories, in which goodness is relevant but not the
primary determinant of moral rightness. Kantianism, divine command theory and
some rights-based theories are generally categorized as deontological theories.
In contrast, teleology (from the Greek telos, meaning goal or end) describes an
ethical perspective that contends the rightness or wrongness of actions is based
solely on the goodness or badness of their consequences. In a strict teleological
interpretation, actions are morally neutral when considered apart from their
consequences. Ethical egoism and utilitarianism are examples of teleological
theories.
While these descriptions appear to draw a clear distinction between theoretical
perspectives, the two categories are not mutually exclusive. Alternatively, the
terms consequentialist and non-consequentialist are sometimes used. Some
rights-based theories and theories of justice are consequentialist in their concern
for outcomes while also claiming the inherent rightness of obligations related to
human rights and justice. Likewise, virtue ethics and formulations of natural law
both seek goals of human happiness and fulfillment, but in relation to
deontological assumptions about human character and/or rationally derived
obligations.
For more on deontology and teleology see:
New Advent. Teleology. http://www.newadvent.org/cathen/14474a.htm
Wikipedia. Deontology. http://en.wikipedia.org/wiki/Deontology
Wikipedia. Teleology. http://en.wikipedia.org/wiki/Teleology
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6
Principlism and the Moral Principles
The term principle can be defined in several ways. A principle may refer to a
basic truth, law or assumption. For example, a principle may take the form of a
law or rule that describes a natural phenomenon. With respect to ethics, the
term principle can refer to a generalization that can be used in moral reasoning
or a specific rule of good conduct.
A number of specific and commonly recognized moral principles have been
articulated for application in the realm of health care ethics. Some ethicists,
notably Beauchamp and Childress (2004), have used such principles as a
primary framework for ethical analysis and dialogue. In this approach, referred to
as principlism, each principle represents a serious, though not absolute, moral
duty that must be weighed against other duties in resolving an ethical conflict or
dilemma.
Although very influential in contemporary bioethics, principlism has been widely
criticized on several counts. For example, because principlist approaches are
not rooted in particular overarching values, there is no widely accepted standard
for resolving the inevitable conflicts between principles. Individual principles may
be interpreted or weighted differently by different individuals or may not
accurately represent particular cultural viewpoints and assumptions. In fact,
there is no common agreement on exactly what principles are morally relevant
and to what extent some principles are more or less foundational to other
principles. Finally, critics contend that principlist approaches fail to consider
important aspects of character and virtue-based approaches or relational
approaches such as care ethics. Nonetheless, the insightful use of moral
principles has proven an intuitively appealing and widely recognized foundation
for dialogue in health care ethics.
For more on principlism see:
Penn State College of Health Human Development Nursing School. Theoretical
Approaches to Health Care Ethics.
http://www.personal.psu.edu/faculty/d/x/dxm12/n458/theoretical_approaches.htm
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7
Principle of Respect for Persons
In its simplest form, respect for persons maintains that human beings have
intrinsic and unconditional moral worth and should always be treated as if there is
nothing of greater value than they are. This principle rests on the unique
capability of human beings to behave as rational agents, that is, self-aware and
capable of objective thought and the ability to reason. The ability to reason is
believed to give humanity an intrinsic dignity that must be respected above all
other considerations.
This inherent value attributed to human beings means that each person is an end
in him or herself and should not be treated solely as a means to some other end.
It also implies that all persons have equal worth and should be treated equitably
and in ways that we ourselves would want to be treated. Principles of truth
telling, loyalty, privacy, and confidentiality are all rooted in this basic requirement
of unconditional respect and value.
Finally, as rational agents, we are free and capable of making our own decisions
and choosing actions based on our own goals and reasoning. In other words, we
are self-determining or autonomous. The principle of respect for persons affirms
the primary importance of allowing individuals to exercise their moral right of self-
determination. To violate their ability to be self-determining is to treat them as
less than persons. In doing so we deprive them of their essential dignity.
The concept of autonomy is an important extension of this principle. You act
autonomously when your actions are the result of your own deliberation and
choices. Yet there are many ways in which autonomy can be compromised.
Likewise, there are justifiable restrictions that can be placed on individual
autonomy. For example, paternalism is the principle that allows a physician to
act contrary to a patient’s wishes if there is evidence that the patient is not acting
in his or her own best interests and on the basis of a higher level of expertise.
Other allowable restrictions to autonomy include the harm principle, which
protects others from harm; the principle of legal moralism, which allows society
to render an act illegal on the basis of social values and judgments; and the
welfare principle, which allows autonomy to be restricted for the benefit of
others (Munson, 2004)
.
For more on the principle of respect for persons and autonomy see:
Stanford Encyclopedia of Philosophy
http://www.seop.leeds.ac.uk/entries/personal-autonomy/
http://plato.stanford.edu/entries/autonomy-moral/
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/respect_persons.asp
8
http://www.ascensionhealth.org/ethics/public/issues/autonomy.asp
University of Washington School of Medicine
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#prin2
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9
Nonmaleficence
The principle of nonmaleficence states that we should act in ways that do not
inflict evil or cause harm to others. In particular, we should not cause avoidable
or intentional harm. This includes avoiding even the risk of harm. It is important
to point out that this principle can be violated with or without intention. That is,
you don’t have to intend harm to violate this principle. In fact, you don’t even
have to cause harm. If you have knowingly or unknowingly subjected a patient or
colleague to unnecessary risk, you have violated this principle (Munson, 2004).
Beauchamp and Childress (2001) point out the difficulty in defining the nature of
harm. There are many types of harm ranging from physical and emotional injury
to deprivation of property or violations of rights. In health care, the primary focus
on harm relates to a narrower definition including pain, disability, or death.
However, harm can be very much in the eye of the beholder, and a broader
definition of harm is often required in ethical considerations.
Likewise, more than one level of harm may come into play in a situation. For
example, a surgeon will inflict a level of pain and suffering on a patient in order to
avoid their death. The surgeon has imposed one harm in order to avoid a
greater harm. However, in all cases, we are prohibited from acting in ways that
are likely to cause undue risk or needless harm.
For more on the principle of nonmaleficence see:
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/beneficence.asp
University of Washington School of Medicine
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#prin2
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10
Beneficence
The principle of beneficence is often simply stated as an obligation to act in
ways that promote good. Beauchamp and Childress (2001) explain this to
include both the prevention and removal of harm as well as doing good. That is,
we should act in ways that prevent harm, remove harm, and promote good.
Beneficence is not simply the opposite of nonmaleficence. Some would argue
that while we always have a duty not to harm, we don’t always have a duty to
help. However, in health care, we have an implied duty to help by virtue of our
relationship with the patient. This duty is both legally and morally grounded in
that it is reasonable for patients to expect a professional caregiver to act in ways
that will promote their health and well-being. On the other hand, we generally
recognize a limit to the level of service and sacrifice owed to a patient by any
particular health care professional (Munson 2004).
As with harm, the definition of good is difficult. As noted by Munson (2004), the
sheer number of ways one might promote the welfare of another defies a
complete description. In the health care context, welfare is generally seen in
terms of health and physical well-being, although other welfare concerns can be
raised.
For more on the principle of beneficence see:
University of Washington School of Medicine
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#prin3
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/beneficence.asp
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11
Veracity
Veracity is the principle of truth telling, and it is grounded in respect for persons
and the concept of autonomy. In order for a person to make fully rational
choices, he or she must have the information relevant to his or her decision.
Moreover, this information must be as clear and understandable as possible.
Truth telling is violated in at least two ways. The first is by the act of lying, or the
deliberate exchange of erroneous information. However, the principle of veracity
is also violated by omission, the deliberate withholding of all or portions of the
truth. Finally, the principle of veracity can also be violated by the deliberate
cloaking of information in jargon or language that fails to convey information in a
way that can be understood by the recipient or that intentionally misleads the
recipient.
In the health care context, there are two broad applications of this principle. The
first relates to patient care and such issues as informed consent. Patients and
families rely upon physicians and other caregivers for the information they need
to make informed choices about their care. They also expect to be told the truth
about their care, including any errors or untoward events. Alternatively, some
patients or patients’ families do not want to be told the truth, placing the
physician, nurse or other health care professional in a situation in which his or
her duty to obtain informed consent is compromised by the wishes of the patient
or family.
The second application relates more generally to professional ethics and the
basic expectation that we are honest in our professional interactions. This
particular application of veracity is apparent in a broad range of issues including
professional relationships, documentation standards, billing practices, risk
management, peer review, community relations, and regulatory reporting, and
compliance.
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12
Fidelity
The principle of fidelity broadly requires that we act in ways that are loyal. This
includes keeping our promises, doing what is expected of us, performing our
duties and being trustworthy. Role fidelity entails the specific loyalties
associated with a particular professional designation, and Purtillo (2005) lists five
expectations associated with what patients might reasonably expect in terms of
fidelity in the health care context:
1. That you treat them with basic respect.
2. That you, the caregiver or other health care professional, are competent
and capable of performing the duties required of your professional role.
3. That you adhere to a professional code of ethics.
4. That you follow the policies and procedures of your organization and
applicable laws.
5. That you will honor agreements made with the patient.
Fidelity is perhaps the most common source of ethical conflict. In any particular
situation health care professionals may find themselves at odds between what
they believe is right, what the patient wants, what other members of the health
care team expect, what organizational policy dictates and/or what the profession
or the law requires.
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13
Principles of Justice
A general principle of justice requires that we act in ways that treat people
equitably and fairly. Actions that discriminate against individuals or a class of
people arbitrarily or without a justifiable basis would violate this basic principle.
Of special concern in the health care context is the notion of distributive justice.
This conception of justice refers to an equitable balance of benefits and burdens
with particular attention to situations involving the allocation of resources.
Munson (2004) offers four specific principles of distributive justice that can be
considered in situations involving the distribution of material goods and
resources, especially those that are scarce. The principle of equality requires
that all benefits and burdens be distributed equally. The advantage to this
conception of justice is that everyone is entitled to an equal share of resources;
however the principle becomes problematic when not everyone is perceived as
equally deserving of an equal share.
A second principle is the principle of need, which suggests that resources
should be distributed based on need so that those with greater need will receive
a greater share. In theory, this supports the principle of equality in that everyone
will end up with the same share of goods. A difficulty common to both of these
principles is the question of exactly what material goods and resources we are
entitled to. Definitive agreement has not been reached in this society as to
whether health care is such a good.
The last two principles address more directly our sense of fairness. The
principle of contribution maintains that persons should benefit in proportion to
their individual contribution. Those who contribute proportionately more to the
production of goods should receive proportionately more goods in return.
Similarly, the principle of effort recognizes the degree of effort made by an
individual as the determining factor in the proportion of goods to be received.
Obvious difficulties with these principles lie in defining the exact nature and
impact of a contribution and accounting for the inherent differences in the
outcomes of individual efforts regardless of the amount of effort expended.
Two very specific categories of justice, included under the broad umbrella of
distributive justice, are also relevant to the health care context and health care
leadership. Procedural justice requires processes that are impartial and fair.
This form of justice underlies the requirement of due process when conducting
disciplinary action against an employee or the manner in which a patient
complaint is investigated. Procedural justice might also relate to how resources
are allocated in situations where other relevant criteria such as need or effort are
substantively equal.
The second category, compensatory justice, involves compensation for wrongs
or harms that have been done. Damage awards to patients for malpractice or
14
negligence are obvious examples of compensatory justice, along with damages
awarded for discriminatory personnel practices or fines levied for violations of
legal or regulatory requirements.
For more on the principles of justice see:
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/distributive_justice.a
sp
Beyond Intractability
http://www.beyondintractability.org/m/distributive_justice.jsp
Midwest Bioethics Center
http://www.midbio.org/mbc-forum15-2.htm
University of Washington School of Medicine
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#prin2
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15
Virtue Ethics
Virtue-based ethics does not rely directly on ethical principles in its formulation.
In virtue ethics, the focus is on the role of character as the source of moral
action. Human character is shaped over time by a combination of natural
inclinations and the influence of such factors as family, culture, education, and
self-reflection. This means that some people will be more likely to choose
virtuous behavior than will others.
Virtue ethics traces its roots to the ancient Greeks whose original exploration of
morality did not focus on right and wrong, but rather the concepts of human
excellence and human thriving (Taylor, 2002). Generally, a moral act is one that
satisfies two requirements. First, the act must promote the good. Devettere
(2000) defines good in terms of seeking the good life, a life that allows us to
achieve a level of personal happiness and that also serves the communal best
interest. The second requirement for a moral act is that the action must be taken
with the intent to do good. In other words, it is not enough to do the right thing.
Virtuous behavior requires more than just meeting an obligation or performing a
duty. The person of virtuous character is one who displays the proper motive as
well.
Virtues are character traits that predispose a person with good or virtuous
intentions to do the right thing when faced with a moral choice. Writers vary on
what they include on a list of moral virtues. Devettere (2000) emphasizes the
central virtues of temperance, courage, love, justice, and dignity. Other lists
might commonly include respect, honesty, sympathy, charity, kindness, loyalty,
and fairness. Munson (2004) also categorizes a set of practical virtues including
intelligence, patience, prudence, shrewdness, and proficiency. These virtues,
while not moral in and of themselves, can enhance virtuous behavior. For
example, intelligence and prudence can add depth and clarity to ethical
deliberation. Finally, Christian ethics proposes the theological virtues of faith,
hope and charity (Catholic Encyclopedia).
In the health care context, there is an expectation that caregivers and other
professionals act with integrity and virtue. As such, this theory appeals to our
intuitive belief that we can discern the difference between right and wrong action
based on our own moral character and good intentions as professionals. On the
other hand, a weakness of virtue ethics lies in the absence of guidance in
specific situations. Because virtuous character develops over time and in
response to both self-reflection and positive external influences, we may not
always be able to rely on our own incomplete base of experience and insight in
making a particular decision. To complicate matters further, not everyone may
agree on the basis of the good life to be sought through moral choices.
For more on virtue ethics see:
16
Catholic Encyclopedia. Virtue. http://www.newadvent.org/cathen/15472a.htm
Internet Encyclopedia of Philosophy. Virtue Ethics.
http://www.iep.utm.edu/v/virtue.htm
Philosophy Pages. Aristotle. http://www.philosophypages.com/ph/aris.htm
Stanford Encyclopedia of Philosophy. Virtue Ethics.
http://plato.stanford.edu/entries/ethics-virtue/
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17
Catholic Moral Tradition
One of the most sophisticated and well-articulated ethical frameworks,
particularly with respect to bioethics, is that of Roman Catholicism. The Ethical
and Religious Directives for Catholic Health Care Services is a comprehensive
statement of ethics pertaining to a variety of ethical issues in health care. This
example of an ethical position, well grounded in the framework of a particular
faith tradition, has been very influential in the general realm of bioethical thought.
The Catholic moral tradition has rich and varied roots; however, all intellectual
viewpoints emphasize an abiding commitment to the promotion and defense of
human dignity from conception to death. Each human life is considered sacred
and deserving of a right to life. Such a right includes proper origination and
development of a life with access to an adequate level of care. Also emphasized
are the need to accept social responsibility in caring for the poor and the
promotion of the common good. In this perspective, the common good is defined
in terms of protecting fundamental rights in order that all individuals are enabled
to realize their common purposes and goals (National Conference of Catholic
Bishops 1995).
One of the founding voices of the Catholic moral tradition is that of Thomas
Aquinas, a Dominican saint who lived in the thirteenth century. He is associated
with a particular interpretation of natural law, a philosophical tradition dating
back to early pre-Socratic philosophers. In general, natural law proposes
fundamental laws that have been laid down by nature itself and are discoverable
through experience, observation, induction and insight into commonly shared
aspects of human nature and behavior. Aquinas viewed human beings as
intelligent, rational creatures, created in the image of God, whose human reason
is answerable to the basic principle of doing good and avoiding evil (Catholic
Encyclopedia). Good is simply that which is proper to human nature and
consistent with the objective goal of human happiness. Through the application
of our human reason, in combination with our natural inclination to recognize and
seek the good, we are able to reflect upon and discover laws, in the form of
general tendencies, that satisfy basic human needs and fulfill the divinely
intended nature of human beings (Meaney, personal communication).
Aquinas proposes four basic goals of human nature: to prolong life, procreate,
form community, and seek truth (Ashley & O-Rourke, 1997). For example, our
natural inclination to preserve our lives creates obligations to care for ourselves
and avoid actions that put us in danger of losing our lives. This respect for our
own dignity and life is rationally extended to the dignity and lives of others.
Likewise, the inclination to create and care for offspring generates support for the
institution of marriage and prohibits actions that would interfere with the
procreative process.
18
Catholic natural law is, in essence, a teleological theory based on God’s plan for
man within the universe. However, it is not strictly consequentialist in that
consequences are not seen as the sole determinant of a moral act. Instead, a
moral act is determined by the act itself, the motive or intentions of the actor, and
the circumstances surrounding the act. While rooted in natural law, the Catholic
moral tradition has evolved various approaches to the process of moral
reasoning.
Proportionalism is an approach that evolved in the 20
th
century with the intent of
formulating a dynamic, evolutionary and more pluralistic worldview in light of the
complexity of contemporary society. It relies on intuitive positive values such as
love and loyalty that can be weighed through the reasoning process in any
particular situation to achieve a proportionately favorable outcome. A primary
strength of this approach is its acknowledgement of the very complex issues
presented by rapidly evolving technologies and pluralistic social orders. Critics of
this approach claim that consequences are weighed too heavily allowing for
inherently evil acts to be too easily justified in some situations (Ashley &
O’Rourke, 1997).
An alternative approach is that of prudential personalism. This ethical
framework takes into account the unique manner in which human nature is
embodied in each individual, the role of individual intelligence and free will in
making life choices, and considerations of individual diversity in relation to our
inherently communal nature. This model places friendship with God and other
persons as the supreme good to which all other goods are subordinated, and
rejects abstract ideals and values as the sole basis for moral reflection. Instead,
proponents of prudential personalism contend that a “practical, goal-seeking,
situational, contextual” methodology is possible by starting with the ultimate goal
of human life and posing the question, ”How does this action in its context
contribute to the growth of persons in community?” However, outward
consequences are assessed secondarily to inward motive and self-realization
(Ashley & O’Rourke, 1997).
A strength of the Catholic moral tradition in health care ethics lies in the specific
guidance given with respect to medical decision-making on a number of complex
issues including abortion, assisted reproduction, end-of-life care, euthanasia and
emerging genetic technologies. The primary weakness lies in its applicability as
an ethical justification for people who do not share the assumptions of natural law
in general or specific theological assumptions embedded within Catholic
theology.
For more on the Catholic moral tradition see:
The Catholic Encyclopedia. http://www.newadvent.org/cathen/
19
The Ethical and Religious Directives for Catholic Health Services.
http://www.usccb.org/bishops/directives.shtml
Philosophy Pages. Thomas Aquinas.
http://www.philosophypages.com/ph/aqui.htm
The Provincial Health Ethics Network.
http://www.phen.ab.ca/materials/intouch/vol3/intouch3-08.html
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Kantian Ethics
The German philosopher Immanuel Kant (17241804) is generally credited with
much of the foundational thought in the evolution of deontology and deontological
perspectives. Kant viewed the ability of human beings to reason as the basis of
our status as moral agents. Therefore, Kantian ethics rests on the argument that
“morality is grounded in reason, not in tradition, intuition, conscience, emotion, or
attitudes such as sympathy” (Beauchamp and Childress 2001). To be fully
human is to be a rational being capable of exercising both reason and free will in
making decisions and choosing actions.
Kant further believed that since we cannot control the outcome of our actions, the
morality of an act cannot depend on the outcome or consequences, but must be
judged based on the motive or intent of the actor. A moral action is one that is
performed solely for the purpose of meeting a moral obligation, and the action
itself can only be judged moral in light of the intention behind it. The actual
outcome is not considered morally relevant.
Kant’s test of whether an action meets a moral obligation is referred to as the
categorical imperative. The basic formulation of this imperative is the test of
universalizability, which states that you must act so that the rule or principle
guiding your action can be willed to be a universal law. That is, could I take this
action in all similar circumstances without being logically inconsistent? For
example, telling a lie violates this maxim because you could not logically will that
people be free to lie whenever they wanted without rendering the concept of truth
useless. Therefore, truth telling becomes an important obligation or duty in this
ethical perspective because the truth is one necessary condition for rational
analysis.
A second formulation of the imperative, often used in health care, requires that
we never treat another person solely as a means to our end. For example,
involving people in a risky medical experiment without their knowledge deprives
them of their ability to make a rational choice about participation and uses them
as a means to some other end. The fact that the knowledge gained from the
research might benefit thousands of other people is not relevant in this
perspective.
Kant recognizes two general categories of duties. A perfect duty is one we
must always observe, such as our duty not to needlessly harm another person.
Other duties, such as acting with benevolence, are not required in all
circumstances, so they are termed imperfect duties.
The primary strengths of Kantian ethics in the health care context are that it
prohibits us from using oneself or others solely as means to another end and
requires us to be consistent in our moral action. For example, we should not
experiment on people solely for the benefit of others; and, if it were wrong to
21
involve one set of subjects in dangerous research without their consent, then it
would be wrong to involve any subject in dangerous research without their
consent. Some of the weaknesses of a strict Kantian perspective are the
absence of any guidelines for dealing with the inevitable conflicts between duties
and the lack of recognition that emotion and intuition can play a constructive role
in ethical decisions. For example, an absolute duty to tell a patient the truth
might cause a patient harm in certain circumstances; therefore the duty to always
tell the truth conflicts with the duty to avoid needless harm or injury.
Furthermore, human emotion and intuition can be helpful in detecting the
potential for harm, and it is probably not realistic or even desirable to completely
eliminate these natural abilities from our moral actions.
W. D. Ross, also a deontologist but with a more consequentialist orientation,
recognized these shortcomings and proposed a slightly different model of duties.
Ross advocated a set of duties that included fidelity, justice, beneficence, and
nonmaleficence, among others, and he used the term prima facie duties to
describe them. Prima facie, “at first glance,” simply refers to the duty or
obligation that appears to be what I should do without considering any other
factors. My actual duty is the real duty, and there is only one morally justified
course of action in any situation; however, the actual duty may not always be
obvious, particularly when duties conflict. Unlike strict Kantian ethics that prohibit
the consideration of consequences or related factors other than motive, Ross
allows us to consider other factors in determining which prima facie duty or duties
will achieve the greatest balance of rightness over wrongness. This approach is
more likely to avoid unreasonable conclusions that can come from considering
some duties as absolute in all circumstances.
For more on Kantian ethics see:
Ethics Updates. Kant and Kantian Ethics.
http://ethics.sandiego.edu/theories/Kant/
Garrett, J. (2004). A Simple and Usable (Although Incomplete) Ethical Theory
Based on the Ethics of W. D. Ross.
http://www.wku.edu/~jan.garrett/ethics/rossethc.htm
Internet Encyclopedia of Philosophy. Immanuel Kant.
http://www.utm.edu/research/iep/k/kantmeta.htm#Kant's%20Ethics
Online Guide to Ethics and Moral Philosophy. Kant’s Ethics.
http://caae.phil.cmu.edu/Cavalier/80130/part1/sect4/Kant.html
Philosophy Pages. Immanuel Kant.
http://www.philosophypages.com/ph/kant.htm
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22
Utilitarianism
British philosophers Jeremy Bentham (17481832) and John Stuart Mill
(18061873) are credited with the origins of classical utilitarianism, a moral
theory that defines a moral act solely in terms of the outcome or consequences
of that act. This teleological perspective is based on a single guiding principle.
The principle of utility, also referred to as the Greatest Happiness Principle,
states that actions are right if they produce the greatest balance of happiness
over unhappiness (Mill, 1861). Over time, the definition of happiness has been
expanded to include a variety of intrinsic goods other than happiness or pleasure.
Intrinsic goods are goods or conditions that are inherently valuable and might
include love, beauty, friendship, knowledge, and success. Some writers contend
the principle of utility can also refer to individual preferences.
In any given situation, we are likely to have to consider a range of goods and
preferences to determine what will constitute the greatest overall balance of
good. This consideration uses a type of moral cost/benefit analysis in which a
moral act should produce the greatest benefit (happiness) at the least cost
(unhappiness). A moral act may, at times, result in some unhappiness; however,
the overall consequences must be balanced toward the good.
Regardless of how utility is defined, an action according to utilitarianism is right
that produces the greatest benefit for the greatest number of people. Therefore,
no action is right or wrong in and of itself. Actions can only be judged in light of
their consequences. General moral rules may be useful in analysis, but any such
rule can be disregarded in the interest of promoting utility. In addition, motive or
intention carries no moral weight. For example, I may feel it is my duty to tell a
patient the truth but, if the patient is harmed in some significant way by the
information I provide, then I have violated the principle of utility and acted
wrongly.
There are two main applications of utilitarian thought. Act utilitarianism focuses
on the consequences of particular actions in particular circumstances. That is,
an act is right to the extent that it produces the highest utility in that individual
circumstance. This allows you to consider every situation as completely unique.
On the other hand, it also allows for inconsistency in action and requires that you
basically start every analysis from scratch.
Rule utilitarianism takes a somewhat different view by suggesting that the
principle of utility can be used to develop and test rules that can be applied in
similar situations. The basic premise is that if we always follow a set of rules that
generally produce the best consequences, our actions will result in the greatest
social utility or the best outcome for everyone in the long run. In this view, an act
is right if it follows a rule that has been shown to maximize utility in other similar
situations. An obvious drawback to this approach is the sheer number of rules
23
and exceptions likely to be generated, as well as the possibility that the rules
would conflict in some circumstances.
For more on utilitarianism see:
Ethics Updates. Utilitarianism. http://ethics.sandiego.edu/theories/Utilitarianism/
Internet Encyclopedia of Philosophy. Jeremy Bentham.
http://www.utm.edu/research/iep/b/bentham.htm
Internet Encyclopedia of Philosophy. John Stuart Mill.
http://www.utm.edu/research/iep/m/milljs.htm
The Literary Encyclopedia. Utilitarianism.
http://www.litencyc.com/php/stopics.php?rec=true&UID=1169
Mill, J. S. Utilitarianism. http://www.utilitarianism.com/mill1.htm
Philosophy Pages. John Stuart Mill.
http://www.philosophypages.com/ph/mill.htm
Stanford Encyclopedia of Philosophy. Consequentialism.
http://plato.stanford.edu/entries/consequentialism/
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24
Rawlsian Ethics
Contemporary philosopher John Rawls provides one example of an ethical
theory that places the concept of justice at its center. Rawls’ primary concern is
that we be able to design and evaluate social institutions and practices on the
basis of principles of justice. The basis of such principles is found in a concept
that Rawls termed the original position. Imagine a group of people
representing the range of human diversity and then place them behind a veil of
ignorance so that they no longer know who they are on the other side. Rawls
contends that from this original position people would agree to establish a social
order based on the moral standards of an egalitarian form of justice. That is,
they would promote rules and institutions that would ensure their own well-being
once the veil is lifted.
In its strictest sense, egalitarianism requires that all persons receive an equal
distribution of certain political, social, and economic goods and rights; however,
Rawls does not advocate a strict egalitarianism. He maintains that inequalities
are inevitable but can be justified and minimized with at least two principles
discoverable in the original position. The first is the liberty principle, which
advocates that each person should have an equal right to as many basic liberties
as possible and still allow a similar system of liberty for all (Munson 2004). That
is, each individual should possess as much liberty to live and seek opportunity as
is possible, short of infringing on the liberty interests of others.
The second principle that Rawls identifies is termed the difference principle and
requires that social and economic inequalities be arranged so that they benefit
those who are least advantaged. In other words, differences in wealth and social
position are acceptable as long as they can be shown to benefit everyone and, in
particular, those who have the fewest advantages. This principle also requires
that systems allow for all people to have access to goods and positions under
conditions of fair equality of opportunity based on both need and merit (Munson
2004).
Rawls believes that people in the original position would agree on a set of duties
that one owes to both oneself and others. He termed these natural duties and
includes among them the duties of justice, avoiding harm to others, promise
keeping, and helping others in need. Such duties also suggest and support
principles such as respect for persons, nonmaleficence, fidelity, beneficence, and
a form of procedural justice.
Rawls’ theory is obviously applicable to ethical issues in the larger health care
system involving health policy and allocation of resources. Rawls would
approach these issues from the particular perspective of individual liberties and
rights. In addition, the concept of natural duties can also be applied to questions
of autonomy and caregiver obligations. A strength of Rawls’ theory is its dual
emphasis on moral obligation and the need to mitigate the practical
25
consequences of social systems. A primary criticism includes a question of
whether the original position is, in fact, biased by Rawls’ own privileged view of
the current system.
For more on John Rawls and Rawlsian ethics see:
Stanford Encyclopedia of Philosophy. Original Position.
http://plato.stanford.edu/entries/original-position/
Wikipedia. A Theory of Justice. http://en.wikipedia.org/wiki/A_Theory_of_Justice
Wikipedia. John Rawls. http://en.wikipedia.org/wiki/John_Rawls
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26
Feminist Ethics
Feminist theory is a relative newcomer as a source of ethical theory and
represents a diverse range of social and political viewpoints. However, all
formulations of feminist theory are concerned with the “private sphere” while also
committed to ensuring that the dimensions of politics, economics, and power be
included in any ethical analysis. Rooted in the historical devaluation of the
female experience in Western philosophy (Jagger, 2001), feminist ethics is
predominantly concerned with the imbalance of power and the exposure and
elimination of oppression for women and other disadvantaged groups. The term
disadvantaged refers generally to any group with diminished power in relation to
the larger social system. Groups that can be seen to have diminished power
within the health care system include women in general, racial and ethnic
minorities (both males and females), the elderly, children, the poor, and the
disabled.
The basis on which a group might be considered oppressed can vary
considerably. For example, in the health care context the strong history of
research bias towards white men as research subjects has left women, children,
and many racial minorities underrepresented and at risk with respect to many
standard medical treatments. In another vein, feminists point out that the laws
regulating female reproductive rights remain embedded in legal and economic
systems in which the majority of decision-makers are still men. Yet another
source of disadvantage is demonstrated by the fact that women and ethnic
minorities are more likely to be poor, less educated, and uninsured or under-
insuredall of which diminish a person’s power within the health care system.
Feminist ethics does not rely on moral principles per se, arguing that the
commonly cited principles are too abstract to be useful in the context of human
relationships. Instead, actions are generally viewed in relation to their effect on
the quality of relationships among people with an emphasis on considerations of
justice and the concept of caring.
Sherwin (1994) provides a number of specific areas of feminist concern with
respect to the health care context including the following:
The inherent inequality of the physician/patient relationship
The politics of medicine including authoritarian patterns of control and
the differential treatment of men and women
Access to scarce resources by the poor and other medically underserved
groups
The ability of patients to receive and understand the specialized medical
information needed to maintain their autonomous decision making
The unequal burdens of family care giving for women
27
A general strength of feminist ethics is an emphasis on the importance of
considering the context of an individual situation in medical decision-making.
Similarly, the emphasis on relationships allows for the realities of emotion and
intuition to be factors in our deliberations. On the other hand, as pointed out by
Munson (2004), the wide range of feminist views prevents feminist theory from
presenting one unified and coherent theory. Additionally, there does not appear
to be a method for resolving moral conflicts.
For more on feminist theory and feminist ethics see:
Feminist Theory Website. http://www.cddc.vt.edu/feminism/enin.html
FeministEthics.ca. http://www.feministethics.ca/
Stanford Encyclopedia of Philosophy. Feminist Bioethics.
http://plato.stanford.edu/entries/feminist-bioethics/
Stanford Encyclopedia of Philosophy. Feminist Ethics.
http://plato.stanford.edu/entries/feminism-ethics/
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28
Ethic of Care
The ethic of care is discussed extensively in the nursing literature and
specifically with respect to nursing ethics. The ethic of care has its roots in
feminist thought; however, the two perspectives are not one and the same. In
general, feminism argues for recognition that women tend to view the world and
respond to the world differently than men. Sherwin (1992) points out how,
historically, this has tended to devalue or deprive women of their status as moral
agents by creating an anti-female bias in ethical theory.
Carol Gilligan (1993), and other writers, contend there are two different patterns
of moral reasoning, with women generally exhibiting a relationally based ethic
(predominantly concerned with care) and men preferring a rule-based ethic
(more concerned with justice and rights). Gilligan labeled the first pattern of
reasoning, with its focus on feelings and relationships, the ethic of care. The
second pattern of reasoning, with its focus on developing universal rules in order
to ensure fairness, was labeled the justice perspective. It is important to point
out that both men and women are capable of reasoning in either perspective and
may lean toward one in some situations and the other in other situations.
In the ethic of care, problem situations are approached in a more context-specific
way that looks for resolution in the particular details of a problem situation.
Universal principles are only valid if they can be applied with room for
discretionary judgment based on the unique circumstances of each situation.
There is primary attention paid to preserving relationships and generating options
through better communication and cooperation. Also of concern is finding a
solution that avoids harming anyone or that minimizes harm to all involved and
that promotes caring in the situation.
Nel Noddings (1984) is often cited for her model of caring that is developed to be
applicable to both men and women. Noddings suggests that, in reality, we are
not guided by ethical principles but by the ideal of caring itself. The ethic of care
demands that we maintain conditions under which caring can flourish. Noddings
further notes specific standards or ideals within a caring relationship including
caring itself, compassion, concern, and sensitivity to context.
The emphasis on sensitivity to context makes it particularly difficult to illustrate
moral analysis within the ethic of care. If we are not in the immediate context, we
cannot really make a decision based on authentic caring. At the same time, a
primary strength of this perspective is its intuitive correctness in view of the
reality of human relationships. While prior theories based on reason alone reject
emotion and require impartiality, such an approach is inconsistent with our
experience of human relationships. The ethic of care corrects this. On the other
hand, complete rejection of impartiality and ethical principles in favor of sensitivity
29
and emotion may also lead to a rejection of otherwise justifiable obligations and
rights.
For more on the ethic of care see:
Keller, J. (1996). Care ethics as a health care ethic.
http://www.uhmc.sunysb.edu/prevmed/mns/imcs/contexts/care/carejean.html
Online guide to ethics and moral philosophy. Ethic of Care.
http://caae.phil.cmu.edu/Cavalier/80130/part2/II_7.html
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30
Rights and Rights-Based Ethics
As with many ethical perspectives, rights-based approaches also have their roots
with ancient philosophers concerned with the concept of justice, as well as
natural law philosophers who recognized a potential for certain rights inherent in
human nature. Natural rights are generally held to be a gift of nature or God
that cannot be taken away. Modern notions of natural rights are most closely
associated with the seventeenth century British philosopher John Locke (Almond,
1993) and his contention that human beings are entitled to life, liberty and
property. In contemporary theory, these and other moral claims have come to
be referred to as universal human rights and form the basis for establishing
and/or evaluating ethical standards within the social order.
Beauchamp and Childress (2001) define a right as a “justified claim that
individuals and groups can make upon other individuals or upon society; to have
a right is to be in a position to determine by one’s choices, what others should do
or need not do”. In the case of a legal right, the claim must be justified by legal
principles and rules. Likewise, a moral right must find grounding in moral
principles and rules. One form of rights does not necessarily lead to another,
although this distinction is not well recognized in contemporary society.
Beauchamp and Childress go on to point out that, while some rights may be
argued to be absolute, most are better considered as prima facie rights. In
other words, most rights should be observed in the absence of competing claims:
however, all rights are likely to be subject to compelling, competing claims at
some point. For example, the fundamental right to life is often deferred in
situations involving self-defense or killing during war.
Another useful distinction is that of positive and negative rights. A positive right
is “a right to receive a particular good or service from others” (Beauchamp &
Childress, 2001). Therefore, a positive right assumes that someone (individual
or agency) is obligated to do something for you. A negative right is “a right to
be free from some action by others”, so a negative right obligates others to
refrain from action. An important implication here is that a right places an
obligation on another individual or social entity, as well as consideration of
whether the associated duties are then interpreted to be absolute.
While the concept of rights is appealing as a basis for moral argument and
justification in modern democratic societies, it is also open to a number of
concerns (Almond, 1993). First, there is no general agreement on what or who
can be the subject of a right. A similar lack of agreement exists on what kinds of
things there can be a right to. Finally there are questions about whether rights
can ever be inalienable or absolute.
For more on rights and rights-based ethics see:
31
Catholic Encyclopedia. Right. http://www.newadvent.org/cathen/13055c.htm
Internet Encyclopedia of Philosophy. Human Rights.
http://www.iep.utm.edu/h/hum-rts.htm
Stanford Encyclopedia of Philosophy. Human Rights.
http://plato.stanford.edu/entries/rights-human/
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32
Communitarian Ethics
Communitarianism refers to a theoretical perspective that seeks to lessen the
focus on individual rights and increase the focus on communal responsibilities.
The definition of community varies and can refer to anything from the nuclear or
extended family to the political state or nation. In this approach, ethical thought
is grounded in communal values, established social standards and traditions, and
considerations of the larger society. Communitarians emphasize the influence of
society on individuals and contend that values are rooted in common history and
tradition (Beauchamp and Childress 2001).
Tam (1998) suggests that communitarianism is based on three principles. The
first requires that any claim of truth be validated through co-operative enquiry.
Second, communities of co-operative inquiry, which represent the spectrum of
citizens, should validate common values that become the basis of mutual
responsibilities of all community members. And third, all citizens should have
equal access and participation in the power structure of society.
A central premise of communitarianism is the recognition of society as a web of
intersecting communities with differing moral values and standards (Johnson
2005). The key to resolving ethical questions and conflicts lies in respect for
local values that demonstrate careful deliberation and local community
acceptance. Consideration is also given to general alignment and accountability
with the values of the larger society; however, the system of moral rules of a
particular community is best understood in the context of that community’s
current and historical view of social welfare and related social interests, lending a
certain level of cultural relativism to this perspective.
This leads to a second premise that emphasizes the common good as an ideal.
Such a premise downplays the values of individuality, autonomy, and personal
rights, so prevalent in other ethical theories, in favor of a focus on the virtues and
actions that support the interests of society as a whole. While this does include
respect for human life and dignity, allowing for all persons to achieve a
meaningful potential, the common good also calls for concern for long-term
sustainability, intergenerational justice, an emphasis on active and informed
citizenship, and a balance between individual and communal interests. At times,
the common good may require all citizens to consider the needs of the broader
community above the needs of any one individual, group, or organization.
Communitarian thought clearly contributes to the ethical dialogue in the health
care context. This is particularly true with respect to issues such as the best use
of limited health care resources, health care as a right, and the concept of
healthy communities versus an emphasis on individual health.
33
Strengths of the communitarian perspective include the emphasis on strong
connections between people, encouragement of collaboration, diminished
emphasis on self-serving individualism, and sacrifice for the greater good as a
measure of character. On the negative side, many would question how realistic it
is to achieve a common set of global, or even local, values. We might also be
concerned with the potential for erosion of individual rights and no systematic
method for resolving ethical conflicts (Johnson, 2005).
For more on communitarianism see:
Infed Encyclopedia. Communitarianism.
http://www.infed.org/biblio/communitarianism.htm
The Communitarian Network. The Responsive Communitarian Platform.
http://www.gwu.edu/~ccps/platformtext.html
The George Washington University Institute for Communitarian Policy Studies.
http://www.gwu.edu/~icps/vision.html
Stanford Encyclopedia of Philosophy. Communitarianism.
http://plato.stanford.edu/entries/communitarianism/
Wikipedia. Communitarianism. http://en.wikipedia.org/wiki/Communitarian
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34
REFERENCES:
Almond, B. (1993). Rights. In Peter Singer (Ed.) A companion to ethics. Oxford: Blackwell.
Ashley, B. M. & O’Rourke, K. D. (1997). Health care ethics: A theological analysis (4
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Beauchamp, T. L. & Childress, J. F. (2001). Principles of biomedical ethics (5
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Gilligan, C. (1993). In a different voice: Psychological theory and women’s development.
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Jagger, A. M. (2001). Feminist ethics. In Hugh LaFollette (Ed.) The Blackwell guide to ethical
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Johnson, C.E. (2005). Meeting the ethical challenges of leadership: Casting light or shadow.
Thousand Oaks: Sage.
Holmes, R. L. (1993). Basic moral philosophy. Belmont, CA: Wadsworth.
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Back to Table of Contents
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