© Springer International Publishing AG 2017P. Anne Scott (ed.)Key Concepts and Issues in Nursing Ethics10.1007/978-3-319-49250-6_3
3. Utilitarianism as an Approach to Ethical Decision Making in Health Care
Philosophy, School of Humanities and COBRA, National University of Ireland, Galway, Ireland
This chapter outlines core characteristics of Utilitarianism and explores them with regard to their significance in healthcare settings. It presents Utilitarianism as characterised by the following five features: (1) consequentialism, (2) welfarism, (3) equality of moral status and impartiality, (4) maximisation, (5) aggregation. It explains the theoretical underpinnings of each of these characteristics, while illustrating them with regard to issues arising in the nursing and wider healthcare context. The chapter concludes with an outline of common themes and considerations in Utilitarian writings with significance for nursing and healthcare practice.
KeywordsUtilitarianismJohn Stuart MillNursing Ethics
Introduction and Case Study
Resource Allocation for Rare Diseases
Cystic Fibrosis (CF) is a chronic and progressive genetic disease that affects lung function and the digestive system. It is a rare disease with around 70,000 sufferers globally. Due to its genetic basis some geographic areas, such as Ireland, have a particularly high incidence. A range of specific genetic defects are responsible for the creation of sticky mucus which obstructs the lungs of CF sufferers and lead to shortness of breath, frequent lung infections and digestive problems. Over time, the lung function deteriorates and ultimately leads to premature death, with a median age of death of CF sufferers in Western countries in their late 30s. Treatment for CF has improved significantly and quality of life and survival times of CF sufferers have extended continuously over the last few decades; however, no cure has yet been developed. Given the level of impairment and the expectation of premature death of CF sufferers, the development of a drug that promised to target specifically the underlying defects of the disease, rather than merely the symptoms of the disease, in a small subgroup of CF sufferers was welcomed enthusiastically. The company Vertex brought ivacaftor (Kalydeco) to market in 2012, a drug that promised to provide such a sustainable treatment. The drug is suitable for those CF sufferers who have a specific genetic mutation in the cystic fibrosis transmembrane conductance regulator (CFTR), around 5% of all CF sufferers. Its initial cost in the US was 300,000 USD per patient per year. This means a significant cost for the healthcare system, albeit for a very small number of patients. Should this drug be covered by the public healthcare system?
There are different possible responses to this question. Many health care professionals would state that a medication that has a chance to significantly improve the management of a life threatening condition should be provided to patients suffering from that condition, no matter what its price is. In contrast, the theory of Utilitarianism proposes to engage with this question primarily on the basis of assessing and comparing consequences of different alternative options. Utilitarianism considers the overall costs and benefits of the use of the medication and compares it to the overall costs and benefits of other possible options. From a Utilitarian perspective, what needs to be considered is the question whether the benefit to CF sufferers, from this drug, is sufficiently high to justify the expense, and whether other ways of spending the money, for other patients or on other aspects of care, might have potentially better consequences overall.
In the following, the Utilitarian approach will be introduced in more detail and important characteristics of the approach will be explored, drawing on examples for its application to issues arising in the health care setting.
History and Core Characteristics of Utiliarianism
Utilitarianism is one of the “big three” traditional moral theories, together with Deontology and Virtue Ethics. Like any of these theories, Utilitarianism has received enthusiastic endorsement as well as trenchant criticism. In assessing the value of Utilitarianism as an ethical theory for health care, it is important to consider carefully what it entails.
Utilitarianism is a theory that was originally developed in the Enlightenment period when many theorists were expecting scientific insight to change human life for the better. Utilitarianism exemplifies this optimism about the role of science for morality. Jeremy Bentham (1748–1832), one of the founders of Utilitarianism, believed that Utilitarianism could provide a science of morality that could be used for the betterment of human life. He addressed a large number of social issues from a Utilitarian perspective, from law-making to prison reform. His writing was characterised by a strong belief in precision and differentiation – for example in his discussion of pleasures and pains in his Introduction to the Principles of Morals and Legislation (1789) he distinguishes between 14 types of pleasures, 12 types of pain, and over 30 types of influences on the experience of pleasure. Incidentally, Bentham’s belief in the importance of science extended to the treatment of his body after his death: he donated his body to science to University College London, where it was kept embalmed in a show cabinet.
A student of Bentham, John Stuart Mill (1806–1873), wrote the most well-known introduction to Utilitarianism, a small book simply entitled Utilitarianism (1861) in which he explained the core assumptions of Utilitarianism. When Utilitarianism was first proposed it encountered similar criticisms as today and was criticised as a theory that misunderstands the nature and depth of our moral obligations. Critics of utilitarianism in the health care field sometimes argue in a similar vein that the duties and obligations of healthcare professionals to help their patients are absolute, and that a theory that weighs up costs and benefits of different options rather than endorsing absolute requirements does not do justice to the moral duties of health care professionals. In response to similar criticisms at the time, Mill wrote his book as a defence of Utilitarianism as a theory that is indeed capable of doing justice to our deepest intuitions about morality.
Utilitarianism defines the morally good as the achievement of “the greatest good for the greatest number”. Its core ethical principle is the “principle of utility”:
By the principle of utility is meant that principle which approves or disapproves of every action whatsoever, according to the tendency which it appears to have to augment or diminish the happiness of the party whose interest is in question: or, what is the same thing in other words, to promote or to oppose that happiness. (Bentham 1789/2010, I.2., pp. 6–7)
Utilitarianism in the tradition of John Stuart Mill has a number of core ethical characteristics:
Positive or negative consequences are the most important features for assessing the moral quality of a situation (consequentialism)
Effects on an individual’s experiences, interests and well-being are the kinds of consequences that count, especially the avoidance of pain and suffering and the increase in pleasure and happiness (welfarism)
Every individual who is able to have certain types of positive and negative experiences or interests should count equally (equality of moral status and impartiality)
There is a moral obligation to maximise overall benefit, by counting up the overall consequences and choosing the option with the highest overall benefit (maximisation)
Moral quality is determined by aggregating consequences across all affected individuals who can experience positive and negative experiences; Utilitarianism aims for the achievement of the best overall aggregate result across individuals (aggregation)
These core characteristics will be discussed, one by one, in the sections which follow. The main aim of this discussion is to identify and explain criticisms that have been levelled against Utilitarianism and explore whether Utilitarianism can address these criticisms. While the implications for the health care context will be considered throughout, this discussion may nevertheless seem quite theoretical, but it will help define more clearly what exactly Utilitarianism stands for.
The focus on consequences in Utilitarianism distinguishes Utilitarianism fundamentally from the other big theories of ethics. In Utilitarianism, it is the good or bad consequences that determine whether something is right or wrong. In the short case study on CF and the drug Kalydeco above, relevant consequences are the money spent due to the costs of the medication (which will not be available to other patients once spent) in relation to the benefits of the drugs for the CF patients. In contrast to Utilitarianism, deontological theories identify commands and prohibitions that are determined as binding without regard to consequences.1 Similarly, Virtue Ethics is concerned with the practical realisation of good character traits for which consequences are at most indirectly relevant, for example if the assessment of consequences happens to be an important feature of the situationally relevant character trait.2
An important distinction in Utilitarianism is whether it should be concerned with the consequences of individual actions (a position that is called Act Utilitarianism) or with the overall consequences of having particular rules (a position that is called Rule Utilitarianism). When considering the example of the CF drug, Act Utilitarianism would ask the individual health professional to consider, for each patient, whether the likely health benefits for this patient are sufficiently positive to merit the cost of the drug. In contrast, Rule Utilitarianism would focus on developing general rules to apply in such cases, regardless of the very specific features of every individual case. In the case of Act Utilitarianism, the individual is responsible for assessing and comparing the likely consequences of their potential actions. In the case of Rule Utilitarianism, the focus is on decisions about the most advantageous rules to follow for society. Decision-making about the best utilitarian rules is left to experts who have the authority and power to implement rules in society, for example by means of laws, education or incentives. In the case of nursing, the implementation of Utilitarian values would thus lie mostly in the hands of the Nursing Bodies who determine the values and rules of the Nursing Codes of Conduct and who determine how nurses are educated. Individual nurses would primarily be expected to apply those rules rather than make Utilitarian calculations about likely consequences themselves.
In general, Utilitarianism highlights that the consequences of our actions are important for how we understand the morality of our actions. The same action might be right in one context, but wrong in another context. So killing a person might be considered wrong by Utilitarianism when it ends a life that would have been characterised by more pleasure than pain whereas it might be considered right under some circumstances if it ends a life that would otherwise have been characterised by terrible pain. That the vast majority of persons takes consequences to be at least somewhat important for morality can be seen in our rejection of at least some absolute demands of moral duties, even in the face of catastrophic consequences. Famously, the deontologist Kant was of the opinion that a person should never lie, even if telling the truth will lead to a friend’s death, whereas lying would have save his life. For a Utilitarian, consequences would have a significant impact on whether a lie would be ethically justified or not.
Whether Utilitarian consequentialism is a convincing moral position depends on how significant we consider consequences to be, and in particular whether we assume that it is ultimately possible to explain all moral obligations on the basis of consequences. With regard to the practice of nursing, Utilitarianism would assume that the core values of nursing can all be explained by the effects that decisions have on patients, families, health professionals, or other stakeholders. In assessing the value of Utilitarianism for nursing, one needs to reflect on whether that appears to be an accurate depiction of the values of nursing.
Classic or traditional Utilitarianism assumes that the consequences that matter ethically are the impacts on an individual’s experiences and well-being, especially the avoidance of pain and suffering and the increase in pleasure and happiness. This focus on pleasure and pain as core moral characteristics in traditional Utilitarianism was met with scepticism from the outset. Many philosophers have understood morality as a function of the “higher” aspects of human nature, for example rationality or religious faith, while considering bodily or emotional characteristics of human beings to be a “lower” aspect that does not represent what is essential about human beings. In contrast, Utilitarianism appears to focus on the sensory or bodily characteristics of pleasure and pain as core moral features, and thereby on exactly those “lower” features. Accordingly, critics said that Utilitarianism was a theory not adequate for rational and spiritual human beings.