Overview of U.S. Medical Ethics
This section provides an overview of the major schools of thought in Western ethics: consequentialism, deontology, virtue ethics, natural law, and moral relativism. It then highlights principlism, a useful approach to medical ethics that breaks down issues into four major principles: respect for autonomy, beneficence, nonmaleficence, and justice. Moreover, it mentions the themes of negligence and reasonable care, which are often discussed in conjunction with beneficence and nonmaleficence. Finally, this section discusses the ethical principles of allocation of resources.
Centuries of scholarship have resulted in a variety of frameworks for making ethical decisions. Selected frameworks are introduced briefly below, notably biased toward Western ethical approaches from the Scottish and English enlightenment. Please refer to linked resources for more details. Notable proponents of each of these schools are also listed in our supplemental section, located here.
Please note: Noting our Western bias in this discussion, we briefly highlight a select few of the many schools of ethical thought and philosophy that did not originate in Europe in our supplemental section, located here.
- Consequentialism: the idea that the morality of an act depends on its consequences. To decide whether an act would be right or wrong, one should examine the possible results of the act and ask whether the good effects would outweigh the bad effects. As consequentialist ethics is focused on the ends rather than the means, it is also known as teleological ethics (from the Greek word telos, which means “end”). Two forms of consequentialism are utilitarianism and prioritarianism. Sources: Stanford Encyclopedia of Philosophy, Dobrin 2012, Internet Encyclopedia of Philosophy, The Ethics Centre, Internet Encyclopedia of Philosophy
- Utilitarianism: the most well-known theory of ethics within consequentialism. Utilitarianism states that one should choose the act that results in the most good - the act that maximizes the good of all parties involved. In other words, the most ethical action is the one that leads to “the greatest amount of good for the greatest number of people” (quoted in Stanford Encyclopedia of Philosophy). Sources: Stanford Encyclopedia of Philosophy, Dobrin 2012, Internet Encyclopedia of Philosophy, The Ethics Centre, Barnhill 2010, Stanford Encyclopedia of Philosophy
- Prioritarianism: a theory that, along with utilitarianism, falls under consequentialism. Prioritarianism proposes that priority should be given to those who are worse off because benefits have greater moral weight when given to those who are worse off. In contrast to the utilitarian perspective of maximizing good for all parties involved, prioritarianism favors assisting those who are worse off, even if this results in a diminished maximal overall good. Prioritarianism can also be distinguished from egalitarianism. Whereas egalitarianism proposes equality (i.e. treating all equally because all humans are equal in worth and moral status), prioritarianism suggests an approach more similar to equity (i.e. providing a good unequally to those who are worse off rather than those who are better off so that there is greater equality in the end). This is an important distinction to make, and instances may arise where this may be the case. For example, suppose that a government could choose to fund a cure for canker sores (i.e. aphthous ulcers) for everyone versus a cure for an orphan disease that kills a very small number of people. An egalitarian approach would suggest that funding a cure for canker sores as the correct choice, as this may benefit everyone equally, while prioritarianism would favor curing the rare deadly disease instead to help the few who suffer from it.
- Deontology: The word “deontology” comes from the Greek word deon, which means “duty.” Thus, deontological ethics is also known as duty-based ethics. In deontological ethics, one uses reason to arrive at a foundational ethical standard or standards, and one has a duty to act according to those principles. Deontological ethics is also called non-consequentialist ethics because one judges the morality of an act based on how that act conforms to ethical principles, not based on the result of the act. In one version of deontological ethics established by Kant, the basic ethical principle (“categorical imperative”) to which all right acts should conform is to “treat people as an end, and never as a means to an end” (Internet Encyclopedia of Philosophy). In another statement of the categorical imperative, Kant explains that we should always act according to principles which we, as rational agents, would want to be a universal law for all people. The essence of morality is in these principles, not in the results of the acts themselves.
- Virtue Ethics: This is one of the oldest schools of ethics, as it is founded on the ideas of Plato and Aristotle. A virtue is “an excellent trait of character,” a fundamental principle that is deeply held within a person and causes that person to act habitually in a certain way (Stanford Encyclopedia of Philosophy). According to Plato, examples of virtues are wisdom, courage, temperance, and justice (Internet Encyclopedia of Philosophy). Virtue ethics is concerned with forming the good character of a person, that is, becoming a person who embodies the virtues. If one acquires these fundamental dispositions, then making ethical decisions will naturally follow from them. In other words, in virtue ethics, the primary emphasis is on what kind of people we are, not on what decisions we make. The decisions that we make are a result of the virtuous character we have developed.
As discussed above, consequentialism, deontology, and virtue ethics are three methods that we can use to decide how to act ethically. But how do we decide which framework to use? Where do ethical standards come from? Although these questions, which fall under the purview of meta-ethics, are largely beyond the scope of this module, two important answers are highlighted below.
- Natural Law: Natural law moral theory holds that humans can use reason to find basic moral principles that are central to human nature and that orient us toward the flourishing of all human beings. In other words, human nature tells us something about morality. Using human nature (the way humans are) as a starting point, we can reason toward moral standards. Because moral norms are grounded in human nature, they are objectively right or wrong, and all human beings can have a basic understanding of them. Thomas Aquinas and many other natural law proponents operate from a theistic perspective; the natural law is given by God who created human nature, and humans can use reason to decide whether acts are in accord with the natural law.
- Moral Relativism: Moral relativism states that moral norms are not universal; rather, they are relative to a particular time, place, or culture. Because moral norms are relative, it is not possible to prove that one moral stance is generally better or truer than another. Unlike moral objectivists, moral relativists do not believe that any ethical standard is universally or absolutely true in all cases. Different societies have different standards in evaluating a moral judgment (that an act is right or wrong), and these standards may be true for one society but false for another society. Because the truth of moral standards between societies cannot be rationally debated, moral judgments cannot be absolutely true for all people. All prior theories that have been discussed in this section would be considered moral objectivist theories, as a right answer can be discerned based on certain principles.
- How would you describe, in your own words, the difference between consequentialism and deontology?
- What potential objections can be raised against moral relativism? Against natural law theory?
- In a recent article, Emanuel et al. argue that, in a situation of scarce resources, such as a limited number of ventilators during the COVID-19 pandemic, the limited resources should be allocated first to healthcare workers and other workers who maintain and operate critical infrastructure (see “Recommendation 2”). Which ethical framework(s) do they use in arriving at this recommendation?
The four basic principles outlined by Beauchamp and Childress in Principles of Biomedical Ethics provide the foundation for modern American biomedical ethics. These principles are:
1) respect for autonomy 2) justice 3) beneficence 4) nonmaleficence.
These principles provide a practical but reductionist framework to approach biomedical ethics and draw on elements of each of the above schools of ethics. For example, deontologists could argue that the morality of an act in medicine could be based on how that act conforms to these principles, rather than on the result of the act. Consequentialists could instead argue that these principles are heuristic ways to have the best likelihood of maximizing the good effects of an act.
Each of these four principles are considered and may be weighed against one another in the process of ethical decision-making in a given scenario.
- Respect for Autonomy: The principle of respect for autonomy originated in the Belmont Report - which summarized ethical principles for research involving human subjects - as “respect for persons.” Under this principle, patients must be given the opportunity to think, decide, and act independently and without coercion. One key way that this principle is seen in everyday medical practice is through the process of informed consent, in which patients must be informed of the relevant information and given the opportunity to evaluate, consider, and agree to a treatment modality prior to initiating a treatment.
- Justice: The principle of justice is founded upon the idea of fairness. As such, the concept of equality - that all should be treated the same - plays an important role in justice. However, equality can also lead to unfairness because giving the same thing to those who are already better off may not promote justice. Some have argued that justice should actually be based on equity, which is the idea of providing a good un-equally between those who are better and worse off so that there is greater equality in the end. In medicine, the principle of justice has been used to argue that the burdens and benefits of advances in medical treatment and technology should be distributed fairly across all groups of people. Key areas of medical ethics in which justice is often considered are: fair distribution of scarce resources, balancing competing needs, and fulfilling obligations to different communities.
- Beneficence: The principle of beneficence describes the duty to do good for patients. It requires that all interactions, treatments, and decisions have the goal of increasing the well-being of the patient involved. This principle asks that providers develop and maintain their knowledge and skillsets, consider the individual circumstances of their patients, and strive for net benefit. It requires providers to take active steps to help their patients, as opposed to merely avoiding harm. Typically, when patient autonomy is compromised (e.g., incapacity), beneficence is the guiding ethic for decision-making on behalf of the patient’s best interests.
- Nonmaleficence: This requires that providers do not inflict harm on other persons, and that harm is to be avoided or minimized in pursuit of the greater good. This principle is the underlying tenet of the Hippocratic Oath (“Primum non nocere” - “First, do no harm”). Avoiding harm can sometimes be difficult because many beneficial therapies also have serious risks; the pertinent ethical issue is whether the benefits outweigh the burdens. In contrast to beneficence, the core of this principle is avoiding avoidable or unacceptable risks/harm. For instance, nonmaleficence describes avoiding unnecessary pain related to a surgery even if the benefits of having the surgery still outweigh the unnecessary pain (i.e., making sure to give good rather than minimal post-surgical pain control).
So far, we have discussed the rightness of acts, but these principles are also relevant to failures to act, as is illustrated by negligence and reasonable care - legal principles with ethical implications. Negligence is when an unintentional injury results from actions that were not intended to do harm. It requires that a provider have a duty, that he or she breach that duty, and that an injury results that was caused by the breach of duty. Reasonable care describes the degree of care that a reasonable person in a similar situation would use, and it depends on the standard of care for the procedure being performed.
- Negligence occurs in situations in which a duty to use reasonable care is owed to another person. An injury results from a failure to use reasonable care.
- Reasonable care may be determined by the applicable standards of care, by statute, or by previous judicial decisions known as precedents. If a duty is not performed with reasonable care, a physician may be held responsible.
- How can physicians and healthcare providers balance respect for the autonomy of patients while providing their own medical opinions/recommendations? For example, how can we balance a patient’s refusal to quarantine after a positive test for COVID-19 versus a public health requirement to quarantine?
- Should the fundamental principle of justice be based upon equality or equity? For example, should everyone with COVID-19 be given equal access to ventilators, no matter how sick, or should those who are sickest be favored?
- Beauchamp TL and Childress JF. Principles of biomedical ethics. Oxford University Press, USA, 2001.
- Miles SH. The Hippocratic Oath and the ethics of medicine. 2004. Oxford; New York: Oxford University Press.
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