UNION CHRISTIAN COLLEGE

Widdoes St., City of San Fernando, La Union

School of Health Sciences

Reading Material 3 in Health Care Ethics (NCM 108)

Ethical Theories

General Ethics
 Moral problems in health care ethics demand deliberate decisions. Moral decisions made are
justified accordingly by moral rules, which in turn, are grounded in ethical principles and
ultimately in ethical theories.
 In dealing with moral issues, it is better to have certain moral principles by which to act and
make moral decisions to make our moral decisions more defensible and justifiable. Being
able to explain, support, and justify our decisions is of paramount importance, thus the need
to study several ethical theories.
 Attempts to determine whether an act is good or bad, whether we are acting rightly or
wrongly, what is the norm of morality by which to settle whether one’s decisions are licit or
not, legitimate or not legitimate, proper or not proper, suitable or not – have led to the
construction of the diverse ethical formulations of general and universal concepts and
principles, which serve as the basis of good and evil, right and wrong. They are now known
as the different ethical schools of thought formulated by great thinkers the world over. These
ethical theories are usually classified as general ethics.

Classification of Ethical Theories (Beauchamp and Childress, 1979)

 Teleological Ethics also known as Consequential Ethics. Teleological ethics from the Greek
word telos, teleos meaning “end” or “purpose”, so called because it stresses the end-result,
goal or consequence of an act as the determining factor of its rightness or wrongness. It is
also called consequential ethics.
 Deontological ethics from the Greek word deon, deontos, meaning discourse on “duty” or
“obligation” stresses duty as the norm of moral action, hence it is also known as duty ethics. It
underscores the feature of the act or kind of the act itself rather than the balance of harm and
good – the value over the disvalue which is produced by the action

Recently, bioethicists have introduced the classification of ethics into rule and act. Resulting from
the influence of utilitarianism (Shannon and Digiacomo, 1979)
 Rule ethics appeals to a set of criteria, norms, or rules (hence the name) to settle what is
right and just and ethical decision to make. The famous Ten Commandments of the Judaeo-
Christian religion exemplifies rule ethics.
 Act ethics determines rightness and wrongness by weighing the consequences of the act
itself.

Theory 1. Duty Ethics

 Attributed to Immanuel Kant (a German thinker) as the most prominent advocate.
 Stresses duty as the norm of moral actions. The duty ethicist is interested in the question:
What makes an act moral as distinguished from a nonmoral one? What is the difference
between a person who acts morally and one who does not?
 Kant teaches that one acts morally (or performs a moral act) if and only if one does whatever
one is obliged to do, meaning, an act that is performed or done from a sense of duty or
obligation. Thus, what makes an act moral is its being done out of duty, as distinguished from
other acts done for other reasons.
 In this context, duty is that which an individual ought to do, despite the inclination to do
otherwise. Doing one’s duty then is doing what one is obliged to do, an act done from a
sense of duty, and not done in accord with duty. Anyone, therefor, who does something
merely because one feels like doing it, is not acting morally, is not a moral person, nor is he
performing a moral act. Health care professionals act from a sense of duty if they recognize
that there is a special obligation to their patients because of their relationships with them.
 The essence of morality, for the duty ethicist, is to be found in the motive from which an act is
done. The rightness or wrongness of an action is determined by the motive from which it is
being carried out, regardless of the consequences which doing or not doing so will produce.
 The motive here, refers to the duty that one ought to perform; it is what makes the act morally
good.
 According to Kant, to be able to determine one’s duty in a particular situation, one tests the
act’s universalizability, by applying the categorical imperative. The categorical imperative is
an ethical principle which states “Act only on that maxim which you can at the same will
to become a universal code of behavior.” To illustrate, let’s take the example of stealing,
applying the categorial imperative, to steal or not to steal. Let the maxim or precept be:
“Everybody should steal.”, which would mean everybody should steal. The maxim must be
binding on everyone at all times and in all places, it must become a universal code of
behavior mandating everyone else to steal. But since you cannot will the said maxim to
become a universal principle, then you should not steal. You now recognize that it is your
sense of duty not to steal. Hence the moral dictate of the categorical imperative forbids
stealing, lying, killing, breaking of promises, among many others, under any and all
circumstances. By simply invoking the said formulation of the categorical imperative, one can
readily determine the rightness and wrongness of one’s actions or decisions. Wrong act
involve contradictory, repugnant, or inconsistent results, like when we apply the maxim to
others but not to ourselves, or when we lay down a set of conditions or qualifications to justify
exceptions to a moral rule.

Two Types of Duty (according to Kant)

 Perfect Duty – one which we must always observe, irrespective of time and place. That I
should not harm or inflict injury upon others is a perfect duty. A nurse has a perfect duty
to take care of her patients is a perfect duty.
 Imperfect Duty – one which we must observe only on some occasions. That I should
show love and compassion occasionally to others, based on my own choice, is an
imperfect duty.

Treating Others as Ends

 One important moral principle of duty ethics relevant in the medical context and in any
human relationship states, “Always act so as to treat humanity, either yourself or
others, as an end and never as only a means.”
 To treat others as an end means to respect their rights and regard them as fellow human
beings (this makes it morally good and just); to treat others as a means is to use them for
one’s own personal interest, to degrade and violate their rights and to take advantage of
their innocence or helplessness (which makes it morally bad and unjust).
  Whenever a health care professional performs his duty as such to his patient, he is
treating the patient as an end, that is as a fellow human being with dignity and freedom.
On the contrary, whenever a nurse is remiss of her duty or cheats on her patient through
negligence and dishonesty, the patient is being treated as only a means.

Autonomous and Self Regulating Will

 Kant’s concept of the will as autonomous and self-regulating has contributed a great deal
to our understanding of autonomy as freedom of action. When we say an individual has
an autonomous and self-regulating will, we refer to his/her independence, self-reliance,
and self-contained capacity to make moral decisions by and for herself/himself.
 This means that the reasons and justifications for one’s decisions are one’s own. To
respect an autonomous agent is to recognize one’s own considered value judgment even
if the latter is believed to be mistaken or incorrect. To respect one’s reason in this way is
to acknowledge one’s right to one’s own decision, or view, as may be the case.

Basis of Human Dignity

 Kant’s notion of autonomy is bound to his concept that every person is a rational being
possessing worth and dignity; as such, individual persons are ends in themselves and
are capable of making their own moral decisions. To treat an individual merely as a
means is an infraction of Kant’s concept of autonomy, because one is treated in a way
one does not want to be.
 For Kant, mutual respect for autonomy between persons in moral relation is the basis of
justice; its violation would be a form of injustice.

In the Medical Context. In dealing with issues in medical practice and research, Kant’s ethical
principles are of far-reaching importance:
1. It is always wrong to lie, no matter what the consequence may be. Medical investigators/
researchers should not lie to their patients. Lying, for Kant, is intrinsically wrong.
2. We must always treat people (including ourselves) as ends and not only as means. In
medical experimentation, for instance, a patient must be informed of the procedure to be
undertaken and must give voluntary consent to become a subject. Deceiving a would-be
experimental patient is a surreptitious way of depriving him of autonomy; hence he is
treated only as a means. Deception or lying dehumanizes the patient in such
circumstance, as far as Kant is concerned.
3. We have a duty to treat ourselves as ends to preserve our dignity and worth as human
beings (our good health included).
4. It would be against Kant’s ethical principle for us to volunteer to undergo a risky
experiment that threatens our lives without first knowing the nature, safety, or legitimacy
of the experiment. And, of course, suicide is a mortal violation of Kant’s precept.
5. Kant’s distinction between perfect and imperfect duty suggests that some rights should be
recognized. In a doctor-patient relationship, for example, the physician has an imperfect
duty to accept me as a patient; that is, how he discharges his duty is his own decision, his
own prerogative, his own right. Once I am accepted as his patient however, I can make
legitimate claims, e.g. I can demand not to be harmed, not to be lied to or to be deceived,
hence his perfect duty now is not to inflict injury upon me, and becomes his perfect duty to
acknowledge it.

Difficulties of Kant’s Duty Ethics. Despite its being a fruitful source of principles and ideas for
working out moral dilemmas of medical experimentation and practice, duty ethics meets some
 difficulties in certain areas of decision-making.
1. Kant’s principles have no clear way of resolving cases of conflicting duties. For example,
I promise to keep a secret, but someone also asks me about the thing I am supposed to
keep secret. There are now 2 conflicting duties, my duty to keep the secret and my duty
not to lie, or my duty to tell the truth. If I keep the secret, I will be lying or not telling the
truth. If I tell the truth (or reveal the secret), then I will break my promise to keep it.
According to Kant, I should do both. But in such situation, how can I keep and divulge the
secret at the same time?
2. Kant’s ethics presents a notion that we have a duty to treat others as rational beings or
persons. Is a fetus that is developing in the mother’s womb (be it deformed or not)
considered a person? Is an infant born with serious physical deformities a rational being?
3. Kant’s concept of a rational person is the basis of what he calls an autonomous and self-
regulating will Does a newborn baby or a mentally retarded individual have such a will?
What about an insane person? Without such a will, then, the individual cannot
legitimately consent to being the subject of medical research and experimentation. Nor
can he give permission for necessary medical treatment to be taken up on him.

Theory 2. Utilitarian Ethics

 Formulated by John Stuart Mill and Jeremy Bentham
 This ethical doctrine states that the rightness and wrongness of actions is determined by the
goodness and badness of their consequences.
 The utilitarian principle of utility declares “Actions are good insofar as they tend to promote
happiness, bad as they tend to promote unhappiness.” We should consider the possible
effects or results of each action or moral decisions. We ought to choose the action (among
many other possible ones) that produces the most benefits (comfort or happiness) at the least
cost of pain and unhappiness. Some unhappiness or harm may possibly result from the
action we take, but what matters is the greatest possible balance of happiness over
unhappiness for all individuals affected.
 An alternative formulation of the utility principle is known as the principle of the greatest
happiness: “An action is good (right) insofar as it produces the greatest happiness for the
greatest number of people; bad (wrong) insofar as it produces more harm than benefit for the
greatest number of individuals.” Faced with a moral decision, one should not just consider
one’s happiness or benefit, or the happiness of a particular group of persons (like friends or
relatives), but the overall balance of the greatest benefits for the greatest number of people.
As much as possible, equal benefits for the greatest number of individuals must be taken into
consideration. The more people to be benefited by a particular act, the better.

Act and Rule Utilitarianism. The application of the principle of utility or its alternative
formulation in making moral decisions has given rise to 2 types of utilitarianism:
1. Act Utilitarianism – determines rightness and wrongness by weighing the consequences
of the act itself. It takes into account the possible results of each particular act, case or
decision. The act utilitarian asks: “What possible good or evil consequences will result
from this decision or action in this particular circumstance?”
2. Rule Utilitarianism – appeals to a set of criteria, norms, or rules to settle what is the
right, just, and ethical decision to make. It considers the possible results in the light of a
present rule. The rule utilitarian asserts that once a rule has been formulated (e.g.,
“Patients must be told about the nature of their ailment”), then health care professionals
ought to tell the truth, especially if asked to do so. For the rule utilitarian, it would be
easier to decide on what action to take, without much ado or intellectual deliberations.
 Once a certain rule or policy becomes irrelevant to the demands of a new set of
circumstances, however, it will have to be revised, modified, or altered.

In the Medical Context

 Utilitarianism provides a system of formulating, testing, and evaluating hospital policies
and/or regulations, which usually give rise to the enactment of laws, directives, guidelines
and code of conduct. For example, a set of rules is carefully formulated to regulate
medical experimentation with human subjects. With these rules we can legitimize a
policy that promotes the greatest benefits for the greatest number of beneficiaries in
medical research and practice.
 Every now and then, utilitarianism requires testing the worth of directives or policies
depending upon the urgency of demands and contingencies which makes the task of
evaluation and testing easier in some respects as we no longer need to fathom people’s
motives. It also provides a relatively objective test that can considerably help to make our
moral decisions. Utilitarian principle mandates us to make a reasonable effort in weighing
the likely results of alternative, then choose the action that will produce the most
beneficial outcome for all concerned.
 Both act and rule utilitarianism enable us to recognize that some actions and moral
decisions are not necessarily good per se. Their legitimacy or goodness depends upon
the given circumstances, for example, in some cases abortion is right but in others it is
wrong. This flexibility always depends upon the application of the utility principle after
one has thoroughly weighed the possible consequences of the decision.

Difficulties of Utilitarianism
 It seems that the utilitarian principle of utility justifies that imposition of discomfort or
suffering on a few for the sake of the many. That some individuals are inherently more
important than others is obviously implied. In other words, some people’s happiness or
well-being counts more than the happiness or welfare of the ordinary or impoverished
person. This explains why utilitarianism is accused of lacking in the principle of justice. Is
it morally right to increase general happiness at the expense of one human being? Is it
legitimate to sacrifice a few for the sake of the many?
 In weighing the likely consequences of a particular act or decision (as the utilitarian would
like us to do), it is somewhat impractical (if not impossible) to attempt to determine all the
possible legitimate results that must be taken into account before a moral decision can be
adjudged as right or wrong.
 Utilitarianism ignores the motives from which some moral decisions are made. It seems
to endorse that who has the evil motive of cheating someone else is morally justified
provided it has beneficial and desirable consequences for as many people as possible.
This inevitably means that a society in which everybody acts from evil motives but
nonetheless produce desirable results is a good society.

Theory 3. Situation Ethics

 Prof. Joseph Fletcher, an American ethicist and theologian, the advocate of Situation Ethics
 Prof. Fletcher offered 3 general approaches to morality, namely:
1. Legalistic (or normative) – prescribes certain general moral prescriptions, laws, or
norms by which to judge, determine and settle the rightness and wrongness of human
judgments or decisions. It is too restrictive and circumscribed; hence it is inadequate for
and insensitive to the complexity of ever-varying situations in which one finds oneself.
 2. Antinomianism approach – prescribes no absolute precepts or moral principles by which
to be guided in making decisions. It is too liberal and unconventional, which may lead to
anarchy and moral chaos.
3. Situationist approach

 Situationism or Situation Ethics states that the norms depends upon a given situation, but
whatever the situation may be, one must always act in the name of Christian love.
 Three Types of Love according to Fletcher:
1. Eros. Erotic love means sexual love
2. Philia. Filial love refers to the affection that binds a parent to his/her child, a brother to his
sister, a sister to her sister, or among siblings.
3. Agape. Agapeic love refers to one’s care, concern, and kindness towards others.
Christian love, according to the situationists, best exemplifies agape. Love of and for
one’s neighbor (any fellow human) just as Christ himself exemplified is a love which is
concerned for the well-being of another, regardless of his station in life. It is characterized
by charity, respect, and responsibility to and for the other. This is the kind of love which
one should act and settle what is right and wrong, just and unjust, in any complicated
situation.
Why not eros or phiia? These two are biased and partial; they have preferences and
inclinations. They are usually motivated by selfish interests and ulterior motives.
 The most reliable norm by which to settle moral issues is agapeic love, according to the
situationists. Only one thing is intrinsically good, namely love: nothing else. If we base our
moral decisions on it, we can never go wrong. This kind of love goes beyond racism and
religionism, sexism, nepotism, favoritism, kinship, and ethnocentrism.
 Christian love is literally benevolence; it is a matter of loving the unlovable, the unlikable,
the uncongenial, the unresponsive; it wills the neighbor’s good whether we like him or not.
Agape transcends the patient’s outward features or traits, and reaches out to the core of his
being a subject, an I, a fellow human being.
 Of equal importance is Fletcher’s moral principle that “love and justice are the same. For
justice is love distributed.” Love and justice go hand in hand. To love means to be just to
the other we love. If one says that he/she loves someone, but at the same time treats the
latter unfairly, one is not being faithful or honest with oneself, one does not really love the
other in that situation, one loves only oneself. In the context of agape, as we love an
individual, we also care for that person and respect and protect his/her dignity as we expect
the same to be done to us.
 For the situationist, an evil means does not always nullify a good end, for only the end
justifies the means; nothing else; it all depends upon the situation. Circumstances do alter
cases. An act which is right in some circumstances may be wrong in others, that is, we may
do what would be bad in some situations, if, in this one, agape gains the balance. To illustrate
the point, if by lying I can save the life of another person, then by all means I have to lie. (For
obvious reasons, situation ethics justifies and endorses the use of placebos in drug testing
and paternalistic interventions.) If and when the emotional and spiritual well-being of the
parents (husband and wife) and children in a particular family, under a given situation and
circumstance, can best served by divorce or separation, then so be it, as love requires it.

In the Medical Context:

 Situation ethics combines love and justice in treating ill patients. Health care
professionals and personnel should not only be fair to patients; they should also show
loving care and concern for them as well. Agapeic love serves to check selfish motive as
 well as uncaring health personnel; it enjoins no preferential treatment for either erotic or
filial considerations.
 Medical assistance or heath care services is not motivated by kinship, favoritism,
friendship, comradeship, camaraderie, padrino system, utang na loob, or pakikisama. A
patient who seeks medical treatment should be extended help irrespective of creed, rce,
color, or ideology. Health care should be rendered above and beyond monetary gains.
Money should not dictate medical procedures and exigencies.
 People who need immediate medical service should be given their due within the context
of justice and love. Walang palakasan, walang kinikiingan. What ought to be done (not
whom you know or what you can dole out) should be what matters in emergency cases.
 Situation ethics make moral decisions flexible and adaptable to varying situations.
“Circumstances alter cases. One person’s meat is another person’s poison.” What
makes an act good is whether it is expedient, edifying, constructive, and humane, whether
it builds up rather than destroys, condemns, or kills an innocent individual.

Difficulties of Situation Ethics

 Situationism (contextualism) may encourage ethical relativism (i.e., no prescriptive norm),
that is to say, it may serve to legitimize personal interests and ulterior motives in certain
instances among those who make moral decisions.
 Medical misuse and abuse may be surreptitiously committed under the pretext of agapeic
expediency. Advocates of peaceful or easy death may be emboldened in justifying their
unfounded decisions under the circumstances.

Theory 4. Christian Ethics

 Advocated by St. Thomas Aquinas, otherwise known as Natural Law Ethics
 This ethical doctrine teaches that there exists a natural moral law, which is manifested by the
natural light of human reason, demanding the preservation of the natural order and forbidding
violation.
 For the natural law ethicist, the source of the moral law is reason itself, which directs us to do
good and avoid evil; this is called the voice of reason or voice of conscience.

Voice of Reason
 The Christian ethicist professes that the norm of morality is no less than the voice of
reason (conscience). We know we are acting rightly if we heed the voice of reason; we
know we are acting wrongly if we act against it. I know I am doing the right thing, if and
when I follow the voice of conscience; otherwise, I feel a sense of guilt, self-reproach, or
remorse. This explains why the natural law ethicist says we cannot run away from our
conscience, as Judas Iscariot allegedly tried but failed when he betrayed Jesus.
 What is the good? It is that which is suitable to and proper for human nature, according to
Christian ethics. When an act is suitable to human nature, then it is good and it must be
done; whenever it is not proper for human nature, it is bad and must be avoided. How do
we know that a particular act is or is not suitable in nature? By means of whether or not
one is following and obeying the voice of reason (conscience), or acting contrary to it.

Three Natural Inclinations. The good is built into the human nature, and it is that to which we
are directed by our natural inclinations as both physical and rational creatures. The three natural
inclinations are:
 Self-preservation. We are naturally inclined to preserve our life. Herein lies the value of
health care ethics. This natural inclination urges us to care for our health, not to harm or
 kill ourselves, or put ourselves in danger. Thus, any act that violates this basic inclination
is wrong; it contradicts human nature as the Creator has intended it to be. Suicide, self-
immolation, mercy killing or easy death, and putting oneself in unnecessary jeopardy are
by nature evil; whereas any act that promotes health, vim, vigor, and vitality (physical
exercise, walking) on the other hand, is by nature good. Even smoking and habitual
drinking, which are detrimental to one’s health, are not suitable to human nature; hence
they are evil.
 Just dealings with others. Reason by nature leads us to treat others with the same
dignity and respect that we accord ourselves. This is the basis of justice, which arises out
of human relations. Any act of injustice, such as subjecting others to indignities,
degradations, and inhumanities, is against nature. Moreover, all forms of man’s
inhumanity to man, such as exploitation or sexploitation, oppression, seduction,
abduction, deception, swindling, cheating, kidnapping for ransom, murder, rape,
harassment, and intimidation are by nature evil.
 Propagation of our species. We are naturally inclined to perpetuate our species which
is viewed as a natural good. We are obliged not to pervert or thwart this natural
inclination. Each member of the human organism serves a purpose intended by nature.
The reproductive organs (genitals) are by their very nature designed to reproduce and to
perpetuate the human species. Any act or intervention that will frustrate and stifle the
very purpose for which the human reproductive organs have been designed by nature is
unnatural and hence is evil. Accordingly, any form of contraceptive would defeat the very
purpose for reproduction, for it could destroy the human genitals’ reason for being, and
hence its use is against the natural moral law.

The Principle of Double Effect

 One of the three moral principles of Christian ethics which are relevant in the medical
context.
 The principle of double effect applies in a situation in which a good effect and an evil
effect (which is permitted to occur but not directly intended) will result from a good cause.
The performance of such an act (from which a good effect and evil effect will follow) is
considered morally legitimate provided four conditions are fulfilled:
1. The action directly intended must be good in itself, or at least morally indifferent;
2. The good effect must follow from the action at least as immediately as the evil effect;
3. The foreseen effect must not be intended or approved but merely permitted to occur;
and
4. There must be a proportionate and sufficient reason for allowing the evil effect to
occur while performing the action
A very good example is the case of a woman who has an ectopic pregnancy. The life of
the mother can be in danger if pregnancy continues. In the present state of medical
science, only the surgical removal of the fetus can save the mother’s life. It would be
unreasonable not to remove the fetus and let both human lives perish. Right reason
dictates that it is better to save one life than to let both human beings die.

The Principle of Totality (2nd moral principle of Christian ethics relevant in the medical context)
 The principle of totality states that an individual has the right to cut off, mutilate, or remove
any defective or worn out, nonfunctioning part of his body; to dispose of his organs or to
destroy their capacity to function “only in so far as the general well-being of the whole
body requires it.” Under Christian ethics, we have a natural obligation not only to preserve
our lives but also to preserve the integrity of our bodies.
 The Precept “a good end does not justify an evil means”
 Christian ethics teaches that no matter how good an end may be, we may not employ
an evil means to attain it. To inject a lethal drug into a terminally ill patient, supposedly
for purposes of ending his misery, may be argued to be legitimate, but to do so with the
end in view of profiting from his death make the act morally evil. A good act with a bad
motive makes the moral action bad.

In the Medical Context

 The principles of double effect and totality are relevant to the moral issues of medical
experimentation involving human subjects. In human experimentation, if available
scientific data indicate that a sick person may greatly benefit from participating in an
experiment (such as therapeutic research), the experiment is morally justifiable, provided
informed consent is observed.
 Christian ethics prescribe ordinary (inexpensive) measures to be taken in the preservation
of human life. Extraordinary (expensive) measures are to be avoided whenever possible,
if and when these would only subject the patient to years of prolonged pain and agony,
producing him serious physical and mental inutility and uselessness.
 In light of the principles of the inviolability of life and stewardship, euthanasia in all its
forms, along with suicide, is considered immoral. It is presumed to be a direct violation of
God’s dominion over creation and of our natural inclination (hence an obligation) to
preserve life. The outright killing of any innocent individual, whether healthy or unhealthy,
whether desperate, impoverished or terminally ill, even if done at that individual’s own
request, is always intrinsically wrong.
 With the moral precepts of self-preservation and perpetuation of the species, Christian
ethics considers abortion and the use of positive methods of contraception to be morally
wrong. From the moment of conception, the conceptus (fetus) is considered to be a
person with all the rights of a person; hence, abortion at any stage of pregnancy is morally
wrong.

Difficulties in Christian Ethics

 The objection raised against the Christian ethicist’s conscience theory is that conscience
is nothing but the product of one’s moral and cultural upbringing and development, so that
conscience differs from one individual to another insofar as individuals live and grow up in
the different places or situations. This being the case, conscience or human nature is not
a reliable norm of morality even as it implies subjective considerations depending upon
ones own perceptions of reality (e.g., man, the world, God or no-God). Despite the
advocates’ claim that moral principles are objective truths discoverable in the nature of
things through reason and reflection, Christian ethics is virtually an ethical relativism in
disguise.

Theory 5. Pragmatist’s Ethics

 Propounded by William James and Charles Peirce, pragmatism is more of a theory of
knowledge than of morality.
 For the pragmatist, the true and valid form of knowledge is one that is practical, workable,
beneficial, and useful. Being practical, it is one that we can practice and it produces results.
Being workable, it is one that we can put to work; it can be worked out, and it works. Being
beneficial, it benefits people, and being useful, it is one that can be used to attain good
results.
 One can determine whether or not an idea or knowledge is practical, useful, workable, and
beneficial by means of the consequences or results, otherwise, it is inconsequential and
meaningless. For example, the effectiveness or non-effectiveness of a particular drug or
medicine is determined by its effect on a person who takes it.

Concept of Truth
 From the pragmatist’s view “truth happens to an idea; it becomes true and is made true
by events. Its verity is, in fact, on its verification. Its validity is the process of its
validation.” Truth, in other words, is not a quality or property of ideas. Truth is made true
by events and happenings. For example, how can we know whether or not the idea that
“Sprite tastes good” is true? By tasting it, of course. So the tasting process is the
happening or event that makes the idea true. This way of viewing truth bears a startling
significance in the medical context, especially in drug testing. “To test the toxicity or
effectiveness of a particular drug, it must be tested on consenting patients. It is the
process of testing (the event or happening) that attests to its toxicity or right dosage, as
the case may be.
 The pragmatist’s consideration of the practicality, usefulness, workability, and beneficiality
of the true and valid nature of knowledge can render a disparately needed service to
applied or health care ethics by providing a means for settling moral disputes. With
regards the use of placebos in drug testing, or the practice of using humans in medical
experimentation, one may arrive at a decision by raising such questions as: Is it useful
and beneficial to the patients involved in the process, as well as to others who will benefit
from the knowledge to be gained? It is workable and practical? It becomes increasingly
clear that pragmatism may prove to be an effective method of justifying one’s moral
decisions.

In the Medical Context

 One can gauge whether a particular act or moral judgment is right or wrong, legitimate or
not, by considering the practical usefulness and beneficiality to a patient. Should
the patient be told the truth about the nature of his/her serious illness? Or would it be
more practical to withhold the information for the patient’s own good?
 Should lying be a more practical thing to do if by doing so I can save the life of another?
Would it rather be more humane and beneficial for a grossly deformed fetus to be aborted
now than to let it see the light of day only to suffer and live a life of unbearable misery?
With the teachings of pragmatism in mind, we can weigh the situation and circumstances,
as well as the possible consequences of a particular decision, and then make our decision
on these moral problems.
 To be able to determine which contraceptive method is the most effective and reliable
one, for example, family planning personnel and the couples themselves may gauge from
the consequences or results of each method. A survey may be conducted among
contraceptive pill users as well as those who use other techniques. Family planning
centers and clinics have been engaging in these pragmatic procedures.

Difficulties of Pragmatist’s Ethics

 The pragmatist has been accused of too materialistic because of a pragmatic claim that
truth is the cash value of an idea. That being the case, it appears that a moral judgment
is good, or that a decision is right, depending upon the monetary considerations that such
a judgment or decision will incur. We can sense here its relevance to business ethics.
Would a particular decision on a business transaction augment the company’s income?
  Likewise, the pragmatist is accused of being too individualistic. Is a certain act good
simply because it makes a big difference to me or to you? Should we not consider the
difference it makes to others as well? The rightness or wrongness of moral decisions
being determined by their practical consequences, the pragmatist does not give us the
technique or ways by which to weigh the possible effects. This may lead to a capricious
or self-serving judgment which makes it subjectivistic or self-centered.

Theory 6. Ross’s Ethics

 Propounded by William D. Ross, a British scholar and moral philosopher
 In Ross’s view, rightness belongs to acts independent of motives, hence, we speak of right
acts or wrong acts. On the other hand, moral goodness belongs to motives, and we speak
of offer motives. This being the case, it is possible for an individual to perform a right act with
a wrong motive, as well as a wrong act with a good motive. From this we can discern that a
right act is not necessarily identical with goodness. For example, a physician is seen giving an
injection. The act itself is right (a right act), but if said physician is giving that injection with a
bad motive, then the act itself is bad (bad act). In this case, Ross professes that what makes
an act good is if it is done with a good motive (taking into account the other circumstances).
 Then, in considering the rightness of an act, as well as the goodness of a motive, we also
have to determine the circumstances surrounding the act as such, what the injection is, why
he is injecting it. So, if h is injecting the right drug (what) to cure the patient (why) because it
is his duty as a physician to do so (why he is doing it), then his act of injecting is right, and his
motive is good as well. Clearly enough, in making moral decisions, we should stress the
good motive and the right act, and not the consequence.
 Sir David Ross (as his colleagues in the academe call him) offer two principles by which to
resolve cases of conflicting duties. If and when moral rules come into conflict in particular
situations, how are we to determine which one applies? To resolve the question, Ross makes
a distinction between actual duty and a prima facie duty.

Actual and Prima Facie Duty

 Actual duty is one’s real duty in a given situation. It is the action one ought to chose from
among many other actions.
 Prima facie duty (which means “at first view”) is one that directs or commands what one
ought to perform when other relevant functions are not taken into account.
In a particular situation where there are several prima facie duties which we are supposed to
fulfill, since we cannot fulfill 2 or more duties at the same time, we have to determine our
actual duty at a given time. Suppose, for example, that I promised to lend money to a friend in
dire need. It is thus my prima facie duty to hand in the money on that date agreed upon. But
on that day that I am supposed to give the money, my mother suffered an attack of bronchial
asthma, and needs to be hospitalized (which of course entails expenditures). I am now faced
with two conflicting prima facie duties – my duty to fulfill my promise to my friend, and my duty
to bring my mother to the hospital. I could not afford to do both as I have no extra money for
both needs. How would I resolve the predicament? Which of these two duties is my actual
duty in such a situation?

Twofold Principle. We can profit from Ross’s twofold principle in resolving cases of conflicting
prima facie duties.
1. Act in accordance with the more stringent stronger, and more severe prima facie duty.
2. Act in accordance with the prima facie duty, which has a greater balance of rightness over
wrongness compared to another prima facie duties.
 Applying Ross’s twofold principle to my predicament, my actual duty in the example cited is
determined by an examination of the weight of both prima facie duties in conflict. Which one
is stronger of the two? Here we can see that the prima facie duty of promise keeping (as I
have done to my friend) is not absolute, for it can be overridden by a stronger prima facie duty
under certain conditions (such as my duty to an ailing mother in serious condition).

For Ross, we have to rely on our moral intuition as the ultimate guide in particular cases of
conflicting prima facie duties. What we can do in such a situation would be:
1. Learn and discern the facts in the case.
2. Consider the possible consequences of our actions.
3. Reflect on our prima facie duties.
4. Decide on the best course of action under the circumstances.

In the Medical Context

 Whenever health care professionals are faced with cases of conflicting duties (e.g.
paternalistic duty vs. duty to respect patient’s autonomy), Ross’s twofold principle by
which to determine one’s actual duty in a particular situation will be very helpful. It
encourages doctors and nurses to show discernment and sensitivity with regard to the
unique aspects of varying situations before making a moral decision. Ross’s precept
urges healthy people to be judicious, prudent, and flexible in the light of the facts at hand,
then explore the possible consequences of our decisions.
 Also helpful is Ross’s view that a good act or decision is one that is made not only with a
good motive, but with a right act (means) as well. A right act borne with a bad motive is
morally questionable.

Difficulties of Ross’s Ethics

 While Ross’s twofold principle by which to settle conflicting duties is considerably
beneficial and useful, persons differ in their moral perceptions so that his “more-stringent-
duty principle” varies from one individual to another.
 Likewise, a particular duty having the greatest balance of goodness over badness is
nothing but the arbitrary result of heeding one’s own perceptions and there are as many
perceptions as there are so many individuals living in different situations; hence, we are
led back to ethical relativism (i.e., no objective moral principle which is binding on all,)

Theory 7. Rawls’s Theory of Social Justice

 Conceived and espoused by John Rawls, a Harvard thinker
 Rawls built his concept of social morality (which serves as the basis of social justice) on the
ultimate dignity of human beings.
 Health care professionals will greatly profit from his ethics of social justice, particularly in the
relevance to the physician-patient relationship.

The inviolability of an Individual

 First of all, Rawls maintains that every individual is inviolable. This inviolability, which is
founded on justice, is so sacrosanct that not even the general welfare of society can override
or supersede it. The greater good to be shared by all members, for example, should not be
used to justify the loss of freedom of others. In other words, an individual should not be used
as a means in order to attain what is good for others. Every human being is of equal worth.
 Second, an erroneous theory is tolerable in the absence of a better one. This is a case
of choose-the-lesser-evil principle. An act of injustice, for instance, can be tolerated, if and
 only if, it is necessary to avoid an even greater act of injustice. It must be borne in mind,
though, that in the case of a tolerable erroneous theory, it is the only one available at hand,
and so reason dictates that it must be carried out for the sake of those who are supposedly
benefited or affected by it.
 Third, individual liberties should be restricted in order to maintain equality of
opportunity. Without restrictions, some over-ambitious people may use their power, money
and influence against their fellowmen. Restrictions therefore, are intended not to destroy but
to preserve freedom, and amidst these restrictions, equality of opportunity among the citizens
to develop themselves will be best served.
In the Medical Context
 Inasmuch as every individual is inviolable, the patient’s dignity as a human being must be
respected and protected, whether he is indigent or affluent, influential or unimportant, well-
known or unknown. As human being, a patient should not be abused, misused, or used in
order to attain one’s own ends.
 It light of Rawls’s tolerable-erroneous-theory principle interpreted as choose-the-lesser-evil
precept, the prevention of conception so as to prevent the birth of defective babies (in case
either spouse is a carrier of defective genes) is deemed to be morally legitimate.
Contraception with the use of artificial methods so as to prevent the transfer of HIV virus is far
more preferable to abortion in case of conception.
 Rawls’s concept of restricted liberties is very significant in the medical context. Individual
rights are not subject to political bargaining or compromise. Walang palakasan. Restrictions
of individual liberties serve as safeguards against abuses and misuse of one’s own against
others. Walang lamangan.

Difficulties of Rawls’s Theory of Social Justice

 Rawls’s tolerable-erroneous-theory principle or choose-the-lesser-evil precept is subject to
possible abuses by individuals with surreptitious and ulterior motives, by justifying their
acts or decisions, under the pretext of avoiding a greater evil, in order to attain their own
ends and satisfy their own interests.

Ethical Relativism also known as Moral Relativism (by Munson and Paht)
 Claim that there are no universal or absolute moral principles
 Standards of right an wrong are always relative to a particular culture or society. The moral
opinion of one individual is as good as any other for there is no objective basis for saying that
a particular action is right or wrong apart from a specific social group.
 Every culture has its own norm of moral actions. Whether an action is regarded as right or
wrong depends upon the society judging it.
 Ethical relativism contradicts common beliefs and ordinary experiences in several ways. As
an ethical theory it claims that moral principles and/or precepts are relative, and hence are not
binding for everyone, so that even his own view per se is not valid for all.
 In the medical context, when a conflict arises when a patient refuses lifesaving medical
treatment, the propriety of one’s decision is not in question, but rather whether a physician’s
act in violation of that decision is morally proper and legitimate.

___________________
Note: Taken from Chapters 5 and 6, pp. 33 – 63 of Florentino L. Timbreza’s “Health Care Ethics”,
published by National Book Store, Philippines, 2007.
Other Reference: Timbreza, Florentino T. Bioethics and Moral Decisions. De La Salle
University Press, Philippines, 1993.