ETHICAL THEORIES

Sigfredo M. Solano, MD,DHPEd

ETHICS
• From Greek ethos, meaning “disposition” or “character”
• Major ancient Greek philosophers: Socrates, Plato , Aristotle, 5 th
century (B.C.E.) Athens, advocated virtue ethics, emphasizing
acquiring good traits of character.
• Inseparable from Greek phrase ethike aretai (skills of
character)
• Homer (8th-6th B.C.E.) emphasized ethike arêtai, the scope of
ethical inquiry was limited to the roles one fulfilled.
ETHICS
• Role-defined ethics – basis on which more universal principles
build.
• Socrates, Plato & Aristotle transcend role-defined ethics and
argued for distinctive ethike aretai of a good person.
• Cardinal virtues: courage, temperance, wisdom, justice
• “What virtues should a good physician possess?”
• “What should a physician do?”
ETHICS
• Hippocrates and colleagues adopted patient-centered ethics
and sanctity-of-life view.
• Greek physicians took naturalistic approach (based on one
what could see and feel) , adopted a quality-of-life view.
CHRISTIAN ETHICS
• 4th century C.E., Christian virtues of faith, hope and charity.
• Compassion (charity) emphasis on helping others.
• Etymology, “to suffer with”
• Naturalistic physicians  technical competence in curing
disease.
• Religious physicians  compassion in being with patients.
• Compassion = the supreme virtue
• Every patient wants a physician who is knowledgeable and
merciful.
CHRISTIAN ETHICS
• Every patient wants a physician who is knowledgeable and
merciful.
• Virtue ethics in medicine ; apprentice system in medical
education
• What is taught is how to be compassionate, wise, courageous
and patient-centered.
• Physician-in-training should imitate the reasoning and empathy
of good physicians.
Differences:
• Greek ethics – elitist,
perfectionistic, aristocratic,
meritocratic and quality-of-life
attitude
• Advocated eugenics (“good
birth”) ; “most perfect”
• Perfect humanity; Greek
gentlemen should try to
perfect his body and life as a
work of art
• Hippocratic physicians – less
elitist and sanctity-of-life ethics
• Three western religions duties
to the poor and sick; care for
the poor
• Western religions – resisted
with tampering of genes of
humans; humans created in
the image of God ; not to
perfect through genetics
Limitations of Virtue Ethics
1. How to make a particular ethical decision
2. Ethics become more role-defined, the less it meets universal
standards
3. Emphasize status quo over fundamental, social change
Kantian Ethics: Elements
1. Ethics is not a Matter of Consequences but of Duty
 Why an act is done is more important than its good or bad
results.
An act must be done from the right motive.
 The right motive is the desire to do one’s moral duty.
• An ethics of duty (deontological), from “deontos” (duty)
 Acting correctly according to obligation.
• When we act morally, reason tells feelings what to do.
• Kant: the only thing valuable is goodwill ( a willingness to choose
the right act because it is right) Q: How do we know what is right?
Kantian Ethics: Formulations
a) A right act has a maxim that is universalizable.
 An act is right if one can will its “maxim” or rule to be acted
on by all others.
b) A right act always treats other humans as ends-in-themselves,
never as mere means.
 To treat another person as having absolute, infinite moral
worth.
Kantian Ethics:
2. People are only free when they act rationally.
 The person acts morally when she exercises her rational
free will to understand when certain rules are right and then
chooses to bind her actions to those rules.
 Kant calls the capacity to act this way as autonomy (gives
humans higher worth than animals)
 For Kant, very few people act morally.
Problems in Kantian Ethics
1. Kant regarded as supreme rationalist in ethics.
2. Kant is regarded as failing in his Enlightenment Project.
 Hume: argued ethics is emotivism.
 Emotivism and Rationalism are two extreme views on the
issue of reason in ethics.
3. Kant fails how to resolve conflicts between competing,
universalizable maxims.
4. Kant fails to deliberate trade-offs in triage situations.
Kant’s Reply to Critics
• Provides insights to medical ethics.
• To distribute life saving drug, favors lottery.
• Emphasis on people as “ends in themselves” explained the
scandals of human experimentation by Nazi physicians.
• Most important legacy in medical ethics: “autonomous will” of
free rational individual (seat of moral value)
• Autonomy explains why informed consent is necessary to
participate in an experiment.
Social Contract Theory or Contractarianism
• Secular, independent of belief in God.
• People are fundamentally self-interested ; moral rules evolved for
humans to get along with one another.
• Rational for humans to agree to such rules.
• By use of reason, people realize that each is better off in a society
of moral and legal rules backed by the force of opinion and law.
 form a social contract to create “society” to better themselves
Two champions:
1. Libertarians
2. Rawlsians
Social Contract Theory or Contractarianism
• Libertarians (Robert Nozick)
have no government control over their business.
disfavor government programs i.e. Medicare, Medicaid,etc
oppose forced taxation by government.
• Rawlsians (John Rawls)
Social contract should have moral restraints imposed on it.
Rawls’ veil of ignorance (in hypothetical social contract, no one
would know his age, gender, race, health, number of children,
income, wealth or other arbitrary personal information)
Contractarian because people are self-interested and form social
contract.
Social Contract Theory or Contractarianism
• Rawlsians (John Rawls)
People are self-interested and form social contract
Rational way to choose under the veil of ignorance, be the
least well-off person in society (a person does not know
anything personal under the veil)
Choice of difference principle: opt for institutions creating
equality
Rawlsian justice entails that every citizen should have equal
access to medical care ; reduce the natural inequalities of fate.
Children and those with genetic diseases must have good
medical care
 Social Contract Theory or Contractarianism
• Libertarians favor private medical insurance plans in which the
healthy do not subsidize the unhealthy
 allow for profit companies to practice experience rating
• Rawlsians see “healthy” and “unhealthy” as arbitrary distinction
 favor community rating
Natural Law Theory (Thomas Aquinas)
• Explicit about the connection between God and natural laws.
• A rational God made the world work rationally and gave humans reason to
discover his rational natural laws. ; revealed rules how human should act.
• To act rationally was to act morally which was to act in accordance to
natural law.
• Ethics was a matter of following rules laid down by God and his agents.
Ex: sexual relations between man and wife as natural, homosexuality, IVF
1. Doctrine of Double effect
2. Principle of Totality
Natural Law Theory (Thomas Aquinas)
• Conditions to be satisfied in Doctrine of Double Effect:
1. The action was good in itself and not evil.
2. The good effect followed as immediately from the cause as
did the evil effect.
3. Only the good effect was intended.
4. There was as important a reason for performing the action as
for allowing the evil effect.
Ex: ectopic pregnancy, cancerous uterus
Natural Law Theory (Thomas Aquinas)
• Principle of Totality
Changes made to the human body are permitted only to
ensure the proper functioning of the body.
 Ex: amputation of gangrenous leg, removal of cancerous
breast
 Violation of the principle (bodily integrity): sterilization
procedures like vasectomy, tubal ligation, hysterectomy, cosmetic
surgery, breast reduction, breast augmentation, rhinoplasty,
liposuction
Utilitarianism
1. Jeremy Bentham (1748 – 1832)
2. John Stuart Mill (1806 – 1873)
• Right acts should produce the greatest amount of good for the
greatest number of people (“utility”).
Utilitarianism
Four Basic Tenets:
1. Consequentialism: consequences count, not motives or intentions
2. The maximization principle: The number of people affected by
consequences matters; the more people, the more important the
effect
3. A theory of value (or of “good”): Good consequences are defined
by pleasure (hedonic utilitarianism) or what people prefer
(preference utilitarianism)
4. A scope-of-morality premise: Each being’s happiness is to count
as one and no more.
Utilitarianism
• For utilitarians, right acts produce the greatest amount of good
consequences for the greatest number of beings.
• A theory of value (about what is a harmful consequence and abut
what is a good one)
1. Hedonic utilitarianism – good consequence with pleasure
2. Negative utilitarianism – reliving the greatest misery for the
greatest number
3. Positive utilitarianism – benefitting humanity
4. Preference utilitarianism – utility is maximized by furthering the
actual preferences that people have
5. Pluralistic utilitarians – many different things or states are valuable
Utilitarianism
• Distinguish between act and rule utilitarianism:
• Rule utilitarians believe that the normal moral rules maximize utility
Ex: First, do no harm
• Act utilitarians advocate judging each act’s utility
• Applications of utilitarianism:
1. Public health
2. Triage situations – apportionment of scarce resources during
emergencies ; maximizes the value of life in saving the maximal
number of people who will eventually live.
• A physician should not treat each patient equally but should focus only
on those whom he can actually benefit.
• Goal: save the maximum number of lives
Principles
1. Autonomy – right to make decisions about one’s own life and
body without coercion by others ; a rejection of paternalistic
ethics.
2. Beneficence – “doing good to others”; compassion and
helping others ; can be both a principle and virtue to
physicians; can sometimes come in conflict with autonomy.
3. Nonmaleficence – “not harming others” or “First, do no harm”;
accords with Mill’s harm principle and contractarianism.
4. Justice – has both social and political interpretation; requires
physicians to treat patients impartially without bias.
Feminist Ethics: The Ethics of Care
• Feminist theorists (Carol Gilligan): notion of theories of ethics
were more of caring, trust and relationships than rights or
universalization
• The ethics of care considered a branch of virtue ethics that
promote the female virtues of caring, nurturing, trust, intimate
friendship and love
• Seen as an antidote to moral views that are cast only in terms
of rights, utility and duty.
Case-Based Reasoning
• Same as an ancient method of theological reasoning called
“casuistry”
• Ethical theories and moral reasoning play roles in moral life.
• Ex: case of Karen Quinlan and Nancy Cruzan
• Does not deny that overarching ethical principle of morality can
guide us in making day-to-day ethical decisions.
Thank you!