Moral Theories and Ethical Principles

Christopher O. Agulanna
MA (Lagos), MAE (Linkoping), MA (Utrecht), PhD (Ibadan)
Department of Philosophy, University of Ibadan Lecture delivered At a 2 Day Course in Medical Ethics Organized by West African College of Physicians 2nd 3rd June, 2011

By

What is ethics?
Ethics, otherwise known as moral philosophy derives from the Greek word ethikos, which means custom Ethics is the branch of philosophy that addresses questions about moralitythat is, concepts such as good and evil, right and wrong, virtue and vice, justice, etc.

What is ethics?
Ethics is the systematic study of morality The relationship between ethics and morality is similar to that between logic and thinking or that between theology and religion In each of the cases, the latter is the basis of the former

Aim
Ethics aims to achieve two fundamental objectives: (i) to tell us how we ought to act in a given situation, and (ii) to provide us with strong reasons for doing so

Ethics and morality

Ethics and morality are closely related: Morality refers to a set of duties that require us to subordinate our natural instincts in order to obey the moral law. A failure to fulfill our duty brings with it a heavy sense of guilt.

Very often, morality is assumed to have a religious basis an assumption that is not always correct.

Ethics and morality

Ever before we began studying ethics, we already have a sense of morality, with what it means to say of a thing that it is good or bad, right or wrong, etc. Ethics is the systematic study of the fundamental principles underlying our morality.

Ethics and morality

Just as logic is the systematic study of the fundamental principles of correct thinking, and theology is the systematic study of the fundamental tenets of religion, ethics is the systematic reflection on our moral values or beliefs

Definition of ethics
Ethics has been defined in various: It can be defined as the branch of philosophy which deals with the morality of human actions As the branch of philosophy which studies the norms of human behaviour The systematic study of the fundamental principles of the moral law The normative science of human conduct

Branches of ethics
Four major branches:
i. Normative ethics, also known as prescriptive ethics - This branch of ethics actually judges morality. Normative judgments are value judgments: they indicate whether something is good or bad.

Example: To proclaim that abortion is right or wrong; that advanced directive is good or bad; that euthanasia is morally good or bad, etc.

Branches of ethics
ii. Meta-ethics: This is the branch of ethics that concerns itself with the analysis or elucidation of ethical concepts or ideas, e.g., what do the terms good, bad, right, wrong, evil, moral obligation, etc, signify? How may we define a good action? Meta-ethics is also known as analytic moral philosophy

Branches of ethics
iii. Applied ethics: The attempt to apply ethical theory
to real life situations. The discipline has many specialized fields, such as Engineering Ethics, bioethics and business ethics.
It involves the investigation of specific questions that have elicited ethical controversies, such as end of life issues, in vitro fertilization, environmental degradation, world poverty, how to deal with conflicts arising from our multi-cultural world, etc.

Different senses
Ethics can be understood in two ways:
First, it refers to well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. The word ethics is sometimes used to refer to the set of rules, principles, or ways of thinking that guide, or claim authority to guide, the actions of a particular group; and sometimes it stands for the systematic study of reasoning about how we ought to act.

Ethical theories
Ethical theories and principles are the foundations of ethical analysis It is to them we turn to obtain guidance when seeking to make ethical decisions on any matter However, in order for an ethical theory to be useful, the theory must be directed towards a common set of goals Ethical principles are the common goals that each theory tries to achieve in order to be successful. These goals include beneficence, least harm, respect for autonomy and justice.

Ethical principles
A principle is a rule of a general nature An ethical or moral principle (dictionary meaning) is: 1. the principles of right and wrong that are accepted by an individual or a social group; 2. the principle that conduct should be moral Some moral principles are general, others particular

Ethical principles
General moral/ethical principles make some general statement about what is morally right or wrong, or good or bad, or what we should or ought, or shouldn't or ought not to Examples: Thou shalt not kill. You should not take what does not belong to you without permission of the owner. If you make a promise, you ought to keep it.

Moral judgments
Particular moral judgments Not all moral judgments are general principles. Some are about specifics.

Examples: John was wrong in aiding Foluke to abort her baby. Hitler was an evil person.

The role of general moral principles in moral argument General moral principles can serve as the major premise of a moral argument. For example, Killing is wrong. Capital punishment is killing. Therefore, capital punishment is wrong. The concern here is not whether the premises are true or acceptable but to highlight the role of the general moral principle in moral argumentation.

What ethics is not

Ethics is not a manual with answers on how to act. It is only a search for the right kind of morality. Ethics is not a matter of following ones feelings It is not to be identified with religion Being ethical is not the same as following the law Again, being ethical is not the same as doing "whatever society accepts"

Ethics a recapitulation
What, then, is it? It can mean any of the following: A well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. Ethics, for example, refers to those standards that impose the reasonable obligations to refrain from such vices as rape, stealing, murder, assault, slander, and fraud.

Ethical standards also include those that enjoin virtues of honesty, compassion, and loyalty. These include standards relating to rights, such as the right to life, the right to freedom from injury, and the right to privacy. Such standards are adequate standards of ethics because they are supported by consistent and well-founded reasons.

 Secondly, ethics refers to the study and development of one's ethical standards. Here, we should note that feelings, laws, and social norms can deviate from what is ethical. Hence, it is necessary that we constantly examine our standards to ensure that they are reasonable and well-founded.

Ethics - theory vs. praxis

In this wise, ethics involves the continuous effort of studying our own moral beliefs and our moral conduct, and striving to ensure that we, and the institutions we help to shape, live up to standards that are reasonable and solidlybased.

The role of theories

Like science, ethical discourse is guided by theories and principles. Some theories, principles and methods that guide the scientific inquiry are: positivism, pragmatism, empiricism, instrumentalism, and probabilism. Others are the theories of induction and deduction, etc.
The schema in the following slide shows the major theories in ethics

Ethical theories
Ethical Theories

Ethics of Conduct What sort of actions should we perform?

Ethics of Character What sort of people should we be?

Consequentialism The right action is the one that produces the most intrinsic good

Deontology The good is defined independently of the right

For the agent: Ethical Egoism

For everyone affected: Utilitarianism

Kantianism Actions must satisfy the categorical imperative

Aristoteleanism Virtue is a mean between extremes of action or passion

Ethical theories
Should be clear Internally consistent and coherent Complete and comprehensive Simple Generally support ordinary judgment

Ethical theories
There are two fundamental types of ethical theory: i. Consequentialist or utilitarian theory (teleology) Jeremy Bentham and John Stuart Mill ii. Deontological theory Immanuel Kant

Consequentialist theories
Consequentialist theory is one sub class of teleological moral theory Consequentialism refers to moral theories that hold that the consequences of a particular action form the basis for any valid moral judgment about that action (or create a structure or rule for judgment) Says the moral value of an act, rule or policy is to be found in the consequences, not in intentions or motives

Consequentialist theories
From a consequentialist standpoint, a morally right action is one that produces a good outcome, or consequence. This view is often expressed in the maxim "The ends justify the means. The defining feature of consequentialist moral theories is the weight given to the consequences in evaluating the rightness and wrongness of actions.

Consequentialist theories
According to this theory, the consequences of an action or rule generally outweigh other considerations Some questions that consequentialist theories address: i. What sort of consequences count as good consequences? ii. Who is the primary beneficiary of moral action? iii. How are consequences judged and who judges them?

Utilitarianism
Utilitarianism is the most influential consequentialist theory Formulated by Jeremy Bentham in the late 18th century and John Stuart Mill in the 19th century The utilitarian ethical theory is founded on the ability to predict the consequences of an action To a utilitarian, the choice that yields the greatest benefit to the most people is the choice that is ethically correct.

Utilitarianism
There is only one basic principle in ethics, that of utility, the production of the greatest possible balance of value over disvalue for all persons affected
The end justifies the means Promote the greatest good for the greatest number What is right is what is most useful

Utilitarianism
Hedonistic utilitarians argue that the principle to judge our moral thinking is utility, that is, the maximisation of happiness, in the sense of pleasure, and the minimisation of suffering, in the sense of pain. In any situation the morally right thing to do is the action that promotes the greatest happiness for the greatest number of people

Two types of utilitarianism

i. Act utilitarianism considers the consequences of each act, ie white lie A person performs the acts that benefit the most people, regardless of personal feelings or the societal constraints such as laws ii. Rule utilitarianism - considers the general consequences of these kinds of acts, ie the rule that lying is generally bad for society. (Rules are considered valid only if their consequences are good overall)

Utilitarianism: an illustration
In considering what is the right course of action/treatment in any healthcare situation, doctors tend initially to think about the consequences arising from the different options. For example, in deciding whether in particular circumstances a breach of the duty of confidentiality is justified, the physician thinks of the consequences the harms of breaching the duty and the harms of not warning others of a risk to their health.

Criticism
A criticism of consequentialist theory is that it is so concerned with the ways in which the ends or goals are achieved it is so concerned with ends that it often overlooks the moral importance of means. The utilitarian theory requires that the consequences of acts and policies be calculated. In many situations one cannot predict consequences with any certainty, making consequentialism probabilistic we forecast the consequences to the best of our ability.

Criticism
A utilitarian is presumed to have the ability to compare the various types of consequences against each other on a similar scale. However, comparing material gains such as money against intangible gains such as happiness is impossible since their qualities differ significantly

Criticism
Utilitarianism has been charged with overdemandingness - that it does not allow for the existence of supererogation or heroes. For example, we are obligated to constantly behave so that the most people benefit regardless of the danger associated with an act. For instance, a utilitarian who sacrifices her life to save a train full of people is actually fulfilling an obligation to society rather than performing a selfless and laudable act.

Criticism
Act utilitarianism is solely concerned with achieving the maximum good. The theory implies that an individual's rights may be infringed upon in order to benefit a greater population. In other words, act utilitarianism is not always concerned with justice, beneficence or autonomy for an individual if oppressing the individual leads to the solution that benefits a majority of people.

Deontological Theory Deontology (from Greek deon, "obligation, duty) is an approach to ethics that focuses on duty, rules and the intentions of the person doing the act, rather than third-party consequences of the act

Deontology
Some features of an act other than its consequences makes it right or wrong. May be based in religious belief, natural law, common morality or other system. honesty beneficence fidelity nonmaleficence gratitude autonomy justice privacy

Rules
Rules of thumb Binding rules Absolute rules (eg, truth-telling)

Duty/obligation
Deontological theory uses rule rather than consequences to justify an action or policy emphasis is on obligation or duty focuses on objectively obligatory rule General rule - do unto others as you will have them do unto you

Kantian duty ethics

Kantianism is the most well known deontological theory of ethics Kant defended rules as do not lie, keep promises, do not kill on what he claimed were rational grounds Rules should comply with the categorical imperative

Kantianism
The categorical imperative holds that:
Moral rules should be universalisable i.e. applied to rational, moral members of the community rather than to just some All persons should be treated never simply as means but also always as ends in themselves Members of the moral community should take a hand in making the laws as well as living by them

Kantianism
Kants ethics is an ethics of respect for persons One formulation of the CI that is crucially relevant in dealing with issues in biomedical ethics is the one that tells us: Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end

Preliminary Questions
What does it mean to treat an individual as an end? Is it always morally wrong for one person to use another as a means? Are there extenuating conditions to this rule? explain what such conditions would look like

Kantianism

Modern Kantians still stress the importance of generally living by moral rules or laws. However, unlike Kant, many are not absolutist in their application of moral rules or laws

Importance of Kantian theory

Kants ethical ideas continue to have great impact in ethical thinking till date. Mappes and De Grazia argue that his ethical theory remains the underlying framework of much argumentation in b i o m e d i c a l e t h i c s to d ay Fo r exa m p l e , Ka nt s t h e o r y i s m a n i fe ste d i n t h e i d e a o f a d u t i e s o we d to a p at i e nt b y t h e d o c to r t h e d u t y o f ca re a n d t h e d u t y n o t to h a r m

Some difficulties
Although deontology contains many positive attributes, it also contains its fair number of flaws: i. Provides no rationale or logical basis for deciding an individual's duties ii. Does not provide any guidance on how to resolve conflicting duties or obligations iii. Absolutism a big problem

Communitarianism
Is a theoretical perspective that seeks to lessen the focus on individual rights and increase the focus on communal responsibilities Its central claim is the necessity of attending to community alongside, if not prior to, liberty, justice and equality

Communitarianism
Communitarianism emerged in the 1980s as a response to the limits of liberal theory and practice Advocates the need to balance individual rights with social responsibilities Says individuals do not exist in isolation, but are shaped by the values and culture of communities Says we should begin to redress the balance toward the pole of community, or else our society will continue to become normless, self-centred, and driven by special interests and power seeking.

Communitarianism
Communitarians believe that the value of community is not sufficiently recognized in liberal theories of justice, or in the public culture of liberal societies Says real emphasis should instead be on common shared practices, cultural traditions, and shared social understanding among members of society

Communitarian ethics
Grounds ethical thought in communal values, established social standards and traditions, and considerations of the larger society. Communitarians emphasize the influence of society on individuals and contend that values are rooted in common history and tradition Believes that the good of individuals - their very identity and capacity for moral agency - is bound up with the communities they belong to

Three principles
Communitarianism is based on three principles: First, that any claim of truth be validated through cooperative enquiry. Second, that communities of co-operative inquiry, which represent the spectrum of citizens, should validate common values that become the basis of mutual responsibilities of all community members. Third, that all citizens should have equal access and participation in the power structure of society.

A central premise

Is the recognition of society as a web of intersecting communities with differing moral values and standards

Community as a focal point

The key to resolving ethical questions and conflicts lies in respect for local values that demonstrate careful deliberation and local community acceptance.
Holds that he system of moral rules of a particular community is best understood in the context of that community's current historical view of social welfare and related social interests.

The common good as an ideal

Communitarianism downplays the values of individuality, autonomy, and personal rights, so prevalent in other ethical theories, in favour of a focus on the virtues and actions that support the interests of society as a whole

Role in health care

Communitarian thought contributes immensely to ethical discussion in the health care context. This is particularly true with respect to issues such as the best use of limited health care resources, health care as a right, and the concept of healthy communities versus an emphasis on individual health.

Strength
Strengths of the communitarian perspective include the emphasis on strong connections between people, encouragement of collaboration, diminished emphasis on selfserving individualism, and sacrifice for the greater good as a measure of character.

Weakness
On the negative side, many would question how realistic it is to achieve a common set of global, or even local, values. We should also be concerned with the potential of the theory to erode individual rights As a theory, communitarianism provides no systematic method for resolving ethical conflicts

Liberal individualism
Rights-based What is a right?
i. A right is a claim that can be made on society on moral or legal grounds ii. Moral rights are claims justified by moral rules iii. Positive rights require anothers action iv. Negative rights require anothers forbearance

Permissible murder?
A doctor kills a deteriorating and suffering patient using an undetectable method. The patients family is relieved of financial and psychological stress, and the patient is relieved of suffering.
Who benefits? Who suffers? What is the balance?

Permissible murder?
Same as the last case (euthanasia), except through an unlikely chain of circumstance, the doctors act is discovered. He goes to jail after a very painful trial. Who benefits? Who suffers? What is the balance? Is the morality or ethical value of the act altered by the outcome?

Moral dilemma
You are a 1940s doctor in charge of a hospital in which you are treating Jewish patients. Nazi soldiers come and ask you if you have any such patients.
How do you respond if honesty is a rule of thumb? How do you respond if honesty is a binding rule? How do you respond if honesty is an absolute rule?

Moral dilemma
In 1973, the US Supreme Court made a landmark ruling in the legal case Roe v. Wade, allowing that a woman may procure abortion in the first trimester of pregnancy, without the approval of the father, government, or any other authority. In 1977, the Court ruled that government does not have to pay for abortions. Explain the apparent paradox What rights are involved in these decisions? How might your personal ethical theory impact your approach to abortion?

Emphasis on rights
Liberal theories emphasize the role of choice, individual liberty, and freedom from government interference in private matters

Rights refer to legal, social, or ethical principles of freedom or entitlement - they are the fundamental normative rules about what is allowed of people or owed to people, according to some legal system, social convention, or ethical theory.

Ethics of care
Care ethics is a new ethical theory. Believes that the development of morals is not caused by learning moral principles. Instead, people should learn norms and values in specic contexts. Views other people as of fundamental importance and worthy of our respect.

Ethics of care
By contacting other people, and by placing yourself in their shoes, you learn what is good or bad at a particular time. The solution of moral problems must always be focused on maintaining the relationships between people. The connectedness of people is the key to moral progress

Four Principles
Earlier, we mentioned that in order for an ethical theory to be useful, the theory must be directed towards a common set of goals. Ethical principles are the common goals that each theory tries to achieve in order to be successful. In what follows, we discuss four important ethical principles: respect for autonomy, nonmaleficence, beneficence, justice.

Respect for autonomy

Respecting the decision-making capacities of autonomous persons
Tell the truth Respect others privacy Protect confidential information allow individuals to make reasoned informed choices Obtain consent for interventions

Nuremberg Code, Rule 1

Legal capacity to give consent Free power of choice Sufficient knowledge and comprehension
nature, duration, purpose methods and means inconveniences and hazards long term effects responsibility of experimenter to ensure autonomy is respected

Non maleficence:
Healthcare professional should avoid the causation of harm to patient
do not kill do not cause pain or suffering to others do not incapacitate others do not cause offense to others do not deprive others of the goods of life

Nuremberg Code
Rule 4:
The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.

Rule 5:
Experiment should not be conducted where there is an a priori reason to believe that death or disabling injury will occur... Rule 5: Degree of risk should be minimal.

Beneficence
Provide benefits and balance benefits against risks and harm
protect and defend the rights of others prevent harm to others remove conditions that will cause others harm help disabled persons rescue persons in danger

Hippocratic Oath
One basic principle in the Oath is:

do no harm

Justice
Distribute benefits, risks, and costs fairly
to each an equal share to each according to effort to each according to need to each according to contribution to each according to merit

Applying the Four Principles

Mrs Y is 56 years old and has a learning disability. She is admitted to hospital with an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has indicated quite clearly that she does not want a needle inserted for the anaesthetic for the operation to remove the cyst- she is uncomfortable in a hospital setting and is frightened of needles.

Applying the Four Principles

The clinician is concerned that if the cyst is not removed Mrs Y will develop renal failure and require dialysis which would involve the regular use of needles and be very difficult to carry out given her fear of needles and discomfort with hospitals.

The anaesthetist is concerned that if Mrs Y does not comply with the procedure then she would need to be physically restrained.
Mrs Y's niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment.

Question
Should the surgeon perform the operation despite Mrs Ys objections? How would you apply the Four Principles to this case?
See The UK Ethics Network, The Ethox Centre, Department of Public Health and Primary Health Care. The four principles approach. Available at: http://www.ethics-network.org.uk/ethical-issues/ethical-frameworks/the-fourprinciples-approach

Resources
Government of Canada, Context of an Ethical Framework, Available on http://www.pre.ethics.gc.ca/english/policystatement/context. cfm (accessed on August 28, 2008) Andre J. Bioethics as practice The University of North Carolina Press, 2002 Medical Ethics Manual, World Medical Association, 2005 McGee G. Thirty years of bioethics. New Review of Bioethics 2003;1(1):7-13 Levitt M, Williams G. Thirty years of bioethics: all grown up now? New Review of Bioethics 2003;1(1):3-5

Resources
Widdows H, Dickenson D, Hellsten S. Global bioethics New Review of Bioethics 2003;1(1):101-116 McKneally M. What is an ethic? University of Toronto Adebamowo CA. Ethical issues in cancer research. 2005 Ogundiran TO. Enhancing the African bioethics initiative BMC Medical Education 2004; 4(21):1-6 Schklenk U. Introduction to research ethics. Developing World Bioethics 2005; 5(1):1471-8847 (online)

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