Write a Standards of Behavior for a hospital you lead. This document will be used to govern the behavior of every employee, including yourself, and the Governing Board. Be concise but thorough. Consider what behavior you want people to display rather than behavior you do not want them to display.
Example of a Standard of Behavior category: Compassion – representatives of XYZ hospital will interact with each other and those they serve with compassion.
HEALTH
CARE
ETHICS
Critical Issues for the 21st Century
FOURTH EDITION
Edited by
Eileen E. Morrison, EdD, MPH, LPC, CHES
Professor, School of Health Administration
Texas State University, San Marcos
San Marcos, Texas
Beth Furlong, PhD, JD, RN
Associate Professor Emerita, Center for Health Policy and Ethics
Creighton University
Omaha, Nebraska
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Title: Health care ethics: critical issues for the 21st century / edited by
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Description: Fourth edition. | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2017043204 | ISBN 9781284124910 (pbk.: alk. paper)
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Writing is always a collaboration. While writers have
unique ways of seeing the world, they are influenced
by their experiences, research, and education.
Therefore, I dedicate this edition of Health Care
Ethics: Critical Issues for the 21st Century to all
those who contributed to chapters in this work
and those who supported me through its creation.
First, there is my immediate family, Grant, Kate,
Emery Aidan, and Morrigan Leigh, who listened and
encouraged. There are also colleagues, relatives,
and friends who provided feedback and a lift of
spirit when I needed it. Finally, there is my publisher,
Michael Brown; my coeditor, Beth Furlong; and my
Jones & Bartlett Learning editor, Danielle Bessette.
They each added much to the quality and integrity of
this work.
–Eileen E. Morrison
Mentors facilitate one’s journey. My gratitude goes
to Dr. Amy Haddad and colleagues at Creighton
University’s Center for Health Policy and Ethics. I value
the ever-present support of my husband, Robert
Ramaley. Furthering the ethics education of others
with this book is possible because of the collegiality
and support of my coeditor, Dr. Eileen Morrison. It has
been a professional pleasure to work with her.
–Beth Furlong
© f11photo/Shutterstock
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
About the Editors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
PART I Foundations in Theory
1
Chapter 1 Theory of Healthcare
Ethics. . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ethics and Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ethical Relativism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Ethics Theories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Ethics Theories and Their Value to
Healthcare Professionals. . . . . . . . . . . . . . . . . . . . . . . 30
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . . 31
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 2 Principles of Healthcare
Ethics. . . . . . . . . . . . . . . . . . . . . . 41
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Nonmaleficence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Beneficence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Autonomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
PART II Critical Issues for
Individuals
57
Chapter 3 The Moral Status of Gametes
and Embryos: Storage and
Surrogacy. . . . . . . . . . . . . . . . . . 59
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
The Moral Community. . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Making Decisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Surrogacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Storage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . . 69
Additional Readings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Chapter 4 The Ethical Challenges of
the New Reproductive
Technologies . . . . . . . . . . . . . . . 71
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Two Inadequate Approaches to Evaluating
Alternative Reproductive Technology. . . . . . . . . .72
A Basis for Developing an Ethical Position. . . . . . . . 73
A Proposed Ethical Standard. . . . . . . . . . . . . . . . . . . . . 75
Theories of Justice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The Family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Reflective Equilibrium as a
Decision-Making Model. . . . . . . . . . . . . . . . . . . . . . . 53
Donors and the Cultural Ethos. . . . . . . . . . . . . . . . . . . 81
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . . 83
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . . 55
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
iv
Contents
Chapter 5 Ethics and Aging in America . . 87
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
The Growing Population Needing Care . . . . . . . . . . 88
Issues of Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Forces for Improving Access. . . . . . . . . . . . . . . . . . . . . 94
What Are the Prospects for Improved Access?. . . . 96
Update from a Practitioner’s View. . . . . . . . . . . . . . . . 98
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 100
Additional Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
PART III Critical Issues for
Healthcare Organizations 105
Chapter 6 Healthcare Ethics
Committees: Roles,
Memberships, Structure,
and Difficulties . . . . . . . . . . . . 107
v
Ethical Dilemmas Involving
Data on HISs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Smartphone Network of Healthcare
Awareness—Good Idea
or Violation of Privacy?. . . . . . . . . . . . . . . . . . . . . . . 130
Is Health Care a Right or a Benefit? What Data
Protection Should Be Provided to PHI?. . . . . . . 131
Ethical Decision-Making
Models for the Management of HIM. . . . . . . . . . 131
Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 133
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chapter 8 Technological Advances in
Health Care: Blessing or
Ethics Nightmare?. . . . . . . . . . 137
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Medical and HIT Defined. . . . . . . . . . . . . . . . . . . . . . . . 138
The Ethical Obligation. . . . . . . . . . . . . . . . . . . . . . . . . . 138
Science and Technology Innovations
and Ethics Concerns . . . . . . . . . . . . . . . . . . . . . . . . . 139
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Recent Innovations Involving Technology
and Their Ethics Concerns. . . . . . . . . . . . . . . . . . . . 141
Why an Ethics Committee? . . . . . . . . . . . . . . . . . . . . . 108
HIT and the Medical Group Practice. . . . . . . . . . . . . 147
The Function and Roles of Ethics Committees. . . 108
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Ethics Committee Membership. . . . . . . . . . . . . . . . . 111
Questions for Review. . . . . . . . . . . . . . . . . . . . . . . . . . . 150
The Healthcare Ethics Committee’s
Background and Education. . . . . . . . . . . . . . . . . . 113
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Institutional Commitment. . . . . . . . . . . . . . . . . . . . . . 114
Challenges for Healthcare Ethics Committees. . . 115
Chapter 9 Ethics and Safe Patient
Handling and Mobility. . . . . . 153
Update from a Practitioner’s View. . . . . . . . . . . . . . . 116
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Extent of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 119
Problem-Solving. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Ethics Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Chapter 7 Ethics in the Management of
Health Information
Systems. . . . . . . . . . . . . . . . . . . 123
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Operational Definitions. . . . . . . . . . . . . . . . . . . . . . . . . 123
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 157
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Chapter 10 Spirituality and Healthcare
Organizations . . . . . . . . . . . . 161
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
vi
Contents
Evidence-Based Practice: The Answer and
the Challenge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
What Is the Best Way to Reduce or
Eliminate Health Inequalities?. . . . . . . . . . . . . . . . 206
This Thing Called Spirituality. . . . . . . . . . . . . . . . . . . . 164
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Is There a Place for Spirituality in the
Healthcare Workplace?. . . . . . . . . . . . . . . . . . . . . . . 168
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Spirituality in the Business of Health Care. . . . . . . 172
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Integration of Spirituality into Healthcare
Workplaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Chapter 13 The Ethics of Epidemics . . . . 211
Ethics Theories and Spirituality. . . . . . . . . . . . . . . . . . 176
Ethics Principles and Spirituality. . . . . . . . . . . . . . . . . 177
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Questions for Review. . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Chapter 11 A New Era of Health Care:
The Ethics of Healthcare
Reform . . . . . . . . . . . . . . . . . . 183
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 208
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Epidemics, Ethics, and Public Health. . . . . . . . . . . . 211
Modern Epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Determination of the Decision-Making
Responsibility: Individual Autonomy
Versus Paternalism. . . . . . . . . . . . . . . . . . . . . . . . . . . 216
International Perspectives and the
Bioethics Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 217
Healthcare Reform in the United States. . . . . . . . . 183
Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Health System Reform in the 20th Century. . . . . . 184
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Key Provisions of the Healthcare Reform
Legislation of 2010 (ACA). . . . . . . . . . . . . . . . . . . . . 187
How Well Have the Reforms Met the
Expectations of a Just Healthcare System?. . . . 189
Chapter 14 Ethics of Disasters:
Planning and Response. . . . 221
Ethics Considerations Underlying
Healthcare Reform. . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Disaster Planning and Response
by the Federal Government. . . . . . . . . . . . . . . . . . 223
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 191
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
PART IV Critical Issues for
Society’s Health
Disasters in U.S. History. . . . . . . . . . . . . . . . . . . . . . . . . 222
Disaster Preparedness and Response for
Healthcare Institutions. . . . . . . . . . . . . . . . . . . . . . . 226
Professional Readiness for Disasters. . . . . . . . . . . . . 228
Individual Response to Disasters. . . . . . . . . . . . . . . . 228
195
Update from a Practitioner’s Point of View. . . . . . . 230
Chapter 12 Health Inequalities and
Health Inequities . . . . . . . . . 197
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 235
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Why Are Some Health Inequalities also
Health Inequities?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Chapter 15 Domestic Violence:
Changing Theory,
Changing Practice. . . . . . . . . 239
How Can We Measure Health Inequalities?. . . . . . 203
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
What Are Health Inequalities?. . . . . . . . . . . . . . . . . . . 198
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Contents
Personal and Social Barriers. . . . . . . . . . . . . . . . . . . . . 240
Systemic Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Impact of Theory on Clinical Practice. . . . . . . . . . . . 241
Structural Constraints. . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Implications for Training and
Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
vii
Chapter 16 Looking Toward
the Future . . . . . . . . . . . . . . . 261
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
New Considerations in Ethics Theory. . . . . . . . . . . . 261
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 275
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Questions for Discussion. . . . . . . . . . . . . . . . . . . . . . . . 247
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Glossary ������������������������������������������������������������������� 279
Index�����������������������������������������������������������������������������287
© f11photo/Shutterstock
Contributors
Omolola Adepoju, PhD, MPH
Assistant Professor
School of Health Administration
College of Health Professions
Texas State University
San Marcos, TX
Karen J. Bawel-Brinkley, RN, PhD
Professor
School of Nursing
San Jose State University
San Jose, CA
Sidney Callahan, PhD
Distinguished Scholar
The Hastings Center
Garrison, NY
Kimberly A. Contreraz, BSN, MSN, FNP, ACHPN
Director of Palliative Care
St. Vincent Anderson Regional Hospital
Anderson, IN
Dexter R. Freeman, DSW, LCSW
Director
Master of Social Work Program
Army Medical Department Center & School
Army-Fayetteville State University
Houston, TX
Janet Gardner-Ray, EdD
CEO
Country Home Healthcare, Inc.
Charlottesville, IN
Glenn C. Graber
Professor Emeritus
Department of Philosophy
The University of Tennessee
Knoxville, TN
Nicholas King, PhD
Assistant Professor
Biomedical Ethics Unit
McGill University Faculty of Medicine
Montreal, QC, Canada
viii
Scott Kruse, MBA, MSIT, MHA, PhD, FACHE, CPHIMS,
CSSGB, Security+, MCSE
Assistant Professor and Graduate Programs
Director
School of Health Administration
College of Health Professions
Texas State University
San Marcos, TX
Christian Lieneck, PhD, FACMPE, FACHE, FAHM
Associate Professor
School of Health Administration
College of Health Professions
Texas State University
San Marcos, TX
Richard L. O’Brien, MD
University Professor Emeritus
Creighton University
Omaha, NB
Robert W. Sandstrom, PT, PhD
Professor and Faculty Associate
School of Pharmacy and Health Professions
Creighton University
Omaha, NB
Jim Summers, PhD
Professor Emeritus
School of Health Administration
College of Health Professions
Texas State University
San Marcos, TX
Carole Warshaw, MD
Director
National Center on Domestic Violence,
Trauma & Mental Health
Chicago, IL
Michael P. West, EdD, FACHE
Executive Director
University of Texas Arlington-Fort Worth
Campus
Fort Worth, TX
© f11photo/Shutterstock
About the Editors
Eileen E. Morrison is a professor in the School
of Health Administration at Texas State University, San Marcos, Texas, USA. Her educational
background includes a doctorate from Vanderbilt University, Nashville, Tennessee, USA, and a
master of public health degree from the University of Tennessee, Knoxville, Tennessee, USA. In
addition, she holds an associate degree in logotherapy and a clinical degree in dental hygiene.
Dr. Morrison has taught graduate and
undergraduate courses in ethics and provided
workshops to professionals, including those in
medicine, nursing, clinical laboratory services,
health information, and dentistry. She has also
authored articles and chapters on ethics for
a variety of publications. In addition, she is
the author of Ethics in Health Administration:
A Practical Approach for Decision Makers (3rd
ed.), published by Jones & Bartlett Learning,
and a children’s book called The Adventures of
Emery the Candy Man.
Beth Furlong is an associate professor emerita
and adjunct faculty in the Center for Health
Policy and Ethics at Creighton University,
Omaha, Nebraska, USA. Her academic background includes a diploma, BSN, and MS in
nursing, an MA and PhD in political science,
and a JD. Dr. Furlong has taught graduate
ethics courses and provided continuing education unit (CEU) workshops for nurses on
ethics issues. Her publications are in the areas
of health policy, vulnerable populations, and
ethics.
ix
© f11photo/Shutterstock
Preface
T
he history of health care is filled with
change. For example, providers and systems have embraced changes that lead to
cures for disease, new ways to care for patients,
regulation, and funding. However, during the
creation of this fourth edition of Health Care
Ethics: Critical Issues for the 21st Century, the
healthcare system has been in change overload.
It must address changes from technology, the
emphasis on patient-centered care, and fiscal
challenges. It is also trying to address the truly
unknown. For example, legislators continue to
consider the appeal of the Patient Protection
and Affordable Care Act of 2010, while others
are debating its repair. Since healthcare funding, programs, and regulations are linked to
this legislation, the healthcare system will continue to engage in multilayers of contingency
planning for survival and service.
Readers will also notice changes in this
edition as its authors consider the implications
of change with respect to their content areas.
However, the fourth edition still reflects the
organizational model that was used in previous editions. Therefore, the Greek temple
image remains its organizational framework as
a model for addressing ethics issues in health
care (see Figure FM.1).
Like all buildings, this temple needs a
firm foundation and ethics theory and principles serve this purpose. It also makes sense if
one is going to be able to analyze the ethical
Ethical Issues
Organizations
Individuals
Theoretical Foundations
FIGURE FM.1 Healthcare Ethics Organizational Model.
x
Society
Preface
implications of an issue. An appropriate analogy would be that a surgeon cannot be successful unless he or she understands human
anatomy. Likewise, a student who wishes to
analyze the ethics of a particular issue in health
care must have knowledge of theories and principles of ethics. Dr. Summers provides a strong
foundation for applying ethics in the chapters
“Theory of Healthcare Ethics” and “Principles
of Healthcare Ethics” of this edition.
The three main pillars of the temple
model illustrate sections to organize the ethics
issues faced in healthcare situations. Note that
the center pillar represents individuals who are
called patients in the healthcare system. This is
because the healthcare system would not function unless there are patients who need care.
The remaining two pillars represent issues relevant to healthcare organizations and society
and reflect challenges to the future of healthcare organizations and their ability to care for
patients.
Given the current environment in the
healthcare system, the potential for chapters
and their content was extensive. The challenge
for the writers was to select example of topics
that represent ethics challenges for the future
and avoid a non-readable tome. While it was
not possible to address each potential issue,
topics were updated and expanded within
a 16-chapter format. For example, under
the “Critical Issues for Individuals” section,
attention was given to the most vulnerable
xi
patients. Therefore, there are chapters related
to the moral status of embryos and infants and
reproductive technology. To address patients
at the other end of the life continuum, major
revisions were made to the discussion of aging
patients and the ethics of their care. The other
pillars of healthcare organizations and society
also include major revisions of existing chapters. New chapters that reflect current ethics
issues in today’s environment have also been
added. For example, there are chapters on the
ethics of health information management and
the ethics of epidemics.
Health care is truly in the epoch of change,
but ethics will always matter. Even experts in
ethics and health care cannot predict the future
of health care with absolute certainty. However, this does not mean that ethics should not
be part of making decisions amid a challenging environment. In fact, the ethics of what we
do maybe even more important because health
care is always held to a higher standard, even
when it must meet unknown challenges.
However, Morrison and Furlong are
optimistic that students will continue to ask
themselves, “Is this the best ethical decision to
make?” and “How do I know that this it is the
best?” as they progress through their careers.
Patients, healthcare organizations, and the
community rely on their answers so that health
care can be patient-centered, cost-effective,
and fiscally responsible. What a challenging
combination to face in the epoch of change!
PART I
Foundations in
Theory
hange is not new, but it appears to be the theme of the current era of health
C
care. The Patient Protection and Affordable Care Act (ACA 2010) became a
law in 2010 and created major changes in the health care system. Regardless
of the outcome of its status, healthcare organizations will be expected to
provide patient-centered care that complies with legislation, uses qualified
and compassionate professionals, and is conducted with fiscal responsibility.
In addition, the foundation of health care must also be centered in ethical
policies and action.
To address necessary ethics-based decisions amid an environment of
consistent change, you must have a foundation in ethics theory and principles.
While some think that ethics is just about “doing the right thing,” in an epoch of
change, one must justify decisions. In addition, the professionals employed in
healthcare settings have ethics guidelines and duties encoded in their practices.
Of course, patients expect healthcare providers and facilities to be concerned
about their best interests, which include ethical behavior and practices. How
can you justify your decisions in the practice or administration with an ethics
rationale? The first section of this new edition of Health Care Ethics: Critical Issues
for the 21st Century begins with two chapters that will provide this foundation.
The foundation in ethics theory and principles provided in the chapters
“Theory of Healthcare Ethics” and “Principles of Healthcare Ethics” give you
practical tools for analyzing ethics-related issues. In the chapter “Theory
of Healthcare Ethics,” Dr. Summers presents a well-researched overview of
the theories commonly used in healthcare ethics. He includes a model that
illustrates the position of ethics in philosophy. Following that, he discusses
theories that indirectly relate to healthcare, such as authority-based ethics,
egoism, and ethical relativism. Then, he provides a thorough analysis of
theories that are most commonly applied in healthcare practice. These include
natural law, deontology, utilitarianism, and virtue ethics. In his discussions, he
uses several examples to improve understanding concerning the application
of these theories in professional practice.
In the chapter “Principles of Healthcare Ethics,” Summers continues his
scholarly discussion of ethics by presenting the most commonly used ethics
principles in health care. These principles are nonmaleficence, beneficence,
autonomy, and justice. Because justice is the most complex of the four, he
provides additional definitions of types of justice and includes information
for making decisions about justice in healthcare practice. At the end of the
1
2
Part I Foundations in Theory
chapter, Summers also presents a decision-making model called the reflective equilibrium model. This model
demonstrates the application of ethics theory and principles in the practice of making clinical and business
decisions.
You can apply the information given in these two chapters to your understanding of the remaining
chapters in this edition. You will find that having a solid grounding in theory and principles will allow you to
have greater clarity in making ethics-based decisions in your own area of health care. Certainly, as Summers
suggests, principles and theory should be an important part of your ethical decision-making throughout your
practice of health care.
CHAPTER 1
Theory of Healthcare Ethics
Jim Summers
▸▸ Introduction
I
n this chapter, Dr. Summers provides a scholarly review of the main theories that apply to
the ethics of healthcare situations. Why is knowledge of theory important to busy healthcare
professionals? In this time of great change and challenge within the healthcare system, there is
a need to apply ethics in all types of decision-making. To make this application successfully, one
needs a foundation in ethics, in addition to data and evidence-based management tools, including
those offered by advanced technologies. An understanding of ethics theory gives you the ability
to make and defend ethics-based decisions that support both fiscal responsibilities and patient-
centered care. While these kinds of decisions are difficult, without a foundation in ethics theory,
they might prove impossible. Therefore, this chapter and the one that follows, on the principles of
ethics, will serve as your ethics theory toolbox.
▸▸ Ethics and Health Care
From the earliest days of philosophy in ancient Greece, people have sought to apply reason in
determining the right course of action for a particular situation and in explaining why it is right.
Such discourse is the topic of normative ethics. In the 21st century, issues resulting from technological advances in medicine will provide challenges that will necessitate reasoning about the right
course of action. In addition, healthcare resource allocations will become more vexing as new diseases threaten, global climate change continues apace, and ever more people around the world find
their lives increasingly desperate. In the Patient Protection and Affordable Care Act of 2010 (ACA
2010) era, managers of healthcare organizations will find the resources to carry out their charge
increasingly constrained by multiple levels of change, differences in payment structures, and labor
shortages. A foundation in ethics theory and ethical decision-making tools can assist healthcare
leaders in assessing the choices that they must make in these vexing circumstances.
With the current emphasis on patient-centered care, knowledge of ethics can also be valuable when working with healthcare professionals, patients and their families, and policy makers.
In this sense, ethical understanding, particularly of alternative views, becomes a form of cultural
3
4
Chapter 1 Theory of Healthcare Ethics
competence.1 However, this chapter is limited
to a discussion of normative ethics and metaethics. Normative ethics is the study of what is
right and wrong; metaethics is the study of ethical concepts. Normative ethics examines ethics
theories and their application to various disciplines, such as health care. In health care, ethical concepts derived from normative theories,
such as autonomy, beneficence, justice, and
nonmaleficence, often guide decision-making.2
As one might suspect, when normative
ethics seeks to determine the moral views or
rules that are appropriate or correct and to
explain why they are correct, major disagreements in interpretation often result. These disagreements influence the application of views
in many areas of moral inquiry, including
health care, business, warfare, environmental
protection, sports, and engineering. FIGURE 1.1
lists the most common normative ethics theories to be considered in this chapter. Although
no single theory has generated consensus in the
ethics community, there is no cause for despair.
The best way to interpret these various
ethics theories, some of which overlap, is to
use the analogy of a toolbox.
Each of these theories provides tools that
can assist with decision-making. One advantage of the toolbox approach is that you will
not find it necessary to choose one ethics theory over another for all situations. You can
choose the best theory for a task, according to
the requirements of your role and the circumstances. Trained philosophers will find flaws
with this approach, but the practical advantages will suffice to overcome these critiques.
All of the theories presented have a value
in the toolbox, although like any tools, some
are more valuable than others. For example, I
can argue that virtue ethics has much value for
healthcare applications. Before explaining why
this chapter has chosen to present particular
theories, a quick overview is in order.
■■
■■
Authority-based theories can be faithbased, such as Christian, Muslim, Jewish, Hindu, or Buddhist ethics. They
can also be purely ideological, such as
those based on the writings of Karl Marx
(1818–1883) or on capitalism. Essentially,
authority-based theories determine the
right thing to do on the basis of what an
authority has said. In some cultures, the
authority is simply “that is what the elders
taught me” or “that is what we have always
done.” The job of the ethicist is to determine what that authority would decree for
the situation at hand.
Natural law theory, as considered here,
uses the tradition of St. Thomas Aquinas
(1224–1274) as the starting point of interpretation. The key idea behind natural
law is that nature has order both rationally and in accordance with God’s wisdom or providence. The right thing to do
is that which is in accord with the providentially ordered nature of the world.
In health care, natural law theories are
important because of the influence of the
Roman Catholic Church and the extent
to which the Church draws on Aquinas
as an early writer in the field of ethics.
Normative ethical
theories
Natural law
theories
Egoistic
theories
Authority-based
theories
FIGURE 1.1 Normative ethics theories.
Teleological
theories
Deontolgical
theories
Virtue
ethics
Ethical Relativism
■■
■■
■■
Several important debates, such as those
surrounding abortion, euthanasia, and
social justice, draw on concepts with roots
in natural law theory.
Teleological theories consider the ethics of
a decision to be dependent on the consequences of the action. Thus, these theories are called consequentialism. The basic
idea is to maximize the good of a situation. The originators of one such theory,
Jeremy Bentham (1748–1832) and John
Stuart Mill (1806–1873), called this maximization of good utility; thus, the name of
their theory is utilitarianism.
Deontological theories find their origins in
the work of Immanuel Kant (1724–1804).
The term deon is from Greek and means
“duty.” Thus, deontology could be called
the science of determining our duties.
Most authors place Kant in extreme opposition to consequentialism, because he
argued that the consequences themselves
are not relevant in determining what is
right. Thus, doing the right thing might
not always lead to an increase in the
good.3 More contemporary deontologists,
including John Rawls (1921–2007) and
Robert Nozick (1938–2002), reached antithetical conclusions about what our duties
might be.
Virtue ethics has the longest tenure among
all of these views, except for authoritybased theories. Its roots can be traced
to Plato (427–347 bce) and Aristotle
(384–322 bce). The key idea behind virtue ethics is to find the proper end for
humans and then to seek that end. In
this sense, people seek their perfection
or excellence. Virtue ethics comes into
play as people seek to live virtuous lives,
developing their potential for excellence
to the best of their abilities. Thus, virtue
ethics addresses issues any thinking person should consider, such as “What sort
of person should I be?” and “How should
we live together?” Virtue ethics can contribute to several of the other theories in
■■
5
a positive way, particularly in the understanding of professional ethics and in
the training necessary to produce ethical
professionals.
Egoistic theories argue that what is right
is that which maximizes a person’s self-
interest. Such theories are of considerable
interest in contemporary society because
of their relationship to capitalism. However, the ethical approach of all healthcare
professions is to put the interests of the
patient above the practitioner’s personal
interests. Even when patients are not
directly involved, such as with healthcare
managers, the role is a fiduciary relationship, meaning that patients can trust that
their interests come before those of the
practitioners. Egoistic theories are at odds
with the value systems of nearly all healthcare practitioners.
▸▸ Ethical Relativism
Before exploring any of these ethics theory
tools in depth, it is first necessary to confront
the relativist argument, which denies that ethics really means anything. Those who deal
with ethical issues, whether in everyday life or
in practice, will inevitably hear the phrase “It
is all relative.” Given that the purpose of this
text is to help healthcare professionals deal
with real-world ethical issues, it is important
to determine what this phrase means and what
the appropriate course of action is. Philosophers have not developed a satisfactory ethics
theory that covers every situation. In fact, they
are expert at finding flaws in any theory; thus,
no theory will be infallible. In addition, different cultures and different groups have varying
opinions about what is right and wrong and
how to behave in certain situations.4
Does the fact that people’s views differ mean that any view is acceptable? This
appears to be the meaning of such statements
as “It is all relative.” In that sense, deciding
that something is right or wrong, or good or
6
Chapter 1 Theory of Healthcare Ethics
bad, has no more significance than choices
of style or culinary preferences. Thus, ethical
decision-making and practice is a matter of
aesthetics or preferences, with no foundation
on which to ground it. This view makes a normative claim that there is no real right, wrong,
good, or bad.
One could equally say that there is no
truth in science, because scientists disagree
about the facts and can prove nothing, only
falsify it by experiment.5 However, the intrinsic
lack of final certainty in the empirical sciences
does not render them simply subjective. As
one commentator on the rapid changes in scientific knowledge put it, these changes reveal
“the extraordinary intellectual and imaginative yields that a self-critical, self-evaluating,
self-testing, experimental search for understanding can generate over time.”6 Why should
we expect any less of ethics?
Sometimes, there is a claim made that
because there are many perspectives, there cannot be a universal truth about ethics. Therefore,
we are essentially on our own. Hugh LaFollette
argued that the lack of an agreed-upon standard or the inability to generalize an ethics
theory does not render ethical reasoning valueless.7 Rather, the purpose of ethics theories is
to help people decide the right course of action
when faced with troubling decisions. Some
ethics theories work better in some situations
than in others. The theories themselves provide
standards, akin to grammar and spelling rules,
as to making decisions and supporting them
with a particular theory.
Thus, even though ethics might not produce the final answers, we still must make
decisions. Ethics theories and principles are
tools to help us in that necessary endeavor.
The lack of absoluteness in ethics theory also
does not eliminate rationality. Often, we simply must apply our rationality without knowing whether we are correct. The better our
understanding is of ethics, the more likely it is
that the decision we reach will be appropriate.
The ability to reach the appropriate decision is
especially important in the field of health care,
where our decisions affect the health, well-
being, and even the lives of our patients.
▸▸ Ethics Theories
Let us begin to examine the tools in the toolbox, not only knowing that we are fallible, but
also knowing that we are rational.8 The first
tool has little application to healthcare ethics;
however, it is widely believed and therefore
needs to be addressed. It involves the idea of
egoism in ethics.
Egoism
Egoism operates from the premise that people either should (a normative claim) seek to
advance solely their self-interests or (psychologically) this is actually what people do. The
normative version, ethical egoism, sets as its
goal the benefit, pleasure, or greatest good of
the self alone.9 In modern times, the writings
of Ayn Rand10 and her theory of objectivism11
have popularized the idea of ethical egoism.
For example, Rand said, “The pursuit of his
own rational self-interest and of his own happiness is the highest moral purpose of his
life.”12 This is a normative statement and a reasonable description of ethical egoism.
Although this theory has importance to
the larger study of ethics, it is less important
in healthcare ethics because the healing ethic
itself requires a sublimation of self-interests to
those of the patient. A healthcare professional
who fails to do this is essentially not a healthcare professional. No codes of ethics in the
healthcare professions declare the interests of
the person in the professional role to be superior to those of the patient.
Healthcare professionals who do not
understand the need to sublimate their own
interests to those of the patient or their role have
not yet become true healthcare professionals.
An understanding of the need to sublimate
one’s own interests for the sake of the patient
is essential in providing patient-centered care,
Ethics Theories
which has become a key emphasis in healthcare delivery.
Although occasionally healthcare professionals do not put the patient’s best interests
first, it is not a goal of the profession to put
one’s self ahead of the client or patient. A realist might complain, “Yet this is the way most
people behave!” Although that may be true,
the fact that many people engage in a particular kind of behavior does not make it into an
ethics theory. Ethical egoism constitutes more
of an ethical problem than anything else. Most
people who think of an ethics theory consider
it something that is binding on people. However, ethical egoism is not binding on anyone
else beyond self-interest. It is not binding on
all (i.e., normative) and, thus, does not meet
the criteria of a true ethics theory but is simply
a description of human behavior. Indeed, to
care for someone else above your self-interest,
as required by codes of ethics in health care,
is antithetical to the human behavior of truly
pursuing only your self-interest. Later, we shall
see how Rawls uses the idea that people pursue their self-interests to develop a theory of a
just society in which solidarity seems to be the
outcome, as opposed to the extreme individualism ethical egoism typically suggests.
Authority-Based Ethics Theories
Most teaching of ethics ignores religion-based
ethics theories, much to the chagrin of those
with deep religious convictions. A major problem with these theories is determining which
authority is the correct one. Authority-based
approaches, whether based on a religion, the
traditions or elders of a culture, or an ideology,
such as communism or capitalism, have flaws
relative to the criteria needed to qualify as a
normative ethics theory. Each of the authority-
based approaches, to be an ethics theory, must
claim to be normative relative to everyone. Because many of these authority-based
approaches conflict, there is no way to sort them
out other than by an appeal to reason. Not only
do we have the problem of sorting through the
7
ethical approaches, but also arguments inevitably arise concerning the religion itself and its
truth claims. If two religions both claim to be
inerrant, it is difficult to find a way to agree on
which of the opposing inerrant authorities is
correct.
In spite of the philosophical issues arising from the use of religion in healthcare ethics, it is important for healthcare providers to
understand the role of religions and spirituality in healthcare delivery. For example, all religions provide explanations of the cause or the
meaning of disease and suffering. Many theologies also encourage believers to take steps
to remove or ameliorate causes of disease and
suffering. Over the millennia, some of these
religions have even formalized their positions
by becoming involved with healthcare delivery
by providing inpatient and hospital care.
In addition, patients often have religious
views that help them understand and cope
with their conditions. Understanding a person’s faith can help the clinician and health
administrator provide health care that is more
patient-focused.13 For some patients, an ethical
issue may arise if their faith or lack of faith is
neither recognized nor respected. This failure
to address or respect the faith needs of patients
also conflicts with the tenets of patient-
centered care.
Beyond direct patient care, a second reason to understand the authority-based philosophies common in the healthcare environment
is their effect on healthcare policy. The role of
authority-based ethical positions appears to be
gaining importance in the 21st century. Effective working within the health policy arena,
whether at the institutional, local, regional,
state, federal, or international level, requires an
understanding of the influence of the religious
views of those involved in the debates and
negotiations. This knowledge can only serve
to strengthen your ability to reason with them.
In other words, it is important to understand
the “common” morality of those engaged in
the debate. The greater the diversity in beliefs
and reasoning, the more important the need
8
Chapter 1 Theory of Healthcare Ethics
for understanding what those beliefs and reasoning might be.
Religion also plays an important role in the
creation of healthcare policy, because religions
have provided a multiplicity of philosophical
answers to questions about the nature and
truth of the world. They also provide guidance
on that how we should act in the world. They
explain what is right or wrong and why it is
right or wrong. They also help people define
their identities, roles in the world, and relationships to one another. In addition, religions help
us understand the nature of the world and our
place in it.
Thus, as a tool, understanding authority-
based philosophical systems has value because
it can help in the treatment of patients. It also
increases your understanding regarding the
positions of persons who may be involved
in debates over healthcare issues, such as
resource allocations, or clinical issues such
as abortion. In addition, it is important to
understand authority-based philosophical
systems relative to yourself. As a healthcare
professional, your role requires that you do
not impose your religious views on patients.
At the same time, it is not part of the role for
you to accept the imposition of another’s religious values, even those of a patient.
These complex issues relate to professional
ethics and are not part of the scope of this chapter. However, it does seem incumbent on all
healthcare professionals to evaluate their own
faith and to recognize the extent to which they
might impose it on others. From the earliest
tradition of Hippocrates, the charge was to heal
the illness and the patient. More recently, the
Declaration of Geneva from the World Medical
Association stated that members of the medical
profession would agree to the following statement: “I will not permit considerations of age,
disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual
orientation, social standing or any other factor
to intervene between my duty and my patient.”14
In addition, patient-centered care requires that
healthcare professionals avoid judging patients
and treat them as individuals with a caring and
concerned manner. Let us now turn our attention to the oldest non-authority-based ethics
theory—virtue ethics.
Virtue Ethics
Virtue ethics traces its roots most especially to
Aristotle (384–322 bce). Aristotle sought to
explain the highest good for humans. Bringing the potential of that good to actualization
requires significant character development.
This concept of character development falls
into the area of virtue ethics because its goal is
the development of those virtues in the person
and the populace.
Aristotle’s ethics derived from both his
physics and his metaphysics. He viewed everything in existence as moving from potentiality to actuality. This is an organic view of
the world, in the sense that an acorn seeks to
become an oak tree. Thus, your full actuality is
potentially within you. As your highest good,
your potential actuality is already inherent
because it is part of your nature; it only needs
development, nurture, and perfecting. This
idea is still part of the common morality.
Finding Our Highest Good
Just what did Aristotle conclude was our final
cause or our highest good? The term Aristotle
uses for this is eudaimonia. The typical translation is “happiness.” However, this translation is
inadequate, and many scholars have suggested
enhancements. Many writers prefer to use the
translation “flourishing.” Because any organic
entity can flourish, such as a cactus, so the
term is not an adequate synonym.
The major complaint about translating
eudaimonia as “happiness” is that our modern
view of happiness would render it subjective.
No one can know whether you are happy or you
aren’t; you are the final arbiter. Aristotle thought
eudaimonia applied only to humans because
it required rationality that goes beyond mere
happiness. In addition, Aristotle’s eudaimonia
Ethics Theories
includes a strong moral component that is
lacking from our modern understanding of
happiness. In this sense, “happiness” would
necessarily include doing the right thing, that
is, being virtuous. Others could readily judge
whether you were living a virtuous or “happy”
life by observing your actions.
For Aristotle, happiness is not a disposition, as in “he is a happy sort.” Eudaimonia is
an activity. Indeed, children and other animals
unable to engage self-consciously in rational
and virtuous activities cannot yet be in the state
translated as Aristotle’s “happy.”15 Because it is
commonplace to describe children as being
“happy,” this is clearly not an adequate translation. Given these translation problems, I shall
use the term eudaimonia rather than its translations of “happiness” or “flourishing.” Essentially, you can understand eudaimonia best as
a perfection of character nurtured by engaging
in virtuous acts over a life of experience.
The most important element of eudaimonia
is the consideration of what it takes to be a person of good character. Such a person seeks to
develop excellence in himself or herself. Because
Aristotle recognized the essential social and
political nature of humans, developing individual excellence would also have to include consideration of how we should live together.
Developing a Professional as
a Person of Character
Consider what it takes to develop a competent
and ethical healthcare professional. The process involves a course of study at an accredited
university taught by persons with credentials
and experience in the field. It also includes
various field experiences, such as clerkships,
internships, and residencies or clinical experiences with patients. Part of the education
includes coming to an understanding of what
behaviors are appropriate for the role, which is
the definition of professional socialization.
For all healthcare professions, the educational process includes a substantial dose of
the healing ethic by specific instruction or by
9
observation of role models. The most fundamental idea behind this healing ethic teaches
healthcare professionals to sublimate their
self-interests to the needs of the patient. This
education also includes recognition of the
idea that the healing ethic means first doing
no harm and second that whatever actions are
done should provide a benefit.16
An Example of Professional
Socialization: The Character of
a Physician
The goal of professional education and socialization is to produce healthcare professionals
of high character. Many professional ethics
codes describe the character traits that define
high character, or what could be called virtues.17 For example, the 2016 American Medical Association statement of the principles
of medical ethics notes that the principles are
“standards of conduct which define the essentials of honorable behavior for the physician.”18
Essentially, the principles define the appropriate character traits or virtues for a physician.
Relative to virtue ethics, these traits or
virtues combine to create not only a good
physician but also a person of good character.
Like Aristotle’s person of virtue, engaging in
the activities of eudaimonia produces practical
wisdom. “Moral virtue comes about as a result
of habit.”19 The virtues come into being in us
because “we are adapted by nature to receive
them, and they are made perfect by habit.”20
Not only is practice required, but the moral
component is essential, too. Good physicians
are not merely technically competent; they are
persons of good character. How do we know
this? Their actions coalesce to reveal integrity
in all levels of their practice. In addition, a physician or any other person of good character
does not undertake to do what is right simply
to appear ethical. In a modern sense, the properly socialized physicians have internalized the
ethical expectations of their profession. To do
the right thing is part of their identities.21
10
Chapter 1 Theory of Healthcare Ethics
To use Aristotle’s term, physicians have
become persons of practical wisdom. In
describing practical wisdom, Aristotle says the
following:
■■
[I]t is thought to be the mark of a
man of practical wisdom to be able
to deliberate well about what is good
and expedient for himself, not in
some particular respect, e.g. about
what sorts of things conduce to
health or to strength, but about what
sorts of things conduce to the good
life in general.22
The mere fact that inculcation of such character traits is so important in all healthcare professions indicates that these ancient teachings
are part of the common morality, or at least the
professional morality of healthcare professions.
In short, persons of virtue nurture eudaimonia
because they believe it is the right way to live
and that “[w]ith the presence of practical wisdom [they] will be given all the virtues.”23 Good
physicians are living excellent lives; perfecting
themselves is part of their self-identities.24
These persons will act on the ethics principles
that form the core of their identification of
themselves with their role. In health care, these
principles function as virtues.
Principles of Biomedical Ethics
as Virtues
Beauchamp and Childress have popularized
what they call the principles of biomedical
ethics in a textbook of the same name that
has gone through seven editions from 1978 to
2013.25 The following list provides brief definitions of these principles:
■■
Autonomy is the ability to decide for oneself. The word derives from the Greek
words for “self ” (auto) and “rule” (nomos).
Autonomy means that people are free to
make their own decisions. The failure to
respect the personhood of others, making
■■
■■
decisions for them without their consent,
is paternalism.
Beneficence is from the Latin root bene,
meaning “to do well.” More specifically,
it derives from the Latin word benefacere,
meaning “to do a kindness, provide a benefit.” It is the practice of doing the good
thing. Health care has clearly valued beneficence from its early Hippocratic origins.
It is the second part of the dictum “First do
no harm, benefit only.” As an active beneficence, professionalism requires healthcare practitioners to put patients’ interests
before their own. When combined with
beneficence, healthcare professionals hold
dear the virtue of altruism.
Nonmaleficence derives from the Latin
word mal, meaning “bad.” A malevolent person wishes ill of someone. Thus,
nonmaleficence means to not do wrong
toward another.
Justice is a concept with a vast history
and multiple interpretations. The etymology is Latin and suggests more than
just fairness. The words just and justice
include elements of righteousness (“She
is a just person.”), equity (“He received
his just due.”), and lawfulness (“She was
brought to justice.”).26 A just person is fair,
lawful, reasonable, correct, and honest.27
Most writers in ethics discuss two kinds
of justice, distributive and procedural.
Distributive justice determines the proper
sharing of property and of burdens and
benefits. Procedural justice determines
the proper application of the rules in the
hearing of a case.
These concepts are foundational principles of
healthcare ethics.28 A person having these virtues as part of his or her character structure,
self-definition, and actions is considered a
person of good character. In healthcare terms,
such a person would be walking the talk of the
healing ethic and would be a person of practical wisdom.
Ethics Theories
Elitism
A person who seeks to nurture eudaimonia
through his or her actions achieves this goal
after long practice of Aristotle’s practical wisdom. In applying practical wisdom, the person
has learned to live well, exemplifying what we
would call a person of virtue or integrity, a good
person. Such a person often sets the standard
for the right action in a particular situation.
Thus, virtue ethics has the problem of being
elitist. Owing to his view of the hierarchical
nature of reality, Aristotle thought that some
people were simply not capable of maximizing
their potential to reach the highest good.29
Aristotle noted the difficulty in encouraging many to a character of virtue, a life of
nobility and goodness.30 Aristotle believed that
living in fear, living by emotions, and pursuing
pleasures are the motivations for most people.
They lack even a conception of the noble and
truly pleasant, having never known it. Aristotle seemed to despair that once these bad
traits have long been in place, they are impossible to remove. He concluded, “We must be
content if, when all the influences by which
we are thought to be good are present, we get
some tincture of virtue.”31 The person of practical wisdom becomes the standard for ethical
decision-making. This leads to an understanding of how virtue ethics can facilitate the management of ethical conflicts.
Balancing Obligations from the
Virtue Ethics Perspective
Because different principles of ethics or different virtues conflict, it is not possible to practice
in the healthcare professions for long without
encountering some kind of ethical dilemma.
Some treatments involve harm (we are to do
no harm) yet provide a benefit (benefit only).
An experienced healthcare professional must
be able to explain the relative benefits and risks
of such treatments and gain the cooperation of
the patient for the treatments.
11
Sometimes, one principle alone might
create conflict. For example, physicians must
know how to tell the truth to patients. Even
though information can be regarded as therapy, information delivered at the wrong time
or in the wrong way can be devastating. Information not delivered at the right time or never
delivered at all could mean that the physician
is not being honest and is guilty of paternalism. Learning how to deal with these issues
effectively takes experience (practical wisdom)
and theoretical knowledge.
A major component of the patient–
clinician relationship is the patients’ trust that
their caregivers have their best interests at
heart and that they are competent. If patients
perceive caregivers as persons of integrity, virtue, or practical wisdom, their confidence in
their caregivers will increase. That increase in
patients’ confidence has documented effects
on enhancing the placebo effect.32 How caregivers communicate, and even how they carry
themselves, will do much to influence these
perceptions.33 A caregiver who knows how to
do these things is a person of practical wisdom,
at least when it comes to medical practice.
Caregivers with practical wisdom, which,
by necessity, includes being of good character,
or virtuous, will also be able to make appropriate decisions about the means to ends. This
has significant implications for healthcare
ethics. When faced with ethical challenges
in medical care, such caregivers will have the
practical wisdom to know how to weigh the
various issues and concerns and form a conclusion. Because wise and good people can,
and do, come to different conclusions about an
ethically appropriate choice of action, persons
of practical wisdom should consult with one
another.
Healthcare organizations have sought to
institutionalize this approach by using ethics committees. Those with practical wisdom
in health care are far ahead of most professionals in having a decades-long tradition of
ethics committees, ethics consultations, and
12
Chapter 1 Theory of Healthcare Ethics
institutional review boards. The key here is
that persons of good character, pursuing virtuous ends, are much more likely to make an
appropriate choice than those without such
experience or such character. These choices
would appear to refute one of the usual criticisms levied against virtue ethics—that there
is no clear way to resolve disputes when those
who have practical wisdom disagree about the
correct course of action. Mechanisms such
as ethics committees lead the deliberators to
make a decision, even though it may not be
unanimous.
Virtue ethics thus leads to the conclusion
that within health care at least, the probability is good that persons socialized to put the
patient’s interests first will come up with the
ethically correct ranking of options. They will
also respect the patient’s wishes, even if they
do not agree with those wishes.
Of course, this depiction makes the situation sound much better than it is. Persons
well trained in the healing ethic take unethical actions. Is that a fault of the education or
the person? Aristotle would fault the person.
In Aristotle’s view, some people, by nature, are
unable to control their passions, their desires,
and their emotions. Others are unable to act
rationally. Some are just wicked.34 Yes, the theory results in a form of elitism. However, it
seems fair to say that health care has a major
advantage over many other fields in that it has
a strong educational and socialization process for developing the right character. In a
sense, the purpose of the educational process
is to develop a cadre of elite professionals. In
doing so, they should become persons of high
character.
Ethics Theories and Professional
Roles
Knowledge of virtue ethics offers one further
advantage. Persons of practical wisdom should
be better prepared to know when to use a particular ethics theory, depending on the role
in which they find themselves. Again, take
physicians as an example. Although physicians
have a primary obligation to their patients,
it is not their only role. Consider the following physician roles, none of which involves
patients directly: conducting scientific studies;
negotiating with vendors selling equipment
and supplies; and hiring, firing, and supervising employees. In addition, physicians might
be negotiating with third-party payers, lobbying on behalf of health policy issues, and conducting peer reviews of other physicians. They
might also be involved in the management of
healthcare organizations and be part of various
advisory and regulatory agency boards. Many
other non-patient-related tasks could be listed,
such as working with community groups or
serving as faculty, as needed.
Some of the ethics theories work better in
certain roles than others. How do physicians
choose the appropriate theory? The socialization process seeks to develop caregivers
who are persons seeking the highest good, at
least in health care. This foundational process
should develop persons of integrity and practical wisdom who can manage the inevitable
ethical dilemmas and make the best ethical
decisions in any role. They can apply reason to
the situation and make the best-possible decision within their respective role.
Natural Law
The theory of natural law owes a great debt
to Aristotle. Natural law also is important
to Roman Catholic theology, given its origins with Aquinas. Many texts on ethics and
medical ethics leave out natural law or give it
short shrift. Some authors consider the theory
a version of moderate deontology,35 defining
deontology as simply any view that defines
the right thing to do as dependent on something other than consequences. Thus, there is
consequentialism and everything else. In the
realm of healthcare ethics, such an approach
appears overly limiting. As a tool in the ethics theory toolbox, there are a number of good
reasons to know natural law theory. Even if
Ethics Theories
philosophically one can reduce this theory to
another, natural law is sufficiently definitive
and important to consider on its own merits.36
One key to understanding natural law is its
assumption that nature is rational and orderly.
This theory goes back to the ancient Greeks,
who believed that the cosmos was essentially
unchanging in its order. Aristotle certainly
believed this.37 This is now a statement of
physics—a statement about the nature of the
world—rather than a statement about ethics.
Natural Law’s Relationship to
Aristotle, St. Thomas Aquinas,
and the Catholic Church
Aquinas’s beliefs gained prominence in the
Catholic Church at the Council of Trent
(1545–1563). In 1879, Pope Leo XIII declared
Thomism (Aquinas’s theology) to be eternally
valid.38 Nearly all writers recognize Aquinas as
setting the standard for natural law theory, just
as Aristotle serves as the standard-bearer for
virtue ethics.39 Aquinas developed his theory
in his work titled Summa Theologica, meaning “the highest theology.” Aquinas structured
the work in the form of a series of questions,
which he answered.40
The Thomistic conception of natural
law proceeds as follows: “All things subject to
Divine providence are ruled and measured by
the eternal law” (ST IaIIae 91, 2). “The rational creature is subject to Divine providence in
the most excellent way . . . . Wherefore it has a
share of the Eternal Reason, whereby it has a
natural inclination to its proper act and end:
and this participation of the eternal law in the
rational creature is called the natural law” (ST
IaIIae 91, 2). This establishes that natural law
is given by God and thus authoritative over all
humans. Not only can we know the law, but
also as rational and moral creatures, we can
violate it.
Recall Aristotle’s concept of practical wisdom; Aquinas used the same concept. In fact,
he called Aristotle “the philosopher” and cited
13
him as frequently as Scripture. One can find
the importance of practical reason, how it
works, its similarity to Aristotle’s conception
of it, and the most concise statement of what
the natural law compels in Aquinas’s writings.
The first principle of practical reason is
one founded on the notion of good, namely
that good is that which all things seek. Hence,
the first precept of law is that good is to be done
and pursued and evil is to be avoided. All other
precepts of the natural law are based upon this:
whatever the practical reason naturally apprehends as man’s good (or evil) belongs to the
precepts of the natural law as something to be
done or avoided (ST IaIIae 94, 2).
Unfortunately, some have stopped at this
quote and simply say that natural law means
to “do the good and avoid the evil.”41 Because
this lacks clarity about what the good might be
or about any decision rule by which to decide
what to do when goods conflict or when rankings are required, this statement alone does
not constitute an ethics theory. It sells the theory short.42
Aquinas also drew on Aristotle’s idea of
potentiality moving to actuality and states that
in the realm of what is good, “all desire their
own perfection” (ST Ia 5, 1). Again, following Aristotle’s lead, Aquinas noted that when
it comes to practical reason, the rules might
be clear but their application might not be. In
short, the details make the principle more difficult to apply (ST IaIIae 94, 4).
Aquinas then offered an excellent example that shows the difficulty at hand. Everyone
would agree that in general, “goods entrusted
to another should be restored to their owner”
(ST IaIIae 94, 4). However, Aquinas noted
that “it may happen in a particular case that
it would be injurious, and therefore unreasonable, to restore goods held in trust; for
instance, if they are claimed for the purpose of
fighting against one’s country. And this principle will be found to fail the more, according
as we descend further into detail” (ST IaIIae
94, 4). Taking this practical wisdom approach
even further, he generalized that “the greater
14
Chapter 1 Theory of Healthcare Ethics
the number of conditions added, the greater
the number of ways in which the principle
may fail” (ST IaIIae 94, 4).
Aquinas even went so far as to note that
although all are governed by the natural law,
all might not know it or act upon it: “In some
the reason is perverted by passion, or evil
habit, or an evil disposition of nature” (ST
IaIIae 94, 4).43 So what are we to do? In seeking a principle to determine what is good and
what is bad, it is not difficult to find specific
behaviors listed by Aquinas. However, an
excellent philosophical overview of natural
law by Michael Murphy concluded that there
are no obvious master principles but only
examples of flawed acts.44 The Catholic Encyclopedia suggested a number of things that
would be wrong or right under the dictum
to always do good and avoid harm. However,
there was nothing about how to resolve conflicts among these requirements.45 This seems
to add a quandary. All decisions are specific,
and the details will change, so are there any
decision rules?
At this point, scholars disagree on exactly
how Aquinas resolved the quandary, and we
do not need to follow them in those debates.
However, there is still a need for a decision
principle when there are disputes regarding
which of the various actions to take. There are
two such principles, and the one most closely
associated with natural law theory is that of the
double effect.
Principle of Double Effect
The first principle that proposes to distinguish
between a good and an evil is the theory of double effect. Derived from Summa Theologica, the
principle has four key points:
■■
■■
■■
The act must be good, or at least morally
neutral, independent of its consequences.
The agent intends only the good effects,
not the bad effect.
The bad effect must not be a means to
the good effect. If the good effect were to
be the causal result of the bad effect, the
■■
agent would intend the bad effect in pursuit of the good effect.
The good effect must outweigh the bad
effect.46
The theory of double effect has use in medical ethics when dealing with abortion,
euthanasia, and other decisions where there
is a conflict between a good and an evil. For
example, under this view, abortion is an evil,
but saving the life of a mother is a good. Under
this view, euthanasia is an evil, but relieving
pain by the use of morphine is a good. If the
person dies and the death was not intended,
then is it acceptable? Major issues arise in the
application of the theory concerning how to
determine a person’s intent. We know that
not everyone is a person of practical wisdom
who only has a good intent. However, how
would we know the intent in a particular
case?47
At the policy-making level, is it acceptable to cut taxes for the rich at the expense
of the poor? What good comes of it? Because
there are few rich and many poor, does the
good of the rich count more than the good
lost by the poor? Note that the further we
delve into these types of questions, the more
important consequences seem to become,
until natural law becomes a form of consequentialism, perhaps rule consequentialism.48 It is not necessary to resolve these
disputes here, because the purpose is to
understand the theories for the purposes of
making appropriate decisions in health care.
Relative to that end, a second decision rule
for natural law is available.
Entitlement to Maximize Your
Potential
The key to understanding this proposed
decision rule relates to metaphysics: “Ethics
especially is impossible without metaphysics, since it is according to the metaphysical
view we take of the world that ethics shapes
itself.”49 The Thomistic ethic draws heavily on
the Aristotelian metaphysics that describes
Ethics Theories
the world as a hierarchy of being, with all entities in it striving to reach their own complete
state of actualization of their potential. This
means that it is part of the natural order for
all entities to strive to maximize their potential. To deny something its ability to actualize its potential is to violate its very nature.
Such a violation causes harm to the entity and
would be a violation of its nature and of the
natural law to avoid harm. Thus, natural law
proscribes any activities that would violate
an entity’s potential.50 Concerns about termination of potential, at least for rational creatures, are evident in several contemporary
healthcare issues.
Many religions and social activists place
considerable emphasis on social and political factors that prevent humans from actualizing their potential. These groups often are
at the forefront of social justice movements
addressing poverty, ignorance, unhealthy living conditions, and slave-like working conditions. Clearly, healthcare professionals need to
understand natural law theory when working
with patients who believe in its tenets and with
those who advocate social justice. This might
include those who are working to improve
public health, social conditions, or human
rights. Now let us look at another common
ethics theory, deontology.
Deontology
The derivation of deontology comes from the
Greek word deon, which means “duty.” Thus,
deontology is concerned with behaving ethically by meeting our duties. The ethics theory
of deontology originates with the German
philosopher Kant (1724–1804).51 Although
Kant’s influence on deontology is significant,
many other thinkers are part of the deontological tradition as well.52 Nonetheless, just as
we relied on Aristotle for virtue ethics and on
Aquinas for natural law, Kant sets the standard
for deontology. Following the review of Kant,
we shall examine some of the more contemporary advocates of deontological theories.
15
Kant’s Metaphysics and
Epistemology Grounded His
Ethics
Kant is most well-known for his work in metaphysics and epistemology, the Critique of Pure
Reason,53 but he also did groundbreaking work
in ethics. Kant’s writings on ethics appear in
several different volumes, with titles such as
Groundwork of the Metaphysics of Morals54 and
Critique of Practical Reason55 among others.
The concept of honoring commitments clearly did not start with Kant, but his
approach to the issue led to the identification
of his ethics theory with deontology. Kant’s
work in metaphysics and epistemology had
a significant influence on this approach and
his ethical views. As seen with Aristotle and
Aquinas, a complete understanding of ethics
often includes a view about the nature of the
world and how we know it—in other words,
the disciplines of metaphysics and epistemology. Kant concluded that the belief that perception represented the world was incorrect,
or at least incomplete. Instead, the structure
of consciousness processes sense data through
the means of categories of thought and two
forms of intuition, space and time.
Of these categories of thought, the one
that relates most directly to ethics is causality. All experiences are subject to causation,
which in Kant’s view undermines free will. In
the Newtonian world of his time, it was widely
believed that if you could completely know
the behavior of all the matter in existence, you
could predict the future behavior of anything
material. This did not pose a problem for most
people at this time because of the earlier dividing of mind and matter by Rene Descartes
(1595–1650). Like most people, Kant found
free will to be essential for ethics. If one’s every
act is determined, how can one be held responsible for one’s choices?
At the same time, Kant’s reasoning inexorably led him to conclude that we cannot
know what the world is like in and of itself.
It is beyond knowing, because we cannot
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Chapter 1 Theory of Healthcare Ethics
experience anything without use of the categories and forms of intuition. Kant, thus,
divided the realm of being into the phenomenal world of experience and the noumenal
world. We can think about the noumenal
world, but we cannot directly experience it.
Thus, we have “an unavoidable ignorance
of things in themselves and all that we can
theoretically know are mere appearances” (B
xxix).56 Relative to ethics, it should be clear
from Kant’s perspective that the metaphysical issue of whether free will is possible is
foundational.57
Kant argued that knowledge of the sensible world was insufficient for knowing the
moral law.58 Yet he also argued that free will
makes ethics possible. Free will is the precondition of ethics. If all things are determined
by natural causes, then our supposed ethical
choices are specious, an illusion. Humans, as
a natural phenomenon, are determined by natural laws; causality applies to all natural phenomena. However, the self, in and of itself (the
soul), is free from these laws.59
Kant recognized that this puts morality beyond the pale of empirical science, and
indeed, the question about free will is beyond
such testing. However, Kant believed that he
left a “crack in the door” that is wide enough
to allow for morality. He did this by arguing
that the concept of freedom, although not
knowable in a scientific way, is something
we can think about without contradiction:
“Morality does not, indeed, require that freedom should be understood, but only that it
should not contradict itself, and so should
at least allow of being thought” (B xxix).60 In
this sense, Kant redefined humans as participating in two kinds of reality, the phenomenal and the noumenal. According to Kant,
“There is no contradiction in supposing that
one and the same will is, in the appearance,
that is, in its visible acts, necessarily subject to the law of nature, and so far not free,
while yet, as belonging to a thing in itself, is
not subject to that law, and is therefore free”
(B xxviii).61
Freedom of the Will
Like Aristotle and Aquinas, Kant certainly
thought good character was laudable. However, he was concerned that the properties that
constitute good character, without a good will
to correct them, could lead to bad outcomes.
For example, we can misuse courage and perseverance without the direction of a good will.62
Kant went so far as to argue that one should
act on the duty of obligation to the moral law
regardless of any relationship that might have
an outcome such as eudaimonia: “A good will
is good not because of what it performs or
effects, not by its aptness for the attainment of
some proposed end, but simply by virtue of its
volition, that is, it is good in and of itself ” (AK
4:394).63 In other words, a good will is good
because it wills properly. Thus, Kant set a high
standard. Some of his language even suggests
that the true test of a good will is whether the
person continues to act out of duty and reverence for the moral law, even when doing so has
no personal benefit and might “involve many
a disappointment to the ends of inclination”
(AK 4:396).64
Reason, Autonomy, the Moral
Law, and the Will
Kant was distinctive relative to his predecessors in seeking to ground our duties in a
self-governing will. This is an appeal to reason
itself being autonomous, meaning that we are
free to choose. If we choose according to reason, we shall conform to the moral law: “If reason completely determined the will, the action
would without exception take place according to the rule” (AK 5:20).65 One can see the
extremely prominent principle of autonomy
coming into play here.
Typically, an autonomous agent is
one who makes his or her own rules and is
responsible for his or her actions.66 To violate
that autonomy is to violate a person’s innermost selfhood, something Kant developed as
one form of the categorical imperative. Thus,
Ethics Theories
one does not seek the foundation of ethics in
the development of a person of good character seeking to actualize his or her intrinsic
nature in order to seek the end of eudaimonia.
Instead, the subject matter of ethics is not
character but, rather, the nature and content
of the principles that determine a rational
will. Free will is determined by moral principles that cohere with the categorical imperative. This abstruse approach, for many, simply
disconnects the moral law and free will from
real life.
The idea of autonomy here is not the
view that individuals make their own laws.
It means that the laws that bind you in some
sense derive from your own making, your
own fundamental nature as a self.67 For Kant,
the will is free in the sense that you choose
to be bound by these principles of reason.
You freely choose to bind yourself to the constraints of the categorical imperative and the
dictates of reason.
The requirement of the duty to obey the
moral law to express a good will brings the
notion of intent into the discussion. Why a
person acts in such a way as to conform to
the moral law is an important component of
ethical evaluation in the Kantian scheme. Let
us turn to what Kant saw as rational principles that would ground ethics or the moral
law.
Kant attempted to discover the rational
principle that would ground all other ethical
judgments. He called this principle the categorical imperative. The categorical imperative is not so much a rule as a criterion for
determining what ethics principles meet the
test of reason.68 The imperative would have
to be categorical rather than hypothetical, or
conditional, because true morality should not
depend on individual likes and dislikes or on
abilities and opportunities. These are historical “accidents.” Any ultimate principle of ethics must transcend them in order to meet the
conditions of fairness. We shall later see how
Rawls used similar ideas in developing his
concept of a veil of ignorance. Kant developed
17
several formulations of the categorical imperative. The most commonly presented ones
follow:69
■■
■■
“Always act in such a way that you can also
will that the maxim of your action should
become a universal law” (AK 4:421).70
This principle often is caricatured as the
Golden Rule: Do unto others as you would
have them do unto you.71 This does not
capture the full meaning of what Kant had
in mind and may, indeed, miss the essence
of his teachings, as he specifically disavowed that this was his intended meaning (AK 4:430).72
“Act so that you treat humanity, both in
your own person and in that of another,
always as an end and never merely as a
means” (AK 4:429).73 Kant spoke of the
good society as a place that was a kingdom of ends (AK 4:433–434).74
The Categorical Imperative as a
Formal Decision Criterion
Although Kant believed that these two statements of the categorical imperative were formally equivalent, the first illustrates the need
to apply moral principles universally. That a
principle be logically consistent was important
to Kant. This principle of universal application
is also what allowed ethical egoism to be dismissed as something humans do when making
decisions but not as something that is an ethics theory. The second formulation points to
making the radical distinction between things
and persons and emphasizes the necessity of
respect for persons.
Kant’s theory evaluates morality by
examining the nature of actions and the
will of agents rather than goals achieved.
You have done the right thing when you act
out of your obligation to the moral law, not
simply because you act in accordance with
it. Note the fundamental importance of
intent as compared with any concern with
outcomes. One reason for the emphasis on
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Chapter 1 Theory of Healthcare Ethics
duties in Kant’s deontology is that we are
praised or blamed for actions within our
control, and that includes our willing, not
our achieving.
Kant did care about the outcomes of our
actions, but he thought that as far as the moral
evaluation of actions was concerned, consequences did not matter. As Kant pointed out,
this total removal of consequences “is strange
enough and has no parallel in the remainder of
practical knowledge” (AK 5:31).75 Let us now
look at the second version of the categorical
imperative, which is foundational in healthcare ethics.
The Categorical Imperative as
Respect for Persons
The second version of the categorical imperative emphasizes respect for persons. According
to Kant, you should “[s]o act as to treat humanity, whither in thine own person or in that of
any other, in every case as an end withal, never
as means only” (AK 4:429).76 People, unlike
things, ought never to be merely used. Their
value is never a means to our ends; they are
ends in themselves. Of course, a person might
be useful as a means, but you must always treat
that person with respect.
Kant held this view because of his belief
that people are rational and that this bestows
them with absolute worth: our “rational nature
exists as an end in itself ” (AK 4:428).77 This
makes people unique in the natural world. In
this sense, it is our duty to give every person
consideration, respect, and dignity. Individual
human rights are acknowledged and inviolable
in a deontological system. The major emphasis
on autonomy in health care springs from these
considerations and others like them. Although
most people who defend autonomy and treat
people as ends and not merely as means do
not use these formalistic Kantian reasons,
this principle of autonomy is foundational
in healthcare ethics. It is part of health care’s
common morality.
The Categorical Imperative and
the Golden Rule
According to the categorical imperative, if the
maxim or the rule governing an action is not
capable of being a universal law, then it is unacceptable. Note that universalizability is not the
same as universality. Kant’s point is not that
we would all agree on some rule. Instead, we
must logically be able to accept that it could
be universal. This is why the concept seems
very much like the Golden Rule.78 If you cannot will that everyone should follow the same
rule, your rule is not a moral one. As indicated
earlier, many think Kant’s first formulation of
the categorical imperative implies or even is a
restatement of the Golden Rule. However, Kant
specifically repudiates the Golden Rule interpretation (AK 4:430, note 13).79
Kant saw the justification for the Golden
Rule in terms of consequences and fairness. If
it is fair for me to do something, then it should
be fair for everyone. Alternatively, in consequential terms, we typically hear officials, merchants, managers, and parents, when they are
considering exceptions to policy, say, “If I do
X for you, I have to do X for everyone.” If one
made exceptions for each individual, then the
consequences would be unfair for others.80
Kant wanted to get beyond such issues.
He wanted to know whether a person performed an act out of duty to moral law and
thus expressed a good will. He stipulated that
the moral agent acting solely out of a good will
should ignore empirical considerations such as
consequences, fairness, inclinations, and preferences. For Kant, an act carried out from an
inclination, no matter how noble, is not an act
of morality (AK 4:398). Indeed, he went so far
as to say that the less we benefit from acting on
the moral law, the more sublime and dignified
it is (AK 4:425).81
Acts have moral worth if the person acts
solely from duty to the moral law, absent any
emotional inclinations or tangible benefits.
This sets up the difficult standard that we can
Ethics Theories
only know whether persons are morally worthy or obeying the moral law when there is
nothing in it for them. Their actions would be
opposed to their desires, inclinations, and even
their self-interests. Taking such an extreme
position essentially disconnected Kant from
the real world in which people live and make
ethical judgments.
Virtue Ethics and Kant’s Moral Law
Although likely controversial, it seems, for
purposes of healthcare ethics, that the best
way to make sense of Kant is to conceive of
the person of a good will in a manner akin to
Aristotle’s virtue ethics. Thus, to make Kantian
deontology useful, you could say that a person of a good will also is a person of practical
wisdom, as described by Aristotle. Does this
inclusion of Aristotle reject Kant’s work? No,
but a critical analysis and comparison to virtue
ethics are warranted.
Although Kant’s theory suffers from disconnection from any normal motivational
structure in human life, it still has applications
in healthcare ethics.82 The deontological theory emphasizes the attention to duty found in
all codes of ethics in health care. Kant put into
sharp relief the ethical idea that it is wrong for
people to claim they can follow a principle or
maxim that suits their interests but would not
want others to do the same. Most important
for health care is the recognition of human
dignity and autonomy. To use people solely as
a means to an end, whether as teaching material in medical schools, prisoners in research
experiments, or slaves, is fundamentally a violation of all beings.
Deontology poses two problems that lead
many to reject it. First, the statement of categorical imperatives, maxims, duties, rules, or
commandments yields only absolutes. Kant
really had only one absolute—you must act
solely on the basis of a good will. You must
have a reverence for, and an obligation to,
the moral law formalized by the categorical
19
imperative. However, the lack of prescriptive content leaves many unsatisfied. Actions
either pass or fail, with no allowance for a
“gray area.” Virtue ethics handles the gray
areas by depending on the wisdom of the person of practical wisdom. This is one reason
virtue ethics as an ethical tool enables us to
handle the problems of healthcare ethics more
robustly.
The inability to make distinctions between
lesser evils or greater goods is the other problem. We face moral dilemmas when duties
come into conflict and there is no mechanism
for resolving them. Kant, with his limited
description of only one ethical duty (to obey
the moral law), could claim to escape this
problem within his philosophy. He used the
radical view that such decisions are outside the
bounds of morality if based on inclinations or
consequences. Defining the real world of ethics
in this radical way does not help much when
faced with decisions that involve your inclinations and the weighing of consequences. Even
if you have, as Kant seemed to think, only one
duty, it is a formal one, and its various manifestations could conflict.
Virtue ethics and natural law theory face
this problem of conflicting duties as well. For
example, whereas abortion is clearly wrong
under natural law theory, the outcomes of
unwanted children, starving children, child
abuse, malnutrition, etc., also have a moral
bearing. Duties also conflict in healthcare situations. For example, if …
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