Archive for May, 2012

Note on Ethical Relativism

Posted in Uncategorized on May 24, 2012 by pstanden

A Note on Relativism:
“I’m saying that if you mutilate 100 million women and make it so hard for them to give birth that many of them will die trying or their children will be born deformed or crippled, how can you expect the continent to be healthy.”
Alice Walker
Well-intentioned people often believe in and say really stupid things. In 1992 following the publication of her novel, Possessing the Secret of Joy,” Pulitzer-prize winning author, Alice Walker, was attacked for her ethnocentrism and bigotry by academics, feminists and multiculturalists for her condemnation of the African cultural practice of genital mutilation. Her critics claimed that since FGM was a central part of traditional African culture and was outside of Western moral sensibilities, it could not and should not be judged by others.
In similar fashion, it is common response for students studying ethics for the first time to claim that ethics are socially-conditioned or that morals change from person to person. While superficially that may seem true, upon deeper reflection, you will likely find that that is not the case and indeed cannot be the case.
Relativism is the belief that all knowledge is subjective, including moral knowledge. It is the belief that claims of evaluation are relative to and specific to culture, place, custom, language or biological makeup. Advocates of relativism usually claim that the “good” or “morality” is entirely dependent on the specific circumstances, particular persons, or cultures from which it emerged. Note that this is different than the anthropologists “relativism” which is an operative practice used as a tool to understand a culture that is different than your own. The anthropologist may “do as the Romans do” but only in Rome and not back home. As such, it is an intellectual tool that the student of different cultures uses to aid in her understanding of a culture different than her own. Also note that there is frequent confusion between morals and mores: the latter being the socially determined practices of etiquette, folkways and customs specific to any culture. Mores are relative in the anthropological sense.
Moral relativism is the strong claim that all morals are relative to the believer; and if this claim were true, then we would inevitably need to accept that genital mutilation, sex selection abortions, murder, abuse, mercy killing, rape, and even genocide are, well, morally acceptable since we lack a ground to condemn such actions. If a culture or person practices an act that we believe is inhumane, then we need a basis to ground our moral criticism and judgment upon. Lacking that ground—or objective notion of moral right or wrong—pushes us into the corner of silence or apathy. Most philosophers argue that moral universalism—an objective moral good—is the preferred position. On the contrary, and strictly speaking, if relativism is true and all morals are up to the culture or individual, then literally all things are morally permissible. Cleary this is an untenable position, but why?

Moral relativism is a sub species of epistemological relativism which states that:
“All truths are subjective.”
But this is a canard, a specious or unjustified belief. The logic (or grammar) of the sentence above, “all truths are relative” rests on an objective notion of truth, namely, that ALL truth is relative. But to use this logical and grammatical quantifier “all” is to smuggle in an anti-relativist position. The relativist undermines herself by attempting to claim using objective truth that all truth is subjective. The relativist is an objectivist in wolf’s clothing. They obfuscate. They say one thing, but mean another.
What is at the heart of relativism is either a desire to be viewed as open-minded and tolerant or just plain old muddle-headedness. Of course, there may be those who do believe that whatever they do is right and beyond question but ethics has little to offer those of that solipsistic persuasion. In contemporary American society, Americans are trained, socialized and imbibe a kind of noxious moral relativism where anything and all things are permitted. Pop culture, fashion and the domestic economy thrive on this assumption. There are economic reasons for such practices of socialization: It profits the markets, sells products. But as philosophers, we question such assumptions.
In order for ethics to exist the very possibility of an ethical judgment must exist at the objective level. In other words, ethical philosophers argue that there is a universal good accessible through human reason. This good may lack specific content—it does not tell you exactly what to do at any given circumstance. But it does provide a framework or justification for your belief or moral evaluation. Kant’s categorical imperative (CI) is an efficient example of such a content-free claim. An act is moral, Kant says, insofar as the agent can “universalize” the action. In short, would any and all future agents accept my action as moral, be willing to do as I am doing? If the answer is yes, then the act is moral; if, on the other hand, it is not universal then there must be something wrong with the act. As an example, the C.I. provides a framework for ethical evaluation but it does not tell you what to do.
To demonstrate and add to the universalist position of Kant’s C.I. you should know that it actually started life in China in the 6th century BCE! The great Chinese philosopher, Kung-fu-Tzu (Latinized as Confucius) articulated the “golden Rule” in his “Analects”:
“Tsekung asked, “Is there one word that can serve as a principle of conduct for life?” Confucius replied, “It is the word shu (恕) –reciprocity: Do not do to others what you do not want them to do to you” Analects 15.23
To further demonstrate its “universal” nature, this claim traveled into the mountains of central China and was adopted by the Taoists:
“Regard your neighbor’s gain as your gain, and your neighbor’s loss as your own loss.”
Tai Shang Kan Yin P’ien
Traveled over the Himalayas to India where it appears in the Mahabharata:
“This is the sum of duty; do naught onto others what you would not have them do unto you.”
Mahabharata 5
From there it was carried and spread via trade caravans to the Middle East, where it appeared in the foundational religion and philosophy of the Iranian thinker, Zarathustra, whose religion is called Zoroastrianism:
“That nature alone is good which refrains from doing to another whatsoever is not good for itself.”
Dadisten-I-dinik, 94,5
Centuries later it would be written down in the Jewish sacred texts known as the Talmud by Rabbis: “What is hateful to you, do not do to your fellowman. This is the entire Law; all the rest is commentary.”
(Shabbat 3). It will appear in the gospel of Mark Chapter 7, verse 1:
“”All things whatsoever ye would that men should do to you do ye so to them; for this is the law and the prophecy.”
And the prophet Mohammed would approve of it in the Hadith as an embodiment of the ethics of the holy Koran:
“No one of you is a believer until he desires for his brother that which he desires for himself.”
40 Hadith
Quite remarkably, Plato and Aristotle, the great seminal thinkers of Western philosophy, used it and it would appear in The Egyptian Book of the Dead and the teachings of the Shawnee people. Even the Yoruba people of Kenya, Benin and Mali who practice FGM have a saying: “If one is going to take a pointed stick to pinch a baby bird, one should first try it on himself to feel how it hurts.” So from Confucius to Kant to the Yoruba, the world’s religions, many of its philosophies and most of its cultures accept the basic logic of the “golden rule” clearly and cogently demonstrating it as a universal moral practice or good. Yet, because moral education and philosophy is sparingly taught and religion is on the wan in the West, most well-educated people will maintain a logical absurdity and claim still that there is no such thing as a universal moral good.

Phronesis or Pragmatic Wisdom

Posted in Uncategorized on May 18, 2012 by pstanden

An important component to Aristotle’s virtue ethics is the concept of Phrönesis. In book VI of the Nichomachean Ethics, Aristotle’s presents two concepts of wisdom, sophia and phronesis. Sophia is generally translated as wisdom or knowledge and is typically meant to encapsulate the data produced by mathematical and scientific inquiry; whereas, phrönesis is imbued with the further distinction namely the ability to judge between competing choices. It requires, according to Aristotle, a degree of life experience or maturity to correctly judge. He says,
“Whereas young people become accomplished in geometry and mathematics, and wise within these limits, prudent young people do not seem to be found. The reason is that prudence is concerned with particulars as well as universals, and particulars become known from experience, but a young person lacks experience, since some length of time is needed to produce it.” (Nichomachean Ethics 1142a)

This has led most commentators to define phrönesis as a kind of prudence. I would suggest that since Aristotle considers it a species of wisdom that the better translation is “pragmatic wisdom.” I have in mind the kind of wisdom that comes with a life long lived or at least one where one has managed to get the most out of one’s life. To this end, my choice is echoed by Thoreau when he defines a philosopher along eminently practical lines in the chapter on economy on Walden where he says,
“To be a philosopher is not merely to have subtle thoughts, according to its dictates, a life of simplicity, independence, magnanimity, and trust.” (Walden)
The question in becomes how one can profitably gain the kind of pragmatic wisdom from one’s experiences that leads to the development of one’s character and that will, in turn, allow you to judge correctly.

The Ethics of Relationships

Posted in Uncategorized on May 13, 2012 by pstanden

Healthcare is unique among modern professions in that the primary focus is care of the OTHER, the patient. It is an occupation built on a fiduciary relationship. “FIDES”, the Latin root of the word, means “trust”. As such a fiduciary relationship is one built on a sense of abiding trust and confidence that you are acting and making decisions in the best interests of your client, the patient. This trust is the foundation of the special relationships that exists between care-giver and client, between patient and healthcare provider. I would not say it is strictly altruistic, but it is built on a deep sense of acting selflessly.
The key relationship, then, between any healthcare professional and their patient is based upon the twin poles of trust and selflessness. Nevertheless, you are in the position of authority. The patient comes to or is referred to you for care. The patient is seeking your knowledge, skill or insight to allow them to heal, get better or relieve a stressor such as pain. As such, the patient in many cases is emotionally compromised. Because you are in a relationship that exists with this difference, then the relationship is one where special concern must be made by you. For example, you are or will be viewed as an authority in possession of what may be seen by many as a complex and arcane knowledge; this alone places extra duties on you to communicate therapies, policies, protocols, options and alternatives to the patient in clear, easily-understood and accurate language. Much will depend on your ability to accurately and concisely convey complex information to your patient. For example, the patient’s rights to know depend entirely on this aspect. This is one aspect among many that structure this unique set of relationships. Let’s turn to the constellations of issues grouped around the patient-provider relationship.

The set of issues around the patient-provider relationship have to do with the communication of knowledge and services, the delivery of quality treatment, the protection of client information, the ascertainment of permission and the safeguarding of the patient’s autonomy.
Medical ethicists group these issues into and under the following concepts:
Right to Know
But before we delve into a closer examination of each of these important topics, I would like to say a bit about professionalism in healthcare. In 2002, several professional medical societies gathered together to charter a set of “fundamental principles” concerned with maintaining and advancing professionalism in the delivery of health care. Leaders from the American Board of Internal Medicine (ABIM) The American College of Physicians and the European Federation of Internal Medicine sought to establish the primacy of patient autonomy and welfare and articulated the following ten “professional Commitments 1 :
• Professional competency
• Honesty
• Confidentiality
• Appropriate relationships with patients
• Improving quality of care
• Improving access to care
• Just distribution of finite resources
• Scientific knowledge
• Maintaining Trust/ managing conflicts of interest
• Professional responsibilities

What we see here is that the Physicians held certain concepts as central to their practice of good medicine and chief among these are the all-important set of relationships between patient and physician. We may rightly extend these to all areas of healthcare from the actual clinical practice to administration.
This echoes the millennia-long tradition enshrined in the Hippocratic Oath (see PPT) that begins with patient care and introduces such important concepts as confidentiality.
In the United States, patient information is viewed as privileged and protected information and is covered by privacy regulations. It is the cornerstone of healthcare because so much depends on a person’s willingness to share and disclose behaviors, symptoms and lifestyle choices to the healthcare provide. This candid sharing of personal information allows that provider to make the correct assessment of the patient’s condition and if a person feels that their personal information will not be kept secret, they are likely to not be candid. In the U.S. federal law further safeguards the widespread practice of keeping personal information private with the HIPPA regulations (Review HIPPA the U.S. Department of Health and Human Services webpage:
Consent is achieved when a patient or client is fully informed of and understands the implications of, a diagnosis, treatment, costs, side-effects, and short- and long-term consequences of a procedure. In the U.S. a stronger version called INFORMED CONSENT is practiced. The standard of INFORMED CONSENT is what any reasonable patient would want to know about their treatment and what the particular patient needs to know.
As we will see some of the most flagrant violations of human rights have occurred in the history of medicine as a result of not seeking the patient’s consent.

Disclosure and Right to Know:
Closely related to consent are the two concepts of disclosure and right to know. A patient has a clear moral right to know the potential costs, outcomes and goods and harms of any medical treatment. Moreover, the professional has a duty to inform the patient. This may be viewed as a prima facie right so it follows that the healthcare provider has a corresponding moral duty to provide that information in a clear and accessible manner.

Case study:
Susan is a public assistance case worker and one of her clients, George, with whom she is working on a Medicaid claim has HIV. George does not have a phone but provides Susan with his sister’s number. Susan needs to contact George and calls the number. When she talks to his sister she asks how George is doing since she has not seen him since he was hospitalized with PCP pneumonia2. Did Susan violate George’s right to confidentiality?

Studying Medical Ethics

Posted in Uncategorized on May 13, 2012 by pstanden

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:




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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