ETHICAL THEORY. Burkhardt - Chapter 2 - Ethical Theory

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1 ETHICAL THEORY Burkhardt - Chapter 2 - Ethical Theory MORALITY Personal morality: values and duties you have adopted as relevant - Customs, laws, rules, beliefs, family traditions - Impacts health professionals as patients have personal morality Societal morality - shared beliefs re values and duties - Culturally, ethically, class, or geographically generated - Relate to deeper religious and philosophic beliefs - Concern humans and relationship to God (gods) - US: all are created equal re life liberty and pursuit of happiness - Tensions between personal and society morality are common - Debates on health care issues - Abortion, physician-assisted suicide, etc. Group morality: subgroups of society - encompasses members of a group - Clubs, organization, church, etc. - Health care profession constitutes a group - Specific duties not applicable to society at large - Oaths, codes of ethics, standards professional practice - Hippocratic Oath - Educational institutes: honor codes - Institutional codes: - Controversy with Boy Scouts of America and homosexuality - Institutional bylaws th - Federal and state laws - e.g. prescriptive practice, 10 amendment - Conflicts may exist between personal and group morality Martin Luther: break from Catholicism - 95 objections Issues of abortion for some health care professionals ETHICS - systematic reflection on morality - Originally developed as parts of philosophy and theology - Ethicists, ethics committee - Moral judgement: process of making an assessment and arriving at a conclusion - Ethical issue: situation believed to have moral challenges - Ethical problem: - Situation with potential serious negative implications for moral values - Poses difficulty choices - Analysis: identify categories of issues and problems; delineate aspects of morality - Lying vs hurting by telling the truth - Galen: physician who fled Rome during Plaque - Resolution: use of ethical reflection to resolve conflict - may involve consensus building - Action: directed activity - party responsible serves as moral agent Outlined by Lois E Brenneman NPCEU 1

2 MORALITY - Ethics in Research - Social scientists most active - Cultural, religious implications - has impact to Western health care practices Principle of Material Cooperation: cooperation with wrong doing cannot be directly intended - The more remote the cooperation, the better - Cooperation easier to justify under the circumstances if wrongdoing would happen with or without one s personal cooperation - Benefit via the cooperation must greatly outweigh the wrong doing which will result - Even appearances can support wrongdoing Protection through Laws and Policies - State interests: common law comes into practice over time dictates there is a state interest (responsibility) to intervene under four circumstances - Save one s own life - Prevent one s suicide - Protect innocent third parties - Protect persons as the bearer of the integrity of the professions - Requests by patients - Behavior dictated by institutional policies - State Licencing Laws - Professionals become certified, registered or licenced with state or jurisdiction - Requires completion of formal professional preparation requirements - Laws delineate responsibilities and protections (rights) - Right to practice within dictates of judgement vs reasonable expectations of patients - Moral repugnance - Protects procedure only - does not justify refusal to care for patients whose lifestyle is morally repugnant (analogous to conscientious objector in war situation) - Examples: - Roe v Wade - clause which permitted exempting health care professionals who believed it morally wrong to participate - Lethal injection for capital punishment - Directed euthanasia - Institutional Policy Specific health care institutional policies may preclude certain actions - Gag clauses - Injunctions against promoting family planning info Outlined by Lois E Brenneman NPCEU 2

3 PHILOSOPHICAL BASIS FOR ETHICAL THEORY - opposing schools of thought Naturalism: Rationalism - View of moral judgement which regards ethics as dependent on human nature and psychology - Suggests that there is a basic congruence by nearly all people of similar underlying tendency - Allows judgement based on feelings - suggests people s judgements will be much alike - Accounts for cultural differences but speaks to underlying principles - Does not account for aberrant, selfish or cruel choices by rational individuals - Principle holds that collectively all people tend to make similar ethical decisions Desire for happiness, experience pleasure Avoid pain Sympathize with wishes of others Help persons in need - Sympathy is held as motivating factor in moral decision making - Feelings, perceptions of people differ not withstanding apparent similarities - Absolute truths exist independent of human nature - Ethical values have independent origin in nature of universe or nature of God - Principles become known to humans through process of reasoning - Belief in fundamental universal truths which are superior to information from senses - Moral codes are necessarily true; knowledge from senses are contingently true THEORIES OF ETHICS Utilitarianism - Sometimes called consequentialism - form of teleological theory (telos means end -Greek) - Moral theory holding that action is judged good or bad in relation to its consequences - Has basis in naturalism - The right action is that which has the greatest utility or usefulness - No action is inherently good or bad - only outcomes determine value of an action - Root in Roman philosopher Epicurus ( BC) - Pleasure good; pain evil - Pleasure gained by life of moderation, courage, justice and friendship - Deities dwell apart from human existence - humans control own destiny - Jeremy Bentham ( ) father of modern utilitarianism - Action deemed good as it increases happiness, diminishes misery - Action wrong when it has opposite effect - Proposed seven criteria to measure pleasure (vs pain) - Criticized as hedonistic (hedonistic utilitarianism) - He justified concept of pleasure as being synonymous with good, profit, advantage, benefit etc. - John Stuart Mill ( ) described utilitarianism in terms of measuring acts by end result - End justifies the means - Sacrifice good only as it increases total sum of happiness - Greatest happiness principle ; virtue is the manipulation of happiness - Disagreed with notion that ethics are edicts from God - Do unto others as you would have them do unto you Outlined by Lois E Brenneman NPCEU 3

4 Deontology Act utilitarianism - Allows for different sometimes opposing action in different situations - Example: truth is basically good but sometimes lies are justified if outcome better for everyone - Tenants are rough guidelines vs strict rules Rule utilitarianism - Persons should act according to rules that tend to maximize happiness and diminish unhappiness - Example: Truth to be told in all circumstances because overall good so maximized - Holds that while some benefit in individual circumstance may accrue from variance overall benefit is maximized by strict adherence to rules Problems with utilitarianism - Does not give sufficient thought to respect of persons - Harm can come to certain minority groups or individuals in name of greater good Benefits of utilitarianism - Simple precept in promoting happiness for as many people as possible - Useful in deciding distributive justice Rightness or wrongness of an act is function of nature of act not consequences Term comes from Greek work for duty Other terms for deontology: formalism or Kantian (Immanuel Kant) Kant: born 1724 wrote ground-breaking ethical theory Writings shook religious and political systems of the day Continues to influence contemporary ethical philosophy Rules are universal, humans derive certain consistent principles to guide action Awareness of rules is product of pure reason not experience per naturalists theory Moral rules are universal, apply to all people, for all times, in all situations Ethical rules could be known by rational humans Knowledge of right or wrong obtained via a maxim Kant called categorical imperative Categorical: refers to moral rules or imperatives Imperative: command that is derived from principle No action can be judged right which cannot reasonable become a universal law Universal law: that to which all persons can abide Examples: - Promises not universal law since exceptions to fulfilling can arise - Suicide, squandering of talent, helping others also not universal Kant proposes that each person use test of categorical imperative to guide action Practical imperative: Kant - Act so that you treat humanity, whether your own person or that of anther, always as an end and never as a means only. (Make another person s ends as your own) - Practical application of the principle - Domination of another person is morally wrong - Help another in need whenever possible - One must fulfil certain duties Outlined by Lois E Brenneman NPCEU 4

5 Realm of ends - each person a member of a politically organized society - Systematic union of rational beings through common objective laws (Kant) - System which allows for well being of each member - All people equal and competent to make universally legislative decisions - Ethics of democracy Ethics derived from one s fulfilling of duties - imperatives of duty - One must act for sake of obligation - Derived from categorical imperative (act such that one s own actions could become universal law) - Practical imperative (treat all people as ends not as means to an end) - Action stemming from duty has its own moral worth not in results but in principle of acting out of reverence for the law and doing one s duty - Most professional codes of ethics based on Kantian principles Problems: Kantianism is without exception and rigid - Does not assist in choosing among conflicting alternatives or principles - Automatic disregard for consequences of action can occasionally lead to disaster Virtue ethics a.k.a. character ethics: Individual actions based in innate moral virtue - First noted in writings of Homer and later in Plate, Aristotle and early Christian thinkers - Western morality has emerged with cardinal virtues Wisdom, courage, temperance, justice, generosity, faith, hope, charity - Modern writers have included others Honest, compassion, caring, responsibility, integrity, discernment, trustworthiness, prudence - Absent in nursing ethics texts for over 20 years - Reemerging as important framework for evaluating moral behavir - Aristotle s ( B.C.) perspective - Character goodness function of practice of virtuous behavior * * In contrast with virtuous acts being end result of good character - Virtues are tendencies to act, feel and judge developed from proper training - Believed virtue can be learned and improved Practice creates habit of acting virtuously - clear judgement, self-control, symmetry of desire, artistry of means - Virtue was considered result of intelligent pursuit achievement of experience in the full developed (person) - Excellence comes from training and habituation - virtuosity comes from practice - Criteria for virtuous character 1. Virtuous acts chosen for their own sake 2. Choice proceeds from firm and unchangeable character 3. Virtue is disposition to choose the mean * * Golden mean per Aristotle means practicing moderation Avoid both excess and deficiency - Does not list moral principles - Morality defined what should one be vs what should one do Outlined by Lois E Brenneman NPCEU 5

6 Focal Virtues - Phillipa Foot (1993) adds perspective of will to Aristotle s concept - That which is wished for as well as that which is sought - Individual s virtue judged also by innermost desires...and intentions - Virtues (example generosity) lies as much in attitudes as actions - Virtue must engage the will; it is not jsut art or skill to be practiced - Apparently good act is not considered virtuous if intention is not good - Comparison to Aristotle - Aristotle - virtue is one of hope (all have capacity to learn) - Foot: virtuous character less easily accessed - Beauchamp and Childress (1994) relate virtue to biomedical ethics - Character: comprised of a set of stable traits which affect person s judgement and action - Espouse that all have capacity to cultivate or learn moral behavior (like Aristotle s views) - Propose four focal virtues said to be more pivotal than others - Pivotal virtues: compassion, discernment, trustworthiness, integrity Compassion: ability to imagine oneself in situation of another - Attitude of active regard for another s welfare - Imaginative awareness and emotional response of deep sympathy, tenderness and discomfort at another person s misfortune - Embodies internalizing golden rule - Patient s need for compassion may outweigh need for technical care - Caution: compassion must not be allowed to impede objective decisions Discernment - related to classic meaning of wisdom - Sensitive insight involving acute judgement and understanding - Results in decisive action - Enables insight into determining appropriate actions for given situation - Requires sensitivity and attention to demands of a particular context - Ability to make critical distinctions within a given situation - Requires that individual strive to recognize important nuances in human behavior Trustworthiness - confident belief in and reliance upon ability and moral character of another - Belief than another will act with right motives in accord with moral norms - Measured by consistency and predictability in following moral norms - Accounts for reputation one has among co-workers - Important implication in both professional and personal relationships with others Integrity: has been called cardinal virtue - Connotes soundness, reliability, wholeness and integration of moral character - Fidelity in adherence to moral norms sustained over time - Consistency in conviction, actions and emotions; trustworthiness - Compromised by inconsistent behavior or actions unfounded in moral beliefs - Common deficiency vices: hypocrisy, insincerity, bad faith Outlined by Lois E Brenneman NPCEU 6

24.02 Moral Problems and the Good Life

MIT OpenCourseWare http://ocw.mit.edu 24.02 Moral Problems and the Good Life Fall 2008 For information about citing these materials or our Terms of Use, visit: http://ocw.mit.edu/terms. Three Moral Theories