Theories of Ethics
For thousands of years of human experience, people have looked for ways to differentiate right conduct from wrong. Systems have been developed for the purpose of helping individuals to try to make ethical decisions and determine the right thing to do in particular situations. Many people have sought simple rules of decision making that could be used in every situation, such as the Golden Rule of treating others as one would like to be treated, but those simple rules often fail to provide specific guidance in complex circumstances (Shaw and Barry, 1992, pp. 9–10). Therefore the search for methods of identifying the right conduct has led to the development of more complex theories of ethics. Even these more complex theories, however, may be based on attempts to distill a single rule that could be used in every situation. As Bonnie Steinbock and others (2003) have explained, “Traditionally, ethical theories tend to be reductionist; that is, they offer one idea as the key to morality, and attempt to reduce everything to that one idea” (p. 9).
In developing ethical theories, some people have relied on the concept of a social contract as the ultimate source of ethics. Under that approach, morality is based on some type of voluntary agreement. Others have concluded that ethics is based on religion or on the concept of natural law. In his 1963 “Letter from Birmingham Jail,” Martin Luther King Jr. reasoned that ethical conduct is based on natural law, which can supersede unjust human law:
One may well ask, “How can you advocate breaking some laws and obeying others?” The answer is found in the fact that there are two types of laws: there are just laws, and there are unjust laws. […] I would agree with St. Augustine that “An unjust law is no law at all.”
Now, what is the difference between the two? How does one determine when a law is just or unjust? A just law is a man-made code that squares with the moral law, or the law of God. An unjust law is a code that is out of harmony with the moral law. To put it in the terms of St. Thomas Aquinas, an unjust law is a human law that is not rooted in eternal and natural law. Any law that uplifts human personality is just. Any law that degrades human personality is unjust. All segregation statutes are unjust because segregation distorts the soul and damages the personality…[King, 1963].
Under this approach an action is ethical if it is consistent with natural law. The way we know the action is consistent with natural law is that it has the effect of uplifting human personality.
However, all of these possible sources of ethics pose problems for the practical matter of applying ethics. If the source of ethics is religion or divine will, that would seem to imply that believers in different religions could have very different standards of ethical conduct. Moreover, how could we expect those who believe in a minority religion, or no religion at all, to follow ethical standards derived from the religion followed by the majority in their society?
If the source of ethics is natural law and natural law can supersede unjust human law, every individual could decide not to obey those human laws that he or she considers to be unfair. That approach would seem to give people the option to make individual decisions about which laws to obey and which laws to violate. Of course we can sympathize with and support civil disobedience against laws that enforce racism and segregation. But what would we conclude about a modern-day Robin Hood who steals from the rich and gives to the poor and who defends the theft by arguing that natural law takes precedence over the unfair human laws of private property?
If the source of ethics is a social contract, what are the terms of that contract? Who agreed to that contract on our behalf? Moreover, contracts involve mutual obligations among all parties to the contract. If an individual has failed to meet his or her obligations to society under the social contract, would that mean the contract has been breached and society no longer has any obligation to that individual?
Serious problems exist with applying values derived from each of the possible sources of ethics; moreover it is probably impossible for us to reach complete agreement about the underlying source of ethical standards. Nevertheless we can analyze and categorize various ethical theories without having reached agreement on their ultimate source.
A useful method of categorizing ethical theories is to distinguish between consequentialist and nonconsequentialist theories (Shaw and Barry, 1992, p. 57). Consequentialism is the idea that only results determine whether an action is right or wrong, whereas nonconsequentialism is the idea that consequences are not the only thing that matters.
One consequentialist theory is utilitarianism. In focusing solely on the results of an action, utilitarianism holds that an action is right if it results in the greatest good for the greatest number of people (Steinbock and others, 2003, pp. 9–10). It is important to identify both the people who would be helped by a proposed course of action and the people who would be harmed by it. This process of identification is similar to performing a stakeholder analysis. That is only the starting point, however. Merely counting the numbers of people who would be helped or harmed would be an oversimplification of utilitarianism. In determining the greatest good for the greatest number of people, utilitarians also consider the degree of benefit or harm to each person, and not merely the absolute numbers of people who are benefited or harmed. Utilitarianism can be contrasted with egoism, which is another consequentialist theory but which holds that an action is right if it results in the greatest good for the only person who really matters—that one individual! (Shaw and Barry, 1992, pp. 57–58).
As stated earlier, nonconsequentialists argue that ethics do not depend solely on results. Nonconsequentialist theories of ethics are also referred to as deontological theories (Beauchamp and Childress, 1994, p. 56). One of the most important theories in this category is Kantian ethics, named for Immanuel Kant, a German philosopher and professor who lived from 1724 to 1804. As a nonconsequentialist, Kant believed that an action might be wrong even if it results in good consequences, and therefore that “the ends do not justify the means” (Steinbock and others, 2003, p. 14). Kant argued that a proposed action would be ethical if it is an action that we would want everyone to perform in a similar situation. In other words, could we “consistently will” that under a particular set of circumstances everyone else should act in that manner? (Steinbock and others, pp. 9, 15). This concept of Kant’s is called the categorical imperative. In addition, Kant believed that individuals should be treated as ends, and not as a means to an end, or at least not only as a means to an end (Beauchamp and Childress, 1994, p. 58).
Another approach to ethics is principlism, so called because it is based on a set of ethical principles, including autonomy, justice, and beneficence (Beauchamp and others, 2008, p. 22). Sometimes the principle of beneficence is broken down into separate principles of beneficence, or helping other people, and nonmaleficence, or not harming people. In contrast to monistic theories, such as utilitarianism or Kantian ethics, which try to reduce ethical conduct to a single idea, principlism is pluralistic, in the sense that more than one ethical principle may apply in a particular situation (Beauchamp and Childress, 1994, p. 100; Steinbock and others, 2003, pp. 9, 36–37). The moral duties represented by those principles are not absolute but rather apply prima facie, or at first glance (Beauchamp and Childress, pp. 100, 104; Steinbock and others, p. 37). In other words, one moral duty might outweigh another in the circumstances of a particular case. “A prima facie duty, then, is always right and binding, all other things being equal; it is conditional on not being overridden or outweighed by competing moral demands” (Beauchamp and others, 2008, p. 27). According to the proponents of principlism, prima facie moral duties are based on “common-morality theory” and “shared moral beliefs” (Beauchamp and Childress, 1994, p. 100). “A common-morality theory takes its basic premises directly from the morality shared in common by the members of a society—that is, unphilosophical common sense and tradition” (Beauchamp and Childress, p. 100). (The next section of this chapter addresses the question of whether ethical principles that are derived from the shared beliefs of society can be truly global and universal.)
Which of these ethical approaches, if any, is the best one? Steinbock and others (2003) argue against selecting one theory or approach as the exclusive answer to all ethical questions: “In a typical introduction to ethical theory class, each theory is presented and subjected to devastating criticism. The unfortunate result is that students frequently conclude that all of the theories are wrong—or worse, are pretentious nonsense We conclude that it is a mistake to view the various theoretical alternatives as mutually exclusive claims to moral truth. Instead, we should view them as important but partial contributions to a comprehensive, although necessarily fragmented, moral vision” (p. 9). Steinbock and colleagues are correct that no single theory has conclusively demonstrated its correctness and applicability in all situations. However, that seems to leave us with a “buffet approach” to ethical theory. Individuals are left to say to themselves, “I will look over the menu of ethical theories, and then choose some of each. Perhaps, I will take an order of utilitarianism, with a side order of principlism.” In addition to causing uncertainty, this buffet approach would allow individuals simply to make their own decisions and then to justify whatever they have already chosen to do. How, if at all, would this individualized buffet approach help people to make difficult ethical decisions in the real world of health policy and services?
Throughout this book we will consider the various ethical theories described in this chapter. In particular we will consider two fundamental questions: (1) are these ethical theories really global, in the sense of being applicable to all societies and cultures; and (2) are these ethical theories really useful in helping individuals and organizations to make the hard decisions in the real world of health policy, health services, and global health? Then, if these ethical theories are not really useful, how can we encourage individuals and organizations in the health system to do the right thing?
Are Theories of Ethics Global?
It is beyond dispute that people of different cultures will perceive the same things in different ways and make very different decisions when faced with the same circumstances. For example, as discussed in Chapter EIGHT (about allocation of resources), the Akamba people of Kenya have preferences for rationing limited health care resources on the basis of age that are very different from the preferences of most people in the United States (Kilner, 1984, p. 19). It is also clear that different cultures have different values, or at least that they place very different priorities on particular values. Although Western societies generally place a high priority on individual autonomy and equality, some other societies place their high priorities on values such as solidarity of the community, fulfillment of duty, or obedience to a hierarchical order. As Blackhall and others (2001) have written, “Beliefs commonly held in the European-American culture about individuality, self-determination, and the importance of maintaining control too often have been treated as if they were universal ethical principles” (p. 70).
Does this mean that there is no common morality of ethical principles, one that is shared by all human beings, regardless of the society in which they live? Does it mean that there are no universal ethical values that transcend the values of any particular culture? Those two questions are not necessarily the same. As discussed previously, Beauchamp and Childress, who are well-known proponents of principlism, have argued that the prima facie moral duties are based on “common-morality theory” and “shared moral beliefs” (1994, p. 100). It is difficult to conclude, however, that the moral duties of justice and autonomy are really shared by those societies that do not believe in self-determination for women, equal rights for racial and ethnic minorities, or freedom of speech and religion. Patricia Marshall and Barbara Koenig (2004) have described the distinction that Beauchamp has tried to make between those values of common morality that are shared universally and those “particular moralities” that are not shared by all human societies. As Marshall and Koenig also note, however, Beauchamp’s distinction is not helpful as a practical matter in addressing difficult questions of bioethics (p. 256). (An excerpt from Marshall and Koenig’s article appears later in this chapter.)
In fact, different societies can and do reach very different conclusions about important ethical issues. Whether we characterize those differences as a lack of universality or as “particular moralities” about specific issues, such disagreement among societies requires us to address the second question set forth earlier and to ask whether any universal ethical values exist that transcend the values of a particular culture. When societies disagree about ethics, can we ever conclude that the values or practices of one society are unethical and therefore should give way to overriding universal values? Proponents of ethical relativism argue that ethics is dependent on culture and that actions are ethical if they are considered to be ethical by the culture in which they take place (Steinbock and others, 2003, pp. 6–8). For example, an ethical relativist might even argue that slavery is ethical within the context of a culture that considers slavery to be ethical. Of course many people would strongly disagree with that proposition. Many people would insist that there are indeed universal values of ethics and that these universal values transcend the values of that particular society and make slavery, wherever it occurs, horribly unethical. The issue of ethical relativism is addressed in more detail in Chapter FIVE of this book, with regard to the problem of female genital mutilation, which is accepted in some cultures and vehemently rejected in others.
The following excerpt from an article by Marshall and Koenig offers further insights into the question of whether a common morality exists. It also traces the evolution of Western bioethics from its former focus on clinical issues to its current concerns with issues of social justice and population health.
Excerpt from “Accounting for Culture in a Globalized Bioethics”
By Patricia Marshall and Barbara Koenig
As we look to the future in a world with porous borders and boundaries transgressed by technologies, an inevitable question is: Can there be a single, “global” bioethics? Intimately intertwined with this question is a second one: How might a global bioethics account for profound—and constantly transforming—sources of cultural difference? Can a uniform, global bioethics be relevant cross-culturally?…
Although there appears to be agreement about bioethics as a field of study, there is much less consensus about the relevance and applicability of bioethics as a set of guidelines and practices that can be implemented in diverse cultural settings Currently, the exportation of a Western approach to bioethics in clinical and research settings worldwide mirrors the globalization of biomedicine itself. However, unlike the acceptability of biomedical techniques across the world—from efficacious low-tech interventions like antibiotics to complex surgical procedures like heart transplantation and intensive care units—the adoption of bioethics’ concepts and practices has been more contentious, in part because the moral meanings of illness, health, and healing systems are culturally and religiously grounded. Thus, bioethics practices such as advance care planning, full disclosure of a terminal diagnosis, or informed consent in clinical research may be in fundamental conflict with local traditions and beliefs. As anthropologists engaged in a pragmatic vision of bioethics, we have to ask: do such practices actually improve the care of the ill, enhance the well being of populations, or protect subjects in biomedical research?
In this paper, we reflect on the tensions produced as various visions of bioethics circulate in a rapidly globalizing world. Commentators concerned with global health equality and human rights have been vocal critics of an American bioethics focused on the “quandary ethics” of affluence. The physician and anthropologist Paul Farmer contrasts his experiences treating patients in rural Haiti with his work as an attending physician at Harvard. As an infectious disease specialist he uses the same tools in both places; but in Haiti obtaining the drugs that are the tools of his trade is the greatest challenge. Discussions during clinical ethics rounds at a Boston teaching hospital of withholding antibiotics (considered to be futile) stand in stark contrast to the imperative to save lives lost prematurely to treatable infections in Port au Prince…It seems unlikely that a bioethics developed in American hospitals will prove up to the challenges of rural poverty without significant refinements. We are deeply concerned with the implications of exporting American bioethics practices throughout the world. The problem is not simply one of national wealth or access to resources, although these are critical considerations. Given the diversity of human values, we ask if bioethics can only flourish in the context of a liberal democratic state, one that is—at least theoretically—based upon respect for individual rights and recognition of diverse cultural and religious values?…
…In configuring a global bioethics, how do we resolve fundamental cultural and religious differences about the foundations of medical morality? How do we accommodate human rights while maintaining a posture of respect for cultural difference, particularly when there is evidence of abuse or injustice towards individuals or groups? How do we avoid the promulgation of a Westernized bioethics that fosters only an illusion of global consensus about the morality of medical practices? In “real” worlds, morally complex challenges abound….
Bioethics’ Reluctant Engagement with Social Context and Cultural Difference
The past is a necessary prologue in looking toward the future. Moral pluralism and cultural difference have not been central topics of concern in the first decades of American academic bioethics….
Possibly linked to this disregard of “difference” is the field’s failure to engage with questions of global health equity or population health. In the post World War II period, bioethics’ focus on the doctor/patient dyad mirrored the concerns of American biomedicine, which disregarded population health issues and ignored the growing disparities in health care across the U.S. population related to social inequality. In an era of boundless hope and belief in the power of biomedicine, belief in the research enterprise and its applicability to individual health was unquestioned.
Much critical ink has been spilled rehearsing the deficiencies of an individualistic, de-contextualized, American bioethics focused on a limited number of abstract principles: the Georgetown mantra….
The topics engaged by bioethicists reveal the “Americanness” of bioethics. The early focus was invariably on quandary ethics in the context of “high tech” biomedicine, with analyses targeted to “high drama” cases like heart transplantation or refusal of blood products by Jehovah’s Witness patients. This orientation calls attention to specific cases, to the individual, to the “local”—not the global—it is case specific, diminishing the potential for broader social critique.
Cultural Analysis: Adding a Reflexive Critique of Bioethics
We opened this essay by making a distinction between bioethics as an academic field and bioethics as a set of observable cultural practices that circulate independently of their theoretical foundations…. Often the bioethics practices utilized in the clinic or as part of a research protocol take on a life of their own, emphasized as procedures only, disconnected from the foundational theory on which they were once based. Indeed, since practices have rarely been studied empirically, we often have little evidence of their usefulness. In the case of some innovations, for example the widespread adoption of advance directives to guide end-of-life care, we actually have evidence that bioethics practices have generally failed, and that they are differentially valued by ethnically diverse U.S. populations….
…A full cultural critique will continually evaluate how bioethics itself is tied into global power structures, perhaps inadvertently serving to maintain the status quo in biomedicine or in the rapidly changing clinical trials industry. Who funds the bioethics enterprise? What interests are served by its existence? One might argue that the rote purpose of informed consent in research—empowering human subjects—has been transformed by socio-political-economic structures into a legalistic informed consent document that now functions more to protect the interests of institutions (both academic health science centers and pharmaceutical companies) than of subjects. And bioethicists are employed by those same institutions….
Is There a Common Morality?
We acknowledge that our claims about the relevance of cultural context run counter to standard accounts within bioethics. The suggestion that it is impossible to understand (and thus to critique) a moral system without attention to historical contingencies and social traditions is very problematic for many philosophers and philosophically-trained bioethicists. From the vantage point of philosophy, the primacy of the moral sphere—and the objectivity of ethical inquiry—may be threatened by social science claims about the relevance of empirical descriptions of cultural variation to the sphere of ethics….
…The notion of “common morality” is gaining currency in the field of bioethics…. In defending his views about the legitimacy of the concept and how it might be empirically examined, Beauchamp is careful to differentiate between universally shared values and principles which are “located in the common morality” and moral norms (“particular moralities”) that are not universally shared by individuals or populations. This parsing of universality and particularity may help explain the diversity and malleability of behavioral norms for morality across cultures (or religions, or institutions) but it is less helpful in relation to the application of bioethics practices in particular international or culturally “different” settings
In general, we accept a more nuanced view, arguing that the application of general principles is impossible to accomplish without detailed local knowledge. However, there is one universal principle or claim that requires special attention in our analysis: the claim of universal human rights, and the accompanying claim of a right to health care as central to the implementation of global justice. Increasingly, bioethics’ attention to human rights follows from critical self-examination of the cultural sources of past errors, specifically, the field’s reification of individual choice and quandary ethics paired with a neglect of global equity. Although others may disagree, in our view these blind spots stem from bioethics’ American roots and its strong link with powerful interests, such as high-technology biomedicine. From the perspective of the clinic, it was hard to develop a vision that crossed borders.
Scholars in bioethics have begun to consider carefully broader structural issues contributing to global population health, including social, economic, and political factors influencing the disproportionate burden of disease throughout the world. Theorists directly link health with basic human rights. Considerations of social justice and health disparities—both within and between nations—are key dimensions of the new critique….
Looking Ahead in Bioethics
Bioethics must widen its focus beyond its Western view to incorporate and acknowledge moral pluralism and cultural variation or it will lose its relevance and applicability for most of the worlds’ [sic] population. Perhaps the key question for reconfiguring bioethics in a way that recognizes and accounts for cultural difference is simply this: Can bioethics lose the stamp of its American cultural origins? At stake here is the saliency and credibility of the profession—and the practices it upholds—in the global arena. At stake is the ability of bioethicists and others associated with the field to actively engage in thoughtful debate about the implications of cultural difference and its consequences for the production of science and its applications worldwide. At stake is our capacity to achieve praxis in the way we promulgate and “do” bioethics in diverse cultural terrains.
How does bioethics need to change to be more relevant cross-culturally? If it sheds its American focus on individualism will it become “something” else? Bioethics will necessarily change as it continues to incorporate the arguments and sensibilities of cultural difference into its fundamental underlying ideology. As contextual approaches to ethics have shown in recent years, the Georgetown mantra loses its principled rigidity as soon as social context and its inherent moral ambiguity become a part of its interpretive structure.
There are two particular areas in which it is imperative for bioethics to revise its basic orientation in order to become culturally relevant and globally “aware.” First, as we suggest above, it is vitally important that bioethics attend to social justice and focus attention on the broad goals of population health…. Second, bioethics must consider social context, especially the impact of political economy on the moral dimensions of science and healthcare….
Attention to Social Justice and Human Rights
In the arena of human rights and population health, bioethics must address the systematic and powerful ways in which structural forces influence morbidity and mortality in diverse populations….
Attention to Social Context
The second broad area that bioethics must systematically address is social context, particularly political and economic factors that influence profoundly the quality of life and the experience of suffering or health for individuals and populations worldwide….
The African American experience of health disparities in the U.S. provides a good example of why it is imperative for bioethics to consider the primacy of social context in thinking about ethics, science, and biomedicine at all levels, including research, clinical care, and access to health services. Studies indicate that African Americans are reluctant to limit or forego medically futile treatment at the end of life. A lack of “trust” is frequently implicated to explain choices for aggressive medical care. However, African American concerns about the potential for mistreatment or neglect in clinical settings is historically well justified. Consider the legacy of Jim Crow segregation in hospitals, or the abuses of the Tuskegee Syphilis Study Ignoring the political economy of social context, including the long term consequences of entrenched racism, severely limits our capacity to analyze critically the underlying ethical dimensions of biomedical practice or research
Conclusion
Predicting the future is inevitably a risky business. In this essay we have tried to show how a bioethics informed by attention to social context, and sensitive to cultural difference, might look in future decades. Detailed analysis of and attention to the social, political, and economic context will not necessarily solve every ethical dilemma, but it will certainly avoid mistakes based on the naive assumption that applying solutions derived from the U.S. to resource-poor, developing world problems is adequate. Exporting the American institutional review board system to sub-Saharan Africa may allow compliance with federal regulations, but without attention to the local cultural context does little to protect research subjects
For those working in the field of bioethics, our greatest challenge is maintaining the reflexive stance characteristic of the best social science. We have argued that a culturally-informed bioethics will remain critical of its own goals, re-examining them when challenged. The emerging emphasis on issues of population health and global justice is heartening. Our global environment precludes “business as usual”; the field of bioethics can no longer focus its energy and attention on the ethical dilemmas experienced by individual patients privileged by social status with too much medical care
Source: Excerpted from “Accounting for Culture in a Globalized Bioethics,” by P. Marshall and B. Koenig, 2004. Journal of Law, Medicine & Ethics, 32(2), 252–266 (citations, references, and some text omitted). Copyright 2004 by American Society of Law & Medicine, Inc. Reprinted by permission
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