An introduction to ethics

Published on 01/04/2015 by admin

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Chapter 1 An introduction to ethics

Julie Woodley

KEY POINTS

Ethics is a framework for the analysis and resolution of dilemmas and is loosely based on the concept of right and wrong.

A dilemma may have an ethical component if it has a moral agent, a subject, an action and a consequence.

There are a number of ethical theories that can be applied to an ethical dilemma.

Radiographic practice involves a range of ethical considerations and decisions during the normal working day.

INTRODUCTION

The nature of the modern healthcare system means that ethical dilemmas commonly arise, and it is with this in mind that the following chapter will attempt to clarify our understanding of ethics and provide the reader with knowledge that may assist in the analysis and solution of some of the dilemmas likely to be encountered. These dilemmas may involve an individual patient or may have wider ranging societal consequences, as in the problem of whether patients should be given costly drugs or treatments at the expense of other services.

WHAT IS ‘ETHICS’?

Ethics is defined as being ‘the study of the moral value of human conduct’,¹ and whilst this definition is useful the study of ethics has evolved from purely a philosophical pursuit into a branch of philosophy which has enormous implications for healthcare practice in general. It may therefore be useful to examine the fundamentals of the study of ethics in an attempt to examine its applicability to practice.

As Box 1.1 would suggest, ethics is not to be thought of as the musings of philosophers that have no real life applicability, nor should it be regarded as simply a matter of applying common sense. Ethics provides us with a framework by which we can analyse dilemmas and hopefully this structured scrutiny will subsequently lead us to be able to resolve the dilemma we may face.

Box 1.1 The fundamentals of ethics ²

• Ethics is something that must be translatable into action. (It must work in real clinical practice.)

• Each one of us should think ethically and act in a moral way.

• Ethics is about individuals living and working in a community. (It is not just about ‘me ’ and ‘mine’.)

• Individuals not only have specific rights but also duties/obligations towards others.

• We as healthcare workers have special obligations or duties as laid down in our professional code of conduct.

• Clinical practice, ethical analysis and moral action cannot be practised in isolation from one another. (Ethics is a necessary part of good clinical practice.)

WHAT IS AN ETHICAL DILEMMA?

Before we begin to examine the applicability of ethical analysis, it is essential that the exact nature of what essentially constitutes an ethical dilemma be understood, as opposed to being faced with choices that do not really have an ethical dimension to them. As previously stated, the study of ethics can be summarised as the analysis of what is right and/or what is wrong in any given situation and it also assists us with the concept of how we ought to act at any given time. We make a lot of choices during daily life and not all of these choices necessarily have an ethical element involved with them. What we decide to wear, for example, is not normally of great moral concern. While an individual might inadvertently offend people with their terrible dress sense it would not necessarily be doing anyone any great harm, so as a result would not really be worthy of any kind of ethical/moral scrutiny or debate. If, however, this was taken a stage further and a T-shirt with a racist slogan worn, this could truly offend many individuals as they quite rightly would regard individuals from another race as being worthy of their consideration. In other words individuals, or indeed communities, matter and we should consider their feelings, whereas choosing to wear black or purple is not really of any great concern to individuals or society in general. Box 1.2 demonstrates that for a dilemma to have an ethical dimension it should encompass the following elements: 1) a moral agent; 2) a subject; 3) an action and 4) a consequence.³ All these elements have to be present before the dilemma can be defined as having an ethical dimension afforded to it.

To further qualify this statement there are also further conditions. First, the moral agent is someone who is assumed to be rational and capable of moral reasoning; then the subject must be worthy of moral consideration; the action could be good or bad, and the consequence should be of concern. Now, before readers start worrying that they have inadvertently picked up the hard core philosophy book that they leave around when trying to impress their brainy university mates, the author would just like to give an example in order to bring some clarity: If we choose to analyse a widely recognised dilemma, such as euthanasia, it soon becomes apparent that this subject more than fulfils the criteria, which results in it being arguably one of the most complex ethical dilemmas in modern medicine. In this case the moral agent is the physician who is in possession of a moral code and who can be regarded as rational. The subject (the patient) is a human being and therefore is afforded the status of being worthy of moral concern. The action is that their life is shortened by the actions of the physician, and the consequence is that they die. It is easy therefore to see that this dilemma has massive ethical perspectives.

Once we have ascertained that our dilemma has some ethical element we need to investigate the tools we have at our disposal in order to analyse and potentially come up with a solution or solutions to the problem.

BASIS OF MORAL REASONING

This analysis of ethical problems can alternatively be termed ‘moral reasoning’. Here we can look at a problem and apply our moral and/or professional values to it. We can then decide what is the right option or course of action to take. We are all in possession of our own moral code (in other words, what we perceive as being right and wrong) and it is this code that we sometimes consult when deliberating about an issue. There has been much debate regarding our moral/ethical development;⁴ however, it would seem that our moral reasoning capabilities may be influenced by a complex mixture of internal and external factors.

All the elements mentioned in Box 1.3 serve to provide us with our own set of values. These values may change as we mature or gain ‘life experience’ but they may also be supplemented by additional rules or values that come when we adopt a professional role.

Box 1.3 Basis of moral reasoning

Conscience

• An action may feel ‘wrong’. You may not at first be able to analyse this feeling but instinct would suggest that there is a problem.

Peer pressure

• It is very difficult to stand up for what you feel is right when others disagree. It may be easier to just go along with the group view.

Tradition

• Moral values may stem from tradition. A good example is marriage, which was widely regarded as the norm; but over the years other options, such as living together, have become socially acceptable.

Religion

• Many religions provide very clear frameworks to instruct us how to behave if we are to be regarded as a ‘good’ person. Some of these teachings may, however, be regarded as out of date in modern society.

Education

• Being educated means you can be more informed and thus in possession of more information that will assist you to decide what is right or wrong.

Life experiences

• Your values may change once you have actually experienced something; e.g. parenthood or nursing a terminally ill relative.

THE MAIN ETHICAL THEORIES

In an attempt to evaluate the exact nature of human values, philosophers have proposed various theories in order to give more structure to the process of moral reasoning. Many of the theories that can be applied to ethical analysis come from a particular philosophical perspective. These theories can then be translated into principles by which we would wish to live and then further extrapolated into rules which should govern our judgements and in turn our actions. For example, in principle we would like to live a healthy life, so legislation is drawn up requiring authorities to provide basic healthcare provision for their population. These authorities then make judgements as to how that provision should be constructed and then ultimately delivered.

To help the individuals to make such decisions it may be helpful to provide a frame of reference on which to structure their deliberations. It is at this point that we may consult various ethical theories.

DEONTOLOGY

Immanuel Kant,⁵ who was a philosopher in the 18th century, first proposed this theory, based on the idea of rights and duties. He hypothesised that:

• Each of us had a set of duties towards our fellow man.

• We should not treat a fellow human being as a means to an end and, indeed, we should treat others how we ourselves would wish to be treated.

• Certain acts were intrinsically right or wrong (for example he believed killing could not be condoned under any circumstances).

• Rules produced by any community should be rational and universally applicable.

• The rightness of actions should not be judged by their consequences.

Applying this theory, it would be widely accepted that we have a duty of care towards our patients and it would seem sensible that we should carry out that duty in a fair and just manner; i.e. treat all patients with equal regard. The main problem with this theory was how we could construct rules that could be applied universally; in other words, in every circumstance. So although we would like to treat all our patients equally it would seem very unfair to not give priority to those most in need. It would also not seem at all rational to ignore the consequences of our actions, even if they were well intended.

CONSEQUENTIALISM

Later on, in the 19th century, John Stuart Mill and Jeremy Bentham ⁶ went on to develop a theory by which the value of any action was based solely upon the end result or consequence. They termed this theory ‘utilitarianism’ and argued that certain utilities should be maximised if an act was to be performed. Their main utility was happiness and they believed that the aim of all human endeavour should be to strive towards ‘The greatest happiness of the greatest number’. They believed that:

• All acts should be judged upon their consequences.

• Happiness and well-being should be maximised for the greatest number.

The problem with this theory was that it was highly subjective and often discriminated against the individual. For example, a radiological department with £10 000 to spend might be faced with the dilemma of whether to allocate this funding to either an angiography suite or a chest room. Utilitarianism would suggest that it would provide more benefit if it were awarded to the chest room, as it could potentially affect far more people’s well-being than if it was put towards the more expensive procedures carried out in an angiography suite. That may on the face of it seem fair, but you might not think so if you were a patient who then had to have highly invasive surgery because angioplasty could not be funded. This maximising happiness would effectively mean that cheaper treatments that benefited populations would always be chosen over expensive individual treatments, and as a result the seriously ill would almost certainly be discriminated against in most cases.

THE FOUR PRINCIPLES APPROACH

The two aforementioned theories are indeed just that – theories – and much of the criticism levelled against them was that they had flaws when applied to real-world dilemmas. It was with this in mind that Beauchamp and Childress ⁷ attempted to develop a more user friendly and more easily applicable theory that we could apply in any given situation. They framed their arguments into what has been commonly termed ‘the four principles approach’, which is summarised in Box 1.4.

Again, this theory is not without its problems as, whilst it is fairly simple to analyse the dilemma under the four categories and devise possible solutions based on each of the principles, the theory gives us no guidance as to which of these principles should be given the highest weighting in the event of a conflict between them.

For example, if a patient came into your department asking to be treated only by a female radiographer, she would be exerting her autonomy in making that request. Normally this would not be an issue, but if on this occasion the section of the department was staffed purely by men, you would have a problem: by facilitating the request you would please the patient but delay her procedure whilst you reallocated staff (causing possible harm) and you might also inconvenience the patients to whom the female radiographer was already attending. Also, would it be right and fair (justice) that one patient should be able to disrupt others just to exert her choice? The four principles approach does not really help us to decide whether there should be limits to the patient’s autonomy or whether the justice aspect of this course of action should be given more credibility in the decision-making process. It is, however, very widely referred to within healthcare literature and, if nothing else, does assist us to begin to frame the debate and produce alternatives on our journey to a resolution.

NARRATIVE ETHICS

The example used to illustrate the previous point was missing one vital piece of information in that at no point were the reasons behind the patient’s request explained, and this leads us on to a further ethical perspective, termed the narrative approach, in which the patient’s story, narrative, values and emotions become important. The patient’s request may have a religious basis or it may simply be that the patient would feel more comfortable with a female radiographer; but without taking these aspects into consideration it is very difficult to proceed and ultimately take the right course of action. Patients are all individuals and, as such, all come with their own values and narratives which must be respected if at all practicable.

VIRTUE ETHICS

In this branch proponents enquire about how should we live ⁸ rather than looking for instruction on how to act. The theory attempts to analyse what should be desirable qualities or virtues, such as honesty and truthfulness.

FEMINIST PERSPECTIVES

A further group of theories that would appear to have great relevance to healthcare are feminist perspectives towards ethical debate. These views challenge the traditionally male perspectives and apply a more feminine idea of care.

APPLYING ETHICS TO RADIOGRAPHIC PRACTICE

Any one of the previously mentioned theories or combinations thereof may assist us in our decision making process. Whilst this is useful, the fact that we have some form of professional status will bring a further set of values that should also be brought into the equation. Further assistance in how we should act can also be found in the fact that most professions have devised a code of ethics/conduct for their members. Such a code assists the professional in that it gives guidance on how to carry out professional duties and it gives the public some idea of what to expect from the professional under whose care they may find themselves. In other words, it gives guidance on how we should act if we want to be regarded as a ‘good’ professional.

STATEMENTS FOR PROFESSIONAL CONDUCT

Radiography’s professional body, The College of Radiographers,⁹ has over the years produced and adapted what it terms as statements of professional conduct in an attempt to clarify our professional role. So not only are we in possession of our own values, by entering into the radiography profession we agree to act in accordance with these statements (Box 1.5).

Box 1.5 Statements for professional conduct (2004)⁹