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Ethical Issues in Modern Medicine

Abstract

This comprehensive anthology represents the key issues and problems in the ﬁeld of medical ethics through the most up-to-date readings and case studies available. Each of the book's six parts is prefaced with helpful introductions that raise important questions and skillfully contextualize the positions and main points of the articles that follow.

Scientific and technological developments have brought about a change in values and moral believes.

Is there some knowledge that we ought not try to seek?

The traditional definition of life as presence of respiration and heartbeat has been replaced by the notion of whole brain death… yet no non controversial philosophical rationale
with advent of curative, diagnostic and pallative prevcedures, the access to which is increasingy perceived as a matter of right. can pubic health carea fford this… when millions of people lack basic health insurance and decent preventive and primary care?
how our healthcare system might be reformed to provide universal access to a good package of "basic" services, without either bankrupting society or destroying the patient doctor relationship"

Artificial insemination… for some threat to welfare of children and to the institution of marriage. for others logical next step in reproductive rights,

The issues raised in the preceding section pose challenging factual, conceptual, and moral problems. People often have strong feelings about some of these issues (for example, abortion and euthanasia). On some issues, many of us do not know what to think (for example, IVF for older women, or using children born without a higher brain as sources of transplantable organs). The assumption in philosophical bioethics is that careful analysis can help us at least make progress on some of these issues, if not resolve all of them. However, some are skeptical about this assumption. They believe, for a variety of reasons, that ethical disputes are, in principle, unresolvable by rational means.

Princeton philosopher Gilbert Harman defines "moral nihilism" as "the doctrine that there are no moral facts, no moral truths, and no moral knowledge." Extreme nihilists think that nothing is right or wrong; that morality, like religion, is an illusion that should be abandoned. This implies that torturing, raping, and killing a young child is not wrong something few people could accept. More moderate nihilists do not recommend abandoning morality, but, rather, offer a theory about the meaning of moral terms that explains why there are no moral facts, truths, or knowledge.

The theory of moral language that is offered by moderate moral nihilists is known as "emotivism." Emotivists believe that moral utterances do not express facts, or tell us anything about how the world is. Rather, they express our feelings. Therefore, such statements are not-indeed, cannot be true or false, any more than "Go, Yankees!" is true or false. The statement "Abortion is wrong" does not say anything about abortion, but rather expresses someone's negative feelings about abortion.

Another form of moderate moral nihilism denies the possibility of moral truth independent of a particular culture. This view, known as "ethical relativism," says that morality is relative to the society one lives in and the way one was brought up. The rightness or wrongness of an action or practice cannot be determined apart from the cultural or social context in which it occurs.

Support for ethical relativism comes from three sources.

First, it stems from an observation that different cultures have different moral beliefs and practices. However, simply noting moral differences in various cultures does not establish ethical relativism. Ethical relativism goes beyond noting that cultures differ in their moral beliefs and practices;
There are plenty of heated disagreements among scientists. However, scientists agree (in principle) about what kinds of evidence would settle a dispute. There is no such agreement in ethics. In other words, we do not have a decision procedure for resolving ethical disputes. This is the second source of support for ethical relativism.
The third reason for relativism is quite different. It offers a moral reason for adopting relativism: namely, that relativism promotes tolerance toward people who hold moral beliefs different from one's own. This apparently was the motivation of nineteenth-century anthropologists who wished to prevent Western imperialists from imposing their culture on indigenous peoples.

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These terms also have considerable factual content, so that it is not "just a matter of opinion whether a practice is cruel, exploitative, or unjust.

According to relativism, right and wrong are always relative to culture. What a culture (or the majority of a culture) thinks is right is rightfor them. However, a moral reformer challenges the conventional beliefs of his or her own culture.

Relativism simply cannot make sense of the claims of moral reformers. Since we do understand the claims of moral reformers, and at least sometimes are influenced by them, it seems that relativism cannot be true.

At the same time, relativism has two things to recommend it, which we believe can be incorporated into a nonrelativist approach. First, the relativist is right to point out that morality occurs in a cultural context. Before presuming to judge another culture's practices and beliefs, we would do well to try to understand them "from the inside." We may still decide ultimately that a practice is wrong, but we are not entitled to make this judgment without understanding the practice in context. Second, relativism encourages multiple perspectives on and solutions to moral problems. Both of these insights are present in "multiculturalism."

Multiculturalism requires an open mind toward the customs and beliefs of other cultures, but such open-mindedness need not, and should not, be uncritical. It is entirely consistent with a conception of morality as amenable to rational considerations, and the conviction that there can be better or worse moral justifications.

How are we to assess moral reasons and arguments? Intuitively, most of us can probably recognize good-or especially bad-moral reasoning, but in complicated situations we are often left wondering whether a consideration is pertinent. Is assisted suicide wrong because it helps someone to kill himself or herself, and killing is wrong? Or is it right because it helps someone do what he or she reasonably wants to do, and thus promotes autonomy? To answer questions of this sort, we need "a framework within which agents can reflect on the acceptability of actions and can evaluate moral judgments and moral character." Such a framework is known as an "ethical theory."

Traditionally, ethical theories tend to be reduc tionist; that is, they offer one idea as the key to morality, and attempt to reduce everything to that one idea. For example, classical utilitarians maintain that right actions are those that promote the greatest happiness of the greatest number, while Kantians tell us that right actions are those that can be consistently willed universally. Each theory claims to have discovered the single, overarching standard of morality or right action.

In recent years, a number of philosophers have come to doubt that any normative theory can plausibly claim to be the correct theory. It may be that moral reality is sufficiently complex that any one theory gives only partial insight.

We conclude that it is a mistake to view the various theoretical alternatives as mutually exclusive claims to moral truth. Instead, we should view them as important but partial contributions to a comprehensive, although necessarily fragmented, moral vision.

Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873) are generally credited with developing the first detailed and systematic formulation of the ethical theory known as "utilitarianism." The heart of utilitarianism is "the greatest happiness principle," which, as Mill puts it, "holds that actions are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse of happiness." The greatest happiness principle is also known as the principle of utility. The utility of an action is determined by its tendency to produce

The first thing to note about utilitarianism is that it is a "consequentialist" theory. That is, it judges the rightness and wrongness of an action by its consequences, or what will happen if the action is or is not performed. Second, utilitarianism's theory of value says that good consequences are those that produce or promote happiness or pleasure, bad consequences those that produce or promote the reverse. As we will see, both consequentialism and utilitarianism's theory of value have lately come under attack.

utilitarianism is a form of consequentialism, and thus it holds that the results of actions are the only relevant feature in assessing actions. Considerations of an agent's intentions, feelings, or convictions are seen as irrelevant to the question,

Another important feature of utilitarianism is its impartiality. The utilitarian does not say, "The goodness of an action is determined by the amount****of happiness it produces for me." Rather, the good is determined by the overall net happiness achieved. The utilitarian considers his or her own happiness, but no more and no less than the happiness of others. In weighing the effects of an action, utilitarianism maintains that we must take into consideration all of the parties concerned and that all parties shall be given equal consideration. Thus, utilitarianism is committed to the value of equality.

To summarize the advantages of utilitarianism, first, it reduces vagueness by providing a single criterion of right action: namely, the promotion of human happiness. Moreover, happiness, whether understood as pleasure or as preference satisfaction, is something that can be empirically measured. Utilitarianism thus provides an objective standard

for judging whether an action is right or wrong, and a method for resolving moral disputes. Finally, and more importantly, the principle of utility is derived from the very point of morality, which is to improve the lot of human beings living together. Morality does not relate to the satisfaction of some abstract or arbitrary code; rather, it relates to the improvement of the human condition, which means alleviating suffering and increasing happiness**

In addition, the focus on human happiness seemed to conflict with Christian teachings; for example, those teachings espousing the value of suffering.

One objection is to utilitarianism's theory of value: namely, the claim that happiness is the greatest good, the ultimate end. Critics have maintained that this theory leaves out many other "goods," such as health, friendship, creativity, intellectual attainment, and so forth. Mill agreed that these things are all valuable, but argued that they are valuable because they contribute to a happy life, one as rich as possible in enjoyment and as free as possible from pain. However, it remains questionable whether all values are commensurable; that is, whether all values can be reduced to happiness, however happiness is interpreted. And even if it were possible to reduce the plurality of values to a single value, happiness, is it possible to compare and weigh the happiness of one person against that of another?

What if an action will make one person intensely happy but leave several people somewhat depressed? Exactly how are we to arrive at the right utilitarian solution? Moreover, some people feel things more intensely than others. Should we pay attention to the strength of desires? On the one hand, it seems that we should, since the intensity of an individual's happiness or unhappiness affects the total amount, and utilitarianism tells us to maximize happiness. On the other hand, this gives an advantage to the passionate over the phlegmatic that seems to violate Bentham's dictum that everyone counts for one, nobody for more than one.

A second objection to utilitarianism is that it requires us to calculate the probable consequences of every action, and this task is impossible. The sheer calculations alone would prevent anyone from doing anything. In response, it should be noted that both Bentham and Mill thought of utilitarianism primarily as a guide to legislative policy, rather than as a guide to individual behavior.

Being utilitarians in our private lives does not mean that we must calculate all the consequences of every act, which would be impossible. Instead, we can rely on what Mill calls secondary principles, like "Don't lie," and "Don't harm others." We know from centuries of experience that adherence to these secondary principles promotes the greatest happiness for all, while departure from them causes insecurity and misery.

A more recent criticism of utilitarianism (or consequentialism generally) concerns the**
**theory of responsibility it implies. For nonconsequentialists, it can be very significant whether an outcome occurs because of something I did, whereas for consequentialists all that matters ultimately is what happens. This has led some consequentialists to reject a time-honored distinction in medicine, the distinction between killing and "letting die." Many doctors believe that it is permissible for them to stop treatment when death is desirable; for example, in the case of a terminally ill patient in a great deal of pain who wants to die. However, they think

it would be wrong (as well as illegal) actively to kill a patient in that same situation. Utilitarians, by contrast, are likely to regard killing and letting die as morally equivalent, since the outcome-a desirable death is achieved in both cases (see Part 3, Section 6).

A final major criticism of utilitarianism is that it is inadequate as a moral theory because it conflicts with some of our most basic moral intuitions.**

Suppose we could greatly increase human happiness and diminish misery by occasionally, and perhaps secretly, abducting derelicts from city streets for use in fatal but urgent medical experiments. If utilitarian considerations were decisive, this practice might well be justifiable, even desirable. Yet it is surely wrong. Such a case suggests that we cannot always explain good and bad simply in terms of increasing or decreasing overall happiness.*

However, they maintain that the fact that this practice would con flict with many people's deeply held moral convictions is not a worthwhile criticism of utilitarianism. Many utilitarians are quite skeptical of "deeply held moral convictions," which they regard as often no more than irrational superstitions.

Rule-Utilitarianism versus Act-Utilitarianism

Mill left unresolved the question whether the greatest happiness principle is to be applied to specific acts or to general kinds of acts. It has been suggested that if we apply the principle to kinds of acts, we can avoid some of the criticisms of utilitarianism. The version of utilitarianism that is primarily concerned with the consequences of specific acts has become known as "act-utilitarianism," while the version primarily concerned with the consequences of general policies is called "rule-utilitarianism."

Act-utilitarianism tells us to apply the principle of utility directly to the particular act in question.**

An act-utilitarian would seek to determine which alternative in this particular case would maximize happiness and/or minimize suffering

By contrast, rule-utilitarianism uses the principle of utility not to decide which acts to perform or avoid, but rather to formulate and justify moral rules. The correct moral rules are those that

promote the greatest happiness of the greatest number. Faced with a decision about how to act, ruleutilitarianism tells us that we are not to appeal. directly to the principle of utility. Rather, we are to consider whether this action falls under a rule that is justified by the principle of utility.**

Rules are regarded differently by rule-utilitarians. Rules are not just devices to help us figure out what will maximize happiness in a particular case. The rules themselves are justified on the grounds that having these particular rules maximizes happiness. But once we decide what the best rules are (that is, which ones are most likely to maximize happiness over the long run), then those are the rules we should follow, even if following them in a particular situation doesn't maximize happiness.

Thus, the rule-utilitarian can apparently avoid the sorts of situations that make act-utilitarianism unsatisfactory to many. In brief, the rule-utilitarian agrees with the act-utilitarian that the value of just practices resides in their tendency to promote happiness; but he will not agree that it is permissible to perform an unjust act in order to maximize happiness.**

Is Rule-Utilitarianism an Improvement over ActUtilitarianism? Act-utilitarians make this criticism of rule-utilitarianism: It makes no sense for a utilitarian to insist that a rule that will have less than optimal consequences should be followed simply. because the rule maximizes happiness in general.

It would not be rational from the standpoint of utility to refuse to break a moral rule when by doing so you could maximize welfare. For this reason, Smart calls rule-utilitarianism "superstitious rule worship."9

But now it seems that whatever would lead the act-utilitarian to break the rule would lead the rule-utilitarian to modify the rule. Thus, the two versions give exactly the same advice; they are "extensionally equivalent," so rule-utilitarianism cannot be an improvement over act-utilitarianism.

A related objection to rule-utilitarianism is that it collapses into act-utilitarianism. For whenever an act-utilitarian would say it was right to break a moral rule, it seems that the rule-utilitarian would generally agree, but instead say that the rule should be modified.