Studying Medical Ethics

Medical Ethics:

Welcome. You are about to embark on an exciting discovery to determine how you reason morally. We will start our class in healthcare ethics by determining how each of you reason
about and make moral decisions. To achieve this, we will study the major normative ethical theories that philosophers argue humans use to guide and determine their moral choices and which structure our moral outlooks. Most philosophers accept three major normative theories that may be summarized as follows:

Character-based

Principle-based

Outcome-based

In the first, character-based ethics, the rightness of an act is determined by if it fits your sense of self-worth. Briefly, when considering an act your ultimate reasons for acting are that you would not be able to sleep at night if you did otherwise.

In principle-based approaches, the rightness of an act is set by adhering to a principle that you accept and believe to be universally binding. So, if you think it is wrong to lie, you never lie and no one should lie. Period. In other words, it does not necessarily make you feel “good” or produce the best outcomes every time, but it is the right thing to do, always. In other words, by telling the truth, you may feel pretty lousy even if you’ve done the correct thing.

The final approach, the outcome-based model looks at the actions end results, the outcomes. A morally good act is one that produces greater positive benefits than negative ones. It matters less either how you produce them or what kind of character you possess. The goal in this last approach is to create more good than bad.

A recent addition to the set of moral theories that we are going to study is care ethics. This approach develops in the wave of feminism and their critiques of Western ethical theory. It builds on the work of such thinkers as Carol Gilligan and Nell Noddings (See text and PPT), and rather than viewing the moral actor as an autonomous, rational agent looks instead to the network of intimate relationships that form a context in one’s lived reality. One should act then with the greatest regard to those relationships. It is not solely based on character, rules or the results but about the integrity and compassion of living relationships and solicitude.

Essentially, and with all these varied approaches, what you are engaged in here is a pursuit of and for the “good.” You are a fledgling philosopher trying to define the good, the moral good. In attempting to define what the “good” means you will use one of these normative theories. In choosing the moral theory that best “ fits,” you are trying to figure out what theory or set of practices guides you through your life. It sounds cliché but you are looking for your personal, moral North Star, the guiding light that orients your moral universe, gives meaning and order to your moral outlook. This theory provides meaning to your considered moral beliefs. Of course, most humans never reflect on this process but students of philosophy do and that is your first charge. Welcome to philosophy. It is challenging to determine which of the available major normative theories best “fits,” but it can be an eye-opening and instructive discovery. Let’s review…

Are you a virtue theorist a la Aristotle? As such, you would determine right and wrong by the kind of character you believe yourself to possess. In this practice, you primarily use your sense of self-esteem to guide your actions and frequently ground your beliefs in that understanding. You may frequently hear yourself say, “I’m just not that kind of person,” when confronted with a disagreeable choice. Your vocabulary is likely peopled with words such as nobility, courage, generosity, integrity and the like.

Or are you principle-based theorist? Did you know that all of the world’s religions promulgate a set of rules to guide behavior (e.g. think of the Decalogue—the 10 commandments). Modern healthcare professions are replete with codes of ethics (e.g. AMA or APTA codes). See the syllabus for the moral code for your profession. Deontology begins in antiquity when Kung-fu-tzu (Confucius) articulated his influential “golden rule,” but Immanuel Kant is the best—even if most difficult— spokesperson for this approach. In this approach, you guide you behavior by your adherence to rules. You are a good person because you did what was right irrespective how you feel or the outcomes achieved. You stuck to your guns. My favorite example of a deonotologist is the character, Piggy from Golding’> > s “The Lord of the Flies”. His glasses are stolen by the tough guy Jack andP Piggy asked for his glasses because “right is right”. Piggy believed, as deontologists do that right is universal and that you have a duty to follow it. If you believe that adhering to universally accepted rules of conduct, then you are a deontologist.

If neither one of these approaches fulfills your sense of moral reasoning, then you may like the sounds of consequentialism. This theory postulates that the good is achieved when you produce more beneficial outcomes for a larger percentage of individuals than any other alternative. The good becomes, then, a maximizing of the consequences. The English political philosopher, Jeremy Bentham and his godson, the polymath, John Stuart Mill, are the two best spokesmen for this ethical theory, a theory they ultimately tagged utilitarianism. Their approach views the good as a calculus maximizing pleasures over pains for the greatest numbers of persons involved. An ethical ends justifies the means approach.

So there you have them: the three major normative approaches. I submit that you are one or the other. There are some minor theories and options but for the most part these three theories encompass the way humans practice ethics. Which one best “fits” you? Well, I bet you are saying to yourself that you practice all three, right? Let’s think more closely about that.

Reverend Frederick Neu speaks of maintaining a good “one-two punch” in ethics. The pugilistic metaphor is helpful because you are probably finding it difficult to choose a single theory. Sometimes you follow rules, sometimes your sense of character, and at work in the ER, say, you are asked to think like a consequentialist. Well, we probably do use different approaches for differing situations, but it is my argument that each person has a predominant ethical theory in the same way as you have a dominant hand. You may still be a switch-hitter but you sign your checks with the same hand. Somewhat analogously, our choices in life reveal a moral predilection, a dominant moral handedness, so to speak. Another way of thinking about ethics is to take a page from contemporary political identities. Many Americans today identify themselves as “independent” but their voting patterns are still predominately Republican or Democratic. We seem to fear self-identifying and confining ourselves. But is that sensible? The problem is that we rarely reflect on where our morals come from. Most of us, just unthinkingly adopt the moral worldviews of our parents and the religions we were born in raised in. In and of itself, there is nothing terrible about this but philosophy is about reflecting and examining one’s ideas. Ethical philosophers challenge us to reflect on those inherited beliefs to see if they are indeed the ones we choose to adhere to.

I invite you to read more about these theories in learning about ethics. The place to begin is with the major theorists themselves. For virtue theory take a look at Aristotle’s “Nichomachean Ethics”. For deonotology try Kant’s “Groundwork for the Metaphysics of Morals” and for consequentialism turn to J.S. Mill’s “Utilitarianism”. For two very interesting modern views on morality, look at Alistair MacIntyre’s “After Virtue.” or Iris Murdoch’s “The Sovereignty of the Good.” Enjoy.

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