16RC1 Cahana Medical professionalism: Where does it come from? A review of different moral theories Alex Cahana Department of Anaesthesiology and Pain Medicine, Department Bioethics & Humanities University of Washington School of Medicine, Seattle, Washington, USA Philosophy must be understood backward but lived forward (Kierkegaard 1846, 1992, vol 2:187) Introduction This is an article about ethics. It is about making the right choice in various situations where our moral intuition does not always provide adequate and coherent guidance. You should treat others as you would like to be treated is an old and often useful saying; it allows us to tell moral right from wrong in many circumstances (e.g. preserve life and relieve pain in end-of-life care), but sometimes an act may be simultaneously morally right and wrong (e.g. abortion). So how can we really tell moral right from wrong? In order to answer this and subsequently behave professionaly and perform good choices, a theoretical and systematic understanding of our moral life is necessary. Intuition simply does not suffice. If ethical theory provides consistency and rationality necessary for our moral judgment, a philosophical reflection on our moral life through the search of values and norms is needed. In these day-to-day dilemmas, choosing an ethical theory to apply and appropriately implement can be very difficult. Fortunately since 1979, Beauchamp and Childress textbook Principles of Biomedical Ethics serves us with coherent guidelines for practical judgments in medical ethical dilemmas and sets the tone for our professional behavior. Where did these principles come from? They definitely did not appear suddenly as spontaneous creation of the authors, but rather have been conceived from other ethical theories. In this manuscript I wish to present briefly eight theories which have affected our moral reasoning throughout times and which have I believe, inspired at least partly the development of medical professionalism and deontology (duty). This presentation should not be taken as an exhaustive historical review but rather as a rational reconstruction of conceptual nature. Objectivism versus Subjectivism The debate whether morality is objective or subjective dates back to the ancient Greek, found in Plato s dialogues between his teacher Socrates and the Sophists, who were a group of thinkers who held that ethical argument is rather a matter of rhetoric and has nothing to do with true science. They contended that moral discussion is about persuading people to believe what you believe (dogma), rather than proving to them that the beliefs you hold are true (episteme). This dispute continues today, where on one hand many hold that good, bad, right and wrong reflect opinion and desire (subjectivism), whereas others, like Socrates and Plato, think it reflects the objective nature of things (objectivism). Why is moral subjectivity so obvious? Perhaps because there are so many conflicting moral opinions; or because it is impossible to prove the superiority of one moral view over another; or because there are no observable moral facts. But although moral differences on abortion, euthanasia and capital punishment do exist, there is little moral disagreement on many other issues like slavery, child abuse and cheating at sport. It would be probably difficult to find someone who thinks that rape, murder and theft are good, and that honesty, loyalty and generosity are bad. Take this moral inference for example: - 1 -
1. You promised to visit your neighbour in the hospital. 2. Promises ought to be kept 3. So, you ought to visit your neighbour in the hospital. Moral subjectivism concedes that you can draw valid inferences like that one because from a logical point of view, if you accept propositions number 1 and number 2, you necessarily arrive at a moral conclusion (number 3). What moral subjectivism denies is the objective truth of the second proposition: for it, that promises ought to be kept is only a matter of opinion or of taste. On the contrary, for moral objectivism, that promises ought to be kept is really binding because it is true, and as every moral norm has the same status, there is a right answer for every moral dilemma. Moral questions pertain to norms and values. But on what values should a moral theory focus? The more convenient way to answer this question is to ask another one: What is, morally speaking, the best sort of life to aim for? Egoism For many of us the answer to this question would be: rich and famous. Albeit tempting as a response, it is logically incomplete since rich means to have money, and money within itself has only an instrumental, not intrinsic value. Since money has no value in itself, it seems that the answer should be: a life which you are rich enough to do whatever you want and famous for achieving it. Thus the idea that the best life is one in which I ought to aim at getting what I want, is called egoism (and not selfishness as we shall see). Now it is important to distinguish egoism from the subjectivism described earlier. For the subjectivist moral conduct could be prompted and justified by any general human subjective feeling and not necessarily one s own will. For the egoist on the other hand, moral ought depends exclusively on one s want to. For example: Suppose I can advance my career dishonestly. Why should I be honest? For the subjectivist, honesty is in the eye of the beholder and so there is really no moral problem, whereas for the egoist the moral question is: do I have a reason to be honest when it is not in my interest to do so? This difference brings into light another important distinction, that between egoism and selfishness. Selfishness is the tendency to seek and promote one s own comfort and satisfaction before that of anybody else. Selfish people always try to get the best seat or the largest slice of cake. By contrast egoism is the belief that I should do what only matters to me, which may include non-selfish acts, like working long hours or helping my best friends. This fundamental desire to fulfill personal needs as a centerpiece to a good life is know as rational egoism which recommends to always do whatever one wants, because the only good (that is moral ) reason to do something is because you want to do it. Needless to say that rational egoism voiced mostly by 19th century German philosopher Friedrich Nietzsche, was in direct conflict with Judeo-Christian tradition of deny thy self. But the Judeo-Christian argument was mainly due to the confusion between the concept of desire (morally reprehensible longings and inclinations) and the concept of self-interest (things of vital importance to my well being). So when returning to the question what is the best sort of life to aim for, the egoist complete answer would be: a life which is in my best interests, interests which are not desires, which have an objective (not subjective) value and have a rational appeal. Thus any ethical theory to develop must include the concept of in-my-interest. But what is in-my-interest? - 2 -
Hedonism Since a good life is one in which one promotes one s interest and thus avoids human desires of dubious value, the question to be examined now is what is considered best interest? For the hedonists the answer is quite clear - pleasure. The main aim in life is the pursuit of pleasure and the avoidance of pain, so pleasure is what we ought to pursue and pain what we ought to avoid. The most known hedonists were the epicureans, named after the ancient Greek philosopher Epicure who viewed that life must strive at ataraxia and apathia, that is tranquility of mind and health of body. Hence the importance of entertaining true opinions (false opinions will disturb our temper), to drink good wine, to be in good company and participate in sophisticated culture. These pleasures are a natural good and are mild and gentle. Thus drunkenness, gluttony and vulgarity are not part of the hedonistic life since they induce pain and displeasure. If hedonism is a natural good, then we are to maximize pleasure and minimize pain in our lives as much as possible. This idea of maximizing the most pleasure for the greatest number of people possible was developed by 18 th -19th century English philosophers Jeremy Bentham and John Stuart Mill. Contrary to Bentham nevertheless, Mill distinguished between higher and lower pleasures as read in his famous dictum, I prefer to be a dissatisfied Socrates, than a satisfied pig. Unfortunately Mill did not have a reliable method specifying how to discriminate higher and lower pleasures and thus his idea remained a relatively arbitrary stipulation (he proposed the criterion of the expert, i.e. of the person who knows both types of pleasure). Because all types of pleasures are not good and because there are other goods in life beyond pleasure, any moral theory to develop must include something more than just the promotion of pleasure. Aristotle, proposed that pleasure is indeed good, but it is not the highest good. In fact people seek pleasurable sensations, but only because of the happiness it comes along: we want to be happy, that is to flourish; when we succeed, we feel pleasure, but pleasure is only an accompanying good. So the life we seek is a pleasurable and happy life, but is it a good one? What constitutes a good and morally worthy life? Virtue theory For Aristotle it is not pleasure that is important as the hedonists claimed, but rather happiness (eudaimonia), and it is happiness which is of moral value. It is the happy life, which we must pursue and in order to obtain eudaimonia one must excel, seek wisdom and share this wisdom with others (friendship). But excellence (arête) is for Aristotle the same as virtue. So virtues such as practical or moral wisdom (phronesis) and social skills (professionalism) are the supreme values that construct a worthy happy life. Good means not any good, but good-for-man. Existentialism The question how shall I live is inescapably existential, because nothing determines its answer except ourselves, and this remains true even if we adopt a theological ethics or any other moral doctrine. We alone are responsible for the decisions we make. Therefore existentialists, especially the 20 th century French philosopher Jean Paul Sartre, emphasize that moral conduct is based on responsibility, liberty and autonomy. What is important for existentialists is not what is chosen as a moral act, but rather the manner in which it is chosen. They call fleeing from painful moral decisions and giving oneself deterministic excuses bad faith, which suggests in turn that we are autonomous moral agents and that we alone, are responsible for our acts. It is wrong to think that one chooses pre-existing values from a catalogue, but rather the act of choice itself, in radical liberty, confers it value (existentialism is a form of ethical anti-realism: values do not pre-exist in a platonic world, they are created by free acts). Moreover, context is very important: ethical theory is something practical, within a social construct and is based on acting in good faith. - 3 -
So the heart of existentialism is radical freedom in respect to moral norms, a freedom that we are condemned to. By our choice we define ourselves and we must assume full responsibility for these choices. These choices are difficult since it is easy to behave in bad faith. For those who are skeptical with this concept of radical freedom but still want to take responsibility and liberty seriously, the question that arises is how do we make these right choices? What guides us into good faith? Kantianism For the 18 th century German philosopher Immanuel Kant the answer was simple - reason. Since material benefits (of value for egoism and hedonism) or personal talents (important for virtue theory and existentialism) can be used well or badly, they cannot constitute moral good. Thus only reason can guide us into proper moral conduct, i.e doing-the-right-thing. Among all moral theories it is probably that of Kant, which has most influenced principle-based theory of bioethics. For Kant the question of a good life is fraught with ambiguity. Do we mean the happiest life which makes it worthy or the worthiest life which makes us happy? In order to answer this Kant says that what matters from a moral point of view is not what we do, but what we intend to do. However he adds that our intentions (will) and actions should be tested in their ability to be applied everywhere by everybody (universalizability). In other words, people do what is right because it is right, regardless to whether it gives them or others pleasure (as it is the case with desires or inclinations). Kant referred to these universal rules as categorical imperatives, which basically state that for pure practical reason one must act in a specific way (taking the previous example): 1. You ought to visit your neighbor in the hospital because you promised. 2. But you don t want to 3. Whether you want or not, you ought to keep your promise (rule of duty). Thus Kant s moral ought transcends desires and wants. We are not asking what will everyone do, but rather what if everyone were to do it? (i.e. lie, steal, cheat etc.). Kant puts his categorical imperative like this: I should never act in such a way that I could not also want that my maxim should be a universal law. But this imperative has a second reading, too: I should never act in such a way that I treat another person like a mere mean or instrument for the ends I pursue. This second reading has a deep and central impact on our professional and bioethical beliefs: everybody agrees now that it is forbidden to instrumentalize a human person, it is a violation of his or her dignity. The main problem however with Kantian law is that the moral emphasis is only on our intention and will to do our duty, without looking at the consequences of our acts. This critique has been classically voiced by the consistent Nazi example, where a Jew was made known to a Nazi soldier on his demand, simply because it is universally wrong to lie. By this example it is clear that moral quality of life cannot be decided purely in terms of intention and will and the consequences of our acts must be taken into account. Utilitarianism or Consequentialism While Kant s conception of best human life is that of moral duty, others criticized this concept as duty for the sake of duty and returned to the importance of giving place to having a happy and fulfilling life. Thus we return to the idea of maximizing happiness and minimizing pain in the world, otherwise known as the greatest happiness principle. This principle, was introduced by Jeremy Bentham and further developed by his successor, John Stuart Mill, who stated that my pleasures and pains are not to be regarded by me as anymore important than yours, when it comes to deciding what is right or wrong for me or anyone else. This of course ensures that utilitarianism is not a selfish doctrine. - 4 -
But utilitarianism is niether an altruistic theory. On the contrary, individuals may suffer in the name of utility. In order to avoid unacceptable acts on individuals (for example to kill one to save many others) contemporary utilitarians also introduced the distinction between act utilitarianism and rule utilitarianism, where the latter assures conduct most conducive to greatest happiness. Thus even in a context of where killing one to save many others would be an act utilitarianism, the rule precludes this because the consequences of a rule permitting the murder of an innocent for the greatest common good, would in fact decrease the greater happiness (nobody will be in security anymore). We see then that utilitarianism has a hedonic aspect to it, but more importantly a consequentialist feature, which puts it in direct opposition to Kant (which gives importance to duty for duty s sake) and to existentialism (which prides in liberty). So utilitarianism is a consequentialist doctrine where only the consequences of actions matter from a moral point of view. Thus in Kant s eyes the acts of Don Quixote (fighting mills) are morally worthy since his intentions (fight evil) are morally worthy, in Sartre s eyes these acts are morally worthy since Don Quixote is true to himself, whereas for the utilitarian, these acts are of no moral value since they are of no consequence. For a utilitarian the end does justify the means, but remains silent on social agreement. So how do we distribute happiness justly? Contractualism In order to answer this we must analyse the different interpretations of social contract. The egoist will try to keep for himself all he needs to fulfill his wants, whereas the altruist will give others all they need at the expense of himself. But those two attitudes are not adequate as a basis for social and political life, where we must distribute the burdens and fruits of cooperation for the benefit of all. Social agreement or contract is the basic tool to gap the bridge between egoistic motivation and altruistic over-obligation. As John Locke, one of the first proponent of the social contract doctrine stated in 17 th century, this agreement should allow individuals to enjoy a life as good as possible and to have maximum freedom as compatible with an equal amount of freedom for all (here is one of the two roots of the doctrine of autonomy and informed consent, the second one residing in the Kantian concept of autonomy). Twentieth century American philosopher John Rawls, who influenced the principle of distributive justice developed a more comprehensive social contract theory in his theory of justice referred as fairness. He put forth two principles of distribution: egality of rights for all and limits on inequalities of wealth and income. Inequalities are morally justified only if they are to the benefit of all and especially to the benefit the least advantaged members of society. These two principles will be chosen by all members of the political community, Rawls contended, if they are put under a veil of ignorance. In other words the principles of justice must be chosen without knowledge of whether the moral agent is male or female, rich or poor, powerful or powerless, abled or disabled. The idea of course is to introduce impartiality into moral deliberations, ensuring fairness and freedom, while limiting as much as possible the gap between the rich and poor. In summary I have tried to show that our professional conduct has been inspired from various moral theories. As our presentation is a conceptual reconstruction, it does not pretend full historical accuracy. Critiques say that medical deontology ( ethical principlism ) is actually ethical fundamentalism and claims with good reason that other theories need to be taken into account (Hans Jonas ethics of responsibility, Carol Gilligan feminist ethics of care, Emmanuel Levinas ethics of alterity, Business ethics). However I postulate that in order to understand the strength and the limits our professional conduct and our approach to solve medical dilemmas, it is better to be aware of it s multiple origins. - 5 -
Key learning points: Medical professionalism - A potpourri of moral theories Reasonable objectivism, that states that for many moral questions there is a right answer because for any moral question there might be a right answer, presents the interest in developing a systematic approach to deal with moral dilemmas and not to count upon moral intuition alone. Egoism, different from selfishness, inspires the principle of beneficence (promote good) in emphasizing that one s own desire (e.g. patient) is of moral value and merits to be the centre of a good life. Hedonism, which replaces desires with maximizing pleasure and minimizing pain, reminds us that non-maleficence (do no harm) is an important principle to follow. Virtue theory, stating that a happy virtuous life is the most important value to attain, presents itself as strive to professional excellence as a deontological obligation. The radical freedom expressed in existentialism translates itself into the importance for the professional to accept full responsibility for one s own decision. Kantianism, the greatest inspirer of the respect of autonomy, reminds us not to instrumentalize the other. Both utilitarianism and contractualism have shaped distributive justice and insert fairness within the social agreement. Suggested reading Introduction: Beauchamp TL, Childress JF. Principles of Biomedical ethics. Oxford University Press, 2001 Objectivism vs. Subjectivism Pappas N, Plato and the Republic. London, Routledge, 2003 Egoism Young J, The death of God and the meaning of life. London and New York, Routledge, 2003 Hedonism Gosling JCB. The Greeks on pleasure. Oxford, Clarendon press, 1982 Virtue theory Hughes G, Aristotle on Ethics. London and New York, Routledge, 2001 Existentialism Howells C, The Cambridge Companion to Sartre. Cambridge University Press, 1992 Kantianism Stratton-Lake P, Kant, Duty and Moral worth, London and New York, Routledge, 2000 Utilitarianism Crisp R, Mill on Utilitarianism. London and New York, Routledge, 1997 Contractualism Rawls J, A theory of Justice, Oxford University Press, 1973-6 -