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Comparing and contrasting the major ethical theories through stories and classroom discussion

has allowed me to discover what theories may guide my behaviors, and eventually my physical

therapy practice. While each of the theories of Deontology, Utilitarianism, Virtue Ethics and

Ethics of Care have elements that I may utilize when I am faced with an ethical dilemma, I feel

that some of the theories guide and influence my behaviors more consistently than others.

Deontology is an ethical theory of conduct that is based on rules and moral principles. The

hierarchy of the principle will ultimately guide the behavior. For example, if I believe in always

telling the truth, all words and actions arise from this rule. The rules include the word “ought” to

reinforce following the action.1 Within Deontology there are hypothetical and categorical

imperatives.1 The hypothetical imperatives are more transient as they are related to a potentially

fleeting desire or goal. For example, if I wish to be a successful student, I “ought” to attend

classes and do the required assignments and exams. Yet, if it is not necessary anymore, the

hypothetical imperative is no longer applicable. Conversely, the categorical imperatives are

absolute commitments and moral obligations that must be followed. For example, if my patient

has a myocardial infarction, I would be obligated to call 911 for this medical emergency. Not

acting would be immoral and therefore it is my “duty” to follow the categorical imperative.

Immanuel Kant, one of the philosophers who contributed to Deontology, determined that “good

will” was the ultimate source of morality.1 According to Kant, when there is intentional effort to

do right and good especially amid adversity, this is commendable, more so than if the good will

happens unintentionally.1

Utilitarianism is an ethical theory that is centered around outcomes and consequences of

decisions. An individual’s behaviors and actions are dictated by the overall welfare expected
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because of the decision. The philosopher Betham suggested humans were motivated by the

emotional or cognitive states of “pleasure and pain”, using pleasure and happiness as synonyms.2

The four components of Utilitarianism include Consequentialism, Hedonism, Maximalism, and

Universalism.2 Consequentialism essentially says decisions should be based on the one that

creates the maximum welfare for the most people, independent of who those people may be.

Hedonism means that happiness is the primary goal of life and decisions are based on that goal.

Maximalism takes Hedonism a step further suggesting that the pursuit of happiness overrides

other basic rights, or if we maximize community happiness it is not important whether that

causes some people to suffer. Universalism means that all people’s happiness is treated equally

regardless of age, socio-economic status, race, etc. When faced with an ethical dilemma,

Utilitarianism decision-making weighs the potential pleasure and pain consequences of each

choice present. Ultimately, the decision is one that offers the greatest overall positive outcomes.

Virtue Ethics is a character-based ethical theory developed by the philosopher Aristotle that

looks at developing virtues to foster moral behavior and subsequently moral actions. Virtue

Ethics is also based on the “doctrine of the mean” which proposes to find the balance between

two extremes of behavior considered the excess vice and the deficiency vice.3 The mean of the

two vices is considered “virtue” and used for decision making and actions.3 Therefore, if we

have a tendency toward one extreme we would be encouraged to move toward the other extreme

to balance our natural propensity. This in turn may lead to imbalance if taken too far to the other

extreme. Furthermore, Aristotle defined the “final good” towards which virtues should strive as

happiness, but happiness may not be a universally accepted definition.3 For instance, two

individuals may potentially disagree over what happiness entails for them.
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The Ethics of Care is based on relationships and considering all the parties (including oneself)

involved when making decisions and ensuing actions. The ultimate decision will impact all the

parties involved differently but the decision will be the most benign for as many people involved.

This theory was developed by Carol Gilligan as a response to the Kohlberg’s theory of moral

development of children, which should be more clearly defined as development of boys as his

research was solely with young males.4 The Ethics of Care has four components, “Moral

Attentiveness”, “Sympathetic Understanding (Responsibility)”, “Competence” and “Harmony

(Responsiveness)”.4 Attentiveness implies the observational skill to become aware of another’s

needs. Responsibility represents the willingness to act on what you observed through

attentiveness. Competence, as in the definition of the word itself, suggests the capacity and

capability to meet identified Responsibility. Responsiveness means observing how the other

person reacts to your actions, allowing supportive and patient centered care.

While each of the theories may have a role in clinical practice, there may be some theories that

are more advantageous for decision making. An ethical scenario in clinical practice could be

treating a patient in severe pain, which perhaps brought out qualities in that person that are

unfriendly and hurtful. Under Deontology, that engenders us to follow Kant’s principle of good

will; it is the therapist’s duty to care for the patient and to intentionally do what is right and good

even when it is difficult to set aside the emotions that emerge from being treated poorly.

Similarly, Ethics of Care would suggest that the health care provider observe the patient reaction

and respond by attempting to nurture towards a better outcome for the patient and involved

parties. In contrast, Utilitarianism could create more ambiguous outcomes because perhaps the

maximum happiness of the situation would prioritize the health care provider’s mental welfare

over the patient’s need for treatment. Virtue Ethics would suggest a provider start with a middle
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ground approach by using such virtues as patience but could also say they needed the courage to

inform the patient that they would be better served by another provider if the verbal abuse was

untenable.

Within clinical practice, understanding and adhering to Medicare rules is another scenario where

different ethical theories may yield different decisions. For example, this summer my clinical

instructor had to be with me at all times during my care of a patient with Medicare because rules

mandated a licensed professional supervise at all times. In addition, we had to finish the therapy

session for the Medicare patient before beginning another patient’s therapy. Deontology would

likely lead a physical therapist to follow the rules of the facility, they might feel a duty to follow

the rules of Medicare, regardless of whether the student physical therapist was prepared to treat

the patient independently. Similarly, Virtue Ethics, might prioritize moderation, and the ability to

serve future Medicare patients in need involved following the rules. Further, Virtue Ethics in the

physical therapy profession aligns with the APTA Core Values such as accountability and

integrity, which would also lead to following the Medicare rules.5 Ethics of Care could

emphasize the responsibility of responsiveness to all patients over Medicare rules governing the

care of one, potentially leading to bending the Medicare rules to serve more patients. This

decision making would fall in the conventional stage of Gilligan’s Stages of Moral Development

putting the needs of others first.4 Utilitarianism might argue that the overall welfare of the health

care organization and the ability to care for Medicare patients provided the most advantageous

outcomes for the community; achieving this outcome requires following the rules.

The most appealing ethical theory to me is the Ethics of Care. After listening to Gilligan speak

about the origin of her theory, I realized how this theory is grounded in caring about other people
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as well as ourselves in the equation of making decisions. Gilligan stated, “We live on a

trampoline, we move someone else moves.”4 This statement captures the potential ripple effect of

our actions, not only our move but the amount of impact it will have on all parties involved. I

hope to explore pediatric physical therapy and Ethics of Care theory works well as it considers

the child, the family, the culture, the teachers, the caregivers as important in the decision making

process. Having worked and volunteered in the field of education, gathering all perspectives in

decision making is essential to achieve optimal outcomes for the child. The next theory I relate to

is the Virtue Ethics. I feel as this theory tries to find balance between two extreme notions of

ideas. I have always tried to live a life that is centered in finding balance, which aligns to this

philosophy. The third theory I would rank is Deontology, as having rules to live by may help to

guide behaviors when faced with urgent decisions in which there may not be time for reflection

and contemplation. However, Deontology may not always lead to optimal real-world decision

making. The last theory in my hierarchy is Utilitarianism, where decision making is based on

beneficial consequences and outcomes. While intellectually this is appealing, in practice I

personally have a hard time sacrificing some people’s welfare for the larger benefit of others.

You may find that you are not living in the moment and considering the things that are in front of

you, this in turn may cause unintended harm or damage.

Reflecting on each of the ethical theories in depth has helped develop a framework for improved

decision making when faced with ethical dilemmas in clinical practice. However, with a wide

range of personalities and a variety of ways to interpret ethical behavior, components of the all

the theories may be seen in clinical decision making and practice. Using this knowledge will not

only assist with my own judgment but also in better understanding the decisions and actions of

others.
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References:

1. Silkwood-Sherer D. Deontology. Presented as part of PTH 695 Ethics in Physical

Therapy at: Central Michigan University Physical Therapy Program, Central Michigan
University; January 31, 2023; Mount Pleasant, MI.
2. Silkwood-Sherer D. Utilitarianism. Presented as part of PTH 695 Ethics in Physical
Therapy at: Central Michigan University Physical Therapy Program, Central Michigan
University; February 7, 2023; Mount Pleasant, MI.
3. Silkwood-Sherer D. Virtue Ethics. Presented as part of PTH 695 Ethics in Physical
Therapy at: Central Michigan University Physical Therapy Program, Central Michigan
University; February 14, 2023; Mount Pleasant, MI.
4. Silkwood-Sherer D. Ethics of Care. Presented as part of PTH 695 Ethics in Physical
Therapy at: Central Michigan University Physical Therapy Program, Central Michigan
University; February 21, 2023; Mount Pleasant, MI.
5. Core Values for the Physical Therapist and Physical Therapy Assistant. American
Physical Therapy Association website. Updated 2021.https://www.apta.org/apta-and-
you/leadership-and-governance/policies/core-values-for-the-physical-therapist-and-
physical-therapist-assistant. Accessed February 20, 2023.
6. Doherty RF, Purtilo RB. Ethical Dimensions in the Health Professions. 6th ed. St. Louis,
MO: Elsevier; 2016.
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