ETHICS and MORALITY

Ethics- is a generic term for various ways of

understanding and examining the moral life.

•Ethics derives from the Greek ethos,

meaning “disposition” or “trait.” Ethos
constituted part of the Greek phrase
ethike aretai (“skills of character”). The
Greek word arete connotes
“excellence,” “good,” and “skill.”
• Greek ethics were teleological: they
assumed that things developed
towards a natural goal. In Greek
medicine, if we want to know what
makes a good physician, we need to
know the goal of medicine. That goal is
to heal the sick. What virtues does this
goal require? Answer: compassion,
knowledge of healing, and skill in
human relations.
• In the views of Socrates, Plato and
Aristotle, these ethika aretai were
courage, temperance, wisdom and
justice (in human relations)- the
excellence necessary to function well
in human society. Today we know
these traits as the cardinal virtues.
• In the fourth century C.E., Christianity
added to the cardinal virtues its
theological virtues of faith, hope, and
charity, bringing the total to seven.
Christianity also added the Seven
Deadly Sins (sloth, lust, envy, greed,
wrath, gluttony, and the master vice,
pride).
• Good physicians always exhibit
compassion. Etymologically,
“compassion” means “to suffer
with,” as Christians believe that
Jesus suffered with, and for,
humans on the Cross.
• Morality- refers to norms about right
and wrong human conduct that are so
widely shared that they form a stable
social consensus.

– As a social institution, it
encompasses many standards
of conduct, including moral
principles, rules, rights and
virtues.
 NATURAL LAW
• Rules for human beings, according to
the Rome’s Stoic philosophers, were so
embedded in the texture of the world
that they were law for humans. These
laws came to be known as “natural
laws.”
• Aquinas there made explicit the
connection between God and the
natural laws: a rational God made the
world work rationally and gave humans
reason to discover these laws.
• These rules commanded humans to
resist their feelings. St. Augustine
taught in the fourth century CE that sin
contaminated human feelings and
therefore lust, sloth, avarice and pride
infected humans.
Natural law theory bequeathed to medical
ethics the famous doctrine of double effect.
This doctrine held that if an action had two
effects, one good and the other evil, the evil
effect was morally permitted: (1) if the action
was good in itself or not evil, (2) if the good
followed as immediately from the cause as
did the evil effect, (3) if only the good effect
was intended, and (4) if there was as
important a reason for performing the action
as for allowing the evil effect.
• This doctrine forbids physicians from
assisting in executions, since it forbids
an intention to assist in killings. On the
other hand, it allows increasing
dosages of morphine for terminal
patients, so long as the intention is to
relieve suffering, not to kill the patient.
The principle of totality- also derives from
natural law. It says that the human body may
be changed only to ensure the proper
functioning of that body. The underlying idea
is that one’s body is not something that one
owns, but that one holds in trust for God:
“The body is the temple of the Lord.” So a
gangrenous leg may be amputated or a
cancerous breast removed, because these
disease threaten the body’s overall health.
 KANTIAN ETHICS
Immanuel Kant (1724-1804) lived during
the Enlightenment, and believed in the
power of reason to solve human
problems.
 The distinctive elements of Kantian
Ethics are the following:
a) Ethics is not a matter of
consequences but of duty. Why an act
is done is more important than its
results. Specifically, an act must be
done from the right motive, and the
right motive is the desire to do one’s
duty. Indeed, there is only one correct
motive in Kantian ethics and that is
the desire to be a good person, to do
what is right, to have a “pure will”
b) A right act has a maxim that is
universalizable. An act is right if one
can will its maxim or rule to be acted
on by all others. “Lie to get out of
keeping a promise” cannot be so
willed because if everyone acted this
way, promise making would mean
nothing.
c) A right always treats other human as
“ends-in-themselves,” never as a “mere
means.” to treat another person as an
“end-in-himself” is to treat him as having
absolute, infinite moral worth, not relative
worth. His welfare cannot be sacrificed to
the good of others or to one’s own desires.
So patients cannot unwittingly be used as
guinea pigs in dangerous experiments to
advance medical knowledge.
d) People are only free when they act
rationally. Kant would agree that much of
how we act is governed by our emotions ,
as well as our biology and genes. But
controversially, Kant denies that we act
morally when we do the right things
because we are accustomed to it, because
it feels right, or because our society favors
the act. We only act morally when we
exercise our understanding about why
certain rules are right and then freely
choose to bind our actions to those rules.
Kant calls the capacity to act this way
autonomy. For him, it gives human higher
worth and dignity than animals.
UTILITARIANISM- originated in late 18th
and early 19th century England as a
secular replacement for Christian
ethics. Its essential idea is that right
acts produce the greatest amount of
good for the greatest number of beings,
which is called “utility.”
The four basic tenets of Utilitarianism:
1) Consequentialism- consequences count,
not motives or intentions
2) Maximization- the number of beings
affected by consequences matters; the
more beings affected, the more important
the result.
3) A theory of value (or of “good”)- good
consequences are defined by pleasure
(hedonic utilitarianism) or what people
prefer (preference utilitarianism) or by
some other good thing.
4) A scope-of-morality premise- each being’s
happiness is to count as one and no more,
and beings who count are to be made
explicit, whether these are only humans or
all sentient creatures.
 Contemporary Times:
Four Principles
1) Autonomy- refers to the right to make
decisions about one’s own life and body
without coercion by others. It honors the
value that democracies place on allowing
individuals to make their own decisions
about whom to marry, whether to have
children, how many children to have, what
kind of career to pursue, and what kind of
life they want to live. Insofar as is possible
and to the extent that their decisions do not
harm others, individuals should be left
alone to make fundamental medical
decisions that affect their own bodies and
lives.
1. ‘I am autonomous if I rule me, and no one else rules I’ (Joel
Feinberg, quoted in Dworkin 1988, p.5).

2. ’To regard himself as autonomous…a person must see himself as

sovereign in deciding what to believe and in weighing competing
reasons for action’ (Scanlon T, in Dworkin 1988, p.5).

3. ‘It is apparent that…”autonomy” is used in an exceedingly broad

fashion. It is sometimes used as an equivalent of liberty…,
sometimes as equivalent to self-rule or sovereignty, sometimes as
identical with freedom of the will…it is identified with qualities of
self-assertion, with critical reflection, with freedom from obligation,
with absence of external causation, with knowledge of one’s own
interests…It is related to actions, to beliefs, to reasons for acting, to
rules, to the will of other persons, to thoughts and to principles’
(Dworkin 1988, p.6).
 SOME ASPECTS OF AUTONOMY
1. To be autonomous one must make evaluations. The
ideal of the autonomous person is the person who forms
overarching desires for how her life is to go (life plans) and
can act on those desires (Young 1985). To create such a
life plan, we need to make evaluations about the kind of life
we should live, or that might be the best for us. Someone
who makes spur-of-the-moment, impulsive decisions
without a clear idea about what is important to them, or
what sort of life they wish to lead, would not be
autonomous according to this view.
 SOME ASPECTS OF AUTONOMY
2. Evaluations should be rational. If a desire or choice is
not based on a rational evaluation, then it is not
autonomous. There are three components of an
autonomous evaluation.

• It is based on a correct understanding of the relevant

facts.
• The facts are evaluated without making a relevant error
of logic.
• The person has been able to imagine what the relevant
states of affairs will be like, i.e. the likely states of affairs
for the various choice options.
 SOME ASPECTS OF AUTONOMY
3. Higher order desires should be respected. A person may
have conflicting desires. For example, Mohammed may
simultaneously desire to gamble and at the same time he
did not have the desire to gamble. The desire to gamble is
a ‘first-order’ desire, and the wish not to desire gambling is
a ‘second-order’ desire. Some (e.g. Dworkin 1988) have
argued that respecting autonomy implies respecting the
higher (second-order) desire, on the grounds that this
higher desire is the one that is part of the life plan.
IMPORTANCE:
1) Autonomy enhances a person’s personal
worth.

2) It protects a person from being used by

others.

3) In health care, it helps develop a mature

therapeutic alliance between health
professionals and patient.
ROLE OF HEALTH PROFESSIONAL
The health professional should help the patient
make his autonomous choice and act on it by:

1) Providing him with information necessary to

weigh risks and benefits.
2) Stating his own convictions and clearly
explaining the reason for this opinion.
3) Not exercising coercion, manipulation, undue
influence, or irrational persuasion.
4) Withdrawing from the case when the health
professional feels it is impossible to support
the patient.
 AUTONOMY
The principle of respect for autonomy directs
that a patient’s wishes should be honored,
including those regarding the nature and
extent of his or her health care. As long as
the patient’s wishes are reasonably
established, the court usually follows the
principle of autonomy when conflict occurs.
Furthermore, when autonomy is applied to
the right to die, a person who has not been
proven to be incompetent and who is
terminally ill has a right to end his or her life.
LIVING WILL

One document that expresses a patient’s wishes

is called “the living will”. It is written by the patient,
dated and witnessed, at the time he is competent. It
is given to his physician, family member or friend
and used as a guide when he is incompetent.

Example: “If such time the situation arises which

there is no reasonable expectation of my recovery
from the extreme mental and physical disability, I
direct that I be allowed to die and not be kept alive
by medications, artificial means or “heroic
measures”.

Such statements should have strong moral force

in making decisions on terminally ill care.
Disregarding them violate non-maleficence.
DO NOT RESUSCITATE ORDERS

To optimize care of the dying and to provide

consistency in procedures some hospitals have
specific “Do not Resuscitate” (DNR) orders which
guide hospital staff on when to and when not to
resuscitate dying patients. In formulating DNR
orders, the following guidelines are suggested:

1. Specify the exact nature of the treatment to

be withdrawn or withheld.
2. Document the exact justification for the
decision.
3. Recognize that the DNR order does not mean
that the patient may be medically, emotionally, or
spiritually abandoned.
4. Ensure that the patient’s condition is regularly
re-evaluated and the DNR order updated.
 AUTONOMY
In the case of Elizabeth Bouvia, she did not want
to die because she made dramatic demands of
public institutions, and pleaded for attention. In this
case, physicians must NOT accede to the wishes
of unstable patients. Only fools would assist every
distraught patient who comes to the ER wishing to
die. But if the physicians will ignore autonomy,
patients can be flogged to death with unnecessary
tubes, surgery, and radiation. The real issue is
whether a quality of life is acceptable to the person
who must endure it, and that is an evaluative
judgement that can be made only by that person.
INFORMED CONSENT

The principles of autonomy is practiced

through free and informed consent, a
necessary condition prior to any action
(diagnostic, therapeutic or research) that
would affect a person’s integrity.
In health care, informed consent is
defined as the willing and uncoerced
acceptance of a medical intervention by a
patient after adequate disclosure by the
health professional of the nature of the
intervention, its expected risks, and
benefits and alternatives available.