COURSECODE: NCM-6308/NCM-5308 BIOETHICS/MIDTERMS

ETHICAL DECISION MAKING

Ethical decision-making refers to the process of evaluating and
choosing among alternatives in a manner consistent with ethical
principles. In making ethical decisions, it is necessary to perceive and
eliminate unethical options and select the best ethical alternative.

The process of making ethical decisions requires:

1. Commitment: The desire to do the right thing regardless of the

cost
2. Consciousness: The awareness to act consistently and apply
moral convictions to daily behavior
3. Competency: The ability to collect and evaluate information,
develop alternatives, and foresee potential consequences and
risks

Good decisions are both ethical and effective:

• Ethical decisions generate and sustain trust; demonstrate

respect, responsibility, fairness and caring; and are consistent
with good citizenship. These behaviors provide a foundation for
making better decisions by setting the ground rules for our
behavior.
• Effective decisions are effective if they accomplish what we want
accomplished and if they advance our purposes. A choice that
produces unintended and undesirable results is ineffective. The
key to making effective decisions is to think about choices in
terms of their ability to accomplish our most important goals.
This means we have to understand the difference between
immediate and short-term goals and longer-range goals.
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DEONTOLOGICAL ETHICS:

The word deontology derives from the Greek words for duty
(deon) and science (or study) of (logos). In contemporary moral
philosophy, deontology is one of those kinds of normative theories
regarding which choices are morally required, forbidden, or
permitted. In other words, deontology falls within the domain of
moral theories that guide and assess our choices of what we ought
to do (deontic theories), in contrast to those that guide and assess
what kind of person we are and should be (aretaic [virtue] theories).

In deontological ethics an action is considered morally good

because of some characteristic of the action itself, not because the
product of the action is good. Deontological ethics holds that at least
some acts are morally obligatory regardless of their consequences for
human welfare. Descriptive of such ethics are such expressions as
“Duty for duty’s sake,” “Virtue is its own reward,” and “Let justice be
done though the heavens fall.”

The first great philosopher to define deontological principles

was Immanuel Kant, the 18th-century German founder of critical
philosophy. Kant held that nothing is good without qualification except
a good will, and a good will is one that wills to act in accord with
the moral law and out of respect for that law rather than out of natural
inclinations. He saw the moral law as a categorical imperative—i.e., an
unconditional command—and believed that its content could be
established by human reason alone. Thus, the supreme
categorical imperative is: “Act only on that maxim through which you
can at the same time will that it should become a universal law.” Kant
considered that formulation of the categorical imperative to be
equivalent to: “So act that you treat humanity in your own person and
in the person of everyone else always at the same time as an end and
never merely as means.” The connection between those two
formulations, however, has never been entirely clear. In any event,
Kant’s critics questioned his view that all duties can be derived from a
purely formal principle and argued that, in his preoccupation with
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rational consistency, he neglected the concrete content of moral

obligation.

TELEOLOGICAL ETHICS:

Teleological ethics, from Greek telos, “end”; logos, “science”, is

a theory of morality that derives from duty or moral obligation from
what is good or desirable as an end to be achieved. Also known as
consequentialist ethics, it is opposed to deontological ethics (from
the Greek deon, “duty”), which holds that the basic standards for an
action’s being morally right are independent of the good or evil
generated.
Teleological theories differ on the nature of the end that
actions ought to promote. Eudaemonist theories
(Greek eudaimonia, “happiness”), which hold that ethics
consists in some function or activity appropriate to man as
a human being, tend to emphasize the cultivation of virtue or
excellence in the agent as the end of all action. These could be
the classical virtues—courage, temperance, justice, and
wisdom—that promoted the Greek ideal of man as the “rational
animal”; or the theological virtues—faith, hope, and love—that
distinguished the Christian ideal of man as a being created in
the image of God.

Teleological ethics

1. Consequentialism

Consequentialist ethics come from the teleological branch of ethical

theory. You will remember that teleological theories focus on the goal of
the ethical action. Consequentialist theories are those that base moral
judgements on the outcomes of a decision or an action. If the outcomes
of an action are considered to be positive, or to give rise to benefits, then
that action is held to be morally right. Conversely, if the outcome causes
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harm, then the action is held to be morally wrong. The judgement of right
or wrong depends on the consequences of the decision or action. The two
main consequentialist theories considered here
are egoism and utilitarianism.

1. Egoism

Egoism is the theory that one's self is, or should be, the motivation
for all of our actions. It is worth distinguishing between egoism as
a descriptive argument (an argument that tells us how the world
actually is) and egoism as a normative argument (an argument that
tells us how the world ought to be). Egoism as a descriptive
argument describes human nature as self-centered. In its strongest
form, it argues that individuals only ever act in their own self-
interest. Even where they appear to be acting in others' interests,
descriptive egoism explains that the person is really motivated by
their own self-interest disguised by arguments (rationalizations) of
'doing one's duty' or 'helping others'. In fact, our motivation behind
doing 'good deeds' may be to make ourselves feel good; to make
ourselves look good in the eyes of others; or because we believe that,
by helping others, others will help us. Even if we donate money to
charity anonymously, we may still only really do this because it
makes us feel good about ourselves. In contrast, egoism as a
normative argument tells us that we should be acting in our own
interests, as this is the only way that overall welfare can be
improved. If everyone acts in their own self-interest, then society will
become more efficient, which will be in everyone's interest. It is
therefore morally right to pursue one's own self-interest.

2. Utilitarianism
The modern form of the consequentialist theory of
utilitarianism derives from 19th century British philosophers
such as Jeremy Bentham and John Stuart Mill, and it has been
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particularly influential in areas of the world influenced by

British culture. Rather than maximize individual welfare,
utilitarianism focuses on collective welfare and it identifies
goodness with the greatest amount of good for the greatest
number of people: the 'greatest happiness principle'. So
maximizing benefits for the greatest number of people involves
net assessments of benefit: utility is the net result of benefits
and 'disbenefits' - or costs. Utility has entered modern
economics as a key quantitative concept. The concept of trade-
offs is specifically embraced and social and environmental cost-
benefit analyses are explicit utilitarian tools for assessing the
goodness of an action. A simple balance sheet of costs and
benefits can be drawn up to assess the overall utility of a
decision.

Utilitarianism has three essential elements:

a) Whether an action is right or wrong is determined solely

by its consequences.
b) The value of the consequences of an action is assessed in
terms of the amount of happiness or well-being caused.
c) In assessing the total happiness caused to a number of
people, equal amounts of happiness are to have equal
value, no one person's happiness having greater value that
another's.

3. Virtue Ethics

Another branch of the teleological strand of ethics is that

of 'being good'. The most well-known of these ethical theories is
virtue ethics. Virtue ethics shifts the analytical emphasis away
from rule-based decision-making (of deontological ethics) or of
the consequences of an action (eg in utilitarianism) towards the
ethics of individuals and the ethics of human character. So, for
example, where a utilitarian would argue that giving to a charity
maximizes well-being in society, and a deontologist would argue
that we have a duty to help others, a virtue ethicist would point
to the fact that helping others displays desirable virtues such
as being charitable or benevolent. Other desirable virtues
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include honesty, courage, friendship, mercy, loyalty, modesty,

patience, and so on. The opposite of virtues is vices.

Natural Law vs Divine Command Theory

Can we have ethics without religion?

The Divine Command Theory of Morality (DCT) is a relatively

simple theory of moral obligation that equates our moral duties to
the commandments of God:

• X is morally obligatory if and only if God has commanded X.

• Y is morally prohibited if and only if God has forbidden Y.

Moreover, the DCT holds that God’s commands are the source
of morality. Consider, for example, the seventh commandment, “thou
shall not commit adultery.” Assuming that God exists and has indeed
issued this command, then, according to the DCT, it is morally wrong
to commit adultery. If God does not exist or has not issued the
command, then adultery is morally permissible.

The motivation behind this theory is obvious: with its universal

rules, the DCT at once solves challenges of relativism and of why one
ought to be moral. Furthermore, the DCT emphasizes the idea that
moral commands are overriding, in the sense that they trump other
motivations such as convenience or self-interest. Other theories seem
deficient in these respects. For example, one might attempt to
support a rule prohibiting adultery on consequentialist grounds,
pointing out the likelihood that adultery leads to suffering.

The DCT is interesting in that, in contrast with most other

theories of ethical action, it emphasizes obedience or submission as
a central virtue—not obedience in general, of course, but to God and
perhaps to God’s representatives. The idea of moral autonomy, of
determining the right course of action using one’s reason, is not
emphasized. One does need to use reason, perhaps to determine
whether an action falls under the scope of a particular
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commandment, but the principal virtue for the DCT is obedience to

the will of God. This may for some people be attractive as it offers an
escape from the weighty demands of moral judgment; one essentially
transfers responsibility to a third party. One major religion reflects
this idea in its very name: in Arabic, “Islam” means submission, and
a “Muslim” is one who submits (to Allah).

On the other hand, the Natural Law Theory of Morality (NLT) is

a legal theory that recognizes law and morality as deeply connected,
if not one and the same. Morality relates to what is right and wrong
and what is good and bad. Natural law theorists believe that human
laws are defined by morality, and not by an authority figure, like a
king or a government. Therefore, we humans are guided by
our human nature to figure out what the laws are, and to act in
conformity with those laws.
The term 'natural law' is derived from the belief that human
morality comes from nature. Everything in nature has a purpose,
including humans. Our purpose, according to natural law theorists,
is to live a good, happy life. Therefore, actions that work against that
purpose -- that is, actions that would prevent a fellow human from
living a good, happy life -- are considered 'unnatural', or 'immoral'.
Laws have a purpose too: to provide justice. From a natural law
perspective, a law that doesn't provide justice (an unjust law) is
considered 'not a law at all.' Therefore, a law that is flawed is one that
no one should follow. In short, any law that is good is moral, and any
moral law is good. Legal positivism is a legal theory that is the
opposite of the natural law theory. Legal positivists believe that a law
can be deeply flawed, and yet still be considered a law.

DOCTRINE OF DOUBLE EFFECT

This doctrine says that if doing something morally good has a
morally bad side-effect it's ethically OK to do it providing the bad
side-effect wasn't intended. This is true even if you foresaw that the
bad effect would probably happen.
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The principle is used to justify the case where a doctor gives

drugs to a patient to relieve distressing symptoms even though he
knows doing this may shorten the patient's life.This is because the
doctor is not aiming directly at killing the patient - the bad result of
the patient's death is a side-effect of the good result of reducing the
patient's pain.

Factors involved in the doctrine of double effect

• The good result must be achieved independently of the bad
one: For the doctrine to apply, the bad result must not be
the means of achieving the good one. So if the only way the
drug relieves the patient's pain is by killing him, the doctrine
of double effect doesn't apply.
• The action must be proportional to the cause: If I give a
patient a dose of drugs so large that it is certain to kill them,
and that is also far greater than the dose needed to control
their pain, I can't use the Doctrine of Double Effect to say that
what I did was right.
• The action must be appropriate (a): I also have to give the
patient the right medicine. If I give the patient a fatal dose of
pain-killing drugs, it's no use saying that my intention was to
relieve their symptoms of vomiting if the drug doesn't have any
effect on vomiting.
• The action must be appropriate (b): I also have to give the
patient the right medicine for their symptoms. If I give the
patient a fatal dose of pain-killing drugs, it's no use saying that
my intention was to relieve their symptoms of pain if the
patient wasn't suffering from pain but from breathlessness.
• The patient must be in a terminal condition: If I give the
patient a fatal dose of pain-killing drugs and they would have
recovered from their disease or injury if I hadn't given them the
drugs, it's no use saying that my intention was to relieve their
pain. And that applies even if there was no other way of
controlling their pain.
 COURSECODE: NCM-6308/NCM-5308 BIOETHICS/MIDTERMS

Problems with the doctrine of double effect:

Some philosophers think this argument is too clever for its own
good.

1. We are responsible for all the anticipated consequences of

our actions: If we can foresee the two effects of our action we
have to take the moral responsibility for both effects - we can't
get out of trouble by deciding to intend only the effect that suits
us.
2. Intention is irrelevant: Some people take the view that it's
sloppy morality to decide the rightness or wrongness of an act
by looking at the intention of the doctor. They think that some
acts are objectively right or wrong, and that the intention of the
person who does them is irrelevant. But most legal systems
regard the intention of a person as a vital element in deciding
whether they have committed a crime, and how serious a crime,
in cases of causing death.
3. Death is not always bad - so double effect is
irrelevant: Other philosophers say that the Doctrine of Double
Effect assumes that we think that death is always bad. They say
that if continued life holds nothing for the patient but the
negative things of pain and suffering, then death is a good thing,
and we don't need to use the doctrine of double effect.
4. Double effect can produce an unexpected moral result: If
you do think that a quicker death is better than a slower one
then the Doctrine of Double Effect shows that a doctor who
intended to kill the patient is morally superior to a doctor who
merely intended to relieve pain.

RAWLS’ THEORY OF JUSTICE

Justice as fairness is Rawls's theory of justice for a liberal
society. As a member of the family of liberal political conceptions of
justice it provides a framework for the legitimate use of political
power. Yet legitimacy is only the minimal standard of moral
acceptability; a political order can be legitimate without being just.
 COURSECODE: NCM-6308/NCM-5308 BIOETHICS/MIDTERMS

Justice sets the maximal standard: the arrangement of social

institutions that is morally best.
Rawls constructs justice as fairness around specific
interpretations of the ideas that citizens are free and equal and that
society should be fair. He sees it as resolving the tensions between
the ideas of freedom and equality, which have been highlighted both
by the socialist critique of liberal democracy and by the conservative
critique of the modern welfare state. Rawls holds that justice as
fairness is the most egalitarian, and also the most plausible,
interpretation of these fundamental concepts of liberalism. He also
argues that justice as fairness provides a superior understanding of
justice to that of the dominant tradition in modern political thought:
utilitarianism.

The Two Principles of Justice as Fairness

These guiding ideas of justice as fairness are given institutional
form by its two principles of justice:
o First Principle: Each person has the same indefeasible
claim to a fully adequate scheme of equal basic liberties;
which scheme is compatible with the same scheme of
liberties for all;
o Second Principle: Social and economic inequalities are to
satisfy two conditions:
▪ They are to be attached to offices and positions open
to all under conditions of fair equality of opportunity;
▪ They are to be to the greatest benefit of the least-
advantaged members of society (the difference
principle).
The first principle of equal basic liberties is to be embodied in
the political constitution, while the second principle applies primarily
to economic institutions. Fulfillment of the first principle takes
priority over fulfillment of the second principle, and within the second
principle fair equality of opportunity takes priority over the difference
principle. The first principle affirms that all citizens should have the
familiar basic rights and liberties: liberty of conscience and freedom
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of association, freedom of speech and liberty of the person, the rights

to vote, to hold public office, to be treated in accordance with the rule
of law, and so on. The first principle accords these rights and liberties
to all citizens equally. Unequal rights would not benefit those who
would get a lesser share of the rights, so justice requires equal rights
for all, in all normal circumstances.
Rawls's first principle confirms widespread convictions about
the importance of equal basic rights and liberties. Two further
features make this principle distinctive. First is its priority: the basic
rights and liberties must not be traded off against other social goods.
The first principle disallows, for instance, a policy that would give
draft exemptions to college students on the grounds that educated
civilians will increase economic productivity. The draft is a drastic
infringement on basic liberties, and if a draft is implemented then all
who are able to serve must be equally subject to it, even if this means
slower growth. Citizens' equal liberty must have priority over
economic policy.
The second distinctive feature of Rawls's first principle is that it
requires fair value of the political liberties. The political liberties are
a subset of the basic liberties, concerned with the right to hold public
office, the right to affect the outcome of national elections and so on.
For these liberties, Rawls requires that citizens should be not only
formally but also substantively equal. That is, citizens who are
similarly endowed and motivated should have similar opportunities
to hold office, to influence elections, and so on regardless of how rich
or poor they are. This fair value proviso has major implications for
how elections should be funded and run, as will be discussed below.
Rawls's second principle of justice has two parts. The first part,
fair equality of opportunity, requires that citizens with the same
talents and willingness to use them have the same educational and
economic opportunities regardless of whether they were born rich or
poor. “In all parts of society there are to be roughly the same
prospects of culture and achievement for those similarly motivated
and endowed”
 COURSECODE: NCM-6308/NCM-5308 BIOETHICS/MIDTERMS

Self Assessment Task:

1. Read the following Case Study. What can you use as a guide in Decision
making based on the ethical duties that we have discussed. Justify your
answer:

A. Patient J, a man 35 years of age, was involved in a fight and sustained a

large laceration to the center of his forehead. The patient presents to the
emergency department alert and oriented without significant findings
other than the 10-cm laceration. However, his speech is slurred, and he
readily admits to drinking 10 beers during the last few hours. The
emergency department is very busy with more urgent cases, and the
patient becomes impatient because of the wait. Patient J wishes to leave,
but is urged by the ED staff to wait and is told that he should not drive.
He is clearly lucid and states that he will not wait any longer and intends
to drive himself home.

Using the acronym R.O.L.E. as their framework, note that the authors
identify the same decision-making issues as the framework and algorithm
examples discussed in this course.

R: Risks of medical treatment. In this case the proposed treatment bears

little risk to the patient. Few people have life-threatening complications
from laceration repair; therefore, the chance of the patient experiencing
untoward harm from the procedure is remote.
O: Opinion of the patient. Why does the patient want to leave the
emergency department? Does he understand the risks and benefits of
the procedure? Is he competent to make this decision in his intoxicated
state?
L: Life quality. Will not having the laceration repaired significantly affect
the patient's quality of life? Would an unsutured wound healing for an
extended period affect the patient in his profession and render him
unable to earn a living? For example, would he be unable to wear
required safety equipment, such as a helmet or goggles, because of the
laceration? Is the patient involved in a profession, such as acting, where
a potentially disfiguring scar could affect his career?
E: External factors. Is there any obligation on the part of the healthcare
team to third parties (i.e., those who may be traveling at the same time
as the patient and who may be endangered from a safety standpoint)?
 COURSECODE: NCM-6308/NCM-5308 BIOETHICS/MIDTERMS

REFERENCES:
1.https://blink.ucsd.edu/finance/accountability/ethics/process.ht
ml
2. https://plato.stanford.edu/entries/ethics-deontological/
3. https://www.britannica.com/topic/deontological-ethics
4. https://www.britannica.com/topic/teleological-ethics
5. https://www.soas.ac.uk/cedep-
demos/000_P563_EED_K3736-Demo/unit1/page_17.htm
6. https://press.rebus.community/intro-to-phil-
ethics/chapter/can-we-have-ethics-without-religion-on-divine-
command-theory-and-natural-law-theory/
7. https://study.com/academy/lesson/natural-law-theory-
definition-ethics-
examples.html#:~:text=Natural%20law%20theory%20is%20a%20leg
al%20theory%20that%20recognizes%20law,a%20king%20or%20a%
20government.
8.
http://www.bbc.co.uk/ethics/euthanasia/overview/doubleeff
ect.shtml#:~:text=Print%20this%20page-
,The%20doctrine%20of%20double%20effect,bad%20effect%20would
%20probably%20happen.
9.
https://plato.stanford.edu/entries/rawls/#JusFaiJusWitLibS
oc