Morality directs people to behave in certain ways and avoid behaving in other ways. It evaluates behavior as right or wrong and may involve measuring the conformity of a person’s actions to a code of conduct or set of principles. Morality is “normative,” it is concerned with how people should behave, not just how they actually do behave.
Some people use the term “ethics” for the systematic study of morality. But really there is such looseness in the use of the terms that in the minds of many morality and ethics are the same. Thus, “What is your ethics?” is usually taken to mean the same as “What is your morality?”
Types of Acts
Though morality uses the categories of right and wrong, those two terms are not enough to capture all that we want to say about different types of behavior. To see this, note that while to say that an action is morally wrong means we ought not to do it, to claim that an action is morally right fails to clarify whether we should do it or are merely allowed to do it (that is, whether it is obligatory or merely permissible). And what of acts that go above and beyond the call of duty? They are morally right, but perhaps we need a term to separate them from other acts that are right in the sense of merely permissible.
Expanding the category of “morally right” to include three different subcategories better captures the distinctions we want:
- morally wrong
- morally right
- morally neutral
- morally obligatory
- morally supererogatory
Morally wrong acts are activities such as murder, theft, rape, lying, and breaking promises. Other descriptions would be that they are morally prohibited, morally impermissible, acts one ought not to do, and acts one has a duty to refrain from doing.
Morally right acts are activities that are allowed. They include the morally neutral, the morally obligatory, and the morally supererogatory.
Morally neutral acts are morally right activities that are allowed but not required. One is neither obligated nor prohibited from doing them. One might call them the "merely morally permissible." Examples of such acts include watching the evening news on television, eating an apple instead of an orange, choosing vanilla over chocolate, whistling while you work, thoroughly chewing your food before swallowing, brushing before flossing instead of after, etc.
Morally obligatory acts are morally right acts one ought to do, one is morally prohibited from not doing them, they are moral duties, they are acts that are required. Such acts might be keeping one's promises and providing guidance and support for one's children.
Morally supererogatory acts are those morally right activities that are especially praiseworthy and even heroic. They go beyond what duty requires. They aren't required, morally, but if they are done it is an especially good thing. Examples include generous support for worthwhile charities, volunteer work for a local nursing home, and risking one's life to save someone from a burning building.
These four categories of acts are not always explicitly distinguished by people but they seem implicitly incorporated into our moral distinctions and decisions. There is, however, some disagreement about exactly what types of act fit into which categories. Thus, for example, while everyone thinks murder to be morally wrong, there is controversy about whether abortion is wrong; some people believe abortion to be wrong and others believe it to be morally permissible.
Kinds of Ethics
We said that morality was concerned with normative standards of right and wrong behavior. Actually that is one type of ethics called “normative ethics.” Besides normative ethics, ethicists also talk of descriptive ethics and metaethics. Descriptive ethics describes existing accepted standards of morality, normative ethics promotes or argues for the “correct” standard of morality, and metaethics analyzes such things as the meaning and justification of moral judgments.
Biomedical ethicists, medical ethicists, healthcare ethicists, nursing ethicists, bioethicists, etc. are mainly doing normative ethics, though restricted to a particular area or domain (healthcare). Healthcare is thus engaged in what some consider a fourth kind of ethics, applied ethics. But really it could be argued that any normative ethics that gets away from general principles and discusses their application to particular situations might be rightfully considered applied ethics. And so some thinkers consider applied ethics just a type of normative ethics, not a separate kind of ethics.
Normative Ethical Traditions
One way to do normative ethics is to focus on analyzing human acts; another way is to focus on human character. This latter approach occurs through “virtue” ethics. Virtue ethics seeks to ascertain the correct virtues that should be possessed by people of strong moral character. Perhaps virtue ethics has a better chance of getting people to do the right thing, but act-based normative ethics seems to stand a better chance of determining what that right thing is in any given situation. In health ethics discussions the act-based approach has been most important so we will discuss it in more detail.
For our purposes there are two basic approaches to determining the rightness of acts, two basic approaches to normative ethics. To understand the difference, consider that when you do something, undertake any action, there is going to be (1) what you actually do, and then there are going to be (2) the consequences of what you do. For example, if I steal another person’s car, there is the act of stealing the car, and then there are the consequences of that theft – the owner won’t have a way to get to work, it will encourage him and others to lock things up better, I might get caught and thrown in jail, etc.
So when looking at an act we can focus on the nature of the act itself or on the consequences. We can say the act is right or wrong because it is a certain kind of act, it fits in with certain principles or rules, or we can say the act is right or wrong because it results in good or bad consequences.
To simplify the matter we’ll call the first kind of approach “deontology” and the second kind “utilitarianism.” Other names for deontology or things like them are “nonconsequentialism” and “path-dependent theories.” Other names for utilitarianism or things like them are “consequentialism” and “cost-benefit approaches.”
To take up utilitarianism first, a simple way to put the basic perspective is to say that when faced with alternative courses of possible action, morality requires us to choose the act or choice or course of action that brings about the greatest good (usually thought of as happiness) for the greatest number of people. The key is that to consider only the consequences of the act, both short-term and long-term consequences. So in the case of car theft, how much happiness is produced for everyone by stealing the car versus the happiness from not stealing the car? Chances are more happiness for everyone would occur from not stealing the car, so that is the right thing to do.
The deontological approach says that consequences are important to consider but they are not the only thing. The “path” to the consequences should be taken into account also; some kinds of act are just wrong regardless of whether they bring about the greatest amount of happiness overall. For example, if by murdering an innocent person I somehow would make many people happy that doesn’t make it right – murdering would be wrong even so, so I shouldn’t do it. What kinds of acts are right or wrong because of the path to the consequences? Opinions vary, but there are certain principles or rules suggested that tell us what kinds of acts are right or wrong.
Deontology stresses that we have certain “duties” or obligations apart from consequences, though often doing the right kind of act will in fact lead to good consequences for the most people. For example, the philosopher W. D. Ross listed a number of apparent duties we all have; they may be paraphrased as:
- Fidelity: duty to keep promises and contracts and not be deceptive
- Reparation: duty to make up for injury one caused to another
- Gratitude: duty to be grateful for favors and if possible return them
- Non-maleficence: duty not to harm others
- Beneficence: duty to do good to others
- Self-improvement: duty to improve oneself
- Justice: duty to see that pleasure or happiness is not distributed out of proportion to what people merit
The average person in the United States has not heard Ross but he or she has heard of another set of rules or principles from the Bible, more precisely the Old Testament or Hebrew scriptures (in the books of Exodus and Deuteronomy); these principles or rules are known as the “Ten Commandments.” Insofar as any of these provide moral rules that tell us how to act and thus distinguish between right and wrong acts, they represent a nonconsequentialist, deontological approach. Here is a paraphrase:
- Worship only the one true God.
- Do not worship idols.
- Do not make wrongful use of the name of God.
- On the seventh day of the week take a Sabbath.
- Honor you father and mother.
- Do not murder.
- Do not commit adultery.
- Do not steal.
- Do not bear false witness against your neighbor.
- Do not covet your neighbor’s wife or possessions.
Certain of these rules are religious rather than moral, but common moral rules specified are to respect your parents and to refrain from murder, adultery, theft, falsely accusing or testifying against another person, and being jealous of and desiring another person’s spouse and possessions.
Principles of Biomedical Ethics
Utilitarian reasoning occasionally surfaces in healthcare ethics, particularly when the discussion is about the allocation of scarce resources and a cost/benefit or cost/effectiveness approach is being used. But the most widely known approach is a deontological approach emphasizing four principles stemming from the Belmont report as tweaked by the ethicists Beauchamp and Childress:
- Respect for autonomy (respect for the freedom of persons)
- Non-maleficence (do no harm)
- Beneficence (do good)
- Justice (fairness)
Autonomy is the freedom of a person to make decisions that control his or her life. In healthcare, patients deserve to have their autonomy respected in that they should be presented with the medical situation, advised of the options and their expected outcomes and risks, and have the freedom to make their own decisions about their treatment rather than being misled or coerced.
Non-maleficence is a principle of ethics widely held outside of healthcare in that each of us has the obligation to refrain from harming another person unless there exist extraordinary circumstances such as the need for self-defense against immanent harm. In healthcare this principle means clinicians have an obligation not to harm patients. Temporary pain and discomfort due to tests, procedures, or other treatment interventions should be balanced by the long-term benefit they will bring.
The principle of beneficence is also recognized outside of healthcare in that each of us has a general moral obligation to do good for one another. But this principle has a limited extent in that no other person has a right to demand my charity toward them. In healthcare it becomes a principle of specific beneficence that a provider owes to his or her patient. The patient does expect the provider will work for the benefit of the specific patient and provide the best possible care. This is based on the fiduciary nature (trust) that characterizes the provider-patient relationship.
The fourth principle is that healthcare should be provided with justice in allocation of resources and in the provider allocating his or her time to patients. The usual understanding of justice in such contexts is “distributive” justice having to do with fair distribution. The application of this principle is not clear cut, however, since there are differing interpretations of what fairness means – equality, based on merit, based on need, etc.
In healthcare ethics we consider particular situations and wonder whether a proposed course of action or inaction is morally obligatory, merely morally permissible (morally neutral), or morally impermissible. We ask questions about what providers and clinicians should do in certain situations. Controversies occur in healthcare ethics and in ethics in general over the correct normative ethical approach, over whether principles, rights, or duties are involved at all, over which principles apply in particular situations and how they apply, and over which principles should prevail if different principles seem to direct different courses of action.
Some “casuistic” approaches purport to eschew principles all together and claim we should decide on a case-by-case basis using similarities with accepted decisions from earlier cases. However, critics would question how those earlier decisions could be justified or distinguished from mere prejudice unless one had principles or rules to draw upon in making those initial judgments.
Metaethics asks questions such as:
- Do moral principles and judgments (“stealing is wrong,” “you ought not to steal that,”) represent knowledge, mere opinion, or expressions of emotion that have no cognitive content?
- How do we know what the correct moral principles are?
- Is morality universal for all people or instead relative to culture?
Metaethics rarely enters into healthcare ethics discussions. Providers and patients generally accept that there are right and wrong behaviors and principles or rules that make them so, almost always without asking how we know of such principles at all.
It is not clear what the implications are of this lack of metaethics discussion. Insistence on metaethics discussion in health ethics certainly would tremendously complicate matters and perhaps even paralyze needed ethical discussion in healthcare. However, on a theoretical level and in an academic context, discussion of metaethics would seem to be very important in creating dialogue among people of different viewpoints about where to get the right ethical principles.