An Introduction to Ethics

1. An Introduction to Ethics Paul Snelling & Kate McMahon-Parkes

2. Exercises in RED

3. Definitions Moral philosophy is …enquiry about norms and values, about ideas of right and wrong, and what should and should not be done. Raphael 1994 A moral or ethical statement may assert that some particular action is right or wrong or that actions of certain kinds are so. Mackie 1977

4. Three senses of Ethics Edwards 1996 • Personal ethics • may be intuitive / ‘gut feeling’ • e.g. what do you feel about abortion, euthanasia etc? • What has contributed to these beliefs? • Group ethics - Ethical codes eg NMC • May conflict with personal ethics. E.g. The NMC directs us to respect the wishes of a pregnant woman over the rights of her unborn child. So a mother with a full term pregnancy could refuse treatment which could then result in the baby dying. How would you feel if you had to care for such a patient? Why? • Philosophical ethics – e.g. deontology, utilitarianism

5. Ethical approaches linked to Healthcare • Kant (1724-1804). • Person /individual based • Believed in duty (Deontology) • Constant conflict between what we should do and what we want to do • If something is wrong for one person, it is wrong for everyone (categorical imperative) • Eg if killing or lying is wrong for me, it is wrong for everybody • Argued that a bad means does not justify a good end. • Strong emphasis on autonomy and individual rights

6. Example of Kantian approach An axe murderer is chasing James. You let James hide in your house. If the axe murderer asks you if James is hiding in your house, according to Kant, you would tell him ‘yes’….. But WHY?

7. Example of Kantian approach cont Why would you tell the axe murderer where James is? Because….. • Lying is wrong • Because a bad means (i.e. lying) does not justify a good end (i.e. saving James) • Because it is the axe murderer’s responsibility to ‘do the right thing’. An autonomous agent must be able to make his own choices. Does this approach work? Sometimes? Never? What do you think?

8. Ethical approaches linked to Healthcare 2 • Jeremy Bentham (1748-1832) & John Stuart Mill (1806-1873) • ‘Utilitarianism’ or ‘consequentialism’ • Bentham created “felicific calculus” (happiness sums) to calculate what would produce maximum pleasure and minimum pain for the most people. • Mill amended the approach to the ‘greatest good’ rather that the ‘greatest pleasure’ • Motives not important; the outcome is what is matters • A bad means justifies a good end The stuffed body of Bentham is kept in University College London, where he is occasionally allowed to take part in college council votes!

9. If a utilitarian were to decide upon an action, they would possibly do a happiness sum to help them decide (bear in mind they will usually carry out an act that gives the greatest happiness to the greatest amount of people). Presume the greatest happiness is +2, and the greatest unhappiness is -2. Given the above, if a utilitarian was sent to kill Hiltler, would he do it, and if so, why? If Kant (a deontologist) was sent to kill Hitler, would he do it?

10. A utilitarian or consequentialist would probably decide that according to his sums, millions of people would be moderately or very happy if Hitler died, and only a few would be unhappy (including Hitler himself). Consequently, he would kill Hilter, as in this case, a bad means (i.e. murder) justifies a good end (happiness of the population and possibly saving of countless lives). • Demonstrates the greatest good for the greatest amount of people • However, Kant (a deontologist) would not kill Hilter as killing is wrong, and a bad means (killing) does not justify a good end. • You can see from this case that applying a different approach to the same question can come up with very different conclusions

11. 4 Principles approach (Beachamp & Childress 2001) • Autonomy • Nonmaleficence • Beneficence • Justice • “Our four clusters of principles do not constitute a general moral theory. They provide only a framework for identifying and reflecting on moral problems” • Beauchamp and Childress 2001, page 15 • In considering the above principles, you may also think about how the utilitarians and deontologists would look at each of them

12. Respect for Autonomy (1) Personal autonomy is, as a minimum, self rule that is free from both controlling influences and from limitations such as inadequate understanding that prevent meaningful choice. Two essential elements are (1) liberty - no controlling influences (2) agency - capacity for intentional action

13. Respect for Autonomy (2) Has both positive and negative obligations Negative - Autonomous actions should not be subjected to controlling constraints by others Positive - Respectful treatment in disclosing information and fostering autonomous decision making

14. Non-maleficence An obligation to do no harm - Primum non nocere. One ought not to inflict evil or harm One ought to prevent evil or harm One ought to remove evil or harm One ought to do or promote good Frankema 1973

15. Non-maleficence Doctrine of Double Effect • Allows an “evil” to occur as long as it is not intended. • The (good) act to be done considered it itself and apart from its consequences must not be intrinsically wrong • Given both a good and an evil effect of an act the evil must not be intended but simply tolerated or permitted • The good must be desirable enough to offset permitting the evil • The evil effect must not be the means of bringing the good effect

16. Doctrine of double effect • e.g. a terminally ill patient is in unbearable pain. She is on 20 mg diamorphine per hour. A dose of 21mg will control her pain BUT will also result in her death. • Doctrine of double effect will allow you to give the fatal dose as your intention is to relieve the pain, not to kill the patient. This stems from the case of Dr Bodkin Adams who was accused of murder in 1957 (he had given a dying patient a fatal dose of opiates in order to control her pain). Courts findings were that he was“…entitled to do all that was proper and necessary to relieve pain and suffering even if the measures he took might incidentally shorten life by hours or even longer.”(www.BMA.org accessed 2005)

17. If you intended to kill the patient (even with the good motive of relieving the pain), how would British law view your act? • Intentionally killing, even if the patient has requested it, and even if it is in their best interests is still murder (in British law)

18. Beneficence A requirement to contribute to the welfare of others • Two principles • Positive beneficence - doing good • Utility - balancing benefits and drawbacks

19. Justice (1) • Distributive justice (e.g. share equally) • Retributive justice (e.g. ‘punish’ those who have ‘done wrong’) Formal Principle of Justice (after Aristotle) “Equals must be treated equally, and unequal must be treated unequally”

20. Justice (2) • To each person an equal share • To each person according to need • To each person according to effort • To each person according to contribution • To each person according to merit • To each person according to free market exchanges. • What do you think about these different types of justice? Are some people more or less ‘deserving’ of healthcare? What are the implications of this? • e.g. 2 people need a liver transplant. One is a businessman who has paid huge amounts of tax, and has liver failure due to excessive alcohol consumption. He has already had one transplant. The other is a disabled teenager who is does not work, and is unlikely to be able to do so; she has cancer of the liver. Who should receive the liver?

21. Challenges to the Principle Based Approach • Too simplistic • Too complicated (!) • Overvalues autonomy • Takes no account of other cultures • Doesn’t actually tell you what to do.

22. How do we solve our moral dilemmas? We analyze them, reflect on them, weigh up the options justify them There is no magic formula!