Cover Page

Contents

Notes on Contributors

Preface to the Second Edition

Source Credits

Chapter 3

Chapter 4

Chapter 6

1 Ethical Reasoning

A Prudential Model of Decision-Making

Possible Ethical Additions to the Prudential Model

How to Construct Your Own Model

How Do Ethics Make a Difference in Decision-Making?

Case 1: Social/Political Ethics The Trolley Problem

Analysis

Case 2: An Admission to the Emergency Room

Analysis

Conclusion

Notes

2 Health The Aim of Medicine

Ethics, Infertility, and Public Health Balancing Public Good and Private Choice

Health, Disease, and Infertility

Infertility as a Disvalued Dysfunction (Disease)

Conclusion

Notes and References

Too Old for the Good of Health?

Introduction: Goodness and Health

Health—Neutral or Normative?

Definitions of Health

Oldness

When Is Old Age?

Health in Old Age

Goodness of Health for Old Age

Conclusion

Notes and References

Health as Self-Fulfillment

Functional Approaches to Health

Public Health Approach

Subjectivist Approaches

Conclusion

Notes

References

Evaluating a Case Study Developing a Practical Ethical Viewpoint

Macro and Micro Cases

Situation One

Situation Two

Notes

3 Physician, Nurse, and Patient The Practice of Medicine

The Oath

A. Paternalism and Autonomy

B. Privacy and Confidentiality

C. Informed Consent

D. Gender, Culture, and Race

Notes

A. Paternalism and Autonomy Medical Paternalism and Patient Autonomy

Introduction

Preliminary Distinctions

The Birth of Medical Paternalism

The Invention of Patient Autonomy

The Four Models of the Physician-Patient Relationship

Vital Issues Concerning Medical Paternalism

Conclusions

Notes

References

Rational Non-Interventional Paternalism Why Doctors Ought to Make Judgments of What Is Best for Their Patients

Two Reasons

‘Framing Effect’

Moral Stakes

Shared Decision-Making

References

B. Privacy and Confidentiality Medical Privacy in the Age of Genomics

Medical Privacy

Genomics: A Revolution in Revelations

DNA, Genes, and Information About Persons

What May Once Have Been a Duty Must Now Become a Right

The Right to Your Genes

Notes

Ethical Issues Experienced by HIV‑Infected African-American Women

Introduction

Method

Findings

Discussion

Conclusion

References

C. Informed Consent Should Informed Consent Be Based on Rational Beliefs?

I. Introduction

II. Rationality and Autonomy

III. An Example of Irrational Belief: Jehovah’s Witnesses and Blood

IV. Three Examples of Holding a False Belief

V. Summary and Implications

Rational Deliberation

Duties as Educators

Acknowledgement

Notes and References

Cultural Diversity and Informed Consent

Case

Discussion

Analysis

Recommendations

D. Gender, Culture, and Race On Treatment of Myopia

Some Flaws in Contemporary Health Care and Bioethics

Feminist Standpoint and Attention to Relationships and Context

The Meaning of Care and the Pitfalls of Care-Based Reasoning

An Illustrative Case

Proportionate Representation as a Remedial Strategy

Notes

Culture and Medical Intervention

Case 1

Dialectical Worldview Positions

A Critical Examination of the Worldview Positions

Case 2

Dialectical Worldview Positions

A Critical Examination of the Worldview Positions

Conclusion

Acknowledgment

Notes

Healthcare Disparity and Changing the Complexion of Orthopedic Surgeons

Introduction

Healthcare Disparity

The Problem from the Patient’s Perspective

Creating Real Diversity in the Physician Population

The Timothy L. Stephens Orthopedic Fellowship Program for Minority Medical Students: Its Goals and Its Progress

Conclusion

Notes

References

Evaluating a Case Study Finding the Conflicts

Case 1

Case 2

Checklist for Detecting Ethical Issues

Macro and Micro Cases

Note

4 Issues of Life and Death

A. Euthanasia

B. Abortion

Note

A. Euthanasia Killing and Allowing to Die

Metaphysical

Moral

Medical

Euthanasia in The Netherlands Justifiable Euthanasia

What Makes a Patient Request Euthanasia

Carrying Out “Passive Euthanasia”

Why Doctors Must Not Kill

B. Abortion An Almost Absolute Value in History

Notes

A Defense of Abortion

1

2

3

4

5

6

7

8

Notes

The Abortion Debate in the Twenty-First Century

The History of the Debate

A Critical Examination of the Premises of Each Side

The Personal Worldview and Abortion

Conclusion

Notes

Evaluating a Case Study Assessing Embedded Levels

Case 1

Professional Practice Issues

Ethical Issues

Case 2

Professional Practice Issues

Ethical Issues

Macro and Micro Cases

Note

5 Genetic Enhancement

Ethical Issues in Human Enhancement

What Is Human Enhancement?

Life Extension

Physical Enhancement

Mood and Personality Enhancement

Cognitive Enhancement

Selecting the Best Children

Notes

References and Further Reading

Limitations on Scientific Research

The Principle of Plenitude

The Limits of Science

Notes

References

Evaluating a Case Study Applying Ethical Issues

Sample “Pro” Brainstorming Sheet for the Position

Key Thoughts on the Subject

Argument

Sample “Con” Brainstorming Sheet Against the Position

Key Thoughts on the Subject

Argument

Macro and Micro Cases

Notes

6 Healthcare Policy

A. The Right to Healthcare

B. The Organ Allocation Problem

C. International Public Health Policy and Ethics

Note

A. The Right to Healthcare

Rights as Freedom of Individual Action

Rights as Entitlements to Goods and Services

The Moral Foundations of Rights: Egoism Versus Altruism

The Failure of Entitlement “Rights”

Healthcare Policy and Ethics

Notes

References

The Moral Right to Healthcare: Part Two

Strengths and Weaknesses of the Present System within the United States

Ethical Arguments on Human Rights and Healthcare

Assessing the “Ought implied Can” Restriction on Universal Health Coverage

Rationing Scenarios

Conclusion

Notes

References

B. The Organ Allocation Problem A Review of Ethical Issues in Transplantation

Organ Procurement

Organ Allocation

Summary and Conclusions

References

Fault and the Allocation of Spare Organs

Historical Fault

A Non-Punitive Principle of Restitution

Self-Inflicted Harm Is Not a Crime

The Threat May Be Current

Priority of Non-Smokers over Smokers in Access to Spare Organs?

Dangerous Sports

Moral Complicity

References and Notes

Applicants

C. International Public Health Policy and Ethics

Introduction

A “Marvelous Momentum” for the Control of Infectious Disease

A Vision for 2020–30? A Comprehensive Global Effort for the Control of Infectious Disease

“Thinking Big,” Both Practically and Ethically

Global Efforts: Results So Far

Human Health in Epidemiological Perspective

Is a Comprehensive Global Effort Realistic? On Eradication, Elimination, and Control

A Comprehensive Global Effort: From Thought Experiment to Plan

References

Shaping Ethical Guidelines for an Influenza Pandemic

Introduction

The Threat of an Influenza Pandemic in the Twenty-First Century

Laying the Foundation for an Ethical Preparedness Plan for an Influenza Pandemic

Health Care Personnel and the Duty/Obligation/Responsibility to Work During an Influenza Pandemic

Other Critical Workers and Duty/Obligation/Responsibility to Work During an Influenza Pandemic

Social Distancing, Isolation, and Quarantine

Allocation of Scarce Health Care Resources

Conclusion

References

TB Matters More

Bioethics and Infectious Disease

Neglected Disease

Mapping the Terrain of Ethical Issues Associated with TB: A Research Agenda

A “Moderate Pluralist” Ethical Approach to TB Control

Note

References

Evaluating a Case Study Structuring the Essay

Sample Essay

Macro and Micro Cases

Note

Further Reading

Chapter 2 Health: The Aim of Medicine

Chapter 3 Physician, Nurse, and Patient: The Practice of Medicine

Chapter 4 Issues of Life and Death

Chapter 5 Genetic Enhancement

Chapter 6 Healthcare Policy

Image






For Arianne

Notes on Contributors

Felicia Niume Ackerman is professor of philosophy at Brown University.

Pieter V. Admiraal is an anesthesiologist at Delft, The Netherlands.

Ellen Agard was Greenwall Fellow in Bioethics at Johns Hopkins University and Georgetown University.

Margaret P. Battin is Distinguished Professor of Philosophy and Adjunct Professor of Internal Medicine in the Division of Medical Ethics and Humanities at the University of Utah.

Nick Bostrom is director of the Future of Humanity Institute at Oxford University.

Michael Boylan is professor and chair of the Department of Philosophy at Marymount University.

Daniel Callahan is senior research scholar and president emeritus at the Hastings Center.

Daniel Finkelstein is a professor of ophthalmology at the Wilmer Ophthalmological Institute and on the core faculty at the Bioethics Institute at Johns Hopkins University School of Medicine.

Leslie P. Francis is professor and chair of the department of philosophy and Alfred C. Emery Professor of Law at the University of Utah.

John-Stewart Gordon teaches at the University of Cologne, Germany.

Richard E. Grant, is an orthopedic surgeon at Einstein Medical Center in Philadelphia, Pennsylvania.

Jay A. Jacobson is professor of internal medicine and Chief, Division of Medical Ethics and Humanities, and member, Division of Infectious Diseases, University of Utah School of Medicine and Intermountain Medical Center.

Leon R. Kass is Addie Clark Harding Professor in the Committee for Social Thought at the University of Chicago.

Paul M. Kelly is Director of the Masters of Applied Epidemiology Programme at the National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia.

David Koepsell teaches at Delft University in The Netherlands.

John David Lewis (deceased) was associate professor in the philosophy, politics, and economics program at Duke University.

Mary B. Mahowald is professor emerita of philosophy at the University of Chicago.

Richard W. Momeyer is on the philosophy faculty at Miami University, Oxford, Ohio.

John T. Noonan Jr was professor of law at the University of California, Berkeley, from 1967 to 1986, and is now the senior judge on the U.S. Court of Appeals, 9th Circuit.

Rosamond Rhodes is associate program director and professor of bioethics at the Mt. Sinai School of Medicine.

Rebecca Roache is a James Martin Research Fellow at the Future of Humanity Institute at Oxford and a Senior Research Associate, Holywell Manor (Balliol College Graduate Centre).

Jan Russell is executive staff assistant in the school of nursing at the University of Missouri-Kansas City, Missouri.

Julian Savulescu is Uehiro Professor of Practical Ethics at Oxford University, UK.

Michael J. Selgelid is Senior Research Fellow in the Center for Applied Philosophy and Public Ethics (CAPPE) and the Menzies Centre for Health Policy at the Australian National University.

Anita Silvers is professor and chair of the Department of Philosophy at San Francisco State University.

Adrian Sleigh is Professor of Epidemiology at the National Centre for Epidemiology and Population Health, ANU College of Medicine and Health Sciences, The Australian National University.

Brian Smart is on the faculty at Keele University, UK.

Charles B. Smith is emeritus professor of medicine at the University of Utah School of Medicine.

Katharine V. Smith is program director in the school of nursing at the University of Missouri-Kansas City, Missouri.

Judith Jarvis Thomson is professor of philosophy at Massachusetts Institute of Technology.

Rosemarie Tong is Distinguished Professor in Health Care Ethics; Director Center for Professor and Applied Ethics, Department of Philosophy, The University of North Carolina at Charlotte, Charlotte, North Carolina.

Edward Wallach is J. Donald Woodruff Professor of Gynecology in the Department of Gynecology and Obstetrics at Johns Hopkins University School of Medicine.

Preface to the Second Edition

Medical Ethics is one of my three texts on applied ethics that is now being published by Wiley-Blackwell. The idea behind each of the books, in general, is to present some of the most pressing questions in applied ethics through a mixture of classic essays and some new essays commissioned precisely for these volumes. The result is a dialogue that I think readers will find enriching.

In addition to the essays, there is an ongoing pedagogical device on how to write an essay in applied ethics—using case response as the model. To this end, the major chapters of the book are followed by two sorts of cases: macro cases and micro cases. In macro cases the student takes the role of a supervisor and must solve a problem from that perspective. In the micro cases the student becomes a line worker and confronts dilemmas from that vantage point. Some felicity at both perspectives can enable the student better to understand the complication of applying ethical theories (set out in Chapter 1) to real-life problems.

Others using the book may choose instead to evaluate selected essays through a “pro” or “con” evaluation. This approach emphasizes close reading of an article and the application of ethical theory (set out in Chapter 1) to show why you believe the author is correct or incorrect in her/his assessment of the problem. In order to make this approach appealing to readers, some effort has been made to offer different approaches to contemporary questions in healthcare ethics.

What is new in this second edition?

It is my hope that this second edition will meet the needs of classroom instruction in a unique way while recognizing that the practice of medicine occurs within a diverse context that must be recognized in order to be effective. The world moves on and the healthcare field has to know when and how to adapt the principles of its historical practice to meet these demands.

As is always the case in projects like this there are many to thank. I would first like to thank all the scholars who have written original essays expressly for this edition. Their fine work has added a unique character to the book. To the anonymous reviewers of this book, a thank-you for your thoughtful comments. I would also like to thank Jeff Dean, my editor, for his support of the project, Robert Hine, my copy-editor, and the whole Wiley-Blackwell team.

I would also like to thank my research team at Marymount: Tanya Lanuzo and Lynn McLaughlin. Their expertise helped with my original essays that are in this volume. Finally, I would like to thank my family: Rebecca, Arianne, Seán, and Éamon. They continually help me grow as a person.

Source Credits

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book:

Chapter 3

“Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgments of What Is Best for Their Patients,” by Julian Savulescu, originally published in the Journal of Medical Ethics 1995; 21: 327–31. Reprinted with permission of the BMJ Publishing Group.

“Ethical Issues Experienced by HIV-Infected African-American Women,” by Katharine V. Smith and Jan Russell, originally published in Nursing Ethics 1997; 4: 394–402. Reprinted with ­permission of Edward Arnold Permissions.

“Should Informed Consent Be Based on Rational Beliefs?” by Julian Savulescu and Richard W. Momeyer, originally published in the Journal of Medical Ethics, 1997; 23: 282–8. Reprinted with permission of the BMJ Publishing Group.

“Cultural Diversity and Informed Consent,” by Ellen Agard, D. Finkelstein, and E. Wallach, originally published in the Journal of Clinical Ethics 1998; 9, no. 2 (Summer): 173–6. © 1998 The Journal of Clinical Ethics, all rights reserved. Used with permission of The Journal of Clinical Ethics.

“On Treatment of Myopia: Feminist Standpoint Theory and Bioethics,” by Mary B. Mahowald, is from Feminism and Bioethics: Beyond Reproduction, edited by Susan M. Wolf. Copyright © 1996 The Hastings Center. Used by permission of Oxford University Press, Inc.

“Culture and Medical Intervention,” by Michael Boylan, was originally published in the Journal of Clinical Ethics 2004; 15(2, Summer): 187–99.

Chapter 4

“Killing and Allowing to Die,” by Daniel Callahan, was originally published in the Hastings Center Report 1989; 19 (Special Suppl.): 5–6. Reprinted by permission. © The Hastings Center.

“Euthanasia in The Netherlands: Justifiable Euthanasia,” by Pieter V. Admiraal, is reprinted by permission of the publisher, Issues in Law and Medicine 1988; 3(4, Spring). Copyright © 1988 by the National Legal Center for the Medically Dependent & Disabled, Inc. pp. 361–70.

“Why Doctors Must Not Kill,” by Leon Kass, was originally published in Commonweal, Aug. 9, 1991. Reprinted with permission of the Commonweal Foundation. For subscriptions, call 1-999-495-6755.

“An Almost Absolute Value in History” is from John T. Noonan (ed.), The Morality of Abortion: Legal and Historical Perspectives. Cambridge, MA: Harvard University Press; pp. 267–272. Copyright © 1970 by the President and Fellows of Harvard College. Reprinted by permission of the publisher.

“A Defense of Abortion,” by Judith Jarvis Thomson, was originally published in Philosophy and Public Affairs (Autumn 1971); 1(1): 273–89. Copyright © John Wiley and Sons.

Chapter 6

“A Review of Ethical Issues in Transplantation,” by Rosamond Rhodes, was originally published in the Mount Sinai Journal of Medicine 1994; 61(1): 77–82. Reprinted with permission of the publisher.

“Fault and the Allocation of Spare Organs,” by Brian Smart, was originally published in the Journal of Medical Ethics 1994; 20: 26–30. Reprinted with permission of the BMJ Publishing Group.

“Applicants,” by Felicia Niume Ackerman, was originally published in Ascent 1985; 10(2): 2–18.

“Toward Control of Infectious Disease: Ethical Challenges for a Global Effort,” by Margaret P. Battin, Charles B. Smith, Leslie P. Francis, and Jay A. Jacobson, is from Michael Boylan (ed.) (2008) International Public Health Policy and Ethics. Springer; pp. 191–214.

“Shaping Ethical Guidelines for an Influenza Pandemic,” by Rosemarie Tong, is from Michael Boylan (ed.) (2008) International Public Health Policy and Ethics. Springer; pp. 215–32.

“TB Matters More,” by Michael J. Selgelid, Paul M. Kelly, and Adrian Sleigh, is from Michael Boylan (ed.) (2008) International Public Health Policy and Ethics. Springer; pp. 233–48.

1

Ethical Reasoning

MICHAEL BOYLAN

What is the point of studying ethics? This is the critical question that will drive this chapter. Many people don’t think about ethics as they make decisions in their day-to-day lives. They see problems and make decisions based upon practical criteria. Many see ethics as rather an affectation of personal taste. It is useful only when it can get you somewhere. Is this correct? Do we only act ethically when there is a win-win situation in which we can get what we want and also seem like an honorable, feeling, and caring person?

A Prudential Model of Decision-Making

In order to begin answering this question we must start by examining the way most of us make decisions. Everyone on earth initiates the decision-making process with an established worldview. A worldview is a current personal consciousness that consists in one’s understanding about the facts and values in the world. It is the most primitive term to describe our factual and normative conceptions. This worldview may be one that we have chosen or it may be one that we have passively accepted as we grow up in a particular culture. Sometimes the worldview is wildly inconsistent. Sometimes the worldview has gaping holes so that no answer can be generated. Sometimes it is only geared to perceived self-interest. And sometimes it is fanciful and can never be put into practice. Failures in one’s personal worldview model will lead to failures in decision-making.

One common worldview model in the Western world is that of celebrity fantasy. Under this worldview, being a celebrity is everything. Andy Warhol famously claimed that what Americans sought after most was 15 minutes of fame.1 Under this worldview model we should strive to become a celebrity if only for a fleeting moment. What does it mean to be a celebrity? It is one who is seen and recognized by a large number of people. Note that this definition does not stipulate that once recognized the object is given positive assent. That would be to take an additional step. To be seen and ­recognized is enough. One can be a sinner or a saint—all the same. To be recognized is to be recognized. If this is the end, then it is probably easier to take the sinner route. In this way, the passion for celebrity is at heart contrary to ethics.

Another popular worldview model is one of practical competence. Under this model the practitioner strives to consider what is in his or her best interest and uses a practical cost-benefit analysis of various situations in order to ascertain whether action X or action Y will maximize the greatest amount of pleasure for the agent (often described in terms of money). Thus, if you are Bernie Madoff (a well-known financial swindler) you might think about the risks and rewards of creating an illegal Ponzi scheme as opposed to creating a legitimate investment house that operates as other investment houses do. The risks of setting off on your own direction are that you might get caught and go to prison. The rewards are that you might make much more money than you would have under the conventional investment house model. Since you think you are smarter than everyone else and won’t get caught, the prudential model would say—go for it! Madoff did get caught, but who knows how many others don’t? We couldn’t know because they haven’t been caught. But even if you aren’t caught, is that the best worldview approach? The prudential model says yes.

Possible Ethical Additions to the Prudential Model

Some people, including this author, think that the prudential model is lacking. Something else is necessary in order have a well-functioning worldview by which we can commit purposive action (here understood to be the primary requirement of fulfilled human nature). First, we have to accept that the construction of our worldview is within our control. What I suggest is a set of practical guidelines for the construction of our worldview: All people must develop a single comprehensive and internally coherent worldview that is good and that we strive to act out in our daily lives. I call this the personal worldview imperative. Now one’s personal worldview is a very basic concept. One’s personal worldview contains all that we hold good, true, and beautiful about existence in the world. There are four parts to the personal worldview imperative: completeness, coherence, connection to a theory of ethics, and practicality. Let’s briefly say something about each.

First is completeness. Completeness is a formal term that refers to a theory being able to handle all cases put before it and to determine an answer based upon the system’s recommendations. In this case, I think that the notion of the good will provides completeness to everyone who develops one. There are two senses of the good will. The first is the rational good will. The rational good will means that each agent will develop an understanding about what reason requires of one as we go about our business in the world. In the various domains in which we engage this may require developing different sorts of skills. In the case of ethics it would require engaging in a rationally based philosophical ethics and abiding by what reason demands.

Another sort of good will is the affective good will. We are more than just rational machines. We have an affective nature, too. Our feelings are important, but just as was the case with reason, some guidelines are in order. For ethics we begin with sympathy. Sympathy will be taken to be the emotional connection that one forms with other humans. This emotional connection must be one in which the parties are considered to be on a level basis. The sort of emotional connection I am talking about is open and between equals. It is not that of a superior “feeling sorry” for an inferior. It is my ­conjecture that those who engage in interactive human sympathy that is open and level will respond to another with care. Care is an action-guiding response that gives moral motivation to acting properly. Together sympathy, openness, and care constitute love.

When confronted with any novel situation one should utilize the two dimensions of the good will to generate a response. Because these two orientations act differently it is possible that they may contradict each other. When this is the case, I would allot the tiebreaker to reason. Others demur.2 Each reader should take a moment to think about their own response to such an occurrence.

Second is coherence. People should have coherent worldviews. Coherence also has two varieties: deductive and inductive. Deductive coherence speaks to our not having overt contradictions in our worldview. An example of an overt contradiction in one’s worldview would be for Sasha to tell her friend Sharad that she has no prejudice against Muslims and yet in another context she tells anti-Muslim jokes. The coherence provision of the personal worldview imperative says that you shouldn’t change who you are and what you stand for depending upon the context in which you happen to be.

Inductive coherence is different. It is about making sure one’s life strategies work together. When they don’t work together we have inductive incoherence: in inductive logic this is called a sure loss contract. For example, if a person wanted to be a devoted husband and family man and yet also engaged in extramarital affairs he would involve himself in inductive incoherence. The very traits that make him a good family man—loyalty, keeping one’s word, sincere interest in the well-being of others—would hurt one in being a philanderer, which requires selfish manipulation of others for one’s own pleasure. The good family man will be a bad philanderer and vice versa. To try to do both well involves a sure loss contract. Such an individual will fail at both. This is what inductive incoherence means.

Third is connection to a theory of being good, that is, ethics. The personal worldview imperative enjoins that we consider and adopt an ethical theory. It does not give us direction, as such, to which theory to choose except that the chosen theory must not violate any of the other three conditions (completeness, coherence, and practicability). What is demanded is that one connects to a theory of ethics and uses its action-guiding force to control action.

The final criterion is practicability. In this case there are two senses to the command. The first sense refers to the fact that we actually carry out what we say we will do. If we did otherwise, we’d be hypocrites and also deductively incoherent. But secondly, it is important that the demands of ethics and social/political philosophy be doable. One cannot command another to do the impossible! The way that I have chosen to describe this is the distinction between the utopian and the aspirational. The utopian is a command that may have logically valid arguments behind it but is existentially unsound (meaning that some of the premises in the action-guiding argument are untrue by virtue of their being impractical). In a theory of global ethics if we required that everyone in a rich country gave up three-quarters of their income so that they might support the legitimate plight of the poor, this would be a utopian vision. Philosophers are very attracted to utopian visions. However, unless philosophers want to be marginalized, we must situate our prescriptions in terms that can actually be used by policy makers. Beautiful visions that can never be should be transferred to artists and poets.

How to Construct Your Own Model

The first step in creating your own model for which you are responsible is to go through personal introspection concerning the four steps in the personal worldview imperative. The first two are global sorts of analyses in which an individual thinks about who he or she is right now in terms of consistency and completeness. These criteria are amenable to the prudential model. They are instrumental to making whatever worldview one chooses to be the most effective possible. This is a prudential standard of excellence. What constitutes the moral turn is the connection to a theory of the good: ethics.

Thus the third step is to consider the principal moral theories and make a choice as to which theory best represents your own considered position. To assist readers in this task, I provide a brief gloss of the major theories of ethics.

Theories of ethics

There are various ways to parse theories of ethics. I will parse theories of ethics according to what they see as the ontological status of their objects. There are two principal categories: (i) the realist theories, which assert that theories of ethics speak to actual realities that exist,3 and (ii) the anti-realists, who assert that theories of ethics are merely conventional and do not speak about ontological objects.

Realist theories

Utilitarianism is a theory that suggests that an action is morally right when that action produces more total utility for the group as a consequence than any other alternative. Sometimes this has been shortened to the slogan “The greatest good for the greatest number.” This emphasis upon calculating quantitatively the general population’s projected consequential utility among competing alternatives, appeals to many of the same principles that underlie democracy and capitalism (which is why this theory has always been very popular in the United States and other Western capitalistic democracies). Because the measurement device is natural (people’s expected pleasures as outcomes of some decision or policy), it is a realist theory. The normative connection with aggregate happiness and the good is a factual claim. Utilitarianism’s advocates point to the definite outcomes it can produce by an external and transparent mechanism. Critics cite the fact that the interests of minorities may be overridden.

Deontology is a moral theory that emphasizes one’s duty to do a particular action just because the action itself is inherently right and not through any other sorts of calculations—such as the consequences of the action. Because of this non-­consequentialist bent, deontology is often contrasted with utilitarianism, which defines the right action in term of its ability to bring about the greatest aggregate utility. In contradistinction to utilitarianism, deontology will recommend an action based upon principle. “Principle” is justified through an understanding of the structure of action, the nature of reason, and the operation of the will. Because its measures deal with the nature of human reason or the externalist measures of the possibility of human agency, the theory is realist. The result is a moral command to act that does not justify itself by calculating consequences. Advocates of deontology like the emphasis upon acting on principle or duty alone. One’s duty is usually discovered via careful rational analysis of the nature of reason or human action. Critics cite the fact that there is too much emphasis upon reason and not enough on emotion and our social selves situated in the world.

Swing theories (may be realist or anti-realist)

Ethical intuitionism can be described as a theory of justification about the immediate grasping of self-evident ethical truths. Ethical intuitionism can operate on the level of general principles or on the level of daily decision-making. In this latter mode many of us have experienced a form of ethical intuitionism through the teaching of timeless adages such as “Look before you leap,” and “Faint heart never won fair maiden.” The truth of these sayings is justified through intuition. Many adages or maxims contradict each other (such as the two above), so that the ability properly to apply these maxims is also understood through intuition. When the source of the intuitions is either God or Truth itself as independently existing, then the theory is realist. The idea being that everyone who has a proper understanding of God or Truth will have the same revelation. When the source of the intuitions is the person himself or herself living as a biological being in a social environment, then the theory is anti-realist because many different people will have various intuitions and none can take precedence over another.

Virtue ethics is also sometimes called agent-based or character ethics. It takes the viewpoint that in living your life you should try to cultivate excellence in all that you do and all that others do. These excellences or virtues are both moral and non-moral. Through conscious training, for example, an athlete can achieve excellence in a sport (non-moral example). In the same way a person can achieve moral excellence, as well. The way these habits are developed and the sort of community that nurtures them are all under the umbrella of virtue ethics. When the source of these community values is Truth or God, then the theory is realist. When the source is the random creation of a culture based upon geography or other accidental features, then the theory is anti-realist. Proponents of the theory cite the real effect that cultures have in influencing our behavior. We are social animals and this theory often ties itself with communitarianism that affirms the positive interactive role that society plays in our lives. Detractors often point to the fact that virtue ethics does not give specific directives on particular actions. For example, a good action is said to be one that a person of character would make. To detractors this sounds like begging the question.

Anti-realist theories

Ethical non-cognitivism is a theory that suggests that the descriptive analysis of language and culture tells us all we need to know about developing an appropriate attitude in ethical situations. Ethical propositions are neither true nor false but can be analyzed via linguistic devices to tell us what action-guiding meanings are hidden there. We all live in particular and diverse societies. Discerning what each society commends and admonishes is the task for any person living in a society. We should all fit in and follow the social program as described via our language/society. Because these imperatives are relative to the values of the society or social group being queried, the maxims generated hold no natural truth-value and as such are anti-realist. Advocates of this theory point to its methodological similarity to deeply felt worldview inclinations of linguistics, sociology, and anthropology. If one is an admirer of these disciplines as seminal directions of thought, then ethical non-cognitivism looks pretty good. Detractors point to corrupt societies and that ethical non-cognitivism cannot criticize these from within (because the social milieu is accepted at face value).

Ethical contractarians assert that freely made personal assent gives credence to ­ethical and social philosophical principles. These advocates point to the advantage of the ­participants being happy/contented with a given outcome. The assumption is that within a context of competing personal interests in a free and fair interchange of values those principles that are intersubjectively agreed upon are sufficient for creating a moral “ought.” The “ought” comes from the contract and extends from two people to a social group. Others universalize this, by thought experiments, to anyone entering such contracts. Because the theory does not assert that the basis of the contract is a proposition that has natural existence as such the theory is anti-realist. Proponents of the theory tout its connection to notions of personal autonomy that most people support. Detractors cite the fact that the theory rests upon the supposition that the keeping of contracts is a good thing, but why is this so? Doesn’t the theory presuppose a meta-moral theory validating the primacy of contracts? If not, then the question remains, “what about making a contract with another creates normative value?”

For the purposes of this text, we will assume these six theories to be exhaustive of philosophically based theories of ethics or morality.4 In subsequent chapters you should be prepared to apply these terms to situations and compare the sorts of outcomes that different theories would promote.

The fourth step, in modifying one’s personal worldview (now including ethics) is to go through an examination of what is possible (aspirational) as opposed to what is impossible (utopian). This is another exercise in pragmatic reasoning that should be based on the agent’s own abilities and situation in society given her or his place in the scheme of things. Once this is determined, the agent is enjoined to discipline herself or himself to actually bring about the desired change. If the challenge is great, then she or he should enlist the help of others: family, friends, community, and other support groups.

How Do Ethics Make a Difference in Decision-Making?

In order to get a handle on how the purely prudential worldview differs from the ethically enhanced worldview, let us consider two cases and evaluate the input of ethics. First, we will consider a general case in social/political ethics and then one from medical ethics. The reader should note how the decision-making process differs when we add the ethical mode. In most cases in life the decisions we make have no ethical content. It doesn’t ethically matter whether we have the chocolate or vanilla ice cream cone. It doesn’t ethically matter if we buy orchestra seats for the ballet or the nose bleed seats. It doesn’t ethically matter if I wear a red or a blue tie today. The instances in which ethics is important comprise a small subset of all the decisions that we make. That is why many forego thought about ethical decision-making: it only is important in a minority of our total daily decisions. In fact, if we are insensitive to what counts as an ethical decision context, then we might believe that we are never confronted with a decision with ethical consequences.

To get at these relations let us consider a couple of cases in which the ethical features are highly enhanced. Readers are encouraged to participate in creating reactions to these from the worldviews they now possess.

Case 1: Social/Political Ethics
The Trolley Problem

You are the engineer of the Bell Street Trolley. You are approaching Lexington Avenue Station (one of the major hub switching stations). The switchman on duty there says there is a problem. A school bus filled with 39 children has broken down on the right track (the main track). Normally, this would mean that he would switch you to the siding track, but on that track is a car filled with four adults that has broken down. The switchman asks you to apply your brakes immediately. You try to do so, but you find that your brakes have failed too. There is no way that you can stop your trolley train. You will ram either the school bus or the car, killing either 39 children or four adults. You outrank the switchman. It’s your call: what should you do?

Secondary nuance: what if the switchman were to tell you that from his vantage point on the overpass to the Lexington Avenue Station there is a rather obese homeless man who is staggering about. What if (says the switchman) he were to get out of his booth and push the homeless person over the bridge and onto the electric lines that are right below it? The result would be to stop all trains coming into and out of the Lexington Avenue Station. This would result in saving the lives of the occupants of the two ­vehicles. Of course it would mean the death of the obese homeless person. The switchman wants your OK to push the homeless man over the bridge—what do you say?

Analysis

This case has two sorts of interpretations: before and after the nuance addition. In the first instance, one is faced with a simple question: should you kill four people or thirty-nine? The major moral theories give different answers to this question. First, there is the point of view of utilitarianism. It would suggest that killing four causes less pain than killing thirty-nine. Thus one should tell the switchman to move you to the siding.

There is the fact that when the car was stuck on the siding, the driver probably viewed his risk as different from being stuck on the main line. Thus, by making that choice you are altering that expectation—versus the bus driver who has to know that he is in imminent danger of death. Rule utilitarians might think that moving away from normal procedures requires a positive alternative. Killing four people may not qualify as a positive alternative (because it involves breaking a rule about willful killing of innocents). Thus, the utilitarian option may be more complicated than first envisioned.

Rule utilitarianism would also find it problematic to throw the homeless person over the bridge for the same reason, though the act utilitarian (the variety outlined above) might view the situation as killing one versus four or thirty-nine. However, there is the reality that one is committing an act of murder to save others. This would be disallowed by the rule utilitarian. If the act utilitarian were to consider the long-term social consequences in sometimes allowing murder, he would agree with the rule ­utilitarian. However, without the long-term time frame, the act utilitarian would be committed to throwing the homeless person over the rail.

The deontologist would be constrained by a negative duty not to kill. It would be equally wrong from a moral situation to kill anyone. There is no moral reason to choose between the car and the bus. Both are impermissible. However, there is no avoidance alternative. You will kill some group of people unless the homeless person is thrown over the wall. But throwing the homeless person over the wall is murder. Murder is impermissible. Thus, the deontologist cannot allow the ­homeless person to be killed—even if it saved four or thirty-nine lives. Because of this, the deontologist would use other normative factors—such as aesthetics to—choose whether to kill four or thirty-nine (probably choosing to kill four on aesthetic grounds).

The virtue ethics person or the ethical intuitionist would equally reply that the ­engineer should act from the appropriate virtue—say justice—and do what a person with a just character would do. But this does not really answer the question. One could construct various scenarios about it being more just to run into the school bus rather than the car when the occupants of the car might be very important to society: ­generals, key political leaders, great physicists, etc. In the same way, the intuitionists will choose what moral maxim they wish to apply at that particular time and place. The end result will be a rather subjectivist decision-making process.

Finally, non-cognitivism and contractarianism are constrained to issues like “What does the legal manual for engineers tell them to do in situations like this?” If the manual is silent on this sort of situation, then the response is: what is the recommended action for situations similar to this in some relevant way? This is much like the decision-making process in the law where stare decisis et non quieta movere (support the decisions and do not disturb what is not changed). In other words, one must act based upon a cultural/legal framework that provides the only relevant context for critical decisions.

In any event, the reader can see that the way one reasons about the best outcome of a very difficult situation changes when one adds ethics to the decision-making machinery. I invite readers to go through several calculations on their own for class discussion. Pick one or more moral theories and set them out along with prudential calculations such that morality is the senior partner in the transaction. One may have to return to one’s personal worldview (critically understood—as per above) and balance it with the practical considerations and their embeddedness to make this call.

Let us now consider a case from medical ethics.

Case 2: An Admission to the Emergency Room

You are an emergency room physician. A 35-year-old woman from Honduras is admitted with a severe upper respiratory infection. In the process of your examination of the woman, Gabriela (mother of four young children), you find a suspicious lump in her breast. You think that it should be subject to further tests (including imaging) that may indicate biopsy because it may be cancerous. The lump has nothing to do with the upper respiratory infection, but you are concerned. The woman says she does not want any tests done on her breast (she explains to a Spanish-speaking nurse who translates for you). Her husband wouldn’t like someone cutting into her breasts. It would be very bad for her. She refuses to sign an informed consent form for the procedure. Instead, she signs a waiver of services recommended form.

You feel in a bind. You did a fellowship in oncology and have a pretty good suspicion that she may be in the early stages of breast cancer and action now will save her life. If you don’t act, no one will know the difference. If you put her out and do the procedure anyway you might save her life but lose your job. Something tells you that there may be other options, but if you discuss these with a supervisor, you might place yourself at risk by going “on record.” This could include a future lawsuit against you should the patient’s husband sue the hospital. What should you do?

Analysis

From the prudential point of view the emergency room physician should take Gabriela’s preference and let things go. It is probable that the patient will progress to breast cancer and die within a few years. However, you gave Gabriela every opportunity to proceed to further tests (at no expense to her). You also used a native speaker as interpreter so that there might be no miscommunication. She also signed a waiver of ­recommended services form. The staff lawyer says you won’t be sued. The prudential option says, “Just sign the discharge papers.”

If we expand the prudential point of view further, it is murkier. This is because the prudential point of view of the emergency room physician may be different from that of the patient, the patient’s family, and others in the Hispanic community. The prudential viewpoint alone cannot answer this disparity.

When moral considerations are introduced into the decision-making process things work differently. First, let’s consider non-cognitivism. There are two operational cultures working here: that of the United States and that of Honduras. This creates a problem.5