Medical Ethics

Michael Boylan

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9781118494752
• eBook ISBN: 9781118657959
• Edition: 2
• Topic: Medicine
• Subtopic: Ethics in Medicine

The second edition of Medical Ethics deals accessibly with a broad range of significant issues in bioethics, and presents the reader with the latest developments. This new edition has been greatly revised and updated, with half of the sections written specifically for this new volume.

• An accessible introduction for beginners, offering a combination of important established essays and new essays commissioned especially for this volume
• Greatly revised - half of the selections are new to this edition, including two essays on genetic enhancement and a section on gender, race and culture
• Includes new material on ethical theory as a grounding for understanding the ethical dimensions of medicine and healthcare
• Now includes a short story on organ allocation, providing a vivid approach to the issue for readers
• Provides students with the tools to write their own case study essays
• An original section on health provides a theoretical context for the succeeding essays
• Presents a carefully selected set of readings designed to progressively move the reader to competency in subject comprehension and essay writing

1

Ethical Reasoning

MICHAEL BOYLAN

What is the point of studying ethics? This is the critical question that will drive this chapter. Many people don’t think about ethics as they make decisions in their day-to-day lives. They see problems and make decisions based upon practical criteria. Many see ethics as rather an affectation of personal taste. It is useful only when it can get you somewhere. Is this correct? Do we only act ethically when there is a win-win situation in which we can get what we want and also seem like an honorable, feeling, and caring person?

A Prudential Model of Decision-Making

In order to begin answering this question we must start by examining the way most of us make decisions. Everyone on earth initiates the decision-making process with an established worldview. A worldview is a current personal consciousness that consists in one’s understanding about the facts and values in the world. It is the most primitive term to describe our factual and normative conceptions. This worldview may be one that we have chosen or it may be one that we have passively accepted as we grow up in a particular culture. Sometimes the worldview is wildly inconsistent. Sometimes the worldview has gaping holes so that no answer can be generated. Sometimes it is only geared to perceived self-interest. And sometimes it is fanciful and can never be put into practice. Failures in one’s personal worldview model will lead to failures in decision-making.

One common worldview model in the Western world is that of celebrity fantasy. Under this worldview, being a celebrity is everything. Andy Warhol famously claimed that what Americans sought after most was 15 minutes of fame.¹ Under this worldview model we should strive to become a celebrity if only for a fleeting moment. What does it mean to be a celebrity? It is one who is seen and recognized by a large number of people. Note that this definition does not stipulate that once recognized the object is given positive assent. That would be to take an additional step. To be seen and ­recognized is enough. One can be a sinner or a saint—all the same. To be recognized is to be recognized. If this is the end, then it is probably easier to take the sinner route. In this way, the passion for celebrity is at heart contrary to ethics.

Another popular worldview model is one of practical competence. Under this model the practitioner strives to consider what is in his or her best interest and uses a practical cost-benefit analysis of various situations in order to ascertain whether action X or action Y will maximize the greatest amount of pleasure for the agent (often described in terms of money). Thus, if you are Bernie Madoff (a well-known financial swindler) you might think about the risks and rewards of creating an illegal Ponzi scheme as opposed to creating a legitimate investment house that operates as other investment houses do. The risks of setting off on your own direction are that you might get caught and go to prison. The rewards are that you might make much more money than you would have under the conventional investment house model. Since you think you are smarter than everyone else and won’t get caught, the prudential model would say—go for it! Madoff did get caught, but who knows how many others don’t? We couldn’t know because they haven’t been caught. But even if you aren’t caught, is that the best worldview approach? The prudential model says yes.

Possible Ethical Additions to the Prudential Model

Some people, including this author, think that the prudential model is lacking. Something else is necessary in order have a well-functioning worldview by which we can commit purposive action (here understood to be the primary requirement of fulfilled human nature). First, we have to accept that the construction of our worldview is within our control. What I suggest is a set of practical guidelines for the construction of our worldview: All people must develop a single comprehensive and internally coherent worldview that is good and that we strive to act out in our daily lives. I call this the personal worldview imperative. Now one’s personal worldview is a very basic concept. One’s personal worldview contains all that we hold good, true, and beautiful about existence in the world. There are four parts to the personal worldview imperative: completeness, coherence, connection to a theory of ethics, and practicality. Let’s briefly say something about each.

First is completeness. Completeness is a formal term that refers to a theory being able to handle all cases put before it and to determine an answer based upon the system’s recommendations. In this case, I think that the notion of the good will provides completeness to everyone who develops one. There are two senses of the good will. The first is the rational good will. The rational good will means that each agent will develop an understanding about what reason requires of one as we go about our business in the world. In the various domains in which we engage this may require developing different sorts of skills. In the case of ethics it would require engaging in a rationally based philosophical ethics and abiding by what reason demands.

Another sort of good will is the affective good will. We are more than just rational machines. We have an affective nature, too. Our feelings are important, but just as was the case with reason, some guidelines are in order. For ethics we begin with sympathy. Sympathy will be taken to be the emotional connection that one forms with other humans. This emotional connection must be one in which the parties are considered to be on a level basis. The sort of emotional connection I am talking about is open and between equals. It is not that of a superior “feeling sorry” for an inferior. It is my ­conjecture that those who engage in interactive human sympathy that is open and level will respond to another with care. Care is an action-guiding response that gives moral motivation to acting properly. Together sympathy, openness, and care constitute love.

When confronted with any novel situation one should utilize the two dimensions of the good will to generate a response. Because these two orientations act differently it is possible that they may contradict each other. When this is the case, I would allot the tiebreaker to reason. Others demur.² Each reader should take a moment to think about their own response to such an occurrence.

Second is coherence. People should have coherent worldviews. Coherence also has two varieties: deductive and inductive. Deductive coherence speaks to our not having overt contradictions in our worldview. An example of an overt contradiction in one’s worldview would be for Sasha to tell her friend Sharad that she has no prejudice against Muslims and yet in another context she tells anti-Muslim jokes. The coherence provision of the personal worldview imperative says that you shouldn’t change who you are and what you stand for depending upon the context in which you happen to be.

Inductive coherence is different. It is about making sure one’s life strategies work together. When they don’t work together we have inductive incoherence: in inductive logic this is called a sure loss contract. For example, if a person wanted to be a devoted husband and family man and yet also engaged in extramarital affairs he would involve himself in inductive incoherence. The very traits that make him a good family man—loyalty, keeping one’s word, sincere interest in the well-being of others—would hurt one in being a philanderer, which requires selfish manipulation of others for one’s own pleasure. The good family man will be a bad philanderer and vice versa. To try to do both well involves a sure loss contract. Such an individual will fail at both. This is what inductive incoherence means.

Third is connection to a theory of being good, that is, ethics. The personal worldview imperative enjoins that we consider and adopt an ethical theory. It does not give us direction, as such, to which theory to choose except that the chosen theory must not violate any of the other three conditions (completeness, coherence, and practicability). What is demanded is that one connects to a theory of ethics and uses its action-guiding force to control action.

The final criterion is practicability. In this case there are two senses to the command. The first sense refers to the fact that we actually carry out what we say we will do. If we did otherwise, we’d be hypocrites and also deductively incoherent. But secondly, it is important that the demands of ethics and social/political philosophy be doable. One cannot command another to do the impossible! The way that I have chosen to describe this is the distinction between the utopian and the aspirational. The utopian is a command that may have logically valid arguments behind it but is existentially unsound (meaning that some of the premises in the action-guiding argument are untrue by virtue of their being impractical). In a theory of global ethics if we required that everyone in a rich country gave up three-quarters of their income so that they might support the legitimate plight of the poor, this would be a utopian vision. Philosophers are very attracted to utopian visions. However, unless philosophers want to be marginalized, we must situate our prescriptions in terms that can actually be used by policy makers. Beautiful visions that can never be should be transferred to artists and poets.

How to Construct Your Own Model

The first step in creating your own model for which you are responsible is to go through personal introspection concerning the four steps in the personal worldview imperative. The first two are global sorts of analyses in which an individual thinks about who he or she is right now in terms of consistency and completeness. These criteria are amenable to the prudential model. They are instrumental to making whatever worldview one chooses to be the most effective possible. This is a prudential standard of excellence. What constitutes the moral turn is the connection to a theory of the good: ethics.

Thus the third step is to consider the principal moral theories and make a choice as to which theory best represents your own considered position. To assist readers in this task, I provide a brief gloss of the major theories of ethics.

Theories of ethics

There are various ways to parse theories of ethics. I will parse theories of ethics according to what they see as the ontological status of their objects. There are two principal categories: (i) the realist theories, which assert that theories of ethics speak to actual realities that exist,³ and (ii) the anti-realists, who assert that theories of ethics are merely conventional and do not speak about ontological objects.

Realist theories

Utilitarianism is a theory that suggests that an action is morally right when that action produces more total utility for the group as a consequence than any other alternative. Sometimes this has been shortened to the slogan “The greatest good for the greatest number.” This emphasis upon calculating quantitatively the general population’s projected consequential utility among competing alternatives, appeals to many of the same principles that underlie democracy and capitalism (which is why this theory has always been very popular in the United States and other Western capitalistic democracies). Because the measurement device is natural (people’s expected pleasures as outcomes of some decision or policy), it is a realist theory. The normative connection with aggregate happiness and the good is a factual claim. Utilitarianism’s advocates point to the definite outcomes it can produce by an external and transparent mechanism. Critics cite the fact that the interests of minorities may be overridden.

Deontology is a moral theory that emphasizes one’s duty to do a particular action just because the action itself is inherently right and not through any other sorts of calculations—such as the consequences of the action. Because of this non-­consequentialist bent, deontology is often contrasted with utilitarianism, which defines the right action in term of its ability to bring about the greatest aggregate utility. In contradistinction to utilitarianism, deontology will recommend an action based upon principle. “Principle” is justified through an understanding of the structure of action, the nature of reason, and the operation of the will. Because its measures deal with the nature of human reason or the externalist measures of the possibility of human agency, the theory is realist. The result is a moral command to act that does not justify itself by calculating consequences. Advocates of deontology like the emphasis upon acting on principle or duty alone. One’s duty is usually discovered via careful rational analysis of the nature of reason or human action. Critics cite the fact that there is too much emphasis upon reason and not enough on emotion and our social selves situated in the world.

Swing theories (may be realist or anti-realist)

Ethical intuitionism can be described as a theory of justification about the immediate grasping of self-evident ethical truths. Ethical intuitionism can operate on the level of general principles or on the level of daily decision-making. In this latter mode many of us have experienced a form of ethical intuitionism through the teaching of timeless adages such as “Look before you leap,” and “Faint heart never won fair maiden.” The truth of these sayings is justified through intuition. Many adages or maxims contradict each other (such as the two above), so that the ability properly to apply these maxims is also understood through intuition. When the source of the intuitions is either God or Truth itself as independently existing, then the theory is realist. The idea being that everyone who has a proper understanding of God or Truth will have the same revelation. When the source of the intuitions is the person himself or herself living as a biological being in a social environment, then the theory is anti-realist because many different people will have various intuitions and none can take precedence over another.

Virtue ethics is also sometimes called agent-based or character ethics. It takes the viewpoint that in living your life you should try to cultivate excellence in all that you do and all that others do. These excellences or virtues are both moral and non-moral. Through conscious training, for example, an athlete can achieve excellence in a sport (non-moral example). In the same way a person can achieve moral excellence, as well. The way these habits are developed and the sort of community that nurtures them are all under the umbrella of virtue ethics. When the source of these community values is Truth or God, then the theory is realist. When the source is the random creation of a culture based upon geography or other accidental features, then the theory is anti-realist. Proponents of the theory cite the real effect that cultures have in influencing our behavior. We are social animals and this theory often ties itself with communitarianism that affirms the positive interactive role that society plays in our lives. Detractors often point to the fact that virtue ethics does not give specific directives on particular actions. For example, a good action is said to be one that a person of character would make. To detractors this sounds like begging the question.

Anti-realist theories

Ethical non-cognitivism is a theory that suggests that the descriptive analysis of language and culture tells us all we need to know about developing an appropriate attitude in ethical situations. Ethical propositions are neither true nor false but can be analyzed via linguistic devices to tell us what action-guiding meanings are hidden there. We all live in particular and diverse societies. Discerning what each society commends and admonishes is the task for any person living in a society. We should all fit in and follow the social program as described via our language/society. Because these imperatives are relative to the values of the society or social group being queried, the maxims generated hold no natural truth-value and as such are anti-realist. Advocates of this theory point to its methodological similarity to deeply felt worldview inclinations of linguistics, sociology, and anthropology. If one is an admirer of these disciplines as seminal directions of thought, then ethical non-cognitivism looks pretty good. Detractors point to corrupt societies and that ethical non-cognitivism cannot criticize these from within (because the social milieu is...

Table of contents

• Cover
• Title page
• Copyright page
• Dedication
• Notes on Contributors
• Preface to the Second Edition
• Source Credits
• 1 Ethical Reasoning
• 2 Health The Aim of Medicine
• 3 Physician, Nurse, and Patient The Practice of Medicine
• 4 Issues of Life and Death
• 5 Genetic Enhancement
• 6 Healthcare Policy
• Further Reading