Chapter 1: Moral Reasoning in Ethics

Introduction
- Morality: concerns beliefs regarding morally right and wrong actions and morally good
and bad persons or character; it is about peoples’ moral judgments, principles, rules,
standards, and theories–all of which help direct conduct, mark out moral practices and
provide the yardsticks for measuring moral worth
Ethics and Bioethics
- Ethics is the study of morality using the tools and methods of philosophy and is also
known as moral philosophy. Ethics seeks to know whether an action is right or wrong,
what moral standards should guide our conduct, whether moral principles can be
justified, what moral virtues are worth cultivating and why, what ultimate ends people
should pursue in life, whether there are good reasons for accepting a particular moral
theory and what the meaning is of such notions as right, wrong, good, and bad.
- Science offers another way to study morality -> Descriptive ethics which is the study of
morality using the methodology of science. Its purpose is to investigate the empirical
facts of morality–the actual beliefs, behaviors, and practices that constitute people’s
moral experience.
- Ethics has three main branches
● Normative ethics: is the search for, and justification of, moral standards or norms;
the standards are moral principles, rules, virtues and theories and the aim of this
branch is to establish rationally some/all of these as proper guides for
actions/judgments
● Metaethics: is the study of the meaning and justification of basic moral beliefs. In
normative ethics we may ask whether an action is right or whether a person is
good, but in metaethics we would ask what it means for an action to be right.
● Applied Ethics:The use of moral norms and concepts to resolve practical moral
issues; employing moral principles, theories, arguments or analyses to try to
answer moral questions that confront people every day.
➔ Bioethics: applied ethics focused on health care, medical science and
medical technology .
Ethics and the Moral Life
- Morality is normative because it concerns moral norms/standards that help us decide the
rightness of actions, judge the goodness of persons/character and prescribe the form of
moral conduct. The following are some features of moral norms:
● Normative dominance: Moral norms are presumed to dominate other norms
● Universality: Moral norms have universality because moral principles or
judgments apply in all relevantly similar situations.
 ● Impartiality: An implicit notion in moral norms suggesting that everyone should
be considered equal & everyone should be treated the same unless there is a
morally relevant difference between persons.
● Reasonableness: To participate in morality - to engage in the practices of moral
life is to do moral reasoning; for our moral judgements to have weight they must
be backed by the best of reasons; note that our feelings are part of our moral
experiences but reasoning can help restrain the potential impulses of our feelings
- We apply moral norms to moral obligations: our duties, what we are obligated to do
(conduct, actions, moral principles to guide our actions) and moral values: concern those
things we judge to be morally good, bad, praiseworthy or blameworthy.
- We can also attribute nonmoral value to things (vacations) since such things themselves
cannot have moral value
- Only actions are morally right/wrong but persons are morally good or bad (ex: a good
person can do something wrong and a bad person can do something right). Also we may
judge actions differently based on the motives behind them
- Right can mean either bolgiatory or permissible. Wrong means prohibited.
- A supererogatory action is one that is above and beyond our duty; it is praiseworthy but
not required
Moral principles in bioethics
- The methods of moral philosophy include critical reasoning, logical argument, and
conceptual analysis.
- There is a distinction between absolute and prima facie principles or duties: An absolute
principle applies without exceptions whereas a prima facie principle applies in all cases
unless an exception is warranted
- The moral principles are: autonomy, nonmaleficence, beneficence, utility and justice
● Autonomy: refers to a person's rotational capacity for self governance or self
determination; individuals must be treated with respect (not violating their
autonomy); decisions cannot be considered entirely autonomous unless they are
fully informed; respect for autonomy is prima facie because an individual's
autonomy may be restricted to prevent harm to others
➔ Paternalism is a principle of autonomy restriction and refers to the
overriding of a person's actions/decision-making for their own good; there
is weak paternalism which is permissible to many and strong paternalism
which is morally objectionable
● Nonmaleficence: This principle asks us not to intentionally or unintentionally
inflict harm on others and is expressed as “above all, do no harm”. Implicit in this
principle is the concept of “due care” since health professionals cannot be
expected to never harm anyone they have to act in due care to minimize harm
● Beneficence: This principle suggests we should do good to others and actively
promote the well being of others and prevent/remove harm to them.
 ● Utility: This principle suggests we should produce the most favorable balance of
good over bad; do what yields the best outcome–the maximum good, and
minimum bad
● Justice: refers to people getting what is fair/what is their due
➔ Retributive justice: concerns the fair meting out of punishment for
wrongdoing..some argue justice is served only when people are punished
for past wrongdoings
➔ Distributive justice: concerns the fair distribution of society’s advantages
and disadvantages (jobs, health care etc); equals should be treated equally
➔ Libertarian theories: emphasized personal freedom, free market ideology,
small government, anti-distributive justice because that violates people's
liberty by taking the resources from the haves to give to the have nots
➔ Egalitarian theories: maintains that a just distribution is an equal
distribution; jobs, food, healthcare should be equally distributed
Ethical Relativism
- The commonsense view of morality and moral standards is that there are moral
norms/principles that are valid or true for everyone, also known as moral objectivism
- Moral objectivism differs from Moral absolutism: the belief that objective moral
principles allow no exceptions/must be applied the same way in all cases & cultures
- Moral objectivism is challenged by ethical relativism which states moral standards are
not objective but relative to what individuals or cultures believe. Therefore there are no
objective moral truths, only relative ones and an action is morally right if endorsed by a
person/culture and morally wrong if condemned by a person/culture.
- Ethical relativism pertaining to individuals is subjective relativism and ethical
relativism regarding cultures is called cultural relativism.
- Subjective relativism implies moral infallibility because it suggests that action can be
morally right for someone if they approve of it (for ex: murder) and if they sincerely
believe their action to be right, their belief approval makes the action right. This contrasts
our commonsense moral experience. Also subjective relativism implies moral
disagreement is an illusion because disagreements cannot occur between 2 people since
each individual has their own personal belief on issues; therefore there is no conflict
- Cultural relativism also implies moral infallibility suggesting that if a culture genuinely
approves of an action then there can be no question about the action’s moral rightness.
- Cultural relativism also implies we cannot legitimately criticize other cultures because if
a culture approves of their actions then those actions are right and other people's
disapproval is irrelevant. There is no objective moral code rather each society makes its
own. Cultural relativism also implies there cannot be moral progress because to imply
moral progress has occurred over time means there must be a moral objective.
 - It is difficult to rely on cultural relativism to form moral decisions because one has to
determine which culture/society they truly belong to and that is difficult because we
belong to many.
- Some people overlook the problems of cultural relativism because they believe it
promotes cultural intolerance but cultural relativism can easily justify cultural
tolerance/intolerance therefore it does not necessarily lead to tolerance or entail it
Ethics and Religion
- Religion has always had moral content mostly in the form of moral precepts, codes or
commandments to guide the conduct of adherents
- The divine command theory says that right actions are those commanded by God, and
wrong actions are those forgiven by God. God is the author of the moral law, making
right and wrong by his people
- For some this theory is problematic and they ask: are actions morally right because God
commands them or does God command them because they are morally right? Some
believe that if actions are morally right just because God commands them to be so, then it
is possible that any actions are morally right; defenders of the divine command theory
state that God would never command anything evil because God is all-good.
- There are good reasons for religious believers to know how to use the critical tools that
ethics offers:
1. Since religious moral codes are often vague, there needs to be interpretation of
codes and this involves consideration of broader norms or theories
2. Believers must deal with moral conflicts and what is often needed is a neutral
standard and critical analyses to arrive at a resolution
3. Public debate on ethical issues in a diverse society requires ground
rules–positions must be explained and reasons must be given in their support and
unexplained assertions are likely to be ignored
Moral Arguments
- Critical reasoning in ethics is called moral reasoning and it employs general principles of
logic and evidence to assess the truth of a statement or the merits of a logical argument
- Argument Fundamentals:
● Argument denotes not an altercation but a patterned set of assertions where one
statement provides support for another statement/gives reasons to believe a claim.
The supporting statements are premises, the supported statement is the conclusion
● Statement (or claim) is an assertion that something is or is not the case and is
therefore the kind of utterance that is either true or false
● Arguments are formulated to show that a claim (conclusion) should be believed;
in its basic structure it has a conclusion supported by at least one premise.
● A good argument is one that gives us good reasons for believing a claim and must
have (1) solid logic: the argument has a proper logical connection between
supporting statements and the statement supported and (2) true premises: what the
 premises state assert must in fact be the case. An argument that fails in either
respect is a bad argument.
● Two kinds of basic arguments are (1) deductive: intended to give logically
conclusive support to their conclusions so that if the premises are true, the
conclusion must absolutely be true (2) and inductive: supposed to give probable
support to their conclusions and are not designed to support their conclusions
decisively–if their premises are true their conclusions are probably true
● Validity for deductive arguments or lack thereof is a separate issue from the truth
of their premises.
● Inductive arguments can have true premises and a false conclusion. If inductive
arguments succeed in lending very probable support to their conclusions, they are
strong and a good argument– cogent (if premises are true then conclusion is
probably true) but if they fail to provide probable support, they are termed weak.
● Conditional statements have two parts: if (antecedent) and then (consequent)
● Modus ponens: valid argument form where the consequent affirms the antecedent
● Modus tollens: valid argument form which denies the consequent
● Invalid argument forms: affirming the consequent or denying the antecedent
- Patterns of Moral Arguments:
● Moral argument: an argument whose conclusion is a moral statement, an assertion
that action is right/wrong or that a person or motive is good or bad.
● If we want to argue that an action is wrong, we must provide a reason for this
moral judgment and the natural/logical move is to reach for a general moral
principle that supports the judgment
● In a moral argument we must have at least one moral premise to draw a
conclusion about the morality of a particular state of affairs and to arrive at a
moral conclusion. We also need a non moral premise for reasoning.
- Evaluating Premises:
● Good arguments have true premises; there are tests to evaluate the truth of
premises–non moral and moral
● Checking the truth of non moral premises can involve the exploration of either
empirical/conceptual matters. An empirical belief/claim is one that can be
confirmed by observation or scientific investigation.
● Evaluating a moral premise can be done through moral principles, theories or our
most reliable moral judgments. Moral judgements are those we deem plausible
after careful reflection that is unbiased as possible. Moral premises can also be
called into question by showing they conflict with credible principles, theories or
judgments
- Assessing Whole Arguments:
● (1) Study the text until you thoroughly understand it. (2) Find the conclusion.
(3) Identify the premises
Obstacles to Critical Reasoning
- Evidence: something that makes a statement more likely to be true
- Denying Contrary Evidence:
● Denying/ignoring evidence that contradicts our beliefs. This can be in the form of
applying more scrutiny than usual to evidence that contradicts our beliefs, seeking
out additional information that confirms our beliefs, or finding a way to interpret
the data so it does not conflict with our expectations.
● It is therefore important to make an effort to look for opposing evidence
- Looking for Confirming Evidence:
● This phenomenon is known as confirmation bias: when we go out of our way to
find only confirming evidence, we can end up accepting an untrue claim and find
ungenuine information.
● Confirmation bias makes false statements seem true and irrefutable. Therefore it
is important that when evaluating claims, we look for disconfirming and
confirming evidence.
- Motivated Reasoning:
● Refers to reasoning for the purpose of supporting a predetermined conclusion, not
to uncover the truth. It is confirmation bias in overdrive, a way of piling evidence
that agrees with our preferred conclusion and of downplaying evidence that
supports the contrary view.
● It is important to be skeptical of all sources (esp. those that support your beliefs),
be wary of your assessments of the credibility of sources that contradict your
beliefs, give opposing views a chance, break out of the filter bubble
- Preferring Available evidence
● The availability error is when we rely on evidence not because it's trustworthy but
because it’s memorable or striking–that is psychologically available. For ex:
believing air travel is more dangerous than driving because of a few vivid media
reports of tragic plane crashes.
- The Dunning-Kruger Effect
● Refers to the phenomenon of being ignorant of how ignorant we are. For ex: when
the least informed person in a discussion decides to educate everyone else on the
topic by presuming to correct peoples misconceptions without doubting for a
minute their own understanding while spewing misinformation.
Chapter 2: Bioethics and Moral Theories (pp.38-57)

The Nature of Moral Theories:

- Moral theories: explain not why one event causes another but why an action is
right/wrong or why a person or a person's character is good or bad. It tells us what it is
about an action that makes it right or what it is about a person that makes them good.
- Moral theories that concentrate on right and wrong actions are theories of obligation
(duty) and are simply known as theories of right action.
- Theories that focus on good and bad persons or character are known as virtue-based
ethics
- Moral theories can fit into moral arguments; in particular, moral premises can contain
moral principles, moral rules or moral theories. Also, principles used in moral arguments
are often supported by moral theories.
- It is important that our considered judgements and theories are consistent in order to
assure the decision we make is correct. If not, we must decide which to revise or discard
(we rarely regard the theory as irreparable bc we will revise it or discard the judgment)
Influential Moral Theories
- Theories of right action are more predominant than virtue-based theories and are based
on one of two broad views about the essential character of right actions:
● Consequentialist: moral theories that insist the rightness of actions depends solely
on their consequences or results. The key question is what or how much good the
actions produce, however good is defined.
● Deontological (non-consequentialist): theories that say the rightness of actions is
determined not solely by their consequences but partly or entirely by their
intrinsic nature. For some or all actions, the rightness depends on the kind of
actions they are, not on how much they produce.
- Utilitarianism: the leading consequentialist theory; it holds the view that right actions
are those that result in the most beneficial balance of good over bad consequences for
everyone involved.
● Different forms of utilitarianism define utility differently, with some equating it to
happiness/pleasure (hedonistic view), and others equating it to the satisfaction of
preference or desires or other intrinsically valuable things/states like
knowledge/perfection.
● Act-utilitarianism is the idea that the rightness of actions depend solely on the
relative good produced by individual actions; an act is right if in a particular
situation it produces a greater balance of good over bad than any alternative acts
(determining rightness requires weighing the effects of each possible act)
● Rule utilitarianism avoids judging rightness by specific acts and focuses on rules
governing categories of acts; it states a right action is one that conforms to a rule
that, if followed consistently, would create for everyone involved the most
 beneficial balance of good over bad–rules are adhered to bc they maximize the
good for all, even though a given act may produce bad effects in some situations.
● Classic utilitarianism is hedonistic because the utility to be maximized is pleasure
(happiness), the only intrinsic good–a right action produces more net happiness.
Classic utilitarianism demands impartiality and the consideration of not only the
happiness of everyone affected but also the equal consideration of everyone's
needs or interests
● In classic utilitarianism, the emphasis is on maximizing the total quantity of net
happiness irrespective of the way it is rationed among individuals (the greatest
happiness for the greatest number)
- Kantian Ethics: Opposes utilitarianism and states that right actions do not depend in the
least on consequences, the maximization of utility or the production of happiness but
rather, the core of morality consists of following a rational & universally applicable
moral rule and doing so solely out of a sense of duty
● All moral duties, according to Kant, are expressed as categorical imperatives: an
imperative that applies without exception and without regard for a particular
need/purpose (“do this–regardless”).
● Hypothetical imperatives are a command to do something if we want to achieve
particular aims
● Through reason & reflection, we can derive our duties from the categorical
imperative and we should act only on that maxim through which you can at the
same time will that it should become a universal law. Our actions have logical
implications (they imply general rules or maxims of conduct). An action is
morally permissible if everyone could consistently act on the maxim and we
would be willing to have them do so. This would uphold two characteristics
essential to morality: universality and impartiality.
● Kant argues there is a moral prohibition against killing the innocent, lying,
committing suicide & failing to help others when feasible
● A renowned formulation of the categorical imperative is the principle of respect
for persons: people must never be treated as if they were mere instruments to
achieve some further end, for people are ends in themselves (worthy). This
worth is derived from peoples' natures as free rational beings capable of directing
their own lives and determining their own ends regardless of their social status.
So, treating people as merely a means to end disregards these characteristics.
● People can be treated as a means if their actions are freely chosen and their status
is not undermined. The issue arises when we treat them simply or merely as
means.
- Principlism: A series of prima facie principles that include: respect autonomy, promote
happiness (beneficence), refrain from harming others (nonmaleficence), and distribute
benefits and burdens fairly (justice).
 ● It is a response to the absolute moral theories of utilitarianism and kantian ethics,
both of which are based on a single absolute moral standard that allows no
exceptions and therefore simplifies ethics by excluding the other moral principles
that are essential to moral deliberation and by not allowing resolutions when there
are conflicts between to or more absolute principles.
● As such, prima facie principles provide a solution because it allows an individual
to determine which principle is weightier in a situation. The two principles would
represent the apparent duties but the weightier becomes the actual duty. This is
helpful because sometimes duties do conflict because others are weightier and
that occasionally doing the right thing means violating a principle.
● Critics of principlism argue that it lacks a stable formula/procedure for assigning
weights to principles to see which is strongest.
- Natural Law Theory: the view that right actions are those that conform to moral
standards discerned in nature through human reason. Guided by the belief that all of
nature is somehow directed towards a particular goal or ends and that humans achieve
their highest good when they follow their true natural inclinations leading to those
goals/ends.
● Implicit in this theory is the element of rationality and the notion that humans are
rational beings and reason enables humans to ascertain the moral law implicit in
nature and apply that objective, universal standard to their lives.
● Natural Law has both religious & non-religious forms; the religious form by
Thomas Aquinas is the theory’s dominant version and states God is the author of
the natural law who gave humans the gift of reason to discern the law for
themselves & live accordingly. Humans have a tendency towards the “good.”
● Natural Law does not provide a relevant moral rule in every case, instead, it offers
guidance through moral principles which may be universal and absolute.
● Natural Law theory posits absolute duties, the opposite of prima facie duties. So,
to resolve dilemmas when moral principles/rules conflict, it uses the doctrine of
double effect: it is always wrong to intentionally perform a bad action to produce
a good effect, but doing a good action that results in a bad effect may be
permissible if the bad effect is not intended although foreseen. This can be seen in
the 4 tests that an action must pass to be judged morally permissible
1. The action itself must be morally permissible
2. Causing a bad effect must not be used to obtain a good effect
3. Whatever the outcome of an action, the intention must be to cause only a
good effect
4. The bad effect of an action must not be greater in importance than the
good effect.
- Rawls Contract Theory: contractarianism refers to moral theories based on the idea of a
social contract, or agreement, among individuals for mutual advantage. John Rawls uses
 the notion of a social contract to generate & defend moral principles governing how
members of a society should treat one another; he asks by what principles should a just
society structure itself to ensure a fair distribution of rights, duties & advantages of social
cooperation.
● The required principles—principles of justice—are those that people would agree
to under hypothetical conditions that ensure fair + unbiased choices..bc if the
starting point of the social contract is fair, then the principles will be just.
● The hypothetical starting point or the “original position” is where a group of
normal rational individual come together to choose the principles that will
determine their basic rights & duties and their share of society’s benefits &
burdens; however, to ensure the decisions are fair & impartial, they must be made
behind a veil of ignorance where social and economic status, race, sex, abilities
are unknown. This will allow participants to not agree to principles that put any
specific group at a disadvantage since they could be apart of that group (they
choose principles that are unbiased and nondiscriminatory)
● The participants would arrange social relationships according to these principles
1. Each person is to have an equal right to the most extensive total system of
basic liberties compatible with a similar system of liberty for all.
2. Social and economic inequalities are to be arranged so they are both (a) to
the greatest benefit of the least advantaged (b) attached to offices &
positions open to all under conditions of fair equality of opportunity.
● The first principle takes precedence over other principles, so basic liberties cannot
be reduced/cancelled to improve economic well-being.
● For the second principle, everyone is entitled to an equal chance to try to acquire
these basic goods, but no one is guaranteed an equal share.
● In any just distribution of benefits and burdens, the first priority is to ensure equal
basic liberties for all concerned, then equality of opportunity, then the
arrangement of any inequalities to the benefit of the least advantages.
- Virtue Ethics: focuses on the development of virtuous character. Character is viewed as
the key to moral life, for it is from a virtuous character that moral conduct & values arise.
● In virtue ethics, someone determines the right action not by consulting rules but
by asking what a truly virtuous person would do or whether an action would
accord with the relevant virtues. The highest goal of humanity is “human
flourishing.”
● Virtue ethics is goal-directed, not rule guided. The moral virtues of benevolence,
honesty, loyalty, compassion, and fairness are ideals we must strive to attain
● Possessing the right virtues means having the proper motivations that naturally
accompany those virtues; to act morally, we must act from virtue -> appropriate
motives
 ● Physicians and nurses are expected to possess virtues of compassion,
trustworthiness, justice and honesty
- The Ethics of Care: a distinctive moral perspective that arose out of feminist concerns
and grew to challenge core elements of most other moral theories. Other theories
emphasize abstract principles, general duties, individual rights, impartial judgements and
deliberative reasoning, but the ethics of care shifts the focus to the unique demands of
specific situations and the virtues & feelings central to close relationships
● Caring is an essential part of morality that most influential theories have not taken
fully into account; caring is an important virtue required in moral theories
● In many theories, the principle of impartiality is pushed too far; everyone cannot
be treated equally because we have special partiality to close friends, family and
those we care for that we do not have to strangers. Most moral theories also
emphasize duties and disregard emotions, attitudes and motivations (the ethics of
care considers these emotional elements)
● Morality should accommodate both an ethic of obligation and an ethic of care.
- Feminist Ethics: an approach to morality aimed at rethinking or revamping traditional
ethics to eliminate aspects that devalue or ignore women's moral experience. It targets the
following assumptions
1. Women’s moral concerns are not as important as men’s
2. Women are morally inferior to men (less mature or less rational)
3. The moral issues that arise from domestic or private life are inconsequential
4. The concepts or virtues traditionally associated with women in western cultures
(caring, interconnectedness, sharing, feeling) are not central to morality
● This form of ethics is defined by a distinctive focus on these issues rather than by
a set of doctrines/common ideology among feminists, many of whom disagree on
the nature of feminist ethics
● Feminist ethics downplays the role of moral principles of western ethics
(autonomy, utility etc) and insists that moral reflection must take into account
social realities–the relevant social practices, relationships, institutions, and power
arrangements. The traditional principles are too broad to help us make judgements
about specific persons embedded in social situations.
● Many theorists in feminist ethics also reject the traditional concept of the moral
agent, which is that abstract individuals are fundamentally autonomous agents
aware of their own preferences and values and motivated by rational self-interest.
- Casuistry: a method of moral reasoning that emphasizes cases and analogy rather than
moral judgements are supposed to be deduced. Casuists say reasonable moral judgments
are arrived at not by applying theories, rights, and rules but by paying careful attention to
specific cases and circumstances.
● In casuistry, judgements about new cases are made by analogy with similar or
paradigm cases, and in law, casuistry operates by consulting precedent
 ● Casuits point out that problems in moral reasoning are especially likely when
theories or principles are strictly applied without regard to the relevant details of
cases.
● Critics say that casuistry is dependent on rules/principles, just as moral theories
are. Also, they question the ability of casuistry to justify a moral decision of the
selection of a paradigm case since casuists hold that justification comes from a
society’s traditions, values/conventions but critics say a solid set of principles.
Standards would be necessary for to counteract the vagueness of these influences.
Criteria for Judging Moral Theories
- Moral theories are meant to explain what makes an action right or a person good, and to
try to determine which moral theory is most likely correct; we apply conceptual
yardsticks–the moral criteria of adequacy. Plausible theories must comply with the
following:
● Criterion 1 - consistency with our considered moral judgments: a moral theory
must be consistent with the data it is supposed to explain (our considered moral
judgment). Moral theories that are seriously inconsistent with our considered
judgments are regarded as badly flawed and in need of radical revision. Our
considered moral judgments may give us good reasons for altering or even
rejecting our moral theory, but if our theory is coherent and well-supported, it
may oblige us to rethink or reject our considered judgment. The goal is to achieve
“reflective equilibrium” where no further changes in theory or data are necessary.
● Criterion 2 - consistency with the facts of the moral life: moral theories should be
consistent with background knowledge–the moral background knowledge, the
basic, inescapable experiences of the moral life (experiences such as making
moral judgements, disagreeing with others on moral issues, being mistaken in our
moral beliefs and giving reasons for accepting moral beliefs). Any moral theory
that is inconsistent with these aspects of moral life is deeply problematic.
● Criterion 3 - resourcefulness in moral problem-solving: a resourceful moral theory
helps us solve moral problems, identify morally relevant aspects of conduct, judge
the rightness of actions, and resolve conflicts among moral principles and
judgment. Any moral theory that lacks problem-solving is neither useful nor
credible.
Chapter 3: Paternalism and Patient Autonomy (pp.97 - 106)

Shades of Autonomy and Paternalism

- Autonomy: person's rational capacity for self-governance/self-determination; it is a
fundamental standard in bioethics and can be violated only for good reasons and with
explicit justification
- In the name of autonomy, medicine has developed the doctrine of informed consent.
- Early medicine was strongly paternalistic because it was inspired by the Hippocratic
tradition. Nowadays, that has changed.
- Weak paternalism refers to persons who cannot act autonomously/whose autonomy is
greatly diminished (ex: psychotic, intellectually disabled, extremely depressed, addicted).
This form of paternalism is not viewed as a violation of autonomy because the patient is
already substantially non-autonomous to some extent, and its purpose is beneficence.
- Strong paternalism is overriding a person’s actions or choices, even though he is
substantially autonomous, and this is considered a violation of autonomy.
- Some people argue the benefits of paternalistic actions must be balanced against the
importance of respecting autonomy (actions that minimally restrict autonomy but produce
great benefits are justified, whereas the opposite would not be)
Refusing Treatment
- Until the late 1980’s, the right of competent patients (autonomous persons able to make
decisions about treatment options) was unsettled, and in some cases, patients were
thought to have no right to decline recommended treatments. Courts frequently overrule
the right to refuse treatments, but this was later reversed, shifting the weight to patient
autonomy over physician and nurse beneficence.
- Courts have stretched this right of competent patients to situations where they become
incompetent.
- In the case of children, the right of parents to refuse treatment based on religious grounds
remains tricky. Courts have argued that though parents may decide many matters on
behalf of their children, they do not have the right to bring serious harm to them.
Futile Treatment
- In some cases, the patient or patient's family wants a treatment that the physician
(typically from beneficent motives) does not want to provide. This leads to a moral
conflict between patient autonomy and the physician's view of what constitutes morally
acceptable care.
- Typically these cases concern whether to supply life sustaining treatment to the patient or
not (for ex, if the patient slips into a vegetative state, is it worth continuing prolonged
life-sustaining treatment)
- These physician-patient conflicts are confrontations about medical futility
 - Medical futility is the alleged pointlessness/ineffectiveness of administering particular
treatments. Physicians may claim treatment is futile therefore, it should not be used or
continued.
- Patients and physicians typically have different definitions of what constitutes futility.
The former may judge a treatment futile if it cannot achieve a specified physiological
benefit, whereas the latter may think a treatment is futile only if it cannot keep the body
alive.
- Futility is a question of values–what should be done in the circumstances
- In the war on acceptability of treatment, physicians appeal to the principle that:
physicians are not obligated to provide treatments that are inconsistent with reasonable
standards of medical practice.
- The sharpest clash in such a situation is between physicians and those who argue for the
sanctity of human life because, in that case, the moral imperative is to keep the body alive
at all costs, and the physician's claim is insignificant.

Applying Major Theories

- Utilitarianism can justify paternalistic actions in the case they promote the greatest good
for patients and minimize suffering, and maximize well-being.
- Act utilitarianism justifies paternalism in the case where a physician may judge that it is
morally permissible to lie to a patient about a beneficial treatment to overcome patient's
refusal to be treated.
- Rule utilitarianism, however would suggest that lying will produce more harm in the long
term because it would create distrust in the medical profession.
- Kantian ethics also rejects paternalism because the means-ends form of categorical
imperative insists on respect for the rights and autonomy of persons–respect that must not
be weakened by calculations of utility/paternalistic urges to act for a patient's own good.
Informed consent is also viewed as mandatory and misleading patients about treatment is
not permissible. These rules are necessary to avoid treating the patient simply as a means
and not an end.
- In cases of medical futility, Kantian ethics argues that if a physician believes a treatment
is pointless, then giving it would be unethical, and their withholding of the treatment is
permissible and forcing the physician to do what they think is wrong would violate their
autonomy.
- Natural law theory is more paternalistic than Kantian ethics, esp in cases of euthanasia.
- The doctrine of double effect would deny a terminally ill patient's request to have
medically assisted death. The Roman Catholic corollary to this is that a hopelessly ill
patient has the right to refuse extraordinary life-sustaining treatments–measures that
cause suffering/hardship but no medical benefit.