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The biomedical ethics committee: a search for an ethical theory

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Title:
The biomedical ethics committee: a search for an ethical theory
Creator:
Peters, George Neal
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Language:
English
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48 leaves : ; 28 cm

Thesis/Dissertation Information

Degree:
Master's ( Master of Humanities)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Humanities and Social Sciences, CU Denver
Degree Disciplines:
Humanities

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Subjects / Keywords:
Bioethics ( lcsh )
Bioethics ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 46-48).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Master of Humanities, College of Arts and Sciences.
General Note:
Department of Humanities and Social Sciences
Statement of Responsibility:
by George Neal Peters.

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University of Colorado Denver
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Auraria Library
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19783298 ( OCLC )
ocm19783298
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LD1190.L58 1988m .P47 ( lcc )

Full Text
THE BIOMEDICAL ETHICS COMMITTEE:
A SEARCH FOR AN ETHICAL THEORY
by
George Neal Peters
B.S. Kansas State University 1958
M.D. Northwestern University 1961
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Master of Humanities
College of Arts and Sciences
1988


This thesis for the Master of Humanities degree by
George Neal Peters
has been approved for the
Master of Humanities Program
by
Frank H. Marsh


iii
Peters, George Neal (Master of Humanities)
The Biomedical Ethics Committee: A Search for An Ethical
Theory
Thesis directed by Professor Frank H. Marsh
Biomedical ethics committees (BMECs) have proliferated
since publication of the President's Commission for the Study of
Ethical Problems in Medicine and Biomedical and Behavioral
Research in 1983. Formal application of ethical decision-making
to biomedical problems created by new technology has a short
history of three decades. BMECs need a normative ethical theory
for biomedicine that is compatible with both the science and the
art of medicine. Two ethical theories fran the Enlightenment are
examined from the standpoint of the BMEC. Either alone is found
inadequate. Current moral development theory and autonomy are
examined and found insufficient to serve as ethical theory for
the BMEC. Rule utilitarianism as an ethical theory is found to
be compatible with medicine as science and as art. The
compatibility of rule utilitarianism with scientific reasoning is
explored since both use an inductive reasoning process held to be
common to both philosophy and science by Sir Harold Himsworth.
The ethical theories that were examined were each tested against
a clinical case in which there were grave ethical questions.
The form and content of this abstract are approved and
recommend its publication..
Signed
Faculty member in charge of thesis


iv
CONTENTS
CHAPTER
I. INTRODUCTION......................................... 1
II. THE ENLIGHTENMENT THEORIES........................... 3
Deontological Theory............................... 4
Utilitarian Theory................................. 9
Rule Utilitarianism............................... 13
III. MORAL DEVELOPMENT AND AUTONOMY...................... 15
Moral Development Theory.......................... 15
Reconstructing Moral Development
Theory and Autonomy............................... 20
IV. AN ETHICAL THEORY COMPATIBLE WITH
MEDICINE AS SCIENCE AND AS ART................... 27
The Philosophical and Scientific
Logic of Inductive Reasoning...................... 27
The Compatibility of Rule Utilitarianism
with Science...................................... 32
V. ANALYSIS OF A CLINICAL CASE......................... 39
BIBLIOGRAPHY.......................................... 46


CHAPTER I
INTRODUCTION
Medicine has always been both an art and a science. The
current challenge to medicine as art has arisen because of its
success as science. Many scientific developments have occurred
in the three decades between 1954, when Fletcher published
Morals and Medicine, and 1983 when the Presidential Commission
Report stimulated the development of biomedical ethics
committees.' An example is the mechanical ventilator which
appeared early in this period of history. Mechanical ventilation
can be lifesaving to one individual but only prolong a welcome
death for another. In either setting, society bears the cost.
The current complexity of biomedical decision-making challenges
medicine as art.
The Presidential Commission report stimulated the
development of biomedical ethics committees (BMECs) in many
health care institutions. Their role is 1.) to educate health
care providers in biomedical ethics 2.) to assist institutions
in development of their policies when ethical implications exist
and 3.) to provide ethical consultation in difficult clinical
cases. These committees have been welcomed for the most part
because they fulfill the traditional role of medicine as art.


2
Ethical decision-making, although it has changed form over time,
has always existed in the practice of medicine. One need only
recall the Hippocratic Oath.
Hie composition of committees vary as do their methods
of doing their three tasks. Many committees lack a theoretical
basis which in turn adversely effects their methodology, and
ultimately their effectiveness, in health care institutions.
For over a century, physicians have used physiology as a
theoretical basis for the science of medicine. What is the
theoretical basis, i.e. what is normative ethical theory, for
this aspect of medicine as art? This thesis argues that
1. ) Neither Enlightenment theory alone, deontological
or utilitarian is workable as ethical theory.
2. ) Ethical theory cannot be derived from an under-
standing of moral development and autonomy of
the individual.
3. ) An ethical theory can be constructed that is
suitable for the biomedical ethics committee that
is compatible with medicine both as science and as
art.
A clinical case is presented to test arguments one and
three


CHAPTER II
TTTR BMT.Tf-WI'HJMBWr THEORIES
The concepts of these two theories form the vocabulary
of ethical debate today. An understanding of them is necessary
to acquire the language for this aspect of medicine as art. Much
of our political life, including the founding of our country,
has been influenced by the Enlightenment with its emphasis on
rationality. We are in turn influenced as individuals by our
society through values it holds. The "categorical imperative" as
well as "the greatest good for the greatest number" paraphrases
of Hrananuel Kant on one hand, and J. S. Mill on the other, are
heard today in hospital hallways and conference rooms. Aside
fran their necessity as ethical language, these theories instruct
us because they differ in what they hold to be most important in
ethical decisions. Which is to be regarded as the higher ethical
principle; the action or the result, the duty to the patient, or
the good that can be achieved? An understanding of the
Enlightenment theories forms the basis for further development of
ethical theory that is becoming normative in the biomedical
setting.


4
Deontological Theory
Immanuel Kant was influenced by the skepticism of his
time and thought that it resulted from the error of seeking a
basis of certainty where it could not be found, i.e., in the
O ,
content of experience. Interested in examining the nature of
thought, he concluded that the only ground of certainty was
located in the form of reason itself. We can have certain
knowledge of scientific facts and moral duties, but morality
itself requires an a priori foundation. He believed that the
ordinary moral consciousness reveals to every man that moral
precepts are universal and necessary. Furthermore, they are
valid for all rational beings: "this test of consistency is the
core of fundamental law, the categorical imperative." He stated
this idea several ways, one of which is: "I am never to act
otherwise than so that I could also will that my maxim should
become a universal law." With this principle not only can we
distinguish between right and wrong actions, but it is also an
unconditional directive for our behavior. Further, for Kant it
is the only basis for determining our duties.
Reason, Kant thought, is not intended to produce
happiness but to produce good will? nothing is good (i.e. of
moral worth) in the world except a good will. A good will is not
good because it achieves good results but is so simply by virtue
of the volition; it is good-in-itself. For example, one sees the
right thing to do and does it, as a matter of duty; because it


5
simply is the right thing to do. Despite its failure to achieve a
proposed end, reason recognizes the good will as its highest
practical destination the will to good-in-itself. It is the
supreme good and the condition of every other good, even of the
desire for happiness. Here Kant uses the example of the moral
duty to preserve one's life even without loving it.
Kant cones closer to the problems of a biomedical ethics
committee with three ethical propositions: 1) An act must be
done from duty to have moral worth. 2) An act done from duty
derives its moral worth not from the worth it produces, but from
the principle by which it is determined. (Here the principle
refers to the principle of volition; worth lies in the principle
of the will. Actions and purposes do not have moral worth.)
3) Duty is the necessity of acting from respect for moral law,
i.e., the categorical imperative which is the supreme law of
morality. He rejects what he calls the hypothetical imperative,
wherein the action is good only as a means to something else.
So far, Kant's ethics admit good only in the form of
duty and insists on consistency through the test of
universalizability. He comes closer to social issues, and
biomedical ethical cases in particular, with the practical
imperative, i.e., that we treat all human beings as ends unto
themselves, not as means. The concepts of duty and
universalizability may seem appealing, but the specific
decision-making process of an ethics committee with a case before


6
it is aided little by them, because Kant does not address
specific human values in their multiplicity nor in their
priority. Any given debate tends to be prematurely closed by
accepting the categorical imperative, which can be too
subjective.
A biomedical ethics committee may be relieved to learn
that W. D. Ross has similar concerns about Kant's ethics.^ He
argues that some positions about the nature of actual duties
involve what he calls "serious errors." At one extreme, those he
calls "infallible conscience theorists," including Kant, believe
we can always have immediate or direct knowledge of our actual
duty. whatever the circumstances. To Ross, Kant's theory fails
to take into account the complexity of the concrete situations in
which we must act and also fails to face the fact of honest
differences of opinion about what ought to be done in a given
context. The act deontologist also assumes there is no problem
about selecting one's actual duty from among the variety of moral
claims simultaneously incumbent upon a person in particular
situations. Ross has different criticisms about this same lack
of specificity when he considers act utilitarianism. He regards
both traditional theories as extremes that do not test well in
practice by the plain man. Ross believes that the most we can
expect from anyone facing a moral dilemma is a morally informed
and carefully assessed judgment which is neither certain nor
immediate.


7
Ross believes that intrinsic goodness is an indefinable
quality of things. He contends that rightness is a distinct but
indefinable characteristic of acts and, further, that rightness
is independent of what ever good may result from such acts. Ross
also argues that certain statements about morally right acts are
self evidently true. He calls prima facie duties those which
are known to us intuitively, although he believes we learn them
much as we do mathematical principles. Prima facie duties have
the characteristic of generating moral claims. In the course of
our daily lives we are confronted with conflicting and competing
prima facie duties. What is not self evidently true is whether
one or another of these duties should take precedence. Duties do
not arise in prearranged harmony of ranked priority nor do they
occur singly. Therefore our judgments about right action are
always tentative, but Ross does not intend to convey the notion
that sane duties have a greater claim on us than others.
Ross describes the following prima facie duties without
claiming completeness or finality for the list:
(1) Some duties rest on previous acts of my own.
These duties seem to include two kinds, (a) those
resting on a promise or what may fairly be called an
implicit premise, such as the implicit undertaking not
to tell lies which seems to be implied in the act of
entering into conversation (at any rate civilized men),
or of writing books that purport to be history and not
fiction. These may be called duties of fidelity, (b)
those resting on a previous wrongful act. These may be
called duties of reparation. (2) Some rest on
previous acts of other men, i.e. services done by them
to me. These may be loosely described as the duties of
gratitude. (3) Sane rest on the fact or possibility
of a distribution of pleasure or happiness (or of the


8
means thereto) which is not in accordance with the
merit of the persons concerned; in such cases there
arises a duty to upset or prevent such a distribution.
These are the duties of justice. (4) Sane rest on the
mere fact that there are other beings in the world
whose condition we can make better in respect of
virtue, or of intelligence, or of pleasure. (5) Some
rest on the fact that we can improve our own condition
in respect of virtue or intelligence. These are the
duties of self improvement. (6) I think that we
should distinguish from (4) the duties that may be
summed up under the title of 'not injuring others.' No
doubt to injure others is incidentally to fail to do
them good; but it seems to me clear that non-
maleficence is apprehended as a duty distinct from that
of beneficence, and as a duty of a more stringent
character.
Prima facie right is self-evident, according to Ross, when we
have reached sufficient mental maturity and have given sufficient
attention to the proposition. When we face situations in which
more than one prima facie duty is incumbent, we must study the
situation in order to form a considered opinion that in these
circumstances one is more incumbent upon us than any other; then
we are bound to think that to do this prima facie duty is our
actual duty in a given circumstance. Ross draws a distinction
between prima facie duty and actual or absolute duty; the latter
does not have the certainty of the former.
We come in the long run after consideration, to
think one duty more pressing than the other, but we do
not feel certain that it is so.
Ross dissociates both on a priori grounds and on an empirical
basis the invariant relationship between what is dutiful (prima
facie or actual) and what is productive of the best consequences.


9
But no act is ever in virtue of falling under
some general description, necessarily actually right;
its rightness depends on its whole nature and not on
any element of it.
Certainly, good is not necessarily a product of right
action; Ross offers valuable insight into our nature saying the
plain man fulfills a promise because he thinks he ought to no
thought to consequences even less toward the notion of the
best possible action. Ross gives us rules in the form of prima
facie duties that are useful in analyzing the ethical problems
that occur in the biomedical setting, and he avoids the problem
of conflicting duties inherent in Kant as well. He allows us to
consider carefully and weigh morally each prima facie duty in
relationship to the patient. We can prioritize duties thus
understood and formulate our actual duty to a particular patient
and take an action, understanding that we will always struggle
with conflicting duties and never really be certain we did the
right action. Lacking, however, in Ross' thought is an eye
toward good for the patient in terms of outcome.
Utilitarian Theory
Uiis theory holds that duty and right are defined in
terms of the goods produced rather than residing in duty itself.
Its proponents believe that the greatest aggregate good, as well
as all moral rightness or wrongness, is to be assessed in terms
of the total range of intrinsic value ultimately produced by
actions. In modern form it arose as utilitarianism in the


10
English industrial revolution with Bentham, whose ethical system
supported social legislation of the time. Its most noted
proponent was J. S. Mill, who argued for Bentham's universal
ethical hedonism and added several concepts of his own. Both
regarded universal ethical hedonism as normative, i.e., stating
what ought to be done. Ethical hedonism is the principle by
which actions are evaluated in terms of consequences irrespective
of the nature of the motive of the person acting. This differs
from individual psychological hedonism, which they term
descriptive since it purports to be an account of the actual
motive for behavior. "The greatest happiness for the greatest
number", a paraphrase of the greatest happiness (or utility)
principle, is central to utilitarian theory. The utility
principle is not essential as a motive for conduct, but it is
essential as the rule by which conduct is judged and sanctioned.
Mill says we experience both external and internal sanctions,
when we respond to the forces of reward and punishment or when
we respond to "our feeling for humanity." Hiis feeling, "the
conscientious feelings of mankind," provide the ultimate sanction
for the principle of utility, or the greatest happiness
principle. It cones fron within us, that feeling of pleasure
when a moral law is obeyed and the feeling of pain which
accompanies the violation of it. Mill admitted there was no
logical proof for a connection between the greatest happiness
principle and sanctions; he thought it obvious. His definition


11
of happiness is specifically not a state of exalted pleasure but
rather a life with "few and transitory pains, many and various
pleasures with a decided predominance of active over passive
not to expect more from life than it can deliver having the
foundation of the whole." In answer to the call for personal
sacrifice in Christian tradition he says, "The utilitarian
morality does recognize in human beings the power of sacrificing
their own greatest good for the good of others. It only refuses
to admit that the sacrifice itself is good." When a person
considers his own happiness and that of others, "the utilitarian
requires him to be as strictly impartial as a disinterested and
benevolent spectator." Mill believes we have powerful feelings
of duty that are acquired but nonetheless natural: "There is
this basis of powerful natural sentiment, and this it is which,
when once the general happiness is recognized as the ethical
standard, will constitute the strength of utilitarian morality."
He notes, "next to selfishness, the principal cause which makes
life unsatisfactory is want of mental cultivation." This
cultivation can occur in many ways and he clearly believes in
human progress, ending his essay with reference to "advancing
civilization."
Can we apply act utilitarianism as a theory to
biomedical ethic cases? Mill does not tell us that we do not
have duties to others, only that we are to judge their moral
value by their consequences. Although he admits to qualitative


12
differences in pleasure as well as to Bentham's quantitative
differences, these do not give us a good starting point in the
clinical setting. We are left with several problems with
universal ethical hedonism: 1) the desire of the individual for
happiness will not always promote the interests of society, and
2) even though individuals do desire their own happiness does
not mean that they should act on the desire. Wfe must fall back
on external and internal sanctions here. Can we rely on what
Mill called our internal sanctions? Mill tells us we will feel
pleasure when a moral law is obeyed. The law is to judge the
moral rightness or wrongness on the basis of consequences
irrespective of the motive. The problem with internal sanctions
is that they are ultimately related to Mill's moral law, i.e.
the principle of utility, the greatest good for the greatest
number. Act utilitarianism lacks a method, or at least a
recognition that whether we judge right from duty or from
utility, in specific circumstances we have no way to arrange and
prioritize the goods or consequences of action. J. C. C. Smart
solves this problem, for himself at least, by defining the
greatest happiness principle as a "rule of thumb" that cannot
always be used. Even though we cannot always, we should be act
utilitarians most of the time. Since Mill, many kinds of
intrinsic value other than happiness have been accepted. G. E.
Moore mentions friendship, knowledge, courage, health, and
beauty. Wfe recall that Ross criticizes both Kant and Mill when


13
he elaborates on the prlma facie duties. He regards the idea
that whatever maximizes good as too simple for the diverse
circumstances we face. He observes that utility is more like the
prima facie duty of beneficence and that it occurs concretely in
situations with other duties.
Rule Utilitarianism
Modern rule utilitarians, such as Beauchamp, hold that
"the greatest aggregate good, as well as all moral rightness or
wrongness, is to be assessed in terms of the total range of
intrinsic value ultimately produced by an action" or paraphrased,
"what is the utility of observing a rule?"^ The conformity of an
act to a valuable rule (prima facie duty) makes the action right,
but its rightness is determined by good achieved. In concrete
situations, the rules are not in priority order, nor are they
single, and we must rely on our own intuition to separate and
order them. By ordering the principles of autonomy, beneficence,
nonmaleficience, and justice, we may select the proper principle
in a given case in terms of an expected good. The good achieved
for the patient as an outcome is the measure of rightness or
wrongness of the choice of rule.
Currents of both Enlightenment theories run deep in our
moral thought in terms of language as well as by the appeal of
their first principles. Neither is wholly acceptable as
biomedical ethical theory, however, because each alone
incompletely addresses concrete human situations. The clinical


14
settings in which we find ourselves are complex and involve
certain obligations or duties to patients that are expected or
even mandated by law. In addition we must look to the best moral
outcome just as we do toward the best biomedical outcome. These
are too interrelated to be ignored. We cannot judge the
rightness or wrongness of a decision or an action exclusively in
terms of duty or of good.


CHAPTER III
MORAL DEVEttSWENT AND AUTONOMY
Each theory considered thus far depends on human
intuition or rationality at its core. Kant believes we know what
is right and wrong action. Mill believes we have internal
sanctions that are obvious. The whole question of development of
human beings in ethical decision-making would appear to be a
fertile area to explore for an ethical theory. If we understood
the nature of human moral development, we could possibly be
closer to a normative ethical theory. An understanding of the
nature of the autonomy of human beings likewise may also lead us
to an ethical theory as well.
Moral Development Theory
In 1932 Jean Piaget described development from the stage
of heteronomy of young children, who abide by extended rules laid
down by adults, to the stage of autonomy where rules are outcomes
of free decisions worthy of respect to the degree that they have
achieved mutual consent. The influence of adults and their
authority regarding right and wrong is essential for the
development of autonomy. Broadly conceived a child passes
through a hierarchy of three stages: 1) when he equates


16
fairness with whatever an adult asks or commands, 2) when his
judgments are made strictly in terms of equality, and 3) when
he weighs all relationships and circumstances in questions of
justice, the stage of equity. At this point he is free of
external forces and is autonomous in his moral judgment. It is
clear in this theory that morality is a cognitive development,
and hierarchial as well.
Rather than watching children play marbles as did
Q
Piaget, Arthur Kohlberg questioned children. He used stories
with moral dilemmas to evaluate the reasons they gave for their
decisions about which action was right or wrong. He was
interested in the reasons given and did not concern himself with
behavior statements. His theory did not differ from Piaget in
basic methodology but perhaps expanded upon it. Kohlberg
described three levels of morality. 1) preconventional, 2)
conventional, and 3) post conventional, which is an autonomous
or principled level. He describes an orderly development
through six stages to reach the postconventional level.
Level 1 - Preconventional
Stage 1 Heteronomous morality
Stage 2 Individualism, instrumental purpose, and
exchange
Level II Conventional
Stage 3 Mutual interpersonal expectations, relationships
and interpersonal conformity


17
Stage 4 Social system and conscience
Level III Post conventional, or principled
Stage 5 Social contract or utility and individual rights
Stage 6 Universal ethical principles
Kohlberg's studies have shown four qualities of stage
development. 1.) Stage development is invariant. One must
crawl before one walks 2.) Subjects cannot comprehend moral
reasoning more than a stage beyond their own 3.) Subjects are
cognitively attracted to reasoning one level above their own
predominant level. Doing such is cognitively more adequate
because it resolves the problem in a simpler way. 4.) Movement
through the stages is affected when cognitive disequilibrium is
affected, when one's outlook is not adequate to cope with a given
dilemma. Kohlberg's theory ends with autonomy and justice at the
pinnacle of morality.
In the biomedical ethical setting, such a theory leaves
us little discretionary room in decision making. For instance,
is there any role for beneficence, or doing good? Are autonomy
and justice too abstract in Kohlberg's sense to be useful in
biomedical ethics? Do they fit our experience? The patient
whose autonomy is compromised may not fare well under a theory
that does not value what good may be done for him on his behalf.
Particularly lacking is the value of cooperation.
In part, answers to these questions arise from study of
criticism of Kohlberg's theory. R. S. Peters regards Kohlberg's


18
work the most important done to date despite its inadequacy.
He says much of moral philosophy in the past has been
unconvincing because it has not dwelt sufficiently to the
different views that can be taken about what is morally
important." He calls for a pluralism: "We are bewildered by
monistic theories such as utilitarianism or some version of
Kant's theory in which the attempt is made to demonstrate that
one type of justification can be given for everything which there
are reasons for doing or being." In other words, these theories
are too simple and never quite ring true. He says of Kohlberg's
work: 1.) it is the most important done to date; 2.) it fails
to spell out certain points in detail; 3.) there is much more
to morality than is covered in his theory; 4.) generalizations
may be true only in the area of morality in which Kohlberg has
concentrated his attention. Peters questions whether there are
invariant sequences of moral development that hold in any
culture. He questions the order of development and, more
importantly, Kohlberg's belief that although content can be
taught, that moral development is cognitive. Peters says this is
too narrow a definition, an over-rigid definition of teaching.
He also questions Kohlberg's belief that character traits are
relatively unimportant in moral development and that processes of
habit formation are of secondary importance. Kohlberg also
downplays virtues, defying a long tradition of moral development
beginning with Aristotle. Justice is abstract, and moral


19
education would look differently if it focused on concern for
others. Peters believes rules without motivation are pointless.
He thinks Kohlberg pays too little attention to the intimate
connection between knowing the difference between right and wrong
and caring:
How do children cone to care? 'Hiis seems to me to
be the most important question in moral education; but
no clear answer to it can be found in Kohlberg*s
writings.
Lastly, Peters asks if Kohlberg is prescribing a morality because
of his focus on autonomy leading to justice in the hierarchy of
stages. Kohlberg*s moral development theory might therefore be
considered one-sided in that it has been erected on features of a
limited interpretation of morality:
A further point must be made, too, about any moral
system in which justice is regarded as the fundamental
privilege: it cannot be applied without a view,
deriving from considerations, other than those of
justice, about what is important. 2
Here we have a theory based on justice and autonomy.
One is reminded of MacIntyre's lament that the only value of
virtue is that it allows the choice of the proper set of rules to
follow.^ At the level of biomedical ethical case consultation,
the principle of justice is a vexing one. Robert Veatch in his
contract theory of the physician-patient relationship wants
allocation of resources (justice) to patients kept at the policy
making level to prevent a dramatic conflict of interest between
the patient and the physician.^ It should be excluded from the
doctor-patient relationship. Even if it isn't, the physician


20
usually makes ethical decisions as if the principle of justice
were not there, or at least he rank orders it last as an actual
duty in the sense that Ross uses the term.
Reconstructing Moral Development Theory
and Autonomy
Carol Gilligan takes us a step beyond criticism of
Kohlberg's moral development theory with reconstructions of its
bases of autonomy and justice in her essay "Remapping the Moral
Domain: New Images of the Self in Relationship.The self and
morality as conventionally defined are in terms of individual
autonomy and responsibility, enabled by will, and guided by duty.
This definition presupposes a reciprocity as expressed by the
categorical imperative. Gilligan sees a problem with an
individual's ability to put himself in another's position; this
implies a capacity for abstraction or generalization as well as a
conception of moral knowledge that always refers back to self.
To her it seems odd that the self stays constant despite its
transit to the place of the other. Too great a value on
detachment exists, "The self, although placed in a context of
relationships, is defined in terms of separation."
Gilligan says: "coming to know others and self is
different than the joining of stories." She describes two
conceptions of morality, and of the self, that lead to different
ways of understanding loss and conflicts of loyalty that arise in
human life. There is the possibility of generating new knowledge


21
and transforming the self through the experience of
relationships. Although empirical evidence supports this
concept, it is not represented in conventional moral development
theory partly due to the image of relationship in the concept of
self. Hiis is a "mirroring" image, to Gilligan a lifeless one,
which emphasizes that we discover self in the other's recognition
devoid of attachment, intimacy, or engagement. In her theory,
"the self is known in the experience of connection defined not
by reflection but by interaction, and responsiveness to human
engagement." Interdependence takes on a new meaning overriding
the traditional contrast between egoism and altruism. In her
studies, two moral "voices" could be distinguished in the way
people framed and resolved moral problems and in their evaluation
of the choices they made -
One that speaks of correction, not hurting, care,
and response and one that speaks of equality,
reciprocity, justice and rights.
These appear in conjunction and in tension, evident in the
confusion in their intersection and in the tendency for one voice
to predominate. Hie pattern of predominance is gender related
but not gender specific. She suggests that these differences in
moral reasoning signify differences in moral orientation which
are tied to different ways of imagining the self in relationship.
Hie values of justice and autonomy, presupposed in
current theories of human growth and incorporated into
definitions of morality and of the self, imply a view
of the individual as separate and of relationships as
either hierarchial or contractual bound by the
alternatives of constraint and cooperation. In


22
contrast, the values of care and connection, salient in
women's thinking, imply a view of the self and the
other as interdependent and relationships as networks
created and sustained by attention and response. 7
In this theory, dependence, rather than a failure of
individuation, denotes a decision on the part of the individual
to enact a vision of love. It is to be there, to help, to talk,
to listen. Of course only one voice can speak at a time, but we
have another voice of self than that which we hear in the
dominant moral development theory.
An attempt to add motivation or virtue by R. S. Peters,
and an expansion of the self and autonomy as well as justice by
Carol Gilligan, suggest the inadequacy of current moral
development theory with its deontological basis. A contemporary
biomedical ethics committee will hear much discourse about duties
to the patient and patient autonomy. A committee should remember
that autonomy is only one ethical principle which is as subject
to scrutiny as the others.
Many contemporary physicians became aware of autonomy
from its derivative, informed consent. As a concept, informed
consent is rooted in many disciplines according to Faden and
Beauchamp; the most influential are moral philosophy and law.18
Ihe law treats informed consent as the duty of the physician,
the omission of which he is liable for, particularly in the event
of an unfavorable medical outcome. The moral philosophical
point of view, defined by these authors, is that a substantial
part of informed consent is the authorization by a patient or a


23
subject for action by another agent, the physician. The
dominant ethic of physicians in the past has been beneficence,
doing good for the patient. We now regard Percival's 19th
century ethic of beneficence as paternalism, but this change of
attitude is recent and not yet universal.-^ Although it is a
pragmatic legal requirement, the daily need for a patient's
informed consent serves to illustrate the concept of patient
autonomy. Carleton Chapman sees "a patient-centered principle
of medical ethics" developing; and although it came from outside
the profession, it is fast becoming essential to the integrity of
Of)
the profession at the present time.
Chapman says we must at least recognize that we have
been operating under the illusion that beneficence is our primary
ethical value when autonomy should be. Precedents developed in
the legal system through malpractice law should drive us to do
our ethics better. Further, we must adopt this concept in order
to retain professional status. Otherwise, we risk a return to
the status of craftsmen. In ethical decision making the
principle of patient autonomy appears to have become dominant at
this time. Implicity, in the case of W. D. Ross, and explicitly,
in the case of Daniel Callahan, physicians are warned not to
make autonomy the only ethical principle or the "trump card" that
always supervenes when balancing ethical principles.^*
Autonomy and individualism themselves are rightly the
object of reassessment. Thomas Heller and David Wellbery


24
introduced their assumptions in planning a conference entitled
"Reconstructing Individualism", at Stanford University in 1984.
They are 1) the long-held conception that the individual human
subject is a maker of the world we inhabit; 2) the
individualist order of the modern Western world has met with
challenges that have rendered its beliefs and doctrines
problematic; 3) and the concept of the individual needs to be
rethought in the wake of severe criticisms. They believe that
an "alternative conceptualization of the experience of
subjectivity will develop through discussion in the form of
humanist conversation." Nothing revolutionary here, but perhaps
the recognition that unchecked individualism (and autonomy) have
not served humanity all that well. Oheir thesis is that autonomy
and individualism can and will be reconstructed. How might that
reconstruction go?
J. B. Schneewind's essay, "The Use of Autonomy in
Ethical Theory," recognizes that autonomy came into the moral
no
vocabulary rather late in human history. He recognizes that
its origins are in political thought, in the ability of a society
to make its own laws. How does a political concept of autonomy
translate to ethical theory? Kant believes self governance is
necessary for human beings who are not dependent on society. He
sees, as well, that self governance creates the moral
responsibility that makes our actions right or wrong. Schneewind
defends autonomy-centered views of morality against three


25
criticisms; 1.) The assertion that because autonomy-centered
theories require the self to be completely unindividuated means
that morality is a matter of abstract universal rules. He
counters that universalizability of moral judgments is "at best a
logical or conceptual matter." Unique personalities are
sanctioned here as well as in any other theory. 2.) Autonomy-
centered theories make too much of individuality and separateness
of persons. Such views threaten community. Here he asserts we
are misreading the traditions of autonomy (Butler, Kant, Rawls).
In fact, a culture is required in which the moral self can look
critically at that very culture. The moral self is not the
whole self; the categorial imperative primarily gives us a test
for a proposal for action from the empirical self. 3.) Only an
inadequate morality can emerge from autonomy-centered theory
because of its impoverished conception of self. Here he says
critics fail to see that the self can sustain and is morally
constituted by precisely the tension between serious commitment
to its contingent likes, loves and loyalties and its equally
serious commitment to the idea of a comprehensive human community
in which no one's project need be unjust." Here Schneewind
suggests that the commitment to an individual ethos is itself a
social project open to substantive moral evaluation.
The moral developmental theory of Piaget and Kohlberg
does not provide a basis for an ethical theory for the biomedical
ethics committee. Autonomy becomes the dominant value as pointed


26
out by Peters and Gilligan with little attention to motivation,
interpersonal relationships, or doing good. The same deficiency
is evident in the attempts of Schneewind to defend and
reconstruct the concept of autonomy itself. Hie clear view of
W. D. Ross is valuable here. He says ethical problems come to us
in multiplicity and without priority. In other words, ethical
problems are complex and require a broader theory than one based
primarily upon autonomy.


CHAPTER IV
AN ETHICAL THEORY COMPATIBLE WITH MEDICINE
AS SCIHICE AM) AS ART
The differences in thinking in science and philosophy
require exploration. These can be illustrated by the
descriptions of science and philosophy given by Leo Tolstoy in
his despair over death which he experienced after writing his two
great novels.^ Frustrated and depressed over the reality of
death, he sought answers about the meaning of life in both
science and philosophy. He failed, saying that science has the
means of finding answers to the questions it poses to itself, but
these questions and their answers have no relation to the meaning
of life. Philosophy poses questions about meaning in life but
its answer is that life in itself has no meaning.
The Philosophical and Scientific Logic
of Inductive Reasoning
The problem may be restated as follows: Are there two
kinds of problems the scientific and the philosophic, each
requiring different methods for solution? Or are there two
different ways of approaching a problem each yielding a different
answer according to the method used? Sir Harold Himsworth
encourages scientists to use scientific methods in solving


28
problems which are considered philosophical.^ In effect, he
says one should use the scientific method in ethical decision
making. He believes that answers differ because of the
methodology used in arriving at them, not because there are two
different kinds of questions. If he is correct, a secure
foundation for the development of a theory for biomedical ethics
is formed. Indeed such a theory would be very compatible with
scientific medicine.
Sir Harold examines intrinsically fundamental thinking
that relates to the scientific method as well as to the
philosophical method. His argument for the usefulness of the
scientific method in defining values is based on his
understanding of inductive reasoning. He asks us to consider the
possibility that failure to advance in a particular field may be
due not to its problems being more difficult, but due to
inadequacies in the method customarily used. Here we are
reminded of the current status of biomedical ethics which has
advanced in terms of discussion. But does it have a solid
methodology for future progress?
In 1748, David Hume destroyed the belief on which
knowledge then rested: "that in light of past experience it is
possible to infer from present events what will happen in the
future."^ Human knowledge rests on the causal relationship
between events; science justifies this view even though Hume's
logic refutes it. He argued since it could be conceived that


29
nature might change her ways it was no longer possible to
consider cause and effect valid. Sir Harold points out that Hume
did not ask what the consequence to cause and effect would be if
nature did not change. He faults Hume for not subjecting his
logical conclusion that there was no logical basis for causal
relationship between events to a test of evidence available to
him at the time. At that time, Newton's law of gravity was known
as was the weight of the atmosphere. Had the law of gravity
disappeared there would be no atmosphere and no life to observe
nature's unrealiability. Sir Harold says:
In consequence, the proposition that the cause of
nature might change, although logically irrefutable, is
irrelevant to any enquiry into the development of
understanding.. .as long as humans exist they can count
on the future resembling the past and, hence, can
implications of his proposition. Sir Harold carefully points out
that both philosophic and scientific questioning are based on
logic and we must not discount what we don't like. Fortunately,
both on a philosophic, logical basis as well as a scientific
basis, we may continue to believe in cause and effect and
predictability to a large degree.
recognizing that it has heretofore failed the test of logic. He
thinks he has established a logical basis for it. Inductive
reasoning is critical in science and in medicine because one
the course of future events fran past
Hume failed here to take into account the full
Sir Harold examines Bacon's inductive reasoning process


30
works from particulars of cases to general principles. From
observations of things and happenings around us, we acquire a
knowledge of individual facts. These lead to general
implications that bear on a particular problem. We then
formulate an hypothesis regarding the solution of the problem.
Wfe then deduce what might follow if the hypothesis is correct and
see if it is by observation. There are two successive steps;
1.) hypotheses are formed and 2.) put to the test of further
experience.
Men do argue fran the particular to the general,
and judging by the achievements of scientific research
do so successfully on what basis do they do this?28
Making sound generalizations depends not on
thought, but on observation. The order in which things succeed
each other is as much a matter of fact as the existence of things
themselves. Furthermore, we are justified in thinking that any
generalization made regarding the duplications of a particular
thing will, insofar as it reflects factual observations, continue
to be true as long as human beings exist.
In other words, man is a pattern forming animal,
and the patterns into which he orders the data supplied
to him by his senses or memory are dictated bv his
experience of how things in nature fit together."
Observation preceding hypothesis formation is important in a
later construction that uses inductive reasoning in biomedical
ethical decision-making. Sir Harold's argument for induction
being a logical process is important as well.


31
It follows, therefore, that, before the intellect
can operate, it must already possess information about
what ideas or concepts are compatible and what are not.
This information derives from the generalizations man
has reached as to what kinds of things go together in
nature and what do not. These are the generalizations
that lie at the basis of the process of induction. For
of what does induction consist but of fitting together
of ideas and concepts into patterns that accord with
the way experience has taught man matters are ordered
in nature? Inasmuch as inductive thought involves
joining ideas and concepts that are compatible and
rejecting those that are not, it is therefore, a
logical process.30
The test of validity of the induction or hypothesis still lies in
observation.
Sir Harold, then, tries to base values and value
judgments in nature and thus to make them accessible to
observation and scientific questioning. He starts with G. E.
Moore's argument that good is not a property of things by
themselves but an attribute with which individuals invest them in
virtue of their own predilections. This is the essential
distinction between properties and values. Buttressed by
Darwin, William James, and Wilfred Trotter he tries to arrive at
an objective explanation of value judgments.
It would seem, therefore, that any idea that comes
to be held in common by a group of men will, ipsofacto,
require an ascendancy over their thought processes.
Thereby it is translated from the status of a concept
to be considered in the light of evidence to that of a
belief which it is morally incumbent on them to accept.31
Society does have a hold on us and our ethics reflect this fact.
The test of validity of "any idea that comes to be held in
common" is factual experience.


32
In short, concepts reached by abstract thought,
however logical, have no title to validity save
insofar as they are endorsed by factual observations.32
Both philosophy and science ask questions. These
questions are not inherently different but they may be based on
different suppositions and divergent answers are frequent.
Sir Harold sees this as a matter of method.
Given the propositions from which science and
philosophy start, both are equally logical. Where
they differ is in their approach to the suppositions
that underlie their propositions. To the scientist, a
proposition is scsnething to be investigated; to the
philosopher, something (provided it is not illogical)
to be accepted as a basis for thought.33
Can we do biomedical ethics in a scientific way? 1.) Can we
use inductive reasoning in solving biomedical ethical problems -
hypothesis formation? 2.) What role does observation play in
biomedical ethics?
The Compatibility of Rule Utilitarianism
With Science
As an ethical theory for the BMEC, rule utilitarianism
provides two distinct advantages that make it compatible with
medicine as science. These are 1.) In general, its thought
process concerns itself with both action and good achieved for
the patient allowing it to be used as a scientific thought
process of hypothesis formation and observation. 2.)
Specifically, it very closely parallels the differential
diagnostic process that physicians use in patient care. This
process is inductive and is essentially that which Sir Harold


33
Himsworth describes and argues for its logical basis. If we have
a philosophical approach that is logical, albeit inductively,
that closely parallels the medical problem solving process, i.e.
differential diagnosis, we have a high degree of compatibility.
Members of BMECs tend to regard themselves as problem
solvers. The differential diagnostic process is evident at work
in most BMECs. This is partly because of the number of
physicians present, and partly because of the medical aspect of
the complex bioethical problems brought to it. Another reason is
that non-physician members, e.g. nurses and administrators, use
essentially the same thought process in their problem solving.
Problem solving is essentially an inductive process, and we are
on common ground in committee despite being in different
disciplines.
What is the differential diagnostic process and how is
it inductive? Patients present themselves to physicians with
symptoms, and signs can be appreciated from physical examination
as well. These two sources constitute observation of facts.
These products of observation may form a pattern which can be
recognized as a disease entity. From past experience, the
physician knows that there are clusters of conditions or
diagnoses that are similar. Differential diagnosis is the act of
rank ordering these possibilities from most likely to least
likely. Once a choice is made, the physician devises sane means
of proving it correct. A hypothetical diagnosis is established


34
and tests are devised (observation) to establish whether the
hypothesis is correct or not. For an example: a female patient
presents in the emergency department with abdominal pain. Since
only one percent of patients with abdominal pain ultimately have
acute appendicitis, observation of more symptoms and signs are
necessary. If the pain is followed by vomiting, and if the pain
moved to the right lower abdomen we are approaching the picture
of acute appendicitis. If the abdomen is very tender and guarded
in the right lower quadrant on physical examination, we have the
most accurate predictor of acute appendicitis. An elevated white
blood count is reassuring even though rarely it is not elevated
in acute appendicitis. There is a great overlap in symptoms and
signs between viral gastroenteritis, ovulation pain, and pelvic
inflammatory disease. No one fact of observation above
establishes the diagnosis. The diagnosis or hypothesis is
arrived at by assembling the observations into a pattern
inductively. The test by observation is an operation to examine
and remove the acutely inflamed appendix. In other diseases, a
test of one sort or another would be used to test the hypothesis
of diagnosis. Differential diagnosis is a problem solving
thought process that we all use in the health care setting. In
fact, our mechanics use it in evaluating our carburetors, but
they call it trouble shooting. It is an inductive process aimed
at testing the hypothesis.


35
How does rule utilitarianism parallel the differential
diagnostic process, specifically, and scientific thought in
general? First, although rightness of an action is judged by
good achieved, the propriety of the action is considered as well.
Second, a selection process or prioritization of ethical
principles occurs when one asks "What is the utility of the
rule?" The rule must be selected that is the best hypothesis in
the case. Many facts about a given patient aside from medical
ones supply the observation that allows a hypothetical rule to be
chosen. Once again, W. D. Ross helps us with the ethical
principles of nonmaleficience, autonomy, beneficence, and
justice. Usually one of these must predominate for any sort of
action to be taken. Seldom is the choice of rule clear cut;
usually two principles are in tension, and frequently they are
autonomy and beneficence. Ultimately, one is chosen with a
residue of discomfort for committee members. An action occurs, a
decision is made to do something or not to do something, and then
the rule as hypothesis is tested or observed. Was it the right
action or decision? Since rule utilitarianism relies on good
achieved as the measure of rightness, observation of results is
critical. There are ways of testing the decision to follow one
principle or another in an ethical decision. Was it consistent
with past cases? Was it within the law? Does it seem correct
two weeks later? Does the patient agree with the decision? Does
the family? Do the caretakers of the patient agree, the nursing


36
staff who have the closest contact? Would we make the same
decision next time if the same observations were made that lead
to the rule hypothesis? Utilitarians have always been willing to
make ethical decisions predictively, and to await validation of
their predictions. In the biomedical setting there is ample
opportunity and, indeed, the obligation, to observe the result of
a decision. Following such a thought process allows us to learn
fran decisions.
Hie requirement that ethical theory be normative, to
function in the realm of the "ought", is much easier to accept if
the theory is compatible with medicine as both art and science.
Singer sees no contradiction in the notion of ethics as a
normative science any more than there is in the notion of a
normative judgment. William James agreed almost a century ago
when he said, "Everywhere the ethical philosopher must wait on
facts."34
Sir Harold is optimistic about solving problems with the
objectivity of science.
It would seem, therefore, that, if man is ever to
attain a degree of control over problems that derive
fran his own activities, comparable to what he now has
over those imposed upon him by factors in his natural
environment, it will onlv be by approaching them in a
comparably objective way. 5
In a sense, biomedical ethics has become a science in
part already. Singer believes there is nothing essential to the
nature of ethics that should prevent such a development from
taking place; he expects to find a scientific ethics with its


37
philosophical part and moral philosophy with its scientific
part.He conceives biomedical ethics as a branch of medicine
that deals with ethical problems arising "in and out of the
practice of medicine as those arising about the practice or
institution of medicine itself."
In order to consider Sir Harold's thesis applied to
biomedical ethics as potentially using the scientific method in
ethical decision making, one must accept that inductive reasoning
has a logical basis. The establishment of an hypothesis must be
a rational, logical process. However, Popper, who is a noted
philosopher of science, disagrees believing that the formation of
an hypothesis is intuitive.^ I do not think we should be
dissuaded from the use of rule utilitarianism in the fashion
which I described. If nothing else, use of such a process allows
a casuistry to develop, a background of precedence valuable in
ethical decision making. Albert Jonsen supports such a
development in his recent text. Describing clinical biomedical
ethics as scientific, objective, or casuistric makes little
difference. We should be content to know that neither
Enlightenment theory alone will address the problems that the
biomedical ethics committee faces now or in the future. Ethical
decision making must be an ongoing process in which we must test
our hypothesis which led to a right action with observations of
moral outcomes. We should also be comforted that at their heart,
the Enlightenment theories rely to some degree on our human
intuition. We should not fear ourselves in this regard. There


38
is no single ethical theory that has served us well in biomedical
ethical decision making. Knowing this frees us to innovate.
Most of us find ourselves thinking along the lines of the rule
utilitarians, a theoretical basis that serves us well for the
moment. Further ethical theory will develop which will continue
to be compatible with science. After all, ethical theory is a
product of ethical activity in part.
No ethical theory can logically make the step fran "is"
to "ought"; i.e., none can claim to be actually normative. In
biomedicine, ethical activity tends to produce normative ethics.
In particular, the process of ethiqal decision making itself is
becoming normative as decisions are made the same way over time.
There is danger of stasis in a casuistry of normative biomedical
ethics, but the rapid change in biomedicine will tend to offset
complacency and the rigidity that might otherwise develop.
Biomedicine and its biomedical ethics may be the birthplace of
ethical theories that have an even broader application for
humankind in the future


CHAPTER V
ANALYSIS OF A CLINICAL CASE
The following case is brought before a biomedical ethics
committee at a general hospital for a retrospective review:
An elderly man of undetermined age is brought to
the emergency room. He is chilled and shaking. His
feet are frostbitten and his clothes are dirty. There
are decubitus sores on his major joints. The man was
found lying in the doorway in the street. The body
temperature was diminished to 92. There was a smell of
alcohol on his breath and overall he appeared to be
extraordinarily malnourished. There was no family
member available and no identification on the
individual. He had a chest x-ray which showed
bronchopneumonia bilaterally. His roan air blood gases
showed a PCO2 of 44, a PO2 of 46 and a pH of 7.36.
(The patient has insufficient oxygen in his blood to
sustain life.) He was completely comatose with no
response to pain or spoken word. Because of the
obvious marks of a derelict and lack of family members,
the physician in charge judged that intervention was
not appropriate for this individual. Therefore, he
treated him with intravenous fluids, antibiotics and
oxygen, but withheld mechanical ventilation. In his
judgment he felt the patient needed ventilation, since
his PCO2 rose to 60 with the oxygen. The decision to
withhold was based on the fact that this man was
apparently without family and home, living on the
streets and his condition was probably not amenable to
therapy.
We are not told the outcome in this case. With a
rising PCO2 on oxygen, but without mechanical ventilation, the
patient could well be dead shortly. Specific issues that would
be raised by a biomedical ethics committee are 1.) Is one
justified in making this kind of decision based on the medical


40
condition and on the lifestyle as well? 2.) Should lifestyle be
used as one measure for implementing effective cost containment
policies?
For the purpose of this analysis our patient is who he
is, both dirty and ill. Aspects of his condition cannot be
separated. From the standpoints of act deontology and act
utilitarianism the answers as to whether to ventilate or not are
abrupt and sure. In one case, the "categorical imperative" has us
treat the patient as aggressively as we can. In the other, "the
greatest good for the greatest number" has us withhold the
ventilator for the next patient who will likely be more treatable
or more worthy, or both. Unfortunately the result of either
theory seems to prematurely close debate on the specifics of the
clinical and ethical problem. It should be noted as well that
decisions were opposite, and in either instance the decision
makers would carry a large residual of doubt. What makes a right
act right? If we are to labor at the level of the first
principles of Kant and Mill we will indeed labor long and in the
dark.
Ross' prima facie duties help us greatly. When they are
translated into ethical principles they begin to allow a method
for solutions to clinical problems. Prima facie duties can be
understood as nonmalificience, beneficience, autonomy, and
justice. We may now consider this case from two standpoints that
incorporate all these principles and allow us to prioritize them.


41
Both rule deontological and rule utilitarian theories use these
ethical principles.
Buie deontology holds that the heart of morality is a set
of binding principles that classify acts as right or wrong. The
problem with this approach is that one cannot look to good
achieved for the patient or society; and that rightness or
wrongness resides only in duty or obligation, in the act itself.
To properly prioritize the ethical principles in a given case is
always difficult, particularly so when the good achieved is not a
measure. Not doing harm (nonmaleficence) certainly would hold
great weight for the rule deontologist in a clinical problem such
as our patient's. Would we be doing him harm by subjecting him to
mechanical ventilation? An endotracheal tube or tracheostomy
would be uncomfortable if he began to improve, but these are
minimal harms compared to preserving his life, his autonomy.
Other supportive measures he would undergo, such as decubitus care
and nutrition, would be of little discomfort for him when he
became alert again. But have we harmed him by saving his life
only for him to lose it again on the streets? In rule deontology,
this question is avoided because goods achieved are not criteria
for whether a given act was ethically right. What about his
autonomy? Unfortunately, he cannot tell us his preferences, so we
are left with a substituted judgment as to whether he would want
to be ventilated and possibly live, or whether he would rather
w
die. Autonomy is a very strong principle, particularly so in rule


42
deontology. Our obligation appears to be to give him every chance
to preserve his life, his autonomy: we would place him on the
I
ventilator. As for beneficence, we have achieved it by
respecting our understanding of his autonomy. Any good that can
be achieved for him will be accepted as such but is not the
standard from which the decision was made. Justice is another
matter since this patient will likely require expensive
resources. To have considered this patient sufficiently unwortihy
as a person to have not ventilated him would have conflicted jso
much with the principle of autonomy that the rule deontologist
could not have seriously considered such a decision. From the
standpoint of each ethical principle, our patient would have been
treated aggressively in a rule deontological approach.
Preservation of his autonomy, however, is the most important
action undertaken.
Rule utilitarianism differs frcm rule deontology in that
it judges the moral validity of the act upon its consequences
using the same principles derived from W. D. Ross. Good for the
patient and society can be achieved by observing a particular
ethical principle. This approach is especially valuable when
principles are in conflict. In our case the process starts with
a search for the dominant principle. It is not automatically
assumed that autonomy is dominant. As in our earlier
consideration, nonmaleficence does not appear to dominate because
little would be done to this patient that could be considered


43
harmful. Rather than assuming that his autonomy should be our
dominant principle, we inquire into what his life must have been
like. What good for him and for society can result from
preserving his life, his autonomy. We do not know his
preferences so we must substitute our judgment for his. We ask
ourselves whether we or most would wish aggressive treatment
including the ventilator with the understanding that if he were
saved he likely would be back on the streets and return again
with a similar problem, perhaps next winter. In this context the
weight of his autonomy appears to remain nearly neutral in the
decision. With autonomy weakened, beneficence assumes greater
weight. Is placing him on mechanical ventilation because of this
principle valid? What good for him can result? His life and his
autonomy can perhaps be saved but these are quite hampered by his
health and derelict status. Ventilating him may not produce any
good for him later, unless one believes that life is a good worth
preservation at all cost for individual and society. Is it just
to use the ventilator on this man when another patient may need
it? Even with ventilators in good supply, one can argue that
cost of such intensive care would not be worth the predicted
outcome knowing what we do about this patient. With considerable
"moral residue" a rule utilitarian could well withhold the
ventilator for this patient under the principle of justice and
the unliklihood of successful treatment. Such a decision would
be morally acceptable only if the patient's derelict lifestyle


44
precluded a good medical outcome. Lifestyle alone as a reason
for withholding an otherwise indicated medical procedure would be
invalid from the points of view of both the rule deontologist and
the rule utilitarian. Both of these theories hold strong
autonomy and beneficience principles. Invoking justice as the
sole basis for withholding a treatment rarely ever happens, or
should happen, in clinical medicine. Its potential to undermine
the physician-patient relationship, actual or potential, is
overwhelming.
Which of these theories is compatible with medicine as
science and as art? Both act deontology and act utilitarianism
focus on the act itself depending on very general first
principles and a great deal of intuition for a decision. Nowhere
is the model of observation, hypothesis formation, and further
testing of the hypothesis by observation, and so on.
Rule deontology recognizes that ethical principles must
be prioritized. Part of our scientific model is fulfilled by
this theory in that hypothesis formation occurs in the form of
selection of the most important principle of the case. However,
in the absence of validity of good achieved by an action, the
observation of the hypothesis to test it is absent. Also, the
principle of autonomy has historically held its greatest strength
in this theory.
Rule utilitarianism, on the other hand, approximates the
way we think about problems in science. If one has observed scxne


45
particular aspects of an ethical problem, one can hypothesize
which principle is dominant, then one can test it in debate and
later in fact. In our case, the patient probably dies without
the ventilator, and certainly he is in no position to report back
to us how he feels about his attending physicians decision.
However, family when available and health care providers provide
observation as to whether the hypothesis was correct, i.e. to
choose the principle of justice as dominant. In most ethical
decisions there is opportunity to reflect on the outcome, the
result, or to test the hypothesis. As we learn we get better,
both at science and at ethics.


BIBLIOGRAPHY
^Fletcher, Joseph F., Morals and Medicine, 1954, Princeton,
Princeton University Press, xi-xv.
Presidents Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research. 1983,
Washington, D. C., Sup. of Documents, U. S. Govt. Printing
Office.
^Kant, Immanuel, The Foundations of the Metaphysics of Morals,
1959, Indianpolis, Bobbs-Merrill, 1-64.
^Ross, W. D., The Right and the Good, 1930, New York, Oxford
University Press, 17-39.
^Mill, J. S., Utilitarianism, On Liberty, Essay on Bentham,
1962, New York, New American Library, 256-295.
Smart, J. C. C., Utilitarianism and Its Applications in New
Directions in Ethics: The Challenge of Applied Ethics,
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