Ethical Issues in Dentistry:
Introduction
I. Introduction to Moral theory.
A. Basic Concepts and Problems.
1. Morality and ethical theory
Morality: A social institution,
concerned with social practices
defining right and wrong. It’s
composed of a set of standards which
is pervasively acknowledged by a
culture or a people.
Ethical Theory: an activity in which
one engages in reflection on the nature
and justification of right actions.
2. Morality and Prudence
Prudence: Self interest (don’t touch
the stove, brush your teeth—not moral
rules)
Morality: Is not reducible to
prudence. Prudence is self-interest
whereas morality extends to others.
Prudence and morality may coincide,
but that which is prudent may not be
moral, and that which is moral may
not be prudent.
3. The Rule of Conscience
Let your conscience be your guide.
Certainly, conscience is not the end all
and be all of morality. People’s
consciences will tell them very
different things in very similar
circumstances. Yet, should you ever do
what your conscience tells you is the
wrong thing? Ethicists disagree.
4. The Common Morality
Those of us who are committed to
morality share a set of norms, even
though these norms may be very
general. We all agree at least that any
of the norms that we hold apply to all
people, or to all who are members of
the moral community. We cannot
arbitrarily exclude any of those we
may not like, or who may not like us.
The common morality applies to
everyone.
The basics of common morality are
best expressed, perhaps, in the three
basic factors of morals: the good, the
right, and the virtuous. The first
factor contemplates ends or outcomes;
the second with duties and obligations,
the third with character formation.
5. Moral dilemmas and
suggestions for solving moral
disagreements
Genuine moral dilemmas are real and
difficult. The Tarasoff case (p. 45-49)
is a good example. It’s a moral
dilemma because there are very good
reasons for mutually exclusive
alternatives. If one set of reasons is
acted upon, events will result that are
desirable in some respects but
undesirable in others.
Resolving moral disagreements:
a. Obtain objective information
b. Provide definitional clarity
c. Adopt a code
d. Use examples and counter-examples
e. Analyze arguments
6. The Problem of Relativism
Cultural Relativism: Cultures vary in
the values that they hold. That is,
values are relative to a culture.
Distinction: Between a relativity of
judgment and a relativity of
standards. We clearly have the
former, but does the latter hold?
Cultural Normative Relativism: What
is thought to be right in one culture is
really right for that culture, regardless
of what another culture thinks about
it.
Individual Normative Relativism:
What is thought to be right for one
individual is really right for that
individual, regardless of what another
individual thinks about it.
Criticisms of both views:
7. Moral Diversity and Moral
Disagreement
Why do we disagree, morally
speaking?
a. Factual disagreements (for
example, over the benefits of a
particular procedure)
b. Scope disagreements about who
should be protected by a moral
norm (what degree of autonomy
for children?)
c.Disagreements about which values
are relevant to a particular moral
dilemma
d. Disagreements about
appropriate specifications
e.Disagreements about the weights of
conflicting norms
f. Disagreements about balancing
norms
g. The presence of a genuine
moral dilemma
h. Insufficient information or
evidence (very common!!)
B. Normative Ethical Theory
First, a distinction: All ethical theories
can be classed as one of two kinds:
teleological (consequentialist) or
deontological. The former says that
the morality of an action is completely
determined by its consequences. The
latter says, no, they’re not; there are
other relevant considerations.
1. The importance and role of
professional standards: Are they
sufficient?
2. Utilitarianism
a.
basic concepts:
i) The principle of utility:
Maximize the good. We ought
to act in such a way as to
maximize value over disvalue.
ii) The Standard of Good. Since
morality consists in maximizing
the good, we must describe what
we mean by good. John Stuart
Mill is a hedonist. His version of
the Principle of Utility, which he
calls the Greatest Happiness
Principle: Actions are right in
proportion as they promote
happiness and wrong as they
produce the reverse of
happiness. By happiness is
intended pleasure and the
absence of pain. Other
utilitarians will have different
theories of good: e.g.,
satisfaction of desires,
satisfaction of preferences, or
some plurality of goods.
Further, utilitarians also hold
that goods are quantifiable.
That is, goods are measurable
and comparable.
iii) The principle implies
consequentialism (the morality
of an action is completely
determined by its consequences)
iv) and
impartiality/universalism
(everyone matters equally).
b. Act and rule utilitarianism:
According to act utilitarianism, every
deliberation requires that we calculate
the consequences by appealing to the
principle of utility. Rule utilitarianism
says that we appeal first to relevant
secondary principles (don’t lie, don’t
steal, etc). The principle of utility
justifies these principles and it settles
conflicts between them.
c. Problems with utilitarianism: 1)
Problems accounting for the dignity of
the individual (The patient in room
605). 2) The real difficulty in
quantifying pleasures or even goods of
any kind. 3) The difficulty of the
distinction between act and rule
utilitarianism.
3. Kant and deontology
a. basic concepts
Kant puts forth a Supreme Principle
of Morality, which he calls The
Categorical Imperative. It’s a
Categorical Imperative as opposed to
a Hypothetical Imperative.
Motives are very important for Kant.
You must not only do what you believe
is right, but you must do so for the
right reason, that is, you act from the
motive of duty. For Kant, good actions
only follow from a good will, and a
good will is the ONLY thing in the
universe that is good in and of itself.
Every other good is corruptible and is
only instrumentally good. But, from a
good will only flows good actions. The
motive for the action comes from an
appeal to a universal rule. In order to
determine our duty, Kant supplies us
with the Categorical Imperative, his
Supreme Principle of Morality:
The first version:
i) The Categorical Imperative:
Always act in such a way that
you can at the same time will
that the maxim of your action
to be a universal law of
nature. In other words, Don’t
make exceptions for yourself!
The second version:
ii) The Categorical Imperative:
Always treat humanity,
whether in the person of
yourself or another, always as
an end in themselves, and
never as a means only. In
other words, don’t use people!
b. Problems with Kantian
deontology: 1) Seems to ignore
the importance of consequences.
Can they be so unimportant? 2)
Leaves little room for virtue. One
can be a perfect Kantian and be
sorely lacking in virtues, such as
compassion.
4. Virtue ethics: Descends from
the classical Hellenistic tradition
represented by Plato and Aristotle.
Here, the exclusive emphasis on duty,
obligation, and rules is misguided.
Instead of looking at rules of
obligation, we should be focusing on
making good people, cultivating
people of good character. Moral
virtues are understood as morally
praiseworthy character traits, such as
courage, compassion, sincerity,
reliability, etc. The focus is on the
ideal person, while action is of
secondary importance. Acquiring
virtues is much like acquiring other
skills, such as cooking and carpentry.
You become just by behaving justly.
However, virtue ethics is more than
purely habitual training. One must
also have a correct motivational
structure. Thus, a person who is
compassionate, not only has a
disposition to act compassionately, but
a morally appropriate desire to be
such.
Consider a dentist who meets
moral obligations but hates her job,
etc. We need virtue to fill out the
morally ideal person.
5. Care ethics
a) The impartiality of traditional
moral theory (esp. Kant and Mill) are
inadequate guides to action. Abstract
formulations take us away from the
concrete situation and from the
relevant social and historical facts
which characterize that situation.
b) Impartiality undermines respect for
the individual because it treats
individuals impersonally, as
interchangeable moral agents without
any uniqueness. In many situations,
impartiality is a vice, not a virtue.
c) Kantian and utilitarian impartiality
leave little room for virtues--empathy,
compassion, love, etc.
d) Rather than focusing on
individuals, care ethics focuses on
relationships. They totally reject the
idea that ethics is based on our being
autonomous agents who make our
choices in a free and equal manner.
Their rethinking claims that social
cooperation (and ethics) are unchosen,
intimate, and among unequals.
Traditional models fail to see this.
e) We need a change of metaphor.
Many traditional metaphors have
been war and sports oriented. The
shift to family metaphors would make
a significant difference.
C. Ethical Principles—distinction
between rules and principles.
Basically, rules tell us specifically what
to do or what not to do. Principles
offer guidelines for how to make
decisions.
1. Autonomy—based in Kant.
Refers to basic self-governance.
For many, the most fundamental
principle of any medical ethics
2. Beneficence—above all, do no
harm
William Frankena’s description of
beneficence:
a. One ought not to inflict evil or harm
(nonmaleficence)
b. One ought to prevent evil or harm.
c. One ought to remove evil or harm.
d. One ought to do or promote good.
3. Justice:
Distributive Justice deals with the
question: how ought the goods and
responsibilities of society be
distributed among its members? In
other words, what is fair?
Formal Principle: Treat equals
equally
Material principles have been
proposed. Here is a good list:
a. to each person an equal share
b. to each person according to
individual need
c. to each person according to
acquisition in the free market
d. to each person according to
individual effort/performance
e. to each person according to societal
contribution
f. to each person according to merit
Utilitarian theory: seeks to maximize
overall value with little (or no)
emphasis on the individual. Any
arrangement that maximizes overall
good is acceptable.
Egalitarianism: less tolerant of
inequalities. In the above list, (a) is
radical egalitarianism. A more
mitigated one would accept
inequalities only in so far as those
inequalities contribute to everyone’s
advantage.
Libertarians (generally c and d above)
tend to value economic autonomy over
any sort of equality. As long as we play
by the rules and don’t cheat, any
economic distribution is fine, even if it
is radically unequal.
Some Concluding Notions:
*Our principles can and do
conflict. How do we resolve such
conflicts? One proposal by W. D.
Ross is promising.
Grounded in the Common
Morality, obligations arise simply
because we live together and
interact. They are not grounded in
Kant or Mill, or rights. Examples
of such obligations: “Promises
create obligations of fidelity;”
“Wrongful actions create
obligations of reparation.”
Prima facie nature of
principles: A prima facie duty is one
that is always to be acted upon
unless it conflicts on a particular
occasion with an equal or stronger
duty. It is conditional, then, on not
being overridden by a stronger
duty.
*Morality and Law—Law and
Morality are NOT identical!
*Legal and Moral rights
Legal Rights: sanctioned by law
Moral Rights: held regardless of law
Negative rights: rights of noninterference
Positive rights: a right to be provided
with some good
*Law, Authority, and
Autonomy
Liberty limiting principles:
a. The Harm Principle: A person’s
liberty is justifiably restricted only to
prevent harm to others caused by that
person.
b. The Principle of Paternalism: A
person’s liberty is justifiably restricted
to prevent harm to self caused by that
person.
c. The Principle of Legal Moralism: A
person’s liberty is justifiably restricted
to prevent that person’s immoral
behavior.
d. The Offense Principle: A person’s
liberty is justifiably restricted to
prevent offense to others by that
person.
*Remark on case studies and
ethical theory
*The domain of ethics