Ethical Reasoning
&
Contemporary Medical
Ethics 2
Lecture 4
28th October 2009
Dr. Ruth Pilkington
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
Respect for Patient Autonomy
Autonomy literally means ‘self-rule’ or ‘selfgovernance’.
An individual’s capacity to make decisions about
their health care needs and to consent to or
refuse treatment depends on their ability to think,
decide and act, freely, on the basis of such
thought and decision.
Two essential conditions for autonomy:
Liberty
Agency
Respect for Patient Autonomy
‘The autonomous individual acts freely in
accordance with a self chosen plan,...A
person with diminished autonomy, by
contrast, is in some respect controlled by
others or incapable of deliberating or
acting on the basis of his or her desires
and plans’, (Beauchamp & Childress (2001))
c.f.
Those with diminished autonomy e.g. prisoners,
learning disabled persons, patient with
Respect for Patient Autonomy
Look at Autonomous Choice rather than Generally
Autonomous Capacity, i.e. a generally
autonomous person may not be able to act
autonomously in certain situations.
Respect for patient autonomy requires doctors (+
family) to help patients make their own decisions
and to respect those decisions (irrespective of
whether one believes those decisions to be
wrong).
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
Non-Maleficence
We should avoid doing harming to others.
‘Primum non nocere’ – [trans. first (or above all) do
no harm] – this would make medicine a very
difficult pursuit!
It is an extremely important principle to avoid
harming others, but cannot take priority and be
expressed as an absolute principle. Must be
considered in the context of the obligation in
medicine of the principle to do good for our
patients (beneficence), e.g cancer surgery.
Also balance required with the principles of
autonomy and justice, e.g. involuntary isolation.
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
Beneficence
The obligation to do good / promote what is
best for the patient.
Sometimes conflict may arise between
doctor's judgement of what is in the
patient’s best interests and his desire to
respect the patient’s different but
autonomous decision.
Must be balanced with the principles of
respect for autonomy, non-maleficence
and justice (e.g.. rights and needs of
others).
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
Justice
Distributive Justice: Decisions re the allocation of scarce
health resources (e.g. outpatient time, drugs, money,
ICU beds,...)
Patients in similar situations (e.g same diseases) should
normally have access to the same health care (e.g.
same diagnostic technologies/pharmaceutical
interventions).
But attempt to distribute our limited resources fairly, so that
in providing for some, others are not left wanting.
Justice also applies to Forensic Medicine (psychiatrists
assessment of sanity for court), Employment Justice (fair
promotion in the workplace), Prohibition of involvement
in Torture (Declaration of Tokyo), etc.
Distributive Justice
Health Resource Allocation
Justice requires that like cases be treated
alike and that the benefits and burdens of
health services be allocated equitably
across patients.
However what criteria?
Clinical factors, patient values, system
goals...
Justice
No consensus moral theory to help resolve
differences between conflicting values,
However
the goal
is
Fairness.
Strict Egalitarianism
Advocates the allocation of equal material
goods (healthcare resources)
to all members of society.
John B. Rawls
(1921-2002)
‘Justice as Fairness’
envisions a society of free citizens holding
equal basic rights cooperating within an
egalitarian economic system.
Rawls : Needs Theory
Rawls rejected utilitarian approaches to
maximizing total welfare and libertarian
‘free for all’.
Believed in a theory of social justice.
Rawls : Needs Theory
‘The Difference Principle’
Some patients have a special claim on
resources that rests not on the
maximization of overall welfare but on the
greater need for treatment.
The Veil Of Ignorance (Rawls)
Imagine self in an ethereal place looking
down on a world of different societies,
each distributing wealth in different ways.
You must choose which society you will
belong to, not knowing what position,
gender, attributes (e.g. personality, IQ),
etc. you will have.
The Veil Of Ignorance (Rawls)
Rawls :
What society would a rational person
choose?
The ‘Difference Principle’
1
The rational person would choose a society
where the worst-off are maximally well off,
i.e. the idea that justice is best achieved
by the worst off groups being maximally
well off.
The intuitive idea is that the social order is
not to establish and secure the more
attractive prospects of those better off
unless doing so is to the advantage of
as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)
those less fortunate.’ (Rawls, 1972)1
The ‘Difference Principle’
However is need or maximizing the welfare of the
worst off the only value?
With other values, should need be given priority?
If one adheres strictly to the idea of need, scarce
resources of a society might be used to provide
minimal help to the few very badly off rather than
much help to many.
Perhaps giving the moderately badly off those
limited resources for more net benefit would be
more equitable?
1
as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)
Ethical Reasoning
In Practice
Use
complementary
ways of
reasoning
Ethical
Reasoning
Tools
Ethical
Problem
Additionally
Judgement
is required
Reflective Equilibrium
Rawls (1921-2002)
‘Reflective equilibrium’ (Rawls, 1972) Reasoning about morality requires a
continual moving between our moral
responses to specific situations and our
moral theories, i.e. our beliefs about what
is right in various individual situations, to
achieve an equilibrium.
Method of Reflective Equilibrium
In Practice
Moral
Theories
Case
Ethical
Reasoning
Ethical
Problem
One’s
Moral
Judgements
Additionally
Judgement
is required
Revision to gain coherence
Rational Dialogue
Aim to achieve reflective equilibrium by
discussion with others, particularly helpful
to achieving convergence and consensus.
Rational Dialogue
Helps to:
1. identify inconsistencies between our
moral views in one situation and another;
and between our theories and our
intuitions
2. ensure we are aware of the perspectives
of different moral theories.
3. ensure we are aware of the perspectives
of different people – and in the medical
setting, this can be particularly important.
‘Med. Ethics and Law – The core curriculum’, Hope,Savulescu, Hendrick, 2008)
The Role of Emotion
Learning the role of emotion (? moral
intuition) and how to assimilate it into our
reasoning.
Intuitively we may arrive at a place we do
not feel comfortable with morally and we
may need to challenge and readjust our
reasoning, to bring our intuitions and
theories into line.
The Role of Emotion
As doctors, our emotional responses need
to be subject to rational analysis.
Feelings of revulsion, pity or fear are not
helpful when trying to decide how best to
help others.
And may lead us to make incorrect
decisions.
The Role of Emotion
Nonetheless, our emotional responses of
humanity, compassion and caring for our
patients are essential components of our
medical work.
Without this sensitivity we may lack
judgement and sacrifice basic ethical
principles of autonomy, beneficence, nonmaleficence and justice.
The Role of Emotion
Integration of emotions with the decisional
factors of the process of retrospective
thinking
Reflective Equilibrium
In Practice
Case
Ethical
Reasoning
One’s
Moral
Judgements
Moral
Theories
Ethical
Problem
One’s
Emotions
Additionally
Judgement
is required
Revision to gain coherence
The Slippery Slope Argument
Runs as follows:
If we allow society to take a certain step or
allow a certain procedure now, the fear is
expressed that this would lead
(unavoidably, down the slippery slope) to
some point in the future, where some
further development of or progression from
that initial decision, not morally
permissible, would come about.
The Slippery Slope Argument
Example:
Banning effective contraception because we fear
that to practise population control is to step on to
a slope that leads inexorably to the extinction of
the human race.1
1 John Harris, The Value of Life
The Slippery Slope Argument
Example:
An opponent of voluntary active euthanasia (VAE)
might argue that allowing such a practice would
lead to non-voluntary euthanasia,
such as the killing of all people over 80 years of
age, etc.
The Slippery Slope
‘The Principle Of The Dangerous Precedent’
[F.M.Cornford (1908)] 1
‘... is that you should not now do an admittedly
right action for fear you, or your equally timid
successors, should not have the courage to do
right in some future case, which ex hypothesi is
essentially different, but superficially resembles
the present one. Every public action which is not
customary, either is wrong, or, if it is right, is a
dangerous precedent. It follows that nothing
should ever be done for the first time.’
1
As quoted in J. Harris, The Value of Life (1985) p. 127
The Slippery Slope Argument
We would be both irrational and immoral if
we cut ourselves off from options that we
clearly perceive to be the beneficial
products of the procedures now being
developed because we fear that we will be
insufficiently resolute to resist the
dangers.1
1 John Harris, The Value of Life, p.127
Feminist Ethics
Feminist ethics
based on feminist belief system that:
1. Gender Inequality exists
2. It is unjust
3. Social and political actions can help correct
existing inequities
Feminist Ethics
Hence an approach to ethics that places a very
high priority on exploring and addressing
questions of social justice, particularly gender
injustice.
Belief that gender and other forms of injustice
(race, disability, socioeconomic class, age,
sexual orientation) have been largely invisible
in the work of mainstream ethical theorists.
Challenging gender assumptions, race
assumptions, age assumptions, etc.
Feminist Ethics
Traditional Ethics
Focuses on the Male : i.e. questions and
methods regarding interactions in the
public sphere
Ignores the Female: i.e. questions and
methods pertaining to the private sphere
of families and communities
Feminist Ethics
1. Liberal Feminism
2. Ethics of Care
3. Oppression Theorists
4. Continental & Post Modern Feminists
Feminist Ethics
Affirms the general right of women to control
their own bodies and lives.
Aims to redress the balance of power
between the sexes and to put them on
equal terms.
Incorporates both men and women in its
model of care. The concept of the moral
agent being relational rather than
independent.
c.f. Roe vs. Wade (1973) US
Ethics of Care
Resists the concept of gender equality
Moral Reasoning : Women vs. Men (Gilligan,
1982)
1. Women have tendency to concentrate on
narratives, contexts, and relationships of care,
i.e. interpersonal relationships and human
connectedness.
2. Men tend to emphasize ‘an ethics of justice’,
involving tiers of general moral principles and
employing a logic of hierarchical justification
Ethics of Care
Moral Reasoning : (Gilligan, 1982)
A competent moral agent should be capable of
both approaches, i.e.
an ethics of care and an ethics of justice approach
Ethics of Care
Similar to Virtue ethics
‘What would the caring person do’?
Nurturing Values such as Care, Love, Trust,
Responsibility are virtues
A question of responsibility to those who are
dependent on others;
The moral importance in preserving
relationships
Ethics of Care
Joan Tronto (1994) : Questions regarding the
responsibility for attending to the human needs
among us should be central to our thinking in
ethics.
4 phases of Caring:
Attentiveness (Recognising Need of Care)
Responsibility (Taking Care of)
Competence (Care giving)
Responsiveness (Evaluating Care Received)
Particularly welcomed in Nursing profession where the
needs of individual patients are central
Contemporary Virtue Ethics
Aristotle – a virtue is the mean between excess and
deficiency,
e.g. Courage mean between Cowardice and
Foolhardiness.
Resurgence in modern ethics since, ‘[t]he bankruptcy of
modern moral philosophy.’ 1
The Qualities of A Good Doctor, e.g. compassionate,
humane, courteous, hard-working
The Qualities of A Good Patient, e.g. self-control,
moderation, reasonable expectations
1 Anscombe,
E, MacIntyre, A, as quoted in Glannon, W. ‘Biomedical Ethics’ OUP(2005)
Contemporary Virtue Ethics
Contemporary focus on the action
An Action is right if and only if it is what an agent
with a virtuous character would do in the
circumstances.
Keep a death bed promise : virtue of justice
Save a wounded stranger by a roadside : virtue
of benevolence
Contemporary Virtue Ethics
Aristotle
‘It is not merely the state in accordance with the
right rule, but the state that implies the presence
of the right rule, that is virtue.’
i.e.
Acting as someone with the virtue of benevolence
would act not only involves providing assistance
to another but also includes having and acting
from a genuine concern for the well-being of that
person and a disposition to have and act from
that concern in particular types of situations.
Strong connection between Motive & Rightness
has a considerable intuitive plausibility
Communitarianism
Aristotle – ‘humans are essentially social beings’.
A reaction to the modern focus on individual rights
and freedoms.
Emphasis on an individual’s responsibilities to their
community and also the responsibility of that
community for the welfare of the vulnerable
therein.
Public pursuit of the common good may take
precedence over an individual’s personal
objectives.
e.g participation in research ‘is a moral duty’ (see