ETHICS :)

 Loubert (1999) defines ethics as “the study of rules, standards and principles that
dictate right conduct among members of the society. Such rules, standards and
principles are based on moral values which serve as a basis for what is considered
right”
 Ethics is underpinned by morals and values
 Values – the beliefs and attitudes that provide direction to everyday living. Values
are personal beliefs and attitudes that guide action
 Morals – morality is concerned with perspectives of right and proper and involves
an evaluation of actions based on some broader cultural context or religious
standard.
 Ethics is a system of moral principles.
 Derived from a greek word “ethos” = custom, habit, character, or disposition.

Ethics covers the following dilemmas:

• how to live a good life

• our rights and responsibilities

• the language of right and wrong

• moral decisions - what is good and bad?

What use is ethics?

 They need to affect the way human beings behave.

 Philosophers argue that if a person realizes that it would be morally good to do
something then it would be irrational for that person not to do it.
 Ethics does provide good tools for thinking about moral issues.

Where does ethics come from?

 God and religion

 human conscience and intuition
 a rational moral cost-benefit analysis of actions and their effects
 the example of good human beings
 a desire for the best for people in each unique situation
 political power
What's the Difference Between Ethics, Morals and Values?

Values - the foundation of a person's ability to judge between right and wrong.

- This system allows each individual to determine what should and shouldn't be.

Morals - formed out of values.

- The actual system of beliefs that emerge out of a person's core values.

Amoral – they have no sense of right and wrong

Immoral – they know right from wrong but chose to do the wrong thing.

Moral dilemma – someone might deem an action to be "good" even if it's breaking a law.

Ethics – the vehicle to our morals.

- Morals in action

Professional ethics – ethics are closely linked to matters pertaining to medicine or law.
We know doctors are held to a strict code of ethics when they swear the Hippocratic Oath.

Ethics and law

Ethics Law
Rules of conduct Developed by government to provide
protection and balance

Comes from people’s awareness of what is Enforced by governments to their people

right and wrong

Moral codes that every person must codifications of ethics meant to regulate
conform to society

does not carry any punishment to anyone The law will punish anyone who happens to
who violates it violate it

comes from within a person’s moral values made with ethics as a guiding principle

Health care practice

 best of science
 noblest of human arts
  offer careers that never challenging
 provides opportunities for personal development

Health care can be:

 rewarding
 engaging
 exciting
 meaningful
 frustrating
 overwhelming

Health care ethics

 Like professional etiquette, health care ethics are designed to promote order and maintain
civility.
 With ethics, you are not dealing with something that can be considered bad manners; you
are dealing with the rights and welfare of other people.
 As professionals, even in our opposition and standing up for our position – it is important
that we remain appropriate and constructive in our actions.
 In health care there are decisions that must not be made. Whereas tolerance is generally
considered a virtue, there are actions that must not be tolerated.

ETHICAL THEORIES

Ethical theories attempt to articulate and justify principles that can be employed as guides for
making moral decisions and as standards for the evaluation of actions and policies.

Ethical theories also offer a means to explain and justify actions, that is:

 If our actions are guided by a particular theory, then we can explain them by
demonstrating that the principles of the theory required us to act as we did.
 We justify our actions by showing that, according to the theory; we had an obligation to
do what we did.

Basic ethical theories:

CONSEQUENTIALIST or TELEOLOGICAL ETHICAL THEORY

 Greek = telos, teleos meaning purpose or end.

  It stresses the end-result, goal or consequence of an act as the determining factor of its
rightness and wrongness.
 Consequentialist Ethics – consequences
 Argue that the morality of an act is determined solely by its consequences – only results
matter.
 Consequence-oriented theories – judge the rightness or wrongness of decisions based
upon outcomes or predicted outcomes.
 Consequentialism is sometimes expressed in common language as: “The end justifies the
means”.
 This ethical theory evaluates behavior in terms of its consequences

3 distinct classifications of consequentialists:

1. For oneself (egoism) – egoists say that one should always act to produce the greatest ratio of
happiness over unhappiness (or good over evil) for the one acting.

2. For some (limited consequentialism) – For many, the consequences for a specific individual
(other than the agent) or number of individuals are the deciding factor in determining the
morality of an act.

3. For everyone (utilitarianism) - utilitarians argue that one should always act to produce the
greatest ratio of long-term happiness over unhappiness for everyone (greatest good for the
greatest number).

UTILITARIANISM

 This ethical doctrine states that: The rightness or wrongness of actions is determined by
the goodness and badness of their consequences.
 Claims that there is only one moral principle – principle of utility (formulated by Mill)
 “Actions are good insofar as they tend to promote happiness, bad as they intend to
produce unhappiness”.
 Goal of utilitarianism is to maximize pleasure and minimize pain

Utilitarianism developed by English philosophers Jeremy Bentham and further refined by John
Stuart Mill, may be divided into 2 classes:

1. Act Utilitarianism – holds that the principle should be applied to particular acts in particular
circumstances.

 Determines the rightness or wrongness by weighing the consequences of the act itself.
  An act is right if, and only if, no other act could have been performed that would produce
a higher utility.
 The act utilitarian holds that we must attempt to determine the consequences of the
various actions that are open to us.
 According to act utilitarianism, we must explore the potential results of each of these
possibilities – explore all possibilities.
 The great strength of act utilitarianism is that it invites us to “DEAL WITH EACH CASE
AS UNIQUE” – it shows sensitivity to specific cases.

2. Rule Utilitarianism – maintains that an action is right if it conforms to a rule of conduct, a set
of criteria, or norms that has been validated by the principle of utility as one that will produce at
least as much utility as any other rule applicable to the situation.

 The rule utilitarian is not concerned with assessing the utility of individual actions, but of
particular rules.
 The basic idea behind rule utilitarianism is that having a set of rules that are always
observed produces social utility.
 For Act Utilitarian it is perfectly legitimate to violate a rule if doing so will maximize
utility in that instance.
 By contrast, the Rule Utilitarian holds that rules must generally be followed, even though
following them may produce less net utility (more unhappiness than happiness) in a
particular case.

NONCONSEQUENTIALIST or DEONTOLOGICAL ETHICAL THEORY

 Greek – deon, deontos meaning “obligation or duty”

 Stresses duty as the norm of moral actions, hence it is also known as duty ethics.
 Do not take consequences into account; instead, we must follow our duty, regardless of
the consequence.
 Ethical theories that evaluate behavior in terms of adherence to duty or obligation
regardless of consequences.
 Deontological Ethical Theories are duty-oriented – an action has features in itself that
makes it right in accordance with duty.
 Formulated by Immanuel Kant
 For Kant, one acts morally (i.e., performs a moral act) if and only if one does whatever
one is obliged to do.
 What makes an act moral is its being done out of duty, as distinguished from act done for
other reasons.
  DUTY in this context is that which an individual ought to do, despite the inclination to do
otherwise.

CATEGORICAL IMPERATIVE

 For Kant, the consequences of an action are morally irrelevant. Rather, an action is right
when it is in accordance with a rule that satisfies a principle he called “CATEGORICAL
IMPERATIVE”.
 A deontological ethical theory, developed by Kant, which states unconditionally that one
must act in such a way as to desire his/her actions to become universal laws binding on
everyone.
 He called this principle “categorical” – this tells us what to do if we want to bring about
certain consequences and it is necessary in itself. “Imperative” – because it is a
command that demanded action.
 It lays down a universal rule which, if followed, will ensure that the person is acting from
a sense of duty.

Formulations of the categorical imperative:

1st formulation - “Act only on that maxim (rule/command) which you can at the same time will
become a universal law”

 All that a person needed to do, according to Kant, was to consider whether a proposed
action could serve as a universal law.
 Kant suggested that when you are faced with a moral choice, you should imagine a world
in which everyone was required to do precisely what you are proposing to do right now.
 Kant calls such a rule a “MAXIM” – all reasoned and considered actions can be regarded
as involving MAXIMS.
 Sometimes called the UNIVERSALIZABILITY Principle – “GENERALIZATION” –
Kant’s ethical guideline asks you to mentally universalize your proposed action and
imagine it a public law, binding to everyone.

2nd formulation - “Always act so as to treat humanity, either yourself or others, as an end and
never only a means”

 It is never permissible to treat people as if they were valued merely as a way of achieving
something else.
  According to Kant, our dignity was derived from our capacity to make rational choices,
and this is violated whenever a person is treated merely as a means to an end (a
thing) and not as a person.
 For Kant, happiness is at best a conditional or qualified good. Nothing is good in itself
except good will.
 Will – is what directs our actions and guides our conduct
 Good will – capacity to act according to principle
 A will becomes good when it acts purely for the sake of DUTY

2 types of duties:

1. Perfect duties - those we are always obligated to observe. Usually negative (e.g., not to cause
harm)

2. Imperfect duties - those that we must observe only on some occasions. Usually positive (e.g.,
give love, compassion).

Kant’s Ethics in Medical Context:

1. No matter what the consequences may be, it is always wrong to lie.

2. We must always treat people (including ourselves) as ends and not as means only.

3. An action is right when it satisfies the categorical imperative.

4. Perfect and imperfect duties give a basis for claims that certain rights should be recognized.

VIRTUE ETHICS

 We can judge the morality of actions based on the goodness of the action itself or the
goodness of the consequences of the action.
 The third branch of normative ethics is virtue ethics, which examines the virtue of the
actor, not the action.
 An action is morally justified if the person doing it is virtuous.
 Aristotle, who argued that the human purpose was to live a life of rationality and virtue
 Virtue ethics stand as a way of viewing the world somewhat subjectively, while still
maintaining an objective view toward ultimate good and the philosophy of do no harm.

Becoming virtuous - Aristotle believed the desire to be virtuous had been built into us. It is our
job as humans to fulfill our nature and be virtuous. The way to be virtuous was to learn through
experience. Virtue forms out of habit.
Golden mean - Central to Aristotle's virtue ethics was the concept of the golden mean. Aristotle
thought of potential actions existing on a moral spectrum.

 Aristotle believed ethical actions were the mean, or average, between two points of
extreme vice.

Rule based ethics

Immanuel Kant was an eighteenth-century German philosopher who believed ethics should be
rule-based, or deontological, in nature. Kant proposed the following deontological rules for
ethical actions:

 In any situation, the moral action is one that you would will the entire world to do in that
situation. Therefore, exceptions to the rule would be very limited or non-existent. In other
words, act as if your action could be universalized.
 Always act out of respect for people. Do not treat people as a mere means to an end.
 You must always act freely, out of a will to do good.

- Kant believed an action could not be a moral action unless you acted out of good
intentions.

Virtue ethics: strengths

 Virtue ethics are first and foremost seen as a holistic understanding of who human beings
are.
 They take into account the physical, spiritual, mental, emotional, and intellectual
properties of human nature.
 Allows the close examination and refinement of the human character through
introspection and therapeutic pursuits.
 The concept of character development coincides well with the idea of the whole person.
If a person has many parts, so to speak, he or she will be able to develop these
components and grow in character.
 Morality is dealt with pragmatically in virtue ethics. Through the practical application of
morals that are developed through societal agreement, there is a basis for community
understanding and growth.
 Partiality is also regarded as a strength in virtue ethics as it allows for an open
understanding and acceptance of social differentiation. In other words, one can be partial
towards people without being seen as unjust or unfair.
  Under a virtue ethics philosophy, justice and righteousness become the primary standard
for which to strive, albeit in a subjective and fluid way.

Weaknesses

 The definition of what is virtuous remains fluid, allowing for problems to creep in.
 Virtue ethics is also seen as a mediocre view of human attainment. In other words, there
seems to be no real motivation for self-sacrifice or extreme altruism that makes other
ethical philosophies meaningful.
 Decision making is a problem in virtue ethics because there are no hard standards by
which to make solid decisions. This is a problem with subjectivity. If there is no rule,
there can be no direction, which makes decision-making very difficult and sometimes
impossible.

Virtue ethics vs Other theories

 Aristotle's perspective on ethics was based on the virtue of being human, in other words,
virtue ethics.
 Aristotle did not consider ethics just a theoretical or philosophical topic to study . To
understand ethics, Aristotle argued, you actually have to observe how people behave.
 Ethics weren't about ''what if'' situations for Aristotle; instead, he took a very practical
approach and much of his ideas on ethics were based on what someone did and how their
virtues impacted their actions.

Virtue ethics principles

 Aristotle, one of the earliest philosophers to examine virtue ethics, explained that virtue is
''the mean'' (or the average) of two extremes. On one end of the extremes, we have a
deficiency of the trait, while the other end is an excess of the trait.

Confucious - Confucius lived during an era of crisis of ideals in China. This time of moral
disruption and loss of traditional Chinese values offered Confucius the opportunity to affect
moral change among his people through the use of wisdom and virtue.

The 6 virtues:

1. Xi – virtue of learning.

 This virtue is important for many reasons, but probably the most important is due to the
danger of ignorance.
 The act of learning and living in wisdom brings with it virtue and a meaningful, impactful
life.
2. Zhi – virtue of character.

 Both zhi and xi state that a person is neither created good nor bad but is free to choose
how he or she will learn, grow, and progress.

3. Li – virtue of community and one's interaction and responsibilities toward others.

 About how people behave and treat each other.

 The idea is that the more fair and just someone is, the more these virtues will spread and
bring about a more fair and just society.

4. Yi – virtue of morality.

 Yi basically comes down to right action or the treatment of others in a right way.

5. Wen – virtue of leisure and self development.

 Wen is the concept of spreading beauty and meaning through developmental pursuits.
 wen is not interested in these pursuits as mere self-aggrandizement, but as a way to affect
other people and society as a whole in meaningful and significant way.

6. Ren – highest virtue.

 The culmination of all virtues and includes moral excellence, love, and all virtues at their
highest possible attainment.

ETHICAL PRINCIPLES

 Provide a foundation for nursing practice. Ethical principles are defined as basis for
nurse’s decisions on consideration of consequences and of universal moral principles
when making clinical judgements.
 4 principles – autonomy, nonmaleficence, beneficence, justice
 4 ethical rules – veracity, confidentiality, privacy, fidelity

AUTONOMY

 “Auto” – self; “Nomos” – governance

 Marks the significance of INDIVIDUAL AUTONOMY which mandates a strong sense
of personal responsibility for one’s own life.
 In health care – a form of personal liberty, where the individual is free to choose and
implement one’s own decisions, free from deceit, duress, constraint, or coercion.
  We act autonomously when our actions are the result of our own choices and decisions –
therefore AUTONOMY = SELF – DETERMINATION
 A recognition of autonomy is a recognition of inherent worth.
 What is this inherent worth? – Persons are by their very nature uniquely qualified to
decide what is in their own best interest
 To act autonomously is to decide for oneself on what to do (self-determination).
 We are exercising our autonomy to the fullest sense only when we are making
INFORMED decisions – by informed, meaning with relevant information and essential
conditions for decision-making.

4 principles of autonomy:

1. Harm principle – We may restrict the freedom of people to act if the restriction is necessary
to prevent harm to others. May be used to justify laws that exert coercive force and so restricting
the freedom of action.

2. Principle of paternalism – Paternalism – a type of human relationship in which one person

acts as a father figure and another acts as a child. In medicine, the view that the physician always
knows best

Weak version: We are justified in restricting someone’s freedom to act if doing so is necessary
to prevent him from harming himself.

Strong version: Justifies restricting someone’s autonomy if by doing so we can benefit him/her

3. Principle of legal moralism – Holds that a legitimate function of law is to enforce morality
by turning immoral into illegal.

4. Welfare principle – It is justifiable to restrict autonomy if doing so will result in providing

benefit to others.

BENEFICENCE – the practice of doing acts of goodness, kindness, and charity.

May be stated in 2 ways:

1. “Do not harm and produce the good”

2. “Do good and do no harm”

As to diseases, make a habit of 2 things:

1. To help – do only that which benefit the patient; produce/do what is good
2. At least to do no harm – patient’s welfare is the 1st consideration – in the best interest of the
patient; avoid harm

Code of ethics

 Ethics are so important to the nursing profession that the American Nurses Association
(ANA) created a specific Nursing Code of Ethics. The code defines ethical principles that
regulate how nurses should act to provide quality patient care.

NONMALEFICENCE

 “Above all, do no harm” is the most famous of all moral maxims in medicine.
 A physician should not by carelessness, malice, inadvertence, or avoidable ignorance do
anything that will cause injury to the patient.
 We violate the principle when we intentionally do something we know will cause
someone harm
 The principle of nonmaleficence does not require that a physician or any health care
professional subject a patient to no risks at all – every form of diagnostic testing and
medical treatment involves some degree of risk to the patient.

Nonmaleficence requires four things:

1. An act is not intrinsically wrong

2. A good effect is intended

3. The good effect isn't a by-product of a bad effect

4. The good outweighs the bad

PRINCIPLE OF JUSTICE

 Justice – basically means the rendering of what is due or merited

 Based on the most famous formulation by Aristotle – “equals must be treated equally,
and un-equals must be treated unequally”.
 Refers to the principle of EQUITY which describes fairness and impartiality regarding
equal access to health care and the allocation of scarce medical resources between two
individuals or to a group of persons who are in dire need of treatment.
2 types of justice:

1. Comparative justice - What an individual or group receives is determined by balancing the

completing claims of other individual or groups

2. Noncomparative justice - The distribution of medical goods or resources is determined by a

certain standard rather than by the needs or claims of individuals

VERACITY/CONFIDENTIALITY/AUTONOMY

TRUTH TELLING – Truth telling in medical ethics involves the moral duty to be honest with
patients about conditions, medications, procedures, and risks, and this can often be unpleasant,
but it is generally necessary.

CONFIDENTIALITY – Amongst the ethical principles of medicine, another major one is

confidentiality, or the obligation of a physician to keep a patient's health information private.

INFORMED CONSENT – Informed consent is the obligation of physicians to fully discuss

treatment options with patients and get their permission to proceed. This stems from the medical
ethical principle that patients should ultimately have control over their own bodies. So,
physicians are expected to make patients fully aware of the process, risks, benefits, side effects,
and expected results of every medical treatment option.