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What is Ethics?
The branch of philosophy concerned with
systematizing, defending, and proposing
concepts of right and wrong conduct.
The term ethics derives from the Ancient Greek
word ethikos, which derives from the word
ethos (habit, or custom).
- In other words, ethics…
- Investigates various moral questions, such
as “What is the best way for people to
live?” or “What actions are right or wrong”
or “What’s the proper course of action in
particular circumstances?”
- Ethicists are philosophers who specialize in
ethics.
3 major areas of study within ethics are
1. Meta-ethics: (Descriptive)
- Moral Ontology: Nature and origin.
- Moral Epistemology: Knowledge.
- Moral Semantics: Meaning of terms.
2. Normative ethics: (Prescriptive)
- Norms/Ethical Systems
3. Applied ethics: (Practical) How do we take moral
knowledge and put it into practice?
1. META-ETHICS
Meta-Ethics asks about the nature, how we
understand, know about, and what we mean
when we talk about right and wrong. A question
such as, "Should I get an abortion?" or “Is it
ever right to kill?” are not meta-ethical
questions. A meta-ethical question is more
general and more abstract: "Is it possible to
acquire knowledge of right and wrong?" or “Are
certain actions objectively right or wrong” “If
certain actions are objectively wrong or right,
what makes them so?”
Various Theories of Meta-ethics
Cognitivism vs. non-cognitivism:
Cognitivism: ethical sentences express actual
propositions that can be true or false, which noncognitivists deny. Cognitivism embodies many views: e.g.
moral realism: ethical sentences express propositions
about mind-independent facts.
moral subjectivism: ethical sentences express
propositions about peoples' attitudes or opinions.
error theory: ethical sentences express propositions, but
they are all false.
Non-cognitivism: non-cognitivists claim that moral
statements are not in the business of describing
properties or making statements that could be true
or false in any sense. Moral statements have no
substantial truth conditions. When people utter
moral sentences they are not expressing states of
mind that are beliefs or that are cognitive in the
way that beliefs are. Rather they are expressing
non-cognitive attitudes more similar to desires,
approval or disapproval, like “Hey!”
• Moral ontology is about the kind of things we
refer to by ethical propositions.
• Non-cognitivists (also Non-descriptivists) say
morality does not need a specific ontology,
since ethical propositions do not refer to
anything. This is known as an anti-realism.
Realists on the other hand claim morality to
have a paradigm.
• Moral Nihilism: meta-ethical view that
nothing is intrinsically moral or immoral.
killing someone, for whatever reason, is
neither inherently right nor inherently wrong.
Moral nihilists consider morality to be human
construction.
Moral nihilism is distinct from moral relativism,
which does allow for actions to be right or
wrong relative to a particular culture or
individual.
• Moral nihilism implies moral skepticism.
• Moral nihilism = "nothing is morally wrong.”
• Expressivism: when someone says
something is immoral he is not
saying it is right or wrong. He
expresses his feelings, emotions.
Torture, is disgusting, not morally
wrong.
• Expressivism: a form of noncognitivism: the view that moral
statements lack truth-value.
• Non-cognitivism implies that moral
knowledge is impossible.
• universal prescriptivism is a noncognitivist form of moral
universalism: judgments about
morality may be correct or not in a
consistent, universal way, but do not
attempt to describe features of
reality.
Error theory:
• There are no moral features in the world;
nothing is right or wrong.
• No moral judgments are true; however,
• Our sincere moral judgments try, but always
fail, to describe the moral features of things.
• Thus, we always lapse into error when
thinking in moral terms. We are trying to state
the truth when we make moral judgments.
But since there is no moral truth, all of our
moral claims are mistaken—hence the error.
2. NORMATIVE ETHICS
Normative Ethics is the study of ethical action. It
is the area of ethics concerned with the set of
questions that arise when considering how one
ought to act, morally speaking. Normative ethics
is distinct from meta-ethics because it examines
standards for the rightness and wrongness of
actions, while meta-ethics studies the meaning of
moral language and the metaphysics of moral
facts.
Normative ethics because deals with norms or
moral systems, which we’ll consider later on.
3. APPLIED ETHICS
Applied Ethics is the examination of
particular moral issues in private and
public life.
Use of philosophical methods to identify
the morally correct course of action in
various fields of human life.
• Bioethics.
• Environmental ethics
• Business ethics.
• Spots ethics.
PERSONAL AUTONOMY AND MORAL
AGENCY
People make many different moral choices without
knowing that they are. We take it for granted that
we are autonomous. But what does it mean?
Autonomous: to make free choices as a selfdetermining individual. Are we all autonomous?
To be fully autonomous, one must satisfy 3
conditions:
1. Independent condition.
2. Competency condition.
3. Authenticity condition.
Infants, comatose people, senile, and so on lack
autonomy because lack (1) independence. Also,
to be autonomous one must make free choices
without the control of anyone or the control of
something from within the subject.
If you are under threat, under age, you lack
autonomy.
If you have OCD, suffer from kleptomania,
addictions, etc. you are not autonomous.
(2) Competency: One must also be rational and
rationally capable of deliberating his or her moral
choices:
- Know what our choices are.
- Able to understand consequences for those
choices.
- Able to evaluate the best choices for us.
- Must make decisions that are true most of the
time.
- And need to be able to reason correctly.
(3) Authenticity: One may be independent,
competent, but not individualistic. Think
about how many “fully functional” adults
make decisions based upon their upbringing,
faith, peer pressure.
EG: refuse medical treatment based on one’s
interpretation of religious doctrines.
• Individuals who lack autonomy are morally
incompetent. When one is morally
incompetent and the state overrules his
choices and actions for his own good, this is
called paternalism.
• Whether or not one is able to make
independent, competent, or authentic
choices, he or she is referred to as a moral
agent.
Moral Agency
• Who/What is a moral agent?
Philosophers argue over the criteria to
determine moral agency:
– Rationality
– Ability to deliberate moral judgment
– Humanity
– Cognitive capacities
– Sentience
– Relationship
…A Challenge
Who are We to Judge?
MORAL RELATIVISM: the concept that morality is
relative. This can be relativism or subjectivism.
Objectivism says that all people are under the
same moral principles. Moral principles are
objective.
Subjectivism: each individual has his/her own
moral principles.
Relativism says that societies decide what is moral.
Who are we to judge?
Who Are We to Judge?
• The Callatians, an Indian people, ate their
dead people, while ancient Greeks cremated
theirs. They viewed each other’s practice as
immoral. So moral relativism concludes that
morality is a matter of what peoples take it to
be.
However, not always clear that people’s moral
principles differ. People’s beliefs differ. Callatians
believed that their dead would continue living if
ingested. Greeks believed flesh could be
corrupted and so cremated the dead. Also Greeks
believed fire to purify the body. Often, two
peoples’ differences are not moral but cultural.
Abortion? People are divided over abortion.
Why? All agree that murder is wrong. We disagree
over whether a fetus is a person.
Implications of Relativism
If you are a relativist, the implication
is that you must admit there was
nothing wrong about Nazi morality
and slavery!
Think About it…
M.L.K, Jr. and William Garrison fought
against segregation and slavery. They
were moral reformers. If you are a
moral relativist, you cannot praise King
or Garrison. In fact, you should
condemn them.
…Also, moral progress is impossible if
relativism is true. If one tries to better
the living conditions and moral
principles of a society he is making
progress. Moral progress implies
moving toward an ideal, objective,
moral standard. But this is what
relativism denies!
Also, relativism says that moral standard of a
particular society is determined by what that
society practices and deems moral. But a
society cannot make moral progress because
progress requires changing the practices that
give that society their moral standards!
Also, relativism says that the
social group you belong to
determines morality, right? But
ask yourself, to which social
group do I belong?
Answer: you belong to many
groups.
Finally, some might say that relativism is
valid because we should have tolerance
and respect other people’s practices
and beliefs. But, if we apply the
principle of tolerance as a universal
principle, then tolerance is ruled out by
relativism! In other words, if you use
the argument from tolerance, you are
not a relativist but an objectivist.
Assessing Ethical Theories
Important in ethics is to determine what makes
things right or wrong. Which theory is best?
A theory’s principles must provide a compelling
explanation of why certain things are good or
right while others are bad or wrong.
Adequate ethical theory needs to satisfy
certain criteria. The more fully the theory
satisfies all these criteria the better the theory.
1. Completeness: theory should be able to
address completely moral concepts. If the
theory leaves something out that must be
included, then that theory is faulty.
Hedonistic theories, don’t account for
justice.
2. Explanatory Power: The theory must give
us insight into what makes something moral
or immoral. It must help us understand the
difference between right and wrong.
3. Practicability: how useful is a theory?
- Clear and precise moral claims. If the
theory’s principles are vague, then it isn’t
a practical theory: “don’t hurt people
unless they deserve it.” Vague.
- Moral guidance to ordinary people.
- Principles should not create conflict.
Imagine a friend lives in the US illegally.
Should you turn him in? A practicable
theory must be able to resolve your
dilemma.
4. Moral confirmation: a theory must
give correct answers to moral
questions. Does it work? A theory is
morally confirmed if we have good
reasons to consider it true. This
criterion resembles the scientific
method. In science we begin testing a
theory’s hypotheses by experiment
and observation.
SOME WAYS NOT TO ANSWER MORAL
QUESTIONS, AND THE IDEAL MORAL JUDGMENT
Moral judgments and personal preferences
Some people like classical music; others do not.
This is disagreement in preferences. Moral
disagreements, disagreements over right or
wrong, are not the same. If I say abortion is
always wrong and you say abortion is never
wrong, then you are denying what I affirm. The
point: right or wrong require reasons. Cannot be
determined just by finding out about the
personal preferences of people.
Moral judgments and feelings
Some philosophers think words like
right and wrong are empty. This
position suggests it doesn’t matter one
way or the other. But morality matters.
So, one must not use personal feelings
to determine what’s right and wrong.
Thinking it is so does not make it so
This should be obvious: upon
reflection you might be surprised.
You might think same-sex marriage
is immoral, but when you reason
logically, you might arrive at the
opposite conclusion.
Irrelevance of statistics
Some people think that the more
people believe something, the truer
something is. Religious people may say
that God exists because the majority
of the world’s population believes in a
god. Clearly this is not true. If the
majority holds that capital punishment
is wrong, that doesn’t make it wrong.
The appeal to a moral authority:
Many people think that there is a
moral authority, and that is God.
However, appealing to such an
authority creates problems
because the existence of God is
controversial.
THE IDEAL MORAL
JUDGMENT
There are different concepts that an
ideal moral judgment must satisfy
Conceptual clarity: if someone
tells us that euthanasia is always
wrong we could not determine
whether that statement is true
before we understand what
euthanasia is. Concepts need
clarity.
–In the case of abortion, for example,
is a fetus is a person?
Information: We answer moral
questions by having knowledge of the
world. For example, in order to know
why eating meet is morally wrong, we
must know the facts, that is, animals
feel pain and like us do not want to feel
pain. They are killed, Chopped up,
packaged, and sold. Many people
ignore, or want to ignore, these facts.
Rationality: must be able to
recognize the connection
between different ideas. The
only way is to use logic. Sally
thinks all abortions are morally
wrong, but she recently has had
an abortion. Sally is not being
rational or logical.
Impartiality: correct answer to moral questions
must be impartial. Impartiality is related to
justice: the principle that justice is the similar,
and injustice the dissimilar, treatment of similar
individuals. If causing suffering to humans is
wrong, but it is not wrong in the case of animals,
this is not impartial.
- we should consider irrelevant characteristics
such as the color of the skin, the color of hair,
nationality, height, age, species, and so on.
Coolness: the idea is that the more
emotionally charged we are, the
more likely we are to reach a
mistaken moral conclusion come
while the cooler or calm or we are,
greater the chances that we will
avoid mistakes.
VALID MORAL PRINCIPLES
besides information, impartiality,
conceptual clarity, etc., ideal moral
judgment must be based on valid or
correct moral principles. Ideally, one
wants not only to make the correct
moral judgment but also to make it
for the correct reasons.
Criteria for evaluating moral
principles:
• Consistency: whatever principle let Sally to believe that all
abortions are morally wrong and yet have an abortion is
morally right, must be an inconsistent principle.
• Adequacy of scope: A successful principle is one that provides
guidance to different circumstances. So, the wider the
principle’s scope, the greater its potential uses, the narrower
its scope, the narrower its range of applications.
• Precision: What we want from an ethical principle is not to be
vague. For example if we are told we should love our
neighbors and we should do no harm we must also be told in
a clear way what love, harm, and a neighbor are supposed to
mean.
Moral Theories
Consequentialism
Consequentialistic Ethics: Egoism
Everything we do has consequences.
Consequentialism defines morally right actions
based on what produces desirable consequences.
Consequentialism: an approach to ethics arguing
that only consequences are what makes something
morally good or bad.
Utility: Desirable consequences.
Disutility: Undesirable consequences.
Hedonism and Consequentialism
• Consequentialistic theories commit to a
definition of utility.
• Hedonistic theories regard
Pleasure/Happiness as utility and pain as
disutility.
• Hedonism views pleasure as the only good.
– Not all pleasures are good.
• Pleasure and happiness are not the same.
• Most consequentialists understand utility as
happiness.
• Only intrinsic good is pleasure. It is good in itself.
• No God or moral authority or moral paradigm.
• Humans are not divine or special, and as
individuals have no intrinsic value.
• The happiness of the majority is what counts.
• Why consequentialism? Something is right based
on consequences.
• I should not make a decision based on principles
or duty. I must consider the consequences of my
actions.
• Right action is one that produces consequences
that maximize happiness for the greatest number
of beings.
- To be practicable, consequentialism must give us accurate
assessment of how much utility something might produce.
- Utility must be predictable and measurable.
- Pleasures can be predicted, but what about happiness?
- Mill (1806 – 1873): consider pleasures conducive to happiness.
- Different kinds of pleasures:
- Pleasure of creating art, thinking of morality, vs. getting
drunk, sex, food, etc.
- Intellectual pleasure are higher than physical.
- Higher pleasures more conducive to happiness.
- “it is better to be Socrates dissatisfied than a pig satisfied.”
- Many people do not know higher pleasures due to lack of
education.
- This makes it an elitist theory.
Act Utilitarianism
• Right actions maximize happiness/pleasure.
• everything we do is motivated by a desire to
maximize pleasure and minimize pain. – the
greatest amount of good for the greatest
number of beings.
• Why pleasure/happiness? Because that’s the
only thing that matter.
• What beings? All sentient beings.
• Act utilitarianism tells us what counts as the
right act—what we ought to do.
Which act ought we
carry out?
We assess an act by
following these aspects:
How we Proceed…
• First we identify the choices.
• Next we determine utility and subtract
disutility by considering 1,2,3,4.
• The outcome that leads to the greatest
overall utility is for act utilitarians the
morally right thing to do.
Mill
John Stuart Mill, argues that it is a mistake to
confuse the standards for right action with a
consideration of our motives to perform a right
action: "He who saves a fellow creature from
drowning does what is morally right, whether his
motive be duty, or the hope of being paid for his
trouble; he who betrays the friend that trusts him,
is guilty of a crime, even if his object be to serve
another friend to whom he is under greater
obligations." According to Mill, scrutiny of motives
or intentions will show that almost all good
behavior proceeds from questionable intentions.
Therefore, Mill argues, our moral analysis should
ignore matters of intention.
Criticisms
• Is happiness all that matters?
• Paradox of Hedonism: if happiness is all that
matters, we must pursue it. But we can’t.
• Try making yourself happy.
• Happiness is like a NYC bus—you never know
when it’s coming.
Rule Utilitarianism
• Certain practices/core values such as promising can
generate consequences conducive to maximization of
utility.
• Rule utilitarianism defines a morally right rule or
practice as one that promotes overall utility.
• Principle of rules: a morally right rule is one that is
widely followed would promote greater utility than if it
did not exist.
• Principle of acts: a morally right act is one that follows
morally right rules. We have a moral duty to obey
those rules unless they come into conflict.
• Act utilitarianism: must decide by calculating
consequences case by case.
• Rule utilitarianism: based on experiences of
consequences, apply certain rules that
maximize utility.
• Hedonistic utilitarianism: maximize
pleasure/minimize suffering.
• Preference utilitarianism: maximize utility
based on people’s preferences. Each individual
preference is unique. But in the end the
aggregative satisfaction is the goal.
• True preferences vs. corrupt preferences.
Deontology – Kant
The only unconditionally good this
is the will.
• 1. Only actions that proceed from duty have
moral worth.
I can act in accordance or in conformity to duty: I
promise that I will give you a lift, but I do it
because I want to avoid the ill consequences from
not doing so. I then am not doing what is right for
the right reason. My action does not proceed
from duty. My will cannot be good.
If I pay my debt because I want you to lend me
more or because I am afraid to pay penalties, my
will is not good because my action dos not
proceed from the recognition that I have a duty.
Or, I can charge difference prices to different
customers. But say that I want to maintain a
good reputation for my business, then I will
conform with the duty that I should not charge
different customers differently. But am I doing it
for the right reason? No because my action does
not proceed from duty.
An action that proceeds from duty has its moral
worth not from the purpose to be attained but
from the maxim by which it is determined. A
maxim is a subjective principle of volition. My
maxim is the principle that motivates me to do
something. So an action is never morally good
because of what I do but rather because of why I
do it.
My will might be motivated by material
incentive = Not good. If I pay you back not
because of reputation or because I want you to
like me, or what not, but because I recognize
that I have a duty, a principle, categorical that
commands me to pay you back. This is good.
• Duty is the necessity of acting from respect
for the moral law.
Categorical imperative
–“Act only according to that maxim
whereby you can at the same time
will that it should become a universal
law without contradiction.”
–Ask yourself “Would I want all people
in all places, at all times to do what I
am about to do?”
The first formulation
• Requires that the maxims be chosen as though they
should hold as universal laws of nature. This is a test to
determine whether a maxim can be universalized:
• Take a moral statement, for example the declaration “I
will cheat for personal benefit.”
• Imagine a possible world in which everyone followed that
maxim.
• Decide whether any contradictions or irrationalities arise
in such a world as a result of following the maxim.
• If a contradiction or irrationality arises, acting on that
maxim is not allowed in the real world.
• If there is no contradiction, that maxim is morally sound;
but if there is, well, then it is not morally sound!
The second formulation
• holds that the rational being is “the
basis of all maxims of action” and
must be treated never as a mere
means but as an end. What this
means is that all rational beings
should never be exploited for
personal gain.
• What makes a being rational?
Freedom!
The third formulation
• All maxims must harmonize with a possible
Kingdom of Ends. This means that we
should act in such a way that we may think
of ourselves as “a member in the universal
realm of ends”.
Virtue Ethics
Virtue Ethics
• A virtue is a dispositional trait that is socially valuable. An
excellent and reliable trait of one’s character.
• A moral virtue is a dispositional trait that is morally valuable.
• emphasizes the role of one's character and the virtues that
one's character embodies for determining or evaluating
ethical behavior.
• Character requires practice.
– Role models.
• No rule can tell me to do the right thing. I must use my
virtues to determine correct action.
• To do wrong is lack of knowledge.
• Goal of virtue ethics is well being/happiness/human
flourishing.
Virtues
•
•
•
•
•
•
•
•
Prudence
Compassion
Generosity
Benevolence
Wisdom
Justice
Courage
Temperance
• Aristotle argued that moral virtues are means
between two corresponding vices, one of
excess and one of deficiency. For example:
courage is a virtue found between the vices of
cowardliness and rashness.
Rashness
Courage
Cowardliness
[___________________I___________________
]
5 Central Virtues in Healthcare
1. Compassion:
– Since healthcare, then compassion is a prelude to
caring. Attitude of altruistic care—Sympathy for
others’ suffering.
– Connected with mercy/merciful.
– Expressed through beneficence to alleviate others’
suffering.
– Compassion is directed to others.
2. Discernement:
– Sensitive insight, astute judgment, understanding how
to act.
– Ability to make competent judgments and reach
judgment without being unduly influenced.
– Practical wisdom?
– For Aristotle a practically wise person understands
how to act with right intensity of feeling, the right
way, right time, balancing reason and desire.
– A Discerning physician will see when a patient needs
comfort rather than privacy. He will measure level of
consolation.
– Discernment is understanding how to balance respect
for autonomy and beneficence—like a parent cares for
his children.
3. Trustworthiness:
– Patients are vulnerable, thus trust is essential in
health care.
– Reliance and trust in the moral character of
another person.
– To merit confidence in one’s character and
conduct.
– Trustworthiness of a health care provider goes
beyond legal relationship.
– How much do we trust health care providers
today?
4. Integrity:
– In morality, Integrity means reliability, soundness,
and integration of moral character.
– Impartiality, objectivity, respecting moral norms.
– 2 aspects of integrity:
• Coherent Integration of emotions, knowledge,
aspirations.
• Being faithful to moral values, defending them if
necessary. People love dogs and eat cows due to lack of
moral conviction.
5. conscientiousness:
– A conscientious person is motivated to do what’s
right because it’s right, has determined through
due diligence what’s right, intends to do what’s
right, and makes appropriate efforts to do what’s
right.
• One issue in health care is conscientious refusal.
– A nurse, for example, may claim conscientious exemption
from participation in abortions or sterilizations, even to the
extent to refuse to fill out admission forms!
Feminist Ethics/Care
• Women see morality differently from men.
• Motherly care.
• Kohlberg stages.
– Medicine dilemma. Would it be right to steal a
medicine that you cannot afford but will safe your
life?
Men tend to respond in legal/obligation terms.
Women prefer compassion.
MEDICAL ETHICS
Medical ethics
Difference between Bioethics and Medical Ethics:
• Medical ethics is a professional, practical ethic
used to resolve moral issues in the practice of
medicine. As a scholarly discipline, medical ethics
is the study of its practical application in clinical
settings as well as its history, philosophy, and
sociology. In virtue of practicing medicine, there
are certain obligations to follow.
• Bioethics is a critical challenge to professional
ethics.
• Historically, Western medical ethics originates
with guidelines on the duty of physicians in
antiquity, such as the Hippocratic Oath. The first
code of medical ethics, Formula Comitis
Archiatrorum, was published in the 5th century,
during the reign of the Ostrogothic king
Theodoric the Great. In the medieval and early
modern period, Islamic scholarship made great
contributions to the field: Avicenna's Canon of
Medicine, Muhammad Rhazes, Jewish thinkers
such as Maimonides, Roman Catholic scholastic
thinkers such as Thomas Aquinas, and the caseoriented analysis (casuistry) of Catholic moral
theology.
• By the 18th and 19th centuries, medical ethics emerged as
a more self-conscious discourse. In England, Thomas
Percival, a physician and author, crafted the first modern
code of medical ethics. He drew up a pamphlet with the
code in 1794 and wrote an expanded version in 1803, in
which he coined the expressions "medical ethics" and
"medical jurisprudence".
• In 1815, the Apothecaries Act was passed by the Parliament
of the United Kingdom. It introduced compulsory
apprenticeship and formal qualifications for the
apothecaries of the day under the license of the Society of
Apothecaries. This was the beginning of regulation of the
medical profession in the UK.
• In 1847, the American Medical Association adopted its first
code of ethics, with this being based in large part upon
Percival's work.
Values
• A common framework used in the analysis of
medical ethics is the "four principles" approach
proposed by Tom Beauchamp and James
Childress. It recognizes four basic moral
principles, which are to be judged and weighed
against each other. The four principles are as
follows:
• Respect for autonomy - the patient has the right
to refuse or choose his treatment.
• Beneficence - a practitioner should act in the best
interest of the patient.
• Non-maleficence - "first, do no harm."
• Justice - concerns the distribution of scarce health
resources, and the decision of who gets what
treatment.
• Other values that are sometimes discussed include:
• Respect for persons - the patient (and the person
treating the patient) have the right to be treated
with dignity.
• Truthfulness and honesty - the concept of
informed consent has increased in importance
since the historical events of the Doctors' Trial of
the Nuremberg trials and Tuskegee syphilis
experiment.
• Values such as these do not give answers as to how to
handle a particular situation, but provide a useful
framework for understanding conflicts.
• When moral values are in conflict, the result may be an
ethical dilemma or crisis. Sometimes, no good solution
to a dilemma in medical ethics exists, and, on occasion,
the values of the medical community (i.e., the hospital
and its staff) conflict with the values of the individual
patient, family, or larger non-medical community.
Conflicts can also arise between health care providers,
or among family members. Some argue for example,
that the principles of autonomy and beneficence clash
when patients refuse blood transfusions, considering
them life saving; and truth telling was not emphasized
to a large extent before the HIV era.
Autonomy
• The principle of autonomy recognizes the rights of
individuals to self-determination. This is rooted in
society's respect for individuals' ability to make informed
decisions about personal matters. Autonomy has become
more important as social values have shifted to define
medical quality in terms of outcomes that are important
to the patient rather than medical professionals. The
increasing importance of autonomy can be seen as a
social reaction to a "paternalistic" tradition within
healthcare. Some have questioned whether the backlash
against historically excessive paternalism in favor of
patient autonomy has inhibited the proper use of soft
paternalism to the detriment of outcomes for some
patients. Respect for autonomy is the basis for informed
consent and advance directives.
• Paternalism is behavior by state to limit some
person or group's liberty or autonomy for what is
presumed to be that person's or group's own
good.
• Some, such as John Stuart Mill, think paternalism
to be appropriate towards children: "It is,
perhaps, hardly necessary to say that this
doctrine is meant to apply only to human beings
in the maturity of their faculties. We are not
speaking of children, or of young persons below
the age which the law may fix as that of manhood
or womanhood." Paternalism towards adults is
sometimes thought to treat them as if they were
children.
• Examples of paternalism: laws requiring the use
of motorcycle helmets, laws, seatbelts, punishing
citizens for not obtaining their driving license in
time, and a psychiatrist confiscating sharp objects
from someone who is suicidal.
• Soft and hard paternalism:
• The terms soft and hard are used in two quite
different senses in this context. Philosophers
usually use "soft paternalism" for paternalism
toward a person whose action or choice is
insufficiently voluntary to be genuinely his or
hers. Hard paternalism in this usage means
paternalism toward a person whose action or
choice is sufficiently voluntary to be genuinely his
or hers.
• Autonomy v. Paternalism: Autonomy is
difficult because as one gets sick, he loses it.
Also, some do not have if due to cognitive
issues. So paternalism creeps in.
Beneficence
• taking actions that serve the best interests of
patients. However, not easy to determine which
practices do in fact help patients.
• James Childress and Tom Beauchamp identify
beneficence as one of the core values of
healthcare ethics. Some scholars, such as
Edmund Pellegrino, argue that beneficence is the
only fundamental principle of medical ethics.
They argue that healing should be the sole
purpose of medicine, and that endeavors like
cosmetic surgery and euthanasia fall beyond its
purview.
Non-maleficence
"first, do no harm." Many consider that should be the
main or primary consideration that it is more important
not to harm your patient than to do them good.
Enthusiastic practitioners use treatments they believe
will do good, without really knowing whether they do
no harm: "The treatment was a success, but the patient
died." It is not only more important to do no harm than
to do good; it is also important to know how likely it is
that your treatment will harm a patient. So a physician
should go further than not prescribing medications they
know to be harmful — he or she should not prescribe
medications unless she knows that the treatment is
unlikely to be harmful; or at the very least, that patient
understands the risks and benefits, and that the likely
benefits outweigh the likely risks.
Principle of double effect
• Double effect refers to two types of
consequences that may be produced by a single
action, and in medical ethics it is usually
regarded as the combined effect of beneficence
and non-maleficence.
• A commonly cited example of this phenomenon
is the use of morphine or other analgesic in the
dying patient. Such use of morphine can have
the beneficial effect of easing the pain and
suffering of the patient while simultaneously
having the maleficent effect of shortening the
life of the patient through suppression of the
respiratory system.
Respect for human rights
• The human rights era started with the formation
of the United Nations in 1945, which was charged
with the promotion of human rights. The
Universal Declaration of Human Rights (1948)
was the first major document to define human
rights. Medical doctors have an ethical duty to
protect the human rights and human dignity of
the patient so the advent of a document that
defines human rights has had its effect on
medical ethics. Most codes of medical ethics now
require respect for the human rights of the
patient.
Conflicts between autonomy and
beneficence/non-maleficence
• Autonomy can come into conflict with
beneficence when patients disagree with
recommendations that healthcare professionals
believe are in the patient's best interest. When
the patient's interests conflict with the patient's
welfare, different societies settle the conflict in
a wide range of manners. In general, Western
medicine defers to the wishes of a mentally
competent patient to make their own decisions,
even in cases where the medical team believes
that they are not acting in their own best
interests. However, many other societies
prioritize beneficence over autonomy.
• Examples include when a patient does not want a
treatment because of, for example, religious or
cultural views. In the case of euthanasia, the
patient, or relatives of a patient, may want to end
the life of the patient. Also, the patient may want
an unnecessary treatment, as can be the case in
hypochondria or with cosmetic surgery; here, the
practitioner may be required to balance the
desires of the patient for medically unnecessary
potential risks against the patient's informed
autonomy in the issue. A doctor may want to
prefer autonomy because refusal to please the
patient's self-determination would harm the
doctor-patient relationship.
• Individuals' capacity for informed decision-making might
come into question during resolution of conflicts between
autonomy and beneficence. The role of surrogate medical
decision makers is an extension of the principle of
autonomy.
• On the other hand, autonomy and beneficence/nonmaleficence may also overlap. For example, a breach of
patients' autonomy may cause decreased confidence for
medical services in the population and subsequently less
willingness to seek help, which in turn may cause inability
to perform beneficence.
• The principles of autonomy and beneficence/nonmaleficence may also be expanded to include effects on the
relatives of patients or even the medical practitioners, the
overall population and economic issues when making
medical decisions.
Euthanasia
• There is disagreement among American
physicians as to whether the non-maleficence
principle excludes the practice of euthanasia.
An example of a doctor who did not believe
euthanasia should be excluded was Dr. Jack
Kevorkian, who was convicted of seconddegree homicide in Michigan in 1998 after
demonstrating active euthanasia on the TV
news show 60 Minutes.
• In some countries such as the Netherlands,
euthanasia is an accepted medical practice.
Legal regulations assign this to the medical
profession. In such nations, the aim is to
alleviate the suffering of patients from
diseases known to be incurable by the
methods known in that culture. In that sense,
the “First do not Harm” is based on the belief
that the inability of the medical expert to offer
help, creates a known great and ongoing
suffering in the patient.
Justice
The idea that the burdens and benefits of new or
experimental treatments must be distributed equally
among all groups in
• society. Requires that procedures uphold the spirit
of existing laws and are fair to all players
involved. The health care provider must consider
four main areas when evaluating justice: fair
distribution of scarce resources, competing needs,
rights and obligations, and potential conflicts with
established legislation. Reproductive technologies
create ethical dilemmas because treatment is not
equally available to all people.
Justice in health care is a form of fairness, or as
Aristotle once said, “giving to each that which is
his due.” This implies the fair distribution of
goods in society. The question of distributive
justice also seems to hinge on the fact that some
goods and services are in short supply, there is
not enough to go around, (medicine, organs,
etc.) thus some fair means of allocating scarce
resources must be determined.
It is generally held that persons who are equals
should qualify for equal treatment. An example
is the application of Medicare, which is available
to all persons over the age of 65. This category
of persons is equal with respect to their age, but
the criteria chosen says nothing about need or
other factors about the persons in this category.
In fact, our society uses a variety of factors as
criteria for distributive justice, including the
following:
1.
2.
3.
4.
5.
6.
To each person an equal share
To each person according to need
To each person according to effort
To each person according to contribution
To each person according to merit
To each person according to free-market
exchanges
• (Beauchamp & Childress, 1994, p. 330)
John Rawls (1999) claims many of the inequalities
we experience are a result of a “natural lottery” or
a “social lottery.” Individuals are not to blame,
therefore, society should providing resources to
help overcome the disadvantaged situation. One of
the most controversial issues in modern health care
is the question pertaining to “who has the right to
health care?” Or, stated another way, perhaps as a
society we want to be beneficent and fair and
provide some decent minimum level of health care
for all citizens, regardless of ability to pay.
Medicaid is a program to help those at the
poverty level. Yet, in times of recession,
thousands of families below the poverty level
have been denied Medicaid as a cost saving
maneuver. The principle of justice is a strong
motivation toward the reform of our health care
system so that the needs of the entire
population are taken into account. The demands
of the principle of justice must apply
systemically in the laws and policies of society
that govern the access of a population to health
care. Much work remains to be done in this
arena.
Informed consent
• Informed consent in ethics usually refers to
the idea that a person must be fully informed
about and understand the potential benefits
and risks of their choice of treatment. An
uninformed person is at risk of mistakenly
making a choice not reflective of his or her
values or wishes. It does not specifically mean
the process of obtaining consent, or the
specific legal requirements, which vary from
place to place, for capacity to consent.
• Patients can elect to make their own medical
decisions, or can delegate decision-making
authority to another party. If the patient is
incapacitated, laws around the world
designate different processes for obtaining
informed consent, typically by having a person
appointed by the patient or their next of kin
make decisions for them. The value of
informed consent is closely related to the
values of autonomy and truth telling.
Confidentiality
• is commonly applied to conversations
between doctors and patients. This concept is
commonly known as patient-physician
privilege. Legal protections prevent physicians
from revealing their discussions with patients,
even under oath in court.
• Confidentiality is mandated in America by
laws. However, numerous exceptions to the
rules have been carved out over the years. For
example, many states require physicians to
report gunshot wounds to the police and
impaired drivers to the Department of Motor
Vehicles.
• Confidentiality is also challenged in cases
involving the diagnosis of a sexually
transmitted disease in a patient who refuses
to reveal the diagnosis to a spouse, and in the
termination of a pregnancy in an underage
patient, without the knowledge of the
patient's parents. Many states in the U.S. have
laws governing parental notification in
underage abortion.
Criticism of orthodoxy
It has been argued that mainstream medical ethics is
biased by the assumption of a framework in which
individuals are not free to contract with one another to
provide whatever medical treatment is demanded,
subject to the ability to pay. Because the welfare state
typically provides a high proportion of medical care, and
because there are legal restrictions on what treatment
may be provided and by whom, an automatic divergence
may exist between patient wishes and the preferences of
medical practitioners and other parties. Some have
questioned the idea that beneficence might in some
cases have priority over autonomy. Violations of
autonomy more often reflect the interests of the state or
of the supplier group than those of the patient.
Guidelines
And Ethics committees
• There are various ethical guidelines. For example, the
Declaration of Helsinki is regarded as authoritative in
human research ethics.
• Often, simple communication is not enough to resolve
a conflict, and a hospital ethics committee must
convene to decide a complex matter.
• These bodies are composed primarily of healthcare
professionals, but may also include philosophers, lay
people, and clergy - indeed, in many parts of the world
their presence is considered mandatory in order to
provide balance.
Truth-telling
• Some cultures do not place a great emphasis
on informing the patient of the diagnosis,
especially when cancer is the diagnosis.
American culture rarely used truth-telling
especially in medical cases, up until the 1970s.
In American medicine, the principle of
informed consent now takes precedence over
other ethical values, and patients are usually
at least asked whether they want to know the
diagnosis.
Conflicts of interest
• Physicians should not allow a conflict of
interest to influence medical judgment. In
some cases, conflicts are hard to avoid, and
doctors have a responsibility to avoid entering
such situations. Research has shown that
conflicts of interests are very common among
both academic physicians and physicians in
practice.
Futility
• The concept of medical futility has been an important
topic in discussions of medical ethics. What should be
done if there is no chance that a patient will survive
but the family members insist on advanced care?
• Advance directives include living wills and durable
powers of attorney for health care. In many cases, the
"expressed wishes" of the patient are documented in
these directives, and this provides a framework to
guide family members and health care professionals in
the decision-making process when the patient is
incapacitated. Undocumented expressed wishes can
also help guide decisions in the absence of advance
directives, as in the Quinlan case.
• Courts have supported definitions of futility to
include simple biological survival, as in the Baby K
case (in which the courts ordered a child born with
only a brain stem instead of a complete brain to be
kept on a ventilator based on the religious belief that
all life must be preserved).
• In some hospitals, medical futility is referred to as
“non-beneficial care.”
• Baby Doe Law establishes state protection for a
disabled child's right to life, ensuring that this right is
protected even over the wishes of parents or
guardians in cases where they want to withhold
treatment.