Utilitarianism

The essence of utilitarian theory is the idea that the morality of an action is determined mainly by its consequences: the morally right action is the one that produces the best result [Beauchamp and Childress, 2001]. Of course, the result of an action may be quite complex. An action that helps one person may harm another person. Withdrawing support from a child in a vegetative state undoubtedly harms the child, since it results in the child’s death, but the action may help the family grieve and may allow society to use limited medical resources to help other patients. The utility principle states that one should act to produce the best overall balance of positive and negative consequences of the act. This idea is embedded in the concept of balancing risks and benefits to achieve the best overall result.

Utilitarian theory is often cited to justify actions that are most likely to increase happiness, but other desirable results are also possible. Individuals may wish to act in such a way as to increase personal quality of life, enjoyment of and satisfaction with life, success in a preferred career, and general knowledge and understanding, or to strengthen personal relationships. Lawyers and policymakers use the utility principle to produce the best overall balance of justice and fairness for society.

Utilitarian thinking is almost intuitive in many aspects of ordinary life. Understanding this form of thinking is important because it may help avoid the potential pitfalls that can result from uncritical application of the theory. Perhaps the most familiar situation is the use of utilitarian theory to justify the killing of defective newborns [Kuhse and Singer, 1985]. Although theoretically logical, such arguments are morally repugnant to persons who apply a different moral standard based on some other approach to ethics. Another problem with utilitarian theory is its failure to protect minorities, which results from its emphasis on producing the most good for the majority. The needs of children with rare neurologic disorders can be overlooked if utilitarian thinking allocates scarce medical resources primarily to children with more common disorders.

Deontology

Deontologic theory is based on the importance of “deon,” or duty. Duty is based more on the intentions that lead a person to act than on the outcomes or consequences of the action. Utilitarian thinking is mostly situational and depends on the specific aspects of a given situation; deontologic thinking strives to be more universal and to emphasize decisions that would apply in all relevant situations. Thus, Kant’s categorical imperative states that we should act only in a way that is consistent with a universal law or obligation [Kant, 1959]. Using people as means to an end implies that different actions (or reactions) are needed, depending on the end or outcome that is desired; therefore, the actions are not universally applicable. For this reason, deontologic thinking stipulates that we should treat all people as “ends” and not as means to an end. This could cause problems in thinking about the morality of organ transplantation if the organ donor is thought of only as a means to the end of survival for the recipient. Clearly, deontologic thinking imposes a duty to respect the rights and value of the donor as much as those of the recipient because anyone could be either a donor or a recipient.

Deontologic thinking emphasizes duties and obligations, but these may conflict. For example, physicians may have different and competing obligations toward patients, families, hospitals, insurance companies, and society. The attempt to describe duties leads to formulation of general or universal rules for moral action, but these rules may also conflict. Rules may be too abstract and impractical to apply to real-life situations. Deontologically based rules do not take into account the messiness of human relationships, a point that it is essential to keep in mind when considering the ethics of care discussed later in this chapter.

Common Morality and Natural Law

What are the universal rules that spring from deontologic thinking? Most Western philosophers would argue that these rules can be derived from the application of reason – from rational, logical thinking about the nature of human existence. The general argument is that “all rational persons would agree that these rules are essential to govern and guide the moral actions of individuals in a cohesive society” [Beauchamp and Childress, 2001]. Beauchamp and Childress [2001] describe the “common morality” as socially approved norms of human conduct that form the basis of ethical theory. This common-sense understanding of what is needed for individuals to behave in society is not derived from theory, but rather forms the basis for potentially competing theories.

Natural law theory is an ancient approach to deriving universal rules through the application of reason [Simon, 1992]. For Thomas Aquinas, natural law sprang from man’s participation in God’s eternal law and was brought into being by the application to action of human intelligence and reasoning [May, 1994]. This application leads first to the principle that all things desire that which is good; therefore, good is to be pursued and evil is to be avoided. Good things are those to which man has a natural inclination, such as life (existence), social interaction, family life, and civil government. To pursue these good things, one should act fairly, love God, and love other persons. Secondary precepts or rules (such as the Ten Commandments) follow from these basic principles.

Secular interpretations of natural law are as old as Aristotle and are still used in some forms of legal theory. Bernard Gert [2002] defined two sets of rules that he believed all rational persons would accept as natural and essential, without relying explicitly on natural law theory. Many of his rules are in fact similar to the Ten Commandments. Gert also emphasized that the rules are not absolute and that violations may be considered in specific circumstances. Beauchamp and Childress [2001] do not define any specific rules as part of their common morality, but they do define four principles that are not absolute and that need to be specified based on actual circumstances. None the less, their four principles may be seen to correlate with the precepts of natural law:

Whatever the source of the common morality, it is the basis for principlism, the ethical theory based on the application of principles to specific situations.

Principlism

Principlism is an approach to ethical problems that is based on the application of the four principles of beneficence, nonmaleficence, justice, and autonomy. It is more of a practical guide than an abstract theory, and it has found widespread acceptance in a variety of settings [Beauchamp and Childress, 2001]. It was adopted explicitly in the Belmont Report, which forms the foundation for research ethics in the United States [Belmont Report, 1979]. Although principlism is perhaps the best-known approach to clinical ethical problems, it is by no means the only approach. Understanding principlism is necessary to consider these alternative systems.

The principle of autonomy has become pre-eminent in Western society, although it may be less prominent in Eastern societies that place a greater value on social harmony. Physicians need to keep this in mind when caring for patients from other cultures. An autonomous choice is one that is based on sufficient knowledge of the facts involved, the ability to understand the situation, and the independence to choose without undue influence of other people. An autonomous person can determine for himself what he thinks is best, and this principle states that other people should respect these choices, even when they do not agree with or approve of them. Autonomy is the basis for the concept of informed consent, which requires that a patient has the capacity or competence to understand the issues, full disclosure of all of the information needed to make a decision, and freedom from any coercion that might influence the decision.

In general, persons younger than 18 years of age are not considered to have the capacity to make fully autonomous choices, although their preferences should be considered and respected, if possible. American law recognizes that persons 18 years of age and older are fully competent, unless a judge has determined otherwise. This recognition is critically important for young adults with neurologic disorders (such as intellectual disability) that may affect their capacity to make fully autonomous decisions. If capacity is in doubt, the family will need to initiate legal proceedings to obtain guardianship when the person becomes 18 years old. A young adult (over 18 years) with a neurologic disorder that results in limited competence is unable to give informed consent, but that individual’s parents cannot give consent for him or her unless they have obtained guardianship. Failure to obtain guardianship when it is necessary can interfere seriously with medical treatment.

The principle of beneficence encourages physicians to do good or to act in the best interest of the patient whenever possible. This principle can also be interpreted to suggest that physicians should seek to promote an optimal quality of life or satisfaction with life. Considerable debate exists about how to measure quality of life [Bowling, 2004; Nordenfelt, 1994; Nussbaum and Sen, 1993; Schalock, 1996]. Objective measures are based on the judgments of others, whereas subjective measures are based on the opinions of the patient about what constitutes a satisfying life. In general, preference is given to subjective judgments when they can be known.

The principle of nonmaleficence encourages physicians to avoid doing harm to patients and dates back to Hippocrates. It is related logically to the principle of beneficence. Both principles are considered when physicians attempt to strike a balance between providing a benefit for the patient (doing good) and not imposing a burden (avoiding harm). This balance may become especially problematic when the same action could produce a good, or desired, effect, as well as a bad, or undesired, effect. The classic example is prescription of sufficient medicine to reduce pain while knowing that it may also cause the patient to stop breathing. This problem is known as the “situation of double effect” [Beauchamp and Childress, 2001]. In Catholic moral theory (which contains the most explicit analysis of such situations), an action that causes double effects is morally justifiable only if it meets all of the following criteria:

This concept is admittedly difficult to apply in practice. Evaluation of each criterion may be arguable in a specific situation. Perhaps the best that can be expected is that physicians will make a good-faith effort to adhere to the principles involved and seek to obtain the optimal balance between benefit and harm for the patient and family.

The principle of justice requires that equals be treated equally, but the basis for an equal distribution of resources may be arguable. Should resources be distributed according to need, effort, merit, contribution to society, or some other factor? Utilitarian, libertarian, communitarian, and egalitarian approaches have been proposed to answer this question [Beauchamp and Childress, 2001]. Rawls [1971] suggests that resources should be distributed to ameliorate the effects of life’s natural and social lotteries. It may be simply bad luck (“losing the lottery”) that a child is born with a disabling condition or is born into poverty. If the child is not responsible for this condition, then society should act to remedy the situation. According to this rule, unfair situations would presumably have priority over merely unfortunate situations. How many resources should be provided to those who have been unfairly deprived? The limits of this redistribution policy may be the extent to which it disables or impoverishes the rest of society [Veatch, 1986].

Jonsen et al. [2010] suggest that ethical issues can be analyzed by asking the following four questions (which are, in fact, practical applications of the four principles discussed previously):

The questions may be somewhat hierarchic, in the sense that medical indications and patient preferences are usually more important than potential social burdens, but physicians should not be too rigid about this. In fact, asking (and answering) these four questions in a particular case is an excellent way to make sure that the relevant issues are identified and evaluated. These issues can then be considered by the caregiving team, patient, and family. Resolution of the issues may vary from case to case, but at least everyone involved will be able to see how the decision was made.

Virtue or Character Ethics

Virtue can be described as a trait that has moral or social value. According to Aristotle, virtuous behavior requires both the right motive and the right action. In other words, wanting (or intending) to do the right thing is not enough by itself. This idea is somewhat at variance with pure deontologic thinking, as described previously. In virtue theory, following a presumably universal rule is not necessarily a moral or virtuous act if it produces a bad result. Similarly, doing right for the wrong reason is not necessarily a moral or virtuous act if the motive itself was not virtuous.

The catalog of virtues is not exhaustive and varies from one writer to another. Pellegrino and Thomasma [1993] suggest eight virtues that are necessary for sound medical practice:

They argue that these eight virtues are necessary but not sufficient for physicians to practice ethically. Possessing these virtues provides evidence of good intent but they must be linked to ethical action. They suggest that principlism, although not specifically part of virtue theory, can provide a guide for virtue-based ethical action.

Ethics of Care

Care-based ethical thinking is prominent in nursing practice but may be somewhat unfamiliar to physicians. It arose as somewhat of an alternative to deontologic, rule-based thinking that depends on adherence to more or less rigid principles. It also arose from feminist research studies comparing male and female approaches to ethical dilemmas. Gilligan [1982] found that males were more likely to look for rules to follow and to insist on adherence to these rules. Females were more likely to look for some situation-based way to resolve a dilemma, taking into consideration the person’s feelings and significant relationships [Gilligan, 1982]. This “feminine” way is not exclusively reserved for women (or for nurses), of course. Rather, it provides an alternative and perhaps more subjective way to evaluate an ethical problem that is especially relevant when a rule-based approach seems to be inappropriate or unhelpful [Held, 2006; Kuhse, 1997; Taylor and Watson, 1989].

Somewhat obviously, care-based ethics does not have any fixed rules. In fact, it challenges the idea that impartial or universal rules should guide ethical action. Instead, it looks at the particularity of the patient and the clinical situation, and seeks to find answers that fit this unique case. Care-based ethics accepts the fact that emotions have important moral value and must be considered carefully. It also emphasizes the patient’s human relationships and the mutual interdependence of the patient, family, and all members of the caregiving team. A care-based approach to an ethical dilemma would say something like, “That can’t be the only possible ethical solution. There must be another way to resolve this problem that is acceptable to everyone here. We all want to do what’s best for the patient, so let’s think about what that means. Maybe we could start by understanding what the patient is feeling and by talking to the family. We should also talk about how we feel about all of this. Let’s brainstorm some ideas and think about what they would involve. Maybe we need to talk to some more people and get more information. If we keep working at it, we’ll find a way.”

This approach will sound familiar to anyone who has been involved in difficult cases in the intensive care unit, which emphasizes the ubiquity and usefulness of this way of thinking in clinical practice. Perhaps an awareness of the sound ethical foundation of care-based ethics will also help clinicians give this way of thinking the respect it deserves.

Casuistry

Casuistry, or case-based ethics, is another alternative to utilitarian or rule-based ethical approaches [Jonsen and Toulmin, 1988]. It rejects the very idea of a “moral calculus” that can be analyzed impartially, based on abstract concepts. Instead of a “top-down” approach, based on pure theory, it takes a “bottom-up” approach, based on the particularity of specific cases. Casuistry looks at specific cases and emphasizes points of agreement about those cases. It recognizes that moral intuition may be more important than adherence to principles. It is common knowledge that members of hospital ethics committees often agree on what needs to be done but cannot always say with clarity why they feel that way (or what ethical theory they relied on to make a particular judgment). This moral intuition may also reflect the influence of the “common morality” described previously. By looking at the particularities of a specific case, casuistry is also sensitive to contextual influences and individual differences.

The method of casuistry is somewhat analogous to the method of case law used in the United States. One first identifies several key cases about which there is a consensus regarding the proper ethical approach. These are cases that have had careful scrutiny in the past and are still believed to be instructive. New cases are then compared with these key cases, selecting those past cases that have the greatest similarity to the current case. One then seeks to develop a consensus about how to resolve the current case, based on how these past cases were resolved. Each new case that is resolved in this way goes into the body of case experience, so that the consensus is revised and modified incrementally in the light of clinical experience.

One can see that casuistry is very similar to what an experienced clinician does naturally, drawing on his or her experience in past cases to sort out the issues in a new case. One has to be careful about which past cases to consider and to what extent the decisions made in those cases apply to the current case. Experience in past cases may also be conflicting, and it may be difficult to sort out the similarities and differences compared with the current case. One also has to be careful about how much weight should be given to one past case compared with another past case. In a very real sense, every new case is different (as every clinician knows), but there is still much to be learned from past experience. Casuistry provides a sound ethical foundation for using this clinical experience in resolving ethical dilemmas.

Spirituality

Spirituality is variously defined, but it can be understood as a belief system that focuses on intangible elements that impart vitality and meaning to one’s life [Koenig, 2002]. Because it is based on beliefs, or faith statements, it is not provable through logical argument. Spirituality in medicine is often based on religious beliefs [Sulmasy, 1997], but it need not be. As an expression of ultimate concern, it reflects the elements of our lives that are the most important and make life worth living. Most people have some spiritual beliefs that become prominent when their health is threatened; yet these beliefs are often not considered by physicians and other health-care providers. Physicians may anticipate that patients would have certain beliefs based on knowledge of their religious background [Numbers and Amundsen, 1998], but individual differences exist, even within a religious tradition. A more direct understanding of the patient’s spirituality would be preferable.

One approach to understanding the patient’s spirituality is the “three ways of looking” [Coulter, 2001]. The first look is to see the person subjectively as an individual human being. Compassion requires distance and objectivity [Pellegrino and Thomasma, 1993