cmf file 1 (1998) - introduction to ethics

Ethics and morality concern the decisions we make about whether something is right or wrong: first about how we make such decisions and secondly about how we carry them out in practice.

Why are ethics important?

Today's healthcare professionals are capable of remarkable feats, many of which would have amazed their predecessors. But such advances in technology carry with them a hidden danger. It is all very well being able to say 'yes' to the question 'Can we do this?' But we also need to pause and ask the question 'Should we do this?' The reason is that just because we have the ability to do something does not necessarily mean that doing it is right.

At some stage in our lives, all of us will be affected by decisions that relate to the issues of giving or receiving healthcare. Questions of what is right and wrong arise all the time. This is what makes medical ethics such an important subject.

The problem is that people in our society have very different ways of working out what is right and wrong. They have individual ideas about how to apply moral principles.

Take a subject like abortion. One person's ideas about morality may lead them to conclude that abortion can never ever be justified. But their next-door neighbour's moral framework may lead them to see abortion as entirely acceptable.

The study of ethics enables us to examine these different points of view. We can then assess the competing claims of the different moral systems. This is very important, because individuals within our society use a great variety of different systems.

Frameworks for decisions

How do people go about deciding what's right and wrong? We need to recognise that people are often under great pressure when they make decisions. Consequently they often don't think about the morality of a situation too carefully. They go with the flow and do what feels right at the time. But the rest of us are justified in asking whether this really is acceptable.

Most of us are aware of a strong sense of right and wrong about what other people do. Especially when they do it to us! Everyone who offers healthcare to their fellow human beings should do so on the basis of principles they have thought through carefully. They need to apply these principles consistently and not allow them to change to suit their mood at the time.

Anything goes...

Perhaps we should just learn to accept our differences. Instead of worrying about how to sort out our disagreements, why not just 'live and let live'? But is this right?

By taking this view there are no absolute standards that we all need to agree on. But it does not take much thought to realise that such ethical relativism is nonsense. If there really are no absolutes, then the absolute statement 'there are no absolutes' cannot be true! If we conclude that we are to tolerate everything, what happens when we try and tolerate intolerance?

This isn't just a philosophical game with words. The relativist's view of morality isn't true in the real world either. Despite the many differences that undoubtedly exist between cultures, a common core of morality is found right across the human spectrum (eg most cultures disapprove of the taking of innocent life).

It's true that the way moral principles are expressed may vary quite widely (eg what exactly is 'innocent' life?). But we find that the underlying principles themselves are remarkably similar.

What do people value?

Let's imagine that you're in charge of a hospital department with limited resources. You have to make a series of life or death choices between different pairs of patients. There are no alternatives: you must come to a decision that will mean that one patient survives while the other is allowed to die.

An old man of 80 OR a young boy of 10
A millionaire OR a person on social security benefit
Someone who will probably walk again OR someone who will always be in a wheelchair
Someone who will need to take painkillers for the rest of their life OR someone whose life will be relatively free of pain
A married woman aged 30 with a husband and three children OR a single woman aged 30
Someone with a history of criminal offences OR someone with an unblemished record
Someone who looks attractive OR someone who is ugly
Someone who is unlikely to have a sexual relationship in the future OR someone who can look forward to an active sex life
Someone who is likely to go back to work and earn their own living OR someone who will always be dependent on welfare benefits
Someone who says 'I really want to get better' OR someone who doesn't seem to care whether or not they recover

Can you analyse why you have made the choices in the way that you have? How easy was it? Your answers to these questions will tell you something about what you value and how you go about deciding what is right and wrong.

It just feels right...

Where do such principles come from? Let's start by thinking about someone who suggests that moral statements are simply an expression of an inner feeling (a view known as emotivism). For example, asked to justify a statement like 'killing people is wrong', they might respond that 'it just feels wrong'.

For these people, moral statements are no more than an expression of how people feel. Morality becomes a matter of subjective taste rather than any absolute standards.

The problem with this view is that most people do seek to justify what they believe to be right and wrong by appealing to their ability to reason rather than their feelings.

Let's look at this question the other way round for a moment. A person had killed somebody else. Very few of us would consider 'I did it just because I felt like it' to be an adequate excuse. There may indeed be extenuating circumstances, but we would expect them to be based on reason not feeling.

A further point to make here is that feelings can be dangerously mis-leading. After all, we often find ourselves in situations where, although we may feel like stealing someone else's bar of chocolate, we know that the right course of action is to go and buy our own!

Feelings are important, but are not by themselves an adequate basis for morality.

It's the way things are...

At the other end of the spectrum, many people believe that morality is a matter of reasoning issues out. They say that it's simply a matter of thinking things through properly. Then we would all arrive at the principles of right and wrong that are built into the nature of things. This is known as the deontological approach to morality.

Of course, the problem here is that even when we try and think things through carefully, people often end up disagreeing.

And anyway, we don't all think things through 'properly'. All sorts of unreasonable fears and attitudes influence the way we think about right and wrong. Even when we know what we ought to do, we don't always go on and do it.

Moral philosophers may be content with the way they think about right and wrong. But those who want to use a system of ethics need to be concerned with what that system actually does. In the real world we're often forced to choose between principles: what are we to do then?

Looking for a result...

Another way of making decisions about what is right and wrong is to look at the consequences of the proposed action. One way of doing this is to argue that what is right leads to people being happy. This is the criterion to use in assessing whether something is right or wrong.

A few people make decisions on the basis of what makes them happy as individuals. This approach is called hedonism.

Others follow the system of utilitarianism. This argues that in a given situation the right course of action is the one that would produce the greatest happiness for the greatest number of people.

On this view, ethics is about judging the amount of pleasure and pain created by the different choices available. Although superficially attractive and straightforward, it raises a number of problems.

First are the difficulties of defining and assessing amounts of pleasure and pain.

Secondly there is the problem of deciding how to resolve situations where people have to compete for what seem to be equal amounts of pleasure for each of them.

Thirdly there is the crucial objection that what is right and wrong should not be based merely on the consequences of an action. It needs to consider the motives and intentions of the people carrying out the action. Do the ends always justify the means?

All you need is love...

A variant of the utilitarian approach is situation ethics. In this case, although we allow our moral principles to guide us, we set them aside if in a particular situation the most loving course of action lies in a different direction.

Once again, the focus is on measuring the consequences of a particular moral choice.

Critics of this approach doubt whether the 'most loving' course of action can be calculated quite so easily. When does a 'situation' begin and end? And what happens when a situation arises where we need to choose whom to love?

In addition, no one has successfully demonstrated that the principle of love really should be allowed to exercise a right of veto over everything else, including, for example, the principle of justice.

Where there's a will...

A further way of deciding right and wrong is based on the ideas of existentialism. This sees everything as essentially meaningless, apart from the fact that I exist and have the ability to make decisions and choices. Morality is therefore no more or less than what I decide it is.

A variant of this, the principle of universalizability, seeks to avoid the obvious extremes of self-interest. This says that a right choice is one in which the person tries to choose what everyone else in the same situation would choose.

However, this approach to morality fails to acknowledge that there is more to being human than making individual choices here and now. We belong to communities with shared values and ancient traditions. Individual choice is important, but not to the exclusion of our fellow human beings.

Going by the book...

Another way of seeking guidance about right and wrong is to look for an external source of authority that we ought to obey. For many people, this is one of the particular benefits of religious faith. If the available evidence has persuaded us that a god exists, then we're also likely to value what that god has to say about how we should live.

The idea is that a superhuman being has revealed what is right and wrong. This may be through certain sacred scriptures, perhaps through special people. Not that this is necessarily the final word. For example, most Christians see the Bible as a collection of writing inspired by God. They seek to use it to guide their moral thinking. But they come to a variety of conclusions as to what it means and how it applies today.

One problem is that many of the situations and questions that we are faced with weren't around when religious documents were written. So even if some people believe in a God who has revealed the principles of what is right and wrong, they still have to decide how such principles work out in practice. They also have to decide what they are going to do if these principles seem to conflict.

A further problem comes when these people try to persuade others that they too should follow what the god they believe in is supposed to have revealed. This is a particular issue in modern Western society as common values that past generations took for granted come under increasing pressure. We may allow someone else the right to their moral views - but only if they keep them to themselves and leave us alone!

Conclusion

Many of the ethical issues faced by healthcare professionals in their daily work are straightforward. However, working out what's right and wrong can sometimes be a complex business.

Each of the above approaches has something to contribute in helping us to resolve such dilemmas and make ethical decisions responsibly.

In hard cases we need to pay attention to a whole spectrum of factors. These include the principles we think through, how we feel about the situations we face and our underlying motives. We also need to consider the consequences of our decisions, our responsibility within society for the choices we make and, if we believe in God, what we understand his will to be. A comprehensive ethical framework needs to include all these aspects.