Duty-Based Ethics (Deontology or Kantianism)
Duty-based ethics (deontology or Kantianism) is commonly associated with the philosopher Immanuel Kant (1724-1804). Kant held that ethics is based on fulfillment of a set of duties that can be determined by reason. The categorical imperative is the rational process which allows us to determine what our duties are. There are two formulations of Kant’s categorical imperative. The first is that any claim is universally applicable. For instance, Kant held that such claims as “Do not kill” and “Do not cause suffering” are universally applicable; we have a duty not to kill and a duty not to cause suffering. As long as we don’t kill or don’t cause suffering, we are acting ethically. Duties thus determine our actions.
The second formulation of the categorical imperative is that humanity should not be treated as a means to an end, but is rather an end in itself. This formulation is often used as the ethical basis for arguing against the buying and selling of organs for transplant. A person selling her kidney would be using herself as a means to make money. The person in need of a kidney would be using the potential donor as a means of getting a needed kidney. Because the donor would be used as a means to an end, the practice is not considered ethical. This ethical framework is sometimes criticized for being absolutist, in that some things are always unethical, regardless of the particular circumstances.
Utilitarianism or Consequentialism
Utilitarianism (or consequentialism) are ethical theories that focus on the consequences of an action. Utilitarianism determines that the right thing is that which does the most good for the greatest number of people. As such, no act is intrinsically ethical or unethical, right or wrong. The focus is on weighing the consequence of an action and calculating how much good can be done for the greatest number of people. Some form of utilitarianism is often used as a way of ethically allocating limited resources. It can be a compelling model for priority setting in health care spending or organ allocation. However, the sort of calculus required is difficult to make both qualitatively (how much good) and quantitatively (by how many).
Virtue ethics is based in part on the Aristotelian belief that cultivating virtue leads to happiness, and lack or excess of virtue leads to unhappiness. The character of the physician is central and determines what one should do, the idea being that the virtuous physician will act ethically. This is an intriguing model for physician happiness (and unhappiness). The idea is that the person cultivating virtue and acting virtuously would have the most professional satisfaction and find happiness. However, it gets somewhat complicated to apply ethically. First, virtues are subjective and may be biased. What one holds to be virtuous another may not find virtuous; for instance, personal sacrifice and suffering may be viewed differently by different people. In addition, relying on virtue alone may introduce physician paternalism or maternalism. If the virtuous physician always knows what choice a patient should make there is little room left for the patient to share in ethical decision-making.
In natural law theory, reason is central. Humanity possesses reason, which is always directed toward what is right, good, and fitting. As such, reason is the means by which universal absolutes are determined. Examples are “Good is to be done and evil avoided” and “Do not kill.” This differs from Kantianism in that natural law is not determined by its universal application or whether people are seen as ends in themselves. What is ethical is derived completely from reason, since reason in itself is always good. Natural law is juridical in that an action is right or wrong based on whether it conforms or is contrary to a law. Natural law forms the ethical basis for some religious beliefs about medical treatments, in particular Roman Catholic reproductive ethics.
While many religious groups base their moral theology on ethical foundations, such as natural law, others rely on a divine command theory. This can be expressed through interpretation of religious texts or divine revelation. These beliefs can be very firmly held based on membership in a religious tradition and be further based on faith in God. Because faith based religious principles are believed to be divinely revealed, it can be difficult to balance them with traditional ethical constructs, which rely on reason.
Common Morality as Universal Morality
Currently, one of the most widely applied ethical frameworks is that of Beauchamp and Childress, first proposed in 1985 in Principles of Biomedical Ethics. Here they argue for a common morality in which universal norms are shared by anyone committed to a moral life. From the universal and common morality can be discerned principles, which answer the question “What should be done?” and virtues, which answer “Who should I be?” As an example, common morality holds truths such as “Do not kill,” “Do not cause pain or suffering,” and “Rescue persons in danger,” and virtues such as integrity, fidelity and honesty. What emerges are the four well known principles of patient autonomy, beneficence, nonmaleficence and justice.
Part of the attractiveness of this model is that it is applicable and accessible. The model is also simple but elegant enough that it can be applied to many different ethical quandaries in order to organize thinking and come up with ethical options for action with each of the principles being considered. It also speaks both to the ethical question of “What should be done?” and the character question of “Who should I be?” It is sometimes criticized for relying too much on intuition to discern what the common morality is. Yet it is likely the most utilized and taught ethical model.
Beauchamp and Childress: The Four Principles
Autonomy is a person’s right to self-governance, in the form of self-determination and freedom. Beauchamp and Childress formulated the principles at a time when physicians sometimes dictated to patients what the treatment would be without much room for the patient’s input. They were also writing just over a decade after the Tuskegee Study of Untreated Syphilis in the Negro Male had ended in 1972. In this study, patients were used as experimental subjects without fully informed consent and in a manner that was deemed unethical. In this context, recognition of patient autonomy was something of an emergent concept. Patient autonomy has both positive and negative obligations. The positive duty is that patients should be informed of the physician’s or researcher’s reasoning, risks, benefits, and alternatives. On the negative, a patient should not be coerced or subject to the control of another in his or her decision-making. The duty here is to properly inform the patient (including ensuring that which is culturally and linguistically appropriate) without coercing or constraining the patient.
Beneficence is the physician’s obligation to do good, to heal, to help the patient. This is a positive obligation; it tells the physician or researcher what is to be done. As we will see, it is grounded in the Hippocratic tradition.
Nonmaleficence is the negative obligation that corresponds to beneficence. Nonmaleficence requires that the physician or researcher not harm or cause undue suffering to the patient. Beneficence and nonmaleficence recognize that the tools of medicine and research are amoral—they can be used for benefit or harm. These principles assure that good is done and that the patient is not harmed. Like beneficence, nonmaleficence is part of the Hippocratic tradition.
Justice requires that we treat all patients the same, the “one standard of care for all” adage. Justice speaks to the fair distribution of benefits, risks, and costs. On a policy level, it is used to guide priority setting and distribution of limited resources.