1.1 Imagine you were running a medical nonâgovernmental organization (NGO) established to preserve the lives of povertyâstricken people in resource poor countries. Your NGO is also usually among the first to provide emergency assistance in case natural emergencies such as tsunamis strike. However, you did notice that agencies evaluating your efficiency1 give you a belowâaverage ranking. That is a worry to your fundraising staff, mostly because you rely on donations and such ratings are said to impact eventually negatively, on your capacity to raise cash. You investigate what the problem is, and it turns out that the ratings agency is critical of your policy of responding mostly in cases of highâimpact disasters such as earthquakes, floods or civil wars, because they invariably require a highly resource intensive intervention. The agencyâs verdict is that, on the same capital outlay, you could preserve more lives in developing countries if you aimed at establishing mediumâ to longâterm health delivery solutions, including setting up primary health care facilities, beginning vaccination programs, and other such relatively lowâcost means. Chartering private jets to fly emergency teams in response to disaster also preserves lives deserving to be rescued, the ratings agency says, but it demonstrably results in a substantially lower number of lives preserved than you could preserve if you dropped such actions in favor of working toward better health care delivery infrastructure in the countries you usually serve.
1.2 So, if your objective is to preserve lives in developing countries, the ratings agency might be correct in saying that you only preserve a suboptimal number of lives. You could do better. Should you change your policy though? After all, what the ratings agency proposes implies, if you were to act on it, is that those in most dire need, say those living in warâtorn countries with minimal health care infrastructure, should be toward the bottom end of your list of priorities, because assisting such people would cost more â per life preserved â to succeed. All other things being equal, more lives could be preserved if the NGO focused on preserving not those most in need but perhaps those whose lives are also threatened but who could be helped with the deployment of fewer resources. Should we only care about the number of lives preserved then, or do other factors matter, too, such as for instance that some people, possibly due to no fault of their own, live in particularly abysmal conditions? Should we factor in the amount of resources required to nurse such people back to a life that would permit them to live independently? Should the age of the toâbeârescued matter? Should it matter whether they have a family dependent on their support? Questions such as these are fundamentally ethical questions. And this chapter is about ethics, it is about right and wrong, good and bad, and how we can go about judging alternative courses of action that might be available to us.
1.3 What are the fundamental purposes of ethics then? Unsurprisingly, one of the purposes of ethics is to offer us clear action guidance when we are faced with a particular ethical problem. Of course, action guidance alone is not sufficient, or else an ethicist telling us what we ought to do is not much different to what a preacher or a taxi driver, engineer or medical doctor could tell us. Anyone can admonish us to do this or do that when faced with an ethically challenging situation. All of us almost certainly would have a view on what the NGO chief should be doing. In fact, most of us would probably happily add our two cents worth of opinion when asked what we think the NGO chief should do, policy wise. Thinking about what she ought to do engages with ethics. That takes us to the second objective of ethics. It is to do with the normative justification for the advice given. The preacherâs advice would derive its authority from the claim that she knows what a higher authority (say a God) wants us to do. Of course, many people today are atheists2 or agnostics3, and many of those who are not atheists hold a large number of different deities dear to their hearts, all with competing action guidance derived from their respective sources of godly wisdom. For all we know, the taxi driver and engineer might just reply that that is how they feel, or possibly even think, about the problem at hand. Let us leave aside, for a moment, that in ancient Greece there were no taxi drivers or engineers as we understand them today. During those times their approach to ethics would have led to them being labeled as Sophists4, that is a group of philosophers who subscribe to the view that there are no objectively right or wrong answers to ethical questions, and that answers to ethical questions are at best reflective of someoneâs subjective, strongly held beliefs or feelings. What gave way to the birth of modern ethics were philosophers like Plato5 and his teacher Socrates who both believed that we can actually give right or wrong answers to questions about what is ethically good or bad. We will return to their take on ethics in a moment. How might the medical doctor in our example respond to the ratings agencyâs ethical challenge? Trying to do better than the Sophists of the world, she could refer to guidance documents issued, for instance by her national medical associationâs ethics people6, or those issued by the World Medical Association7, a worldwide umbrella organization of national medical associations, or possibly the World Health Organization8. But what if these organizations have actually omitted to address the problem at hand in their guidance documents? And, even if they havenât, quotes from a document donât constitute an ethical justification. What if the document quoted got it wrong? It turns out, we have good reason to be skeptical about famous historical medical guidance documents such as the Hippocratic Oath9. Robert M. Veatch explains why the Hippocratic Oath isnât a document medical professionals ought to aspire to. According to Veatch just about everything is wrong about it, from its pledge to questionable Greek deities to a cultish understanding of medicine as a secretive practice to practical guidance that prioritizes individual patient interest always over the greater good of the society (Veatch 2012a, 10â29). To put it in Veatchâs own words, âthe Oath is so controversial and so offensive that it can no longer stand alongside religious and secular alternatives. [âŠ] The Hippocratic Oath is unacceptable to any thinking person. It should offend the patient and challenge the health care professional to look elsewhere for moral authorityâ (Veatch 2012a, 1). Veatch tells us, somewhat reassuringly, that the Oath today is used in so many variations in the worldâs medical schools that sometimes only fragments of the original document seem to remain (Veatch 2012b).
1.4 Be mindful that even if we agreed with the content of the Hippocratic Oath or a modern version of it, and even if they actually provided us with guidance for the problem under consideration, we would again have to take it on authority that we should go about the NGOâs problem in one particular way and not in another, unless there is an ethical justification provided why we should do what it admonishes us to do. Given that in our scenario almost certainly a lot of people would disagree with whatever it is that is being proposed, policy wise, it is important that we get our justification right. Here is where ethicsâ second purpose comes in: In addition to providing us with action guidance, it must also provide us with a reasoned justification for the guidance given.
1.5 As we will discover, there exist a fair amount of competing ethical theories, some more influential than others, that succeed with varying degrees of success both on the action guidance as well as on the action justification fronts. How should we decide then, which one, or which set of them to adopt for our own purposes? Is it ok to use one set of theories for one type of problem and another set of theories for another type of problem? Couldnât we choose virtue ethics for decisionâmaking at the hospital bedside, but decide to go with utilitarianism for matters of resource allocation decisionâmaking? But why should we do that, as opposed to just the opposite? Could there be a metaâtheory telling us which theoretical approach to deploy under what circumstances? Or must we determine which theory is the right one and try to abide by its guidance as best as we can, even if some of that guidance is turning out to be deeply counterâintuitive? Well, these are questions about the nature of ethics; they ask whether there can be a true ethics, whether ethical statements must be of a particular kind, whether they can be objectively true or false, or whether they ultimately boil down to statements expressing our feelings. These and other questions are typically analyzed by metaâethicists. They donât create ethical theories, rather they create theories about ethics. There are also legitimate questions about the extent to which ethical theories truly lend themselves to be âappliedâ in some sense or another to problems such as the one mentioned at the beginning of this chapter. We will not engage in this sort of theorizing about ethics in this chapter, with the exception of a few paragraphs on ethical relativism. The reason for this is that the discussions driving metaâethics are quite technical in nature, and by and large there is no obviously correct solution to many of its controversies. Even in the absence of final answers to many of these questions, however, it is still quite possible to undertake ethical analyses. As we will see throughout this book, some arguments are more plausible than others; certain types of argument, such as for instance slipperyâslope based arguments, are almost always flawed, and so on and so forth. However, you can easily read up on metaâethical theories elsewhere. (McMillan 2018) A wonderful source o...