Critical reasoning in
healthcare ethics
Maggie Barker MD MPhil FFPH
13th September 2014
What is an argument?
• An argument presents a conclusion –look
for words such as ‘so’, ‘therefore’, ‘should’
• Based on information or reasons - often
signalled by words such as ‘since’, ‘as’,
‘because’
• Prudential (practical) argument :‘If you want
x you should do y’
What is a moral argument?
• You should do y, regardless of your aims and
interests, because it is the right thing to
do.’
• A moral argument has a conclusion which
makes a moral claim
• Often expressed as recommendations using
‘should’ or ‘ought’
• ‘Should’, ‘ought’, ‘right’, ‘wrong’ are
evaluative terms
• Evaluative adjectives -‘cruel’, ‘admirable’ –
often used in moral statements: ‘
A moral argument
If there was a prenatal test for autism
would this be desirable? What would we
lose if children with autistic spectrum
disorder were eliminated from the
population? We should start debating this.
There is a test for Down’s syndrome and
that is legal and parents exercise their
right to choose terminations, but autism is
often linked with talent. It is a different
kind of condition.
Main conclusion
• We should start debating whether a
prenatal screening test for autism, with
selective termination of affected
pregnancies, would be desirable.
• This conclusion is arrived at through
analogy with Down’s screening, and
through two intermediate conclusions.
Step 1:Screening for Down’s syndrome
1st intermediate conclusion (and unstated assumption)
Children with Down’s syndrome are being eliminated
from the population
Because:
Reason 1:
• There is a [prenatal screening] test [with selective
termination of affected pregnancies] for Down’s
syndrome
Reason 2:
• This is legal
• Unstated assumption: And ethically acceptable
Reason 3:
• Parents exercise their right to choose terminations
Step 2: Extending screening to autism
2nd intermediate conclusion:
By contrast, if children with autistic spectrum disorder
were also eliminated from the population through
prenatal screening, we would lose something [“talent”].
Because
Unstated reason 4 (explanation by analogy):
• Autism might seem to be like Down’s syndrome and
could equally be the target for prenatal screening.
Parents would opt for terminations, as they do for
Down’s syndrome, so children with autistic spectrum
disorder would be eliminated from the population.
Reason 5:
• But autism is often linked with talent, so it is different.
• Unstated assumptions: Down’s syndrome is not
associated with talent. We lose nothing through
eliminating people with Down’s syndrome.
Facts and values
• ‘Good’ doctor example (10) leads us to the
importance of distinguishing between medical
facts and moral evaluations.
• Factual statements: “blood pressure of 200/120
needs to be treated with drug x”. Evaluate using
techniques of ‘evidence-based-medicine’.
• Evaluative statements: “The situation is significant
enough to justify taking steps to persuade the
patient to take the medicine.” Here ‘significant’
meaning it matters – incorporates values.
Fact/value distinction and the truth of
reasons
• Factual statements can be true or false
• Can evaluative (moral or aesthetic) statements be true or
false? Eg ‘The roses in my garden are beautiful’; ‘Lying
to patients is wrong’
• Beauty is in the eye of the beholder. Is this the case for
moral judgements too? Are morals merely a matter of
personal taste?
– In reality we do seem to treat moral positions as if
they could be either true or false (eg when we try to
convince someone of our conclusion).
– Morals do seem to be based on reason as much as
feeling
– Where we use an evaluative adjective (like the cruel
treatment of the mouse in our example) - isn’t this
actually factual.
The is/ought gap
• Evaluative statements can be factual (cruel cat). But not all factual
statements are evaluative – they tell us what is the case not what
ought to be.
• Moral arguments have evaluative conclusions but their reasons can
be factual or evaluative.
• Arguments that move from non-evaluative reasons to evaluative
conclusions give rise to a worry called the ‘is/ought gap’. Pointed
out by David Hume (1711-76): many moral arguments start out be
talking about what is the case and end up talking about what ought
to be the case – but difficult to see how ought can follow from what
is: “No ought from is”.
– Passive smoking causes cancer. Therefore smoking in public
places should be banned. [a causes b therefore c(which can
result in a) should be d]
– Vivisection causes pain to animals. So vivisection is wrong. [a
causes b. So is c]
Role of emotion
Emotional responses and moral intuitions
need to be subjected to rational analysis.
The ‘yuk’ factor may be irrational.
Rational morality
1. Fair-mindedness
Appreciation of different peoples’ views and
various perspectives
2. Reflective equilibrium with dialogue.
3. Valid reasoning
Valid reasoning: Logically sound
Deductive argument is a series of statements
(premises) that lead logically to a conclusion
– Basic form: Syllogism (modus ponens)
Premise 1: If p then q
Premise 2: p
Conclusion q
Deductively valid argument – does not
necessarily mean that the reasons and
conclusion are true – but that the logic of the
argument is valid.
Valid reasoning: Logically sound
Valid reasoning: Logically sound
Invalid argument in form of syllogism
Premise 1: If p then q
Premise 2: Not p
False conclusion: Not q
Valid reasoning: Conceptual analysis
• Definition of key terms
• Elucidating key concepts
• Making distinctions
• Identifying similarities
Valid reasoning
• Reasoning from principles and theories
• Consistency and case comparison
Spotting ethical issues in clinical
situations
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Patient’s wishes are unclear, or patient refuses treatment
Questionable capacity to consent or to refuse treatment
Disagreement involving relatives
End-of-life issues (advance directive, “do not attempt
resuscitation” decisions, lasting power of attorney,
limitation of treatment etc)
Issue over goal of care or appropriateness of current
treatment
Confidentiality or disclosure issue
Resource or fairness issue
Other
No notable ethical issue
Sokol D 2009;BMJ:338:b879
Cases
The psychiatric home treatment team visit a man
in his 90s at the behest of his GP. He has had
several strokes and emergency admissions to
hospital. Following the strokes he is severely
disabled and can no longer transfer from bed to
chair or care for himself without assistance. He
has expressed the desire to commit suicide
recently and is refusing all medical and physical
care. The home treatment team find that he has
capacity to make decisions regarding his future.
How should this man be treated?
Cases
A woman in her twenties whose pregnancy is
almost at term is brought to the hospital
following a road traffic accident. She is a
Jehovah’s witness, and refuses all blood
products. She is diagnosed with bleeding into
her abdomen and into her uterus, but maintains
her refusal of blood. Her foetus dies in utero,
and she succumbs to her injuries soon after.
Should the emergency and obstetric teams have
respected her refusal of blood?
Cases
An elderly man who lives alone is admitted with
bowel obstruction. He is listed for an emergency
operation the following day, but refuses surgery,
stating that he has no reason to continue living.
Despite steadily deteriorating, he continues to
refuse an operation. Some members of the
surgical team feel that he ought to have an
operation in his own interests, and others think
his choice should be respected. What should be
done?