Approaches to Ethical Decision Making
Jillian Gardner
Steve Biko Centre for Bioethics
Jillian.Gardner@wits.ac.za
Tel: 011 7172719
Outcomes
Identify at least major three approaches to ethical decision making
Differentiate between at least three major approaches to ethical
decision making
Define the four principles of medical ethics and research
Resolve an ethical dilemma through the application of ethical theories
or principles.
Objectives of ethics
Two fundamental objectives of ethics:
(i)
Action guiding and
Action justifying
(ii)
‘The Jonesie Case’
Question: As Commandant, what do you do AND why?
What can you do…?
Ethical Theories and Principles
There are many rival/competing theories that expound different
conceptions of what is means to live morally, in other words that seek
to tell us how to act and why. These different ethical theories provide
different basic principles for deciding what is right and wrong, what
should be done and what should be avoided. All theories derive from
efforts to explain and justify moral decisions.
Ethical theories attempt to supply basic principles we can rely on in
making moral decisions. However, ethical decision making is almost
never a matter of automatically applying principles and generating an
answer.
Some reasons for why this may be so:
The right thing to do often depends on the facts of the case and
these may be difficult to ascertain.
The principles sometimes conflict with one another as well as with
other values or goals
Thus, even if we could decide which ethical theory is the correct one,
the application of that theory to specific practical issues will often be
indeterminate or controversial.
There is no consensus about the right ethical theory. No one ethical
theory tells the whole story. Rather, each represents a partial
contribution to an extraordinarily complex reality.
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Ethical Theories lecture notes & handouts
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So what’s the value of studying ethics if no one can say whether one
ethical theory is superior to another?
The purpose of studying ethics is not to discover which theory is
superior, rather different ethical theories provide insight into a range
of important considerations that should be taken into account in
ethical decision making.
Types on Normative Theories
Subjectivism – Simply put, subjectivism is the thesis that ethics is
inherently subjective and perhaps even merely emotional in content. If
true, then there are no obvious objective criteria for determining what
is ethical and what is not. Moreover, it suggests that there is no
objective right and wrong, and that ethical judgments are merely a
reflection of individual attitudes about what should and should not be
done. Two notable forms: Emotivism and, Relativism
By contrast, Objectivism is the thesis that ethical claims are either
true or false and that there are objective criteria for discerning the
truth of ethical claims. There are two dominant theories that purport
to provide an objective means for discerning what is ethical and what
is not. One is Teleological (Consequentialist) and the other is
Deontological.
Consequentialist Theories
• Teleology: Greek telos (end,
purpose)
• Defining feature of
consequentialist theories is
the weight given to
consequences in evaluating
the rightness and wrongness
of actions, rules, policies.
• In consequentialist theories
the consequences of an
action or rule generally
outweigh other
considerations.
• Consequentialist theories
thus judge rightness or
wrongness of actions, rules
or policies by the value of its
consequences.
• The morally right action is
one that produces the good
outcome, or consequence.
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•
•
•
Deontology
The word deontology derives
from the Greek words for
duty/obligation (deon) and
science (or study) of reason
(logos).
Deontology refers to an
approach to ethics that
focuses on the rightness or
wrongness of actions
themselves, as opposed to
the rightness or wrongness of
the consequences of those
actions. It thus stands in
contrast to consequentialist
and (aretaic) virtue theories
that — fundamentally, at
least — guide and assess
what kind of person (in terms
of character traits) we are
and should be.
Deontology is sometimes
Jillian Gardner
Feb 2008
•
Examples of consequentialist
theories: Ethical egoism and
altruism, Utilitarianism
•
•
•
•
•
described as "duty" or
"obligation" based ethics,
because deontologists believe
that ethical rules "bind you
to your duty".
Thus deontological theories
judge the morality of choices
by criteria different than the
states of affairs those choices
bring about.
They hold that some choices
cannot be justified by their
effects — that no matter how
morally good their
consequences, some choices
are morally forbidden.
For deontologists, what
makes a choice right is its
conformity with a moral
norm. Such norms are to be
simply obeyed by each moral
agent; such norm-keepings
are not to be maximized by
each agent.
Medical professional values
have historically been
deontological in their nature.
Examples of deontological
theories: Kant; Ross
Utilitarian Ethics
Utilitarianism is the most influential type of consequentialist theory. It
is the ethical doctrine that the moral worth of an action is solely
determined by its contribution to overall utility. Utility — the good to
be maximized — has been defined by various thinkers as happiness or
pleasure (versus suffering or pain), though preference utilitarians
define it as the satisfaction of preferences. Basically then utilitarianism
holds that the right action is the one that produces the most utility for
everyone and not the happiness of any particular person. As JS Mill
said: “each to count for one, no one for more than one" (impartiality).
Utilitarians thus treat all interests with equal weight. Right actions are
therefore those which produce the greatest utility for the greatest
number of people i.o.w. rights actions are those which maximize the
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aggregate welfare. So, actions are good or right only insofar as they
promote the greatest utility (good state of affairs) for the greatest
number. Utilitarianism is implicitly used in some healthcare planning
decisions, such as the use of Quality Adjusted Life Years (QALYs) and
is also implicitly inherent in the concept of triage, which at present is
seen by most as ethically justifiable only in extreme emergency
situations.
Note: There are several forms of Utilitarianism, including rule and act
utilitarianism.
Some problems with utilitarianism
Focus on consequences alone can lead to horrendous deeds, so long as
they promise the best consequences.
Rights objections
Self-defeating objection
Impossible to predict beyond any doubt which act will produce the
best or least harmful consequences.
The impossibility of interpersonal utility comparisons
Utilitarianism is too demanding
Kant’s Ethics
Kant's theory is an example of a deontological or duty-based ethics: it
judges morality by examining the nature of actions and the will of
agents rather than goals achieved. Consequences/outcomes are
irrelevant to the question of moral obligation for deontologists; what is
relevant is the nature of the action itself. So rules trump consequences
and certain types of action are wrong regardless of consequences.
Kant argued that reason enables us not only to think but also to act
morally and that all persons are equal with respect to their rationality.
So for Kant moral law is the principle of reason itself and we are
morally obligated to perform those actions that accord with our moral
duty.
Doing the right thing, for Kant involved acting out of good will i.e. a
will that aims for the good and is not merely the objection of desire and
inclination. Motives and intentions therefore matter in the moral
calculus – our actions must be driven by our intention to do what the
universal ethical law requires. For Kant right actions are those that
accord with a single moral obligation – what he called the Categorical
Imperative (contrast hypothetical imperatives). This maxim requires us
to act out of moral duty not merely in accord with moral duty. All other
obligations/duties are generated from the categorical imperative and
can be tested against it.
There are at least three formulations of the categorical imperative,
which Kant believed to be roughly equivalent:
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“Act only according to that maxim by which you can at the same
time will that it would become a universal law.”
“Act in such a way that you always treat humanity, whether in your
own person or in the person of any other never simply as a means,
but always at the same time as an end.”
“So act as though you were through your maxims a law-making
member of the kingdom of ends.”
Some problems with Kant’s Ethics
Demands one performs moral duty regardless of the consequences.
(absolute duties)
There is no consensus regarding a list of duties.
It is not clear which principles should take priority when rights and
duties conflict?
The Ethics of WD Ross
WD Ross combines duty and consequences: prima facie duties. He
argues (p19) that there are seven right making features of moral
action:
Duty of beneficence: A duty to help other people (increase pleasure,
improve character)
Duty of non-maleficence: A duty to avoid harming other people.
Duty of justice: A duty to ensure people get what they deserve.
Duty of self-improvement: A duty to improve ourselves.
Duty of reparation: A duty to recompense someone if you have acted
wrongly towards them.
Duty of gratitude: A duty to benefit people who have benefited us.
Duty of promise-keeping: A duty to act according to explicit and
implicit promises, including the implicit promise to tell the truth.
He called these prima facie duties, because when a person tries to
decide how to act, each of these duties need to be taken into
consideration when deciding which duty should be acted upon. When
more than one of these 'duties' applies to a person in some situation,
only one should be acted upon.
Virtue Ethics
"virtue" (arete) = excellence in fulfillment of a particular function.
Virtue ethics is broadly concerned with the following question: What
kind of person ought I to be? It aims to offer an account of the sort of
characteristics, traits or dispositions an ethical person possesses. The
theory holds that some intrinsic goods are agent relative, contrast
Kantianism and utilitarianism, where agents are neutral and actions
matter. Right being is emphasized over right action.
The central question that Aristotle asks: What is the good life?
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Answer: “The good life is that at which all humans aim.”According to
Aristotle, all human beings endeavour to flourish (eudaimonia i.e.
happiness or joy that pervades the good life). For him, happiness is an
activity of the soul in accordance with virtue, not simply pleasure:
“Virtue in a man will be the disposition which (a) makes him a good
man, and (b) enables him to perform his function well.” In order to
flourish one must live by what can be considered virtues. A virtuous
person is an ethical person.
Aristotle lists the following as moral virtues: courage, temperance
(moderation), liberality (moderation in giving and taking money),
magnificence (correctly dealing with great wealth or power), pride
(claiming what is due to you), gentleness (moderation with respect to
anger), agreeableness, truthfulness, and wit.
Plato and Aristotle believed that an individual learns to live virtuously
by putting into practice living a life of virtue. Moral virtues are thus
acquired through daily practice/exercise i.e. by acting virtuously until
the virtues become embedded in a person’s character and one’s
inclinations are to act virtuously on all occasions (become habit).
A person who has developed virtues will naturally be predisposed to
act in ways that are consistent with ethical principles. Knowing exactly
what is appropriate in a given situation is difficult and that is why we
need a long moral training.
Aristotle’s Mean
We may say about someone that they are for example “too
courageous”, “too generous”, or “too honest”…sometimes being “too
courageous/generous/honest can lead to bad ethical decisions.
Virtue is in between two vices and is generally considered as the
balance (MEAN) between as EXCESS and a DEFICIENCY.
DEFICIENCY_____MEAN______EXCESS
Cowardice
Courage
Foolhardiness
Stinginess
Generosity
Extravagance
Some problems with virtue ethics
Is virtue ethics action guiding? Does it help us decide how we should
go about deciding what to do?
There is no set of approved virtues so how would we know if one is (or
is not) being virtuous?
Assumes people can act and become virtuous through practice and
training.
NOTE: How you act (what you say, what you do and the manner in which
you say & do all are vitally important as a health care practitioner!). Even
today, Aristotle’s Virtue ethics has meaning. In the medical professions,
virtue plays a great role:
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Act better than ordinary citizens;
Exhibit ‘good character’;
Principlism
In this approach, principles are applied to particular cases or
situations in order to determine what is the right thing to do, taking
into account both rules and consequences. So, it uses ethical
principles as the basis for making moral decisions.
Principles of biomedical ethics:
Respect for autonomy
Beneficence
Non-maleficence
Justice
Respect for autonomy
Autonomy is derived from the Greek autos (self) and nomos (rule,
governance, law) – self determining/legislating
Moral responsibility is itself based on the assumption that moral
(rational) agents are free to determine their own actions and pursue
their own aims. Autonomy is therefore a precondition for moral
responsibility.
Virtually all theories of autonomy agree that two conditions are
essential for autonomy; however disagreement exists over the meaning
of these two conditions and over whether additional conditions are
needed.
Beneficence
Can be stated in various and different ways, but generally as: We
should act in ways that promote the welfare of other people. The duty of
beneficence i.e. positive obligation to do good, is inherent in the role of
the physician - act in patients best interests.
Non-maleficence
Captures what is widely considered to be an overriding duty of anyone
who undertakes the care of a patient. The principle can be formulated
in various ways but generally as: We ought to act in ways that do not
cause needless harm or injury to others. It is a negative obligation to
refrain from/avoid causing unnecessary harm.
Justice
The principle of justice emphasizes that physicians should act with
fairness. Sometimes this principle is expressed as the duty of
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physicians to treat patients in similar circumstances equally and to
use resources equitably.
Some problems with Principlism
No hierarchy of principles to resolve conflicts between competing
principles e.g. autonomy vs beneficence
No definite list of principles – proponents have suggested including
others e.g. utility
A principle points in the direction of an argument but is no substitute
for an argument.
Principles are prima facie and can be overridden by other
considerations e.g. justice.
WMA Step-by-Step Guide for Ethical Decision Making
1. Is there an ethical issue? What is it?
2. What do authoritative sources say?
3. What are the alternatives?
4. Discuss proposed solution with those whom it will affect
5. Make a decision (judgment & choice) and act on it, with sensitivity
to others affected
6. Evaluate the decision and be prepared to act differently in future
(www.wma.net)
Prescribed readings:
Udo Schuklenk. Bioethics: Philosophical Aspects
WMA Manual on Medical Ethics
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Ethical Theories lecture notes & handouts
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HANDOUT: ETHICAL THEORIES
o
o
Utilitarianism
John Stuart Mill
Jeremy Bentham
Peter Singer
o
o
o
o
P1 An action is right of it
promotes the best
consequences.
P2 The best consequences
are those in which happiness
is maximized.
Deontology
Immanuel Kant
WD Ross
Tom L Beauchamp &
James F Childress
Robert M Veatch
P1 An action is right if it is in
accordance with a moral rule
or principle.
P2 A moral rule is one that
1. Is laid on us by God OR
2. Is required by natural
law
3. Is laid on us by reason
OR
4. Is required by rationality
OR
5. Would command
universal acceptance
OR
6. Would be the object of
choice of all rational
beings.
o
o
Virtue Ethics
Aristotle
Slote
P1 An action is right if it is
what a virtuous agent would
do in the circumstances.
P2 A virtue is character trait a
human being needs to flourish
or live well.
Adapted from Hursthouse R. Virtue theory and abortion. Philosophy and Public Affairs 1991; 20:
223-246
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Comparison of Ethical Theories
Teleology
Goal
Premise
Deontology
Happiness, goal of action.
When moral outcome is
unclear, one must choose
action that provides best
predictability for good
outcomes.
A calculus of pleasures and
values justifies actions.
A good will.
A person acts morally
because he is required to
act as a person (underlies
the importance of one’s
duties and obligations).
A good will is one that acts
from duty.
Meaning of the good
Happiness is pleasure and
the avoidance of pain.
Norms
Utility: Act always to
maximize the benefit (good),
which is pleasure. This is an
absolute norm. Act always to
maximize the sum of
pleasure for all who will be
affected by one’s act (utility).
Strengths
It is outstanding for resolving
disputes between individuals
and groups.
Weaknesses
One cannot predict
outcomes in advance, thus it
is impossible to set the
standards of one’s moral
actions on the basis of the
act itself.
Acts are done from duty if
they are what reason
requires.
Categorical Imperative: Act
always as if what you will
do will become a universal
law and never treat
persons merely as means
only but always as ends in
themselves.
Norms are absolute.
Helps avoid the
rationalizations to which all
persons are prone; it
corrects for ‘unauthentic’
reasons for being moral.
Cannot provide for
resolution of conflicts
among two or more moral
persons who profoundly
disagree.
Means
Virtue Ethi
Happiness, all act
All human beings
inborn nature that
be good in moral a
but needs molding
direction.
The virtues reinfor
natural tendencies
happiness.
The good is happi
conceived as mes
the common good
Actions should co
the best human be
as evidenced by s
study of nature an
psychology. Norm
only generally and
absolutely.
Combines the stre
Teleology and De
“do good” and “av
is explicitly ground
community.
Is simplistic; does
provide sufficiently
action guides; is to
private, too prone
individual definitio
Thomasma DC. Military Medical Ethics, Vol 1. 2003; p33. (Adapted from Thomasma DC,
Marshall PA. Clinical Medical Ethics: Cases and Readings. New York: University Press
of America. 1995:10)
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Ethical Theories lecture notes & handouts
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