Basic Moral Theory

(Ethics, and some big words)

Tim Harlow, Telford, 27/1/16

“The biggest hindrance to learning

is fear of showing one's self a fool.”

William Least Heat Moon, Blue Highways

What is ethics? • The application of the general

moral principles of society in specific situation- such as healthcare- thus in the end a practical matter; guides our choices, our impact

Moral foundations• We need to understand these to

see where we are coming from, why we make the decisions we do and what the underlying principles are.

Groucho Marx- “These are my principles, if you don’t like them I have others”

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What is the point of ethics?

• We act as moral agents all the time- whenever we act, or choose not to act –range from trivial and banal to important and influential, and reflects the morals of the society we are in

• Medicine: doctors make ethical judgements of differing importance all the time –often without realising it.

Why do we get into trouble with ethics?

• Because we have not gone far enough back-

• Not recognised underlying moral premises

General Principles of Society

• Western, North European

• “Cold” society

• Autonomy highly prized

• Individual is the lens through which society is viewed

• Christian roots- individual responsibility

• Expect to control our environment

Different Society -Asian

• (Gross generalisations to illustrate)

• “Hot” Society

• Individual less important

• Community, group, much more central

• Autonomy seen in collective context

• Privacy interpreted differently

• Reincarnation, Karma

What is Philosophy?• Study of general and fundamental problems,

such as those connected with reality, existence, knowledge, values, reason, mind and language.

• Philosophy is different from other ways of addressing such problems in its critical, generally systematic approach and its reliance on rational argument, not emotion.

What theories exist?

•Aristotle384 – 322 BCE

• Greek- Student of Plato

• Scientist, thinker

• First used term Ethics

Virtue Ethics- the purpose of ethics is to become good- so not theoretical

Concerned with the whole of a person’s life- not just particular actions

Does not give specific guidance, or rules, in specific situations

To be honest, not because “best policy” or because of rules or consequences, but because it reflects and enhances our personal qualities

Good things. Problems.

• Allows choice, evolution of character

• Gives a long term view

• Allows moral discernment and integrity

• Judging people by intentions

• Reflects professional standards

• Can character and intent always be enough?

• Disregards rules

• Disregards consequences

• Just because virtuous character not mean all acts virtuous

Christianity also largely based on Virtue Ethics

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What theories exist?

•Deontology

• Ethical judgements based on duties, adherence to obligation

• RULES

Immanuel Kant 1724 -1804

• German philosopher

“Critique of pure reason”

"Let justice be done, though the world perish"

Deontology (rules not consequences)

• “Categorical imperative”- some things just right or wrong

• Very rational, duties important

• “One must treat everyone as end and never as a means only”

• Thus- killing, lying, stealing, deception, breaking promises, all absolutely wrong all the time

Good things. Problems.

• Consistent

• Considers people as free and autonomous with ability to make judgments and take responsibility

• Consistent with some religions' interpretation of God’s will

• Over emphasises law, under emphasises relationships, humanity

• How to function in real life- things change, muzzy edges?

• Contradictory duties-secret policeman

What theories exist?

• Utilitarianism• The greatest good for the greatest number of

people

• Act Utilitarianism perform action that provides most benefit for the most people- regardless of law, social constraints

• Rule Utilitarianism takes into account the laws and fairness in deciding and implementing the action

• Overlaps with Consequentialism –the balance of outcomes is all that matters

Utilitarianism

• Strengths

• Helpful in populations –public health, screening, NICE guidelines

• Maximises common good

• Weaknesses

• Assumes we can predict consequences accurately...

• Impersonal, devalues individual sacrifice

• Conflicting consequences

Jeremy Bentham 1748 –1832

• British Philosopher and social reformer

• Founded Utilitarianism

• Correct course action is to maximise happiness and minimise pain for maximum number of people

Bentham• Hedonistic Utilitarianism

• Sees actions wholly in terms of maximising pleasure or happiness

• Suggests Happiness is the same as Pleasure, and can be measured

John Stuart Mill 1806 –1873

• English Philosopher, civil servant and political economist

• “On Liberty” 1859

• Free to do as you wish as long as not harm others

AUTONOMY

Mill

• Libertarian View

• “Over himself, over his own body and mind, the individual is sovereign”....

• “The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others.” On Liberty, J S Mill, 1859

CONSEQUENTIALISM

• The CONSEQUENCES of one's conduct are the ultimate basis for any judgment about the rightness or wrongness of that conduct

• The end justifies the means

• No such thing as a bad act, just a bad consequence.

Good things. Problems.

• Respect for individual

• Minimises evil

• Maximises Happiness

• Practical

• Embodies our natural way of thinking and making judgements “That won’t do much good”

• Only talks about happiness, not achievement, morality, understanding

• Killing, telling truth?

• Can we always predict consequences?

• How assess happiness accurately?

• Absolute good or harm?

Law is very consequentialist

• Dangerous driving –prison for up to 6 months (2y if trial) and or fine or both

• Causing death by dangerous driving-prison for up to 14 years

The Law

• “Justice? - you get justice in the next world, in this world, you have the law.” William Gaddis – ‘A Frolic of His Own’ Poseidon Press 1994

• “The law may embody coercion, but law reflects the collective will of the people” Wayne Morrison- Theoretical Criminology, Cavendish 1995

How Ethical is the Law?

• Commit a crime if not mentally ill. Released after their sentence even if still risk of further crime

• Same crime if mentally ill, kept indefinitely until judged not at risk of further crime

• A person cannot be imprisoned because it is suspected they might commit a crime but a mentally ill person can be detained preventatively

What theories exist?

• Communitarian

• Values and beliefs collective

• Democratic, evolutionary.

• Emphasis on community and groups

• “Social capital” important

• Hospices rely on this

Communitarian

• Strengths

• Promotes education, volunteering, social care, values individual liberty

• Charitable work encouraged

• Weaknesses

• Incoherent, moral relativism

• Oppression of minority by majority

• Ill defined, no clear philosophical base

What theories exist?

• Libertarian

• Equality of opportunity

• Individual rewards, property

• Maximises choice

• Freedom from state interference

• Individual responsibility

• USA- health system

Libertarian

• Strengths

• Maximises autonomy

• High value on liberty

• Can be left wing or right wing- who owns the means of production

• Weaknesses

• Prioritises freedom not life -anarchy

• Magnifies social division

• Is equality of opportunity ever possible

What theories exist?

• Egalitarianism

• Equality of entitlement

• Prioritises need

• Humans equal in worth and status

• Agreement about common goals

• NHS based on this

Egalitarianism

• Strengths

• Looks after vulnerable

• Improves social cohesion

• Education improved

• “Fairer” society can promote well being

• Weaknesses

• “Nanny state”

• Individual coercion

• Reduction in choice-lowest common denominator

• Inefficient and unachievable

Consumerism

• Must have access to goods and services

• Must have choice

• Must be well informed

• Must be regulated and of adequate standard

• Allowed to insist on poor choices

• Would Health care professionals be obliged to provide services as long as they were legal?

Ethics reflecting the moral principles of society...

• Israel- only for God to take life.

• Switching off ventilator is taking life

• Ventilators are on a timer cycle which has to be restarted each time, This is not restarted and the ventilation thus withdrawn.

Acts of Commission and Omission

• Commission- doing something to produce a result- so holding a child’s head underwater deliberately in order that they might die and I inherit the money

• Omission- failing to do something to produce a result- finding child had slipped in bath and was unconscious face down in the water doing nothing to help- child dies, I get the money

Culpability?

•Intent matters.

•Duty of care.

Casuistry• Case based reasoning- like UK law, precedent.

Not so much underlying principles but much more the pragmatic matching of cases.

• X was guilty of fraud and Y now has a case that matches that closely so Y is also guilty of fraud.

• Can be used to denigrate a moral approach or judgment as not carefully thought through-clever but unsound reasoning.

“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it

means just what I choose it to mean—neither more nor less.”

The beginning of wisdom is to call things by their proper names- Old

Chinese proverb

Beware the questions that set the terms of

the answer...

“When did you stop beating your wife?”

“We already allow passive euthanasia by

withdrawing ventilation or dialysis, so why not allow

euthanasia?”Return to that later…

Words• Facts- MI, cancer, the sun is shining: so

causes, effects matter.

• Morals- Ought, good, bad: intentions and blame matter

• Moral Intuition- Judgements about morality based on subconscious instinct- As doctors we should think about why we hold views

• Moral Judgements- relative balance of reason and instinct

• Moral Luck- Let off the hook by events...

Terms• Futility

• Dignity

• Goods

• Harms

• Quality of life

• Euthanasia

Futility• “The patient’s clinical condition is such that

any attempted resuscitation is unlikely to restart the heart or breathing” –RD&E DNAR form,

category A

• Apparently objective values but in reality reflecting either collective values, or someone’s interpretation of those values.

• 15% chance worthwhile, 5%, 1%, 40%...?

• Quality of life if resuscitated too poor...

Dignity• a recognition of human worth, of valuing

a human being for all that is worthwhile about them

• People are ends in themselves (Kant) – so society is entitled to a view about a person’s intrinsic worth

Dignity may involve limits to individual autonomy

• Is it dignified to allow a delirious or psychotic person to walk naked in a public place?

• Maybe a broader view of human value must reflect things other than an individual’s view of themselves or another’s view of their capability

“I like my doctor to scan me, to grope for my spirit as well as my

prostate. Without some such recognition, I am nothing but my

illness” (Broyard. Intoxicated by my illness: and other writings on life and death. New

York: Ballantine, 1992) .

Values “Good” or “Harm”-

• Often general agreement but in difficult cases...• Example – Frail patient offered new, expensive,

largely untried treatment for life threatening illness: patient ill and weary, doctor wanting to avoid accusation of negligence, relatives who want to be seen to care, researcher wants to help others, administrator with demands on limited budget...

• World view more subjective than we think, (Fleck, Kuhn),

even scientific knowledge is dependant upon the starting point, the premises.

Quality of life• “This patient’s quality of life is very poor”

• “They would have hated being like this”

• But does the person they are now hate being like this?

Locked in Syndrome- (Bernheim

et al 2008 COMA science group-www.comascience.org)

Self rated overall well being-

• 65 Locked in Patients, 820 controls

• 1/4 were miserable

• 2/3 were same as controls

• 55% wanted to be resuscitated

• 5% wanted euthanasia

• 40% had considered it in past

Terms• Euthanasia- Commission of an action

by a person specifically intended to bring about another person’s death at their clear request before it would otherwise have occurred

• “Active Euthanasia”

• “Passive Euthanasia”

Misapprehension?

• Passive Euthanasia- (BBC website, NHS website and Medical Ethics- A Very

Short Introduction -Tony Hope, Oxford 2004)

Withdrawing or withholding of life sustaining treatment after which the patient dies.

This seems to me incorrect and misrepresents the issue

Why?

Intent matters• Not a purely Consequentialist view

• Distinguishing between

• 1-withdrawing a treatment which has temporarily interrupted a chain of events that would otherwise lead to death, even if that needs an action such as turning off a ventilator

• 2-carrying out an act with the specific intention of ending someone’s life which otherwise would not have ended at that point

Artificial postponement of death-Chain of Causality

Truth: An ethical issue?

• Is it ever ethical for a doctor to lie?

• What about obfuscation or evasion?

• Are there different sorts of truth-facts/opinions?

• What about truth versus brutality?

• Honesty?

• What is the point of the truth, or it is just “right”?

4 Ethical Principles of medicine

• Much criticised but widely used.

• Autonomy-

• Beneficence- doing good

• Non Maleficence- doing no net harm (vaccination, surgery, MHA)

• Justice(Beauchamp T, Childress J- Principles of Biomedical Ethics -1st ed OUP-1979)

Autonomy• Egocentric view- liberal tradition: about here and

now, choices I make for my interests-existential, individualistic western “Cold” societies

• Reflects the broader sweep of life: reflects who one was and who one may become in due course

• Communitarian view- people identified not just as individuals but through relationships-family/friends/tribe/religion- esp in “Hot” societies

• Autonomy relative, never absolute: how much the exercise of my autonomy affect autonomy of others

Justice• Distributive Justice- Individuals should be treated

the same, unless they differ in ways that are relevant to the situation in which they are involved- Impartial, less emotional involvement than fairness

• Fairness- More emotional, more specific to the case- parents do more for their own children than for others

• Postcode lottery? How much should local democracy be able to set priorities for healthcare

• NICE guidelines- just? £30,000 per QALY...

Justice...finite resources

• Finite resources should be allocated according to clinical need and not according to choice-should legitimate needs of other patients be overridden by imperatives to meet preferences-Herceptin etc

• Cost effectiveness is an ethical issue

• Consumer view of healthcare and NHS is profoundly flawed

2 further principles?• 5- Utility – obligation to use stuff

wisely

• 6- Respect for human nature in ourselves and in other people

Premisses• Where we get to depends upon where we start-

World views differ

• Scientist- that there are rules, laws that govern the Universe, universally applicable and immutable

• Individual choice, autonomy, is fundamental

• Obeying God’s commandments is fundamental

• All suffering and illness is an illusion

• Family is a person’s primary loyalty and responsibility

• Duty to institution is paramount

Premisses Analgesia- a Good Thing

• Premise of relative who cannot bear the sight of loved person in any, even transient, pain

• Premise of lawyer- needs patient alert to sign a will

• Premise of patient wants to see final of X Factor

• Premise of nurse who fears giving an injection associated in time with death

• Premise of fellow patient in ward watching person in pain

• Premise of deeply religious woman who sees her pain as purifying her in the eyes of God

How much can recurrent illness be considered a part of someone?

• Careful here...

• Normal model- assume a person has a illness as something separate from themselves- very helpful

• “Self” may be discrete entity or an aggregate, bundle that evolves over time: how severe, recurrent, untreatable and all pervasive must a condition become before this distinction is no longer useful?

• Great dangers here- Kerrie Wooltorton, recurrent self poisoning with antifreeze: ADRT when “well” and then refused treatment- died 3 days later

Capacity and Competence

• MCA- allowed “Unwise and Eccentric decisions”

• Understand, retain, weigh, communicate: sounds all objective

• In reality they are codified opinions, no hard end points: the (4) components we are trying to measure will be fluctuating all the time

Capacity- fluctuating• The notion of “Tests” of capacity can give the

impression of objective truth and of substance to which they are not entitled

• No-one has stable capacity: tiredness, stress, alcohol, grief, worry, fear, excessive responsibility...

• Useful, but still subjective, value driven.

Left Brain and Right Brain

• Left Brain- analysing, detail, logic, “left hemisphere exists to make things certain”, renders inert, mechanical: gives us power.

• Right Brain- wider picture, intuitive, meaning, tone, humour, metaphor, wisdom

• Medicine reflects society: become very Left Brain,

lost in spurious certainty. McGilchrist I. The master and his emissary: the divided brain and the

making of the western world. New Haven CT: Yale University Press, 2009 . http://www.iainmcgilchrist.com/

Which Philosophical underpinning should we use?

• Usually an eclectic philosophical mishmash of “all things considered” together with law, fairness, emotion, prior experience and pragmatism.

Coffee time!!

NOW- PRACTICAL WORK THROUGH OF SOME ETHICAL PROBLEMS USING DIFFERENT UNDERPINNINGS

Welcome back!

• Using four different philosophical positions, Aristotle, Kant, Mill or St Dumbledore’s hospice pragmatic all thing considered eclectic mishmash: work out what they would do in these different situations- and why…

Euthanasia

• The commission of a deliberate act by a doctor- at a patient’s clear, rational, repeated request- to end that patient’s life earlier than it would otherwise end: to kill them.

• What would Aristotle, Kant, Bentham,Mill or St Dumbledore’s say is the correct thing to do- if it was legal?

Runaway train problem

• Runaway train will kill 5 people

• You are on a bridge over railway with a very fat man. If he falls on track it will slow the train just enough to allow time for the 5 people to escape.

• Do you push the fat man off the bridge on to the track and sacrifice one person to save 5?

Clamping Nephrostomy tube

• 46 year old man, incurable cancer, lots metastases with liver and blocked kidneys.

• Kept alive by tube draining kidney (nephrostomy). Believes dying of kidney failure is better and sooner than of liver failure

• Pulling out tube traumatic, risk infection, bleeding: kidney might carry on working.

• Asks you if you will clamp the tube to stop kidney working and so he will die.

Legalising marijuana

• Should marijuana be legalised-with controls, such as with alcohol?

Withdrawing Ventilation• Gill, 61 year- Motor Neurone Disease 3 years.

• Breathing become weaker as respiratory muscles become paralysed. Now has ventilation via tracheostomy, helps breathing and now completely dependant upon ventilator. Gill is completely unable to move limbs but communicates well via computer.

• She wants you to stop the ventilator as she cannot do that herself, and wants you to give her sedative drugs to stop her feeling breathless.

Sedation

• Christabelle, 57y, extensive pelvic tumour with pain controlled, no nausea, paralysed, waist down, weak. Wanted Euthanasia but knows that impossible. Not depressed but finds situation intolerable. Spends a lot of time asleep and disappointed when wakes.

• “Please would you just knock me out so I am sedated until I die natually- I just can’t bear it”.

Torture• Terrorist who has hidden a nuclear bomb in an

unspecified UK city due to go off in 2 hours but will not tell us where it is. Thousands of lives at risk and colossal damage. Should you-

• A- torture her to get her to talk

• B- torture her 3 year old son in front of her to get her to talk

Organ donation• England and Scotland have a donor register,

and people need to opt in. Donor rate 20.6 per million of pop.

• Countries with opt out organ donation have higher rates –Spain 35.7, Croatia 35.1, Portugal 27.3, Belgium 26.9 Hobday, BMJ 2015;351:h6140

• Wales has just changed to an opt out policy.

• What is the correct thing to do?