2 Ethical theories and principles

Introduction

Consider the relatively common scenario in a district general hospital late one evening: an elderly patient who collapsed at home with a large intra-cerebral bleed is now intubated and ventilated in the emergency department. Prior to intubation the patient is deeply unconscious, with a Glasgow Coma Score of three. His case has already been discussed with the neurosurgeons who feel that the transfer to the regional neurosurgical centre for further management is not appropriate because the predicted outcome are universally poor (Figure 2.1).

What is the next course of action? He could be admitted to the intensive care unit (ICU) for further assessment and review the following morning on withholding of sedation. Or should you consider a planned withdrawal of treatment that evening with his extubation and subsequent transfer to a medical ward for palliation? Does the knowledge that he is on the organ donation register make a difference? Will the situation change if this is the last empty bed in the ICU? Now consider your responses when it transpires that the patient is 96, not 69 as first thought. Are the wishes of the patient known to the clinical team? The family have been called and will not arrive this evening. How important is their input into the decisions that are required during the evening?

Ethical reasoning is critical to resolve ethical issues such as this one. However, if such reasoning is going to be able to guide clinicians' actions in ways that are justifiable, ethical theories and principles must be incorporated into this process. This chapter will provide the background to the main ethical theories, the ethical principles that are derived from those theories and that are relevant to contemporary medical ethics.

Three different ethical theories dominate the landscape of medical ethics. These function to determine how particular decisions or actions can be judged to be right or wrong in ethical terms. It is from these three theories that four ethical principles have been derived. The principles are well established in modern medicine. The method behind their application is intended to be simple and easy to apply across many clinical situations. These four principles are also described below.

Consequentialism

Consequentialist ethical theories claim that the rightness or wrongness of an action is judged solely by reference to the outcome of that action. For a consequentialist, the only morally relevant features of any action are its consequences.

Consequentialism is not a single ethical theory, rather it defines a category of theories. Utilitarianism is the most well-known consequentialist approach and the consequentialist theory that is most commonly applied and defended within healthcare. Utilitarianism gets its name from 'utility' - the value that ought to be maximised in determining the moral course of action. Utility is often interpreted in terms of 'welfare' or 'well-being'. There are at least three alternative forms of utilitarianism that can be differentiated by the way that welfare is accounted for:

• Hedonistic utilitarianism, where the right action is the one that involves the maximising of happiness.
• Preference utilitarianism, where the right action is the one that involves satisfying the maximum number of fully informed and rational preferences.
• Ideal utilitarianism, where the right action is the one that involves maximising particular goods in the world - those worthwhile things or activities that are taken to have objective value - beauty, or perhaps friendship.

Part of the strength of utilitarian theories is that they are simple to comprehend and appeal to common sense. They also chime closely with the central activity of providing optimal outcomes for patients and endorse 'well-being' as their central value - a concept that is well recognised and understood within medical practice. However the theory faces a number of practical problems when applied to healthcare decision making. There can be difficulties in predicting and in evaluating the consequences of any particular action. For example, several consequences can arise from one act and it can be difficult to predict the probability of certain consequences following an act. The question is whether there is one consequence that will outweigh all others. Furthermore, problems can be encountered when the act under consideration will benefit one person or group but may be to the detriment of others.

Duty-based ethics

Duty-based approaches define another category of ethical theories. These theories focus on the quality of the action itself rather than the consequences of that action. This ethical approach is also called 'deontology' from the Greek for 'duty', deon. So duty-based ethics are concerned with what people are duty-bound to do, or how they are obliged to act. While such duties might extend to maximising the consequences of any action, it is not the maximisation of consequences per se that would make this action right, but that a relevant duty had been fulfilled. In other cases some actions will be wrong irrespective of the consequences. If one is duty-bound not to lie, for example, no reference to the benefits that might accrue from lying can provide an ethical justification for not telling the truth.

Much of the thinking behind duty-based ethics has arisen from the work of the eighteenth-century German philosopher Immanuel Kant, and Kantian deontology is the most common duty-based ethical theory. The basic premise of Kant's theory is that rational human beings have the capacity to make reasonable decisions and choose the right course of action. Kant formulated his theory and account of moral duties in a number of formulations of what he called the 'categorical imperative', a rule that is true for all people in all circumstances. The right action must i) be one that is universal, ii) involve treating human beings as ends in themselves rather than merely as means to ends, iii) be autonomously willed by rational agents, and
iv) establish the principles for a system of common laws.

More contemporary theorists have drawn upon and revised Kant's work on the morality of actions and rationality to reconfigure how moral duties apply and can be identified. Thomas M. Scanlon offers a different duty-based theory of ethics. He proposes that the judgement as to whether an action is right or wrong depends upon individuals identifying principles that can be mutually recognised and justified by reference to the value of ways of living with others that it would not be reasonable to reject. Scanlon offers a view into the complexities of determining universal duties, which he summarises as 'what we owe to each other' - a form of contractual moral agreement.

Virtue-based ethics

Arising from the ancient Greek philosophies of Plato and Aristotle, virtue ethics are based on an understanding that the rightness or wrongness of an action is based upon the character of the individual, rather than by reference to the action at all. In addition, virtue ethics provides guidance on the characteristics and behaviours a good person will demonstrate.

Virtue-based ethics focuses on the character of the person rather than their actions. The traditional virtues included prudence, justice, fortitude or bravery and finally, temperance. While one of the strengths of a virtue-based approach is that it centres on the person, the weakness is that it is unclear whether this theory can provide any guidance for action in the face of a moral dilemma.

Alasdair MacIntyre has been a key figure in contemporary virtue-based ethics. He has called the virtues or qualities of character 'internal goods'. MacIntyre has been a proponent of how virtues change over time while at the same time emphasising the historical context of ethics. The combination of the qualities of character viewed within both the historical and social context gives an understanding of how ethical issues arise and how the good life can be cultivated.

The four principles

Principlism is a method for ethical decision making in medicine that promotes the application of four principles. These four principles are second-order principles that have been derived from the three main ethical theories to form a useful and universal approach to working through ethical decision making. The aim is to be simple, easy to apply and culturally neutral. Henceforth, when confronting a problem, it can be helpful to apply each principle to allow some clarity and transparency to the situation, taking each different ethical theoretical insight into account.

The first principle, respect for autonomy, is the obligation to allow patients to self-govern their own lives, and to make decisions about their medical care in line with their own conception of their life plans. Respecting patient autonomy is usually understood as allowing healthcare providers to discuss and, if necessary, educate the patient about the different options available, but it does not allow the healthcare provider to make the decision for the patient. Implicit within this is the premise that medical practitioners must respect and follow those wishes, even if they believe that the decision is bad or incorrect.

The principles of beneficence and non-maleficence are closely related. Beneficence is the...