Basic questions relating to the study of ethics have been the subject of much debate and analysis, particularly among philosophers.
Utilitarianism is an ethical theory based on the principle of what is the greatest good for the greatest number of people. This ethical theory is concerned with the impact of actions, or final outcomes, on the welfare of society as a whole. In other words, the “rightness” or “wrongness” of an act is determined solely by its consequences. This view looks at what would satisfy the interests, wants, and needs of most people. Additionally, utilitarianism is a consequences-based ethical theory that follows the premise that the ends (consequences) justify the means (methods for achieving the ends). For example, in the case of limited financial resources, money would be spent in a way to benefit the greatest number of people. In this respect, utilitarianism is considered to be an efficient allocation of resources. In a professional context, a cost/benefit analysis justifies the means of achieving a goal. In other words, if the benefit of a decision outweighs the cost (financial or otherwise) of achieving a goal, then the means to obtain the goal would be justified. A problem arises when utilitarianism, or cost/benefit analysis, is used for making ethical decisions, because some people will inevitably “fall through the cracks.” This could result in serious consequences if a person is denied treatment, and eventually suffers and/or dies because of this denial.
The nation’s Medicare system, in which persons over the age of 65, as well as other qualified individuals, receive healthcare benefits, is one example of utilitarianism. Congress has limited amounts of funds to allocate for medical coverage and uses those funds to cover the elderly and others, such as the disabled, under the government Medicare Act. However, not all people require the benefit. In the case of Medicare, for example, not all elderly persons need to have medical coverage provided for them by this act, because some are wealthy and can afford their own coverage. On the other hand, there are people with low incomes who are not yet 65, and are not indigent (impoverished) enough to qualify for Medicaid, but still require some type of medical insurance. Another example of utilitarianism occurs when there is a limited supply of donor organs. Under a utilitarianism approach, patients with the most immediate need (and who would benefit the most) would receive the organ. Using this approach for organ distribution, terminally ill or elderly persons with a limited lifespan would not be the first to receive a scarce resource such as a new heart. A weakness of the utilitarianism approach to moral reasoning is that it is impossible to quantify all the variables. Therefore, it can result in a biased allocation of resources, ignoring the rights of some vulnerable people such as the young, sick, handicapped, or elderly who lack representation or a voice.
Rights-based ethics , or a natural rights ethical theory, places the primary emphasis on a person’s individual rights. This ethical theory states that rights belong to all people purely by virtue of their being human. Under our rights-based democracy, all Americans have the right to freedom of speech. Employees have the right to due process, which entitles them to a fair hearing in the case of dismissal from their jobs. In the previous example of limited donor organs, using a rights-based ethical approach, every patient needing a donor organ would have the same right to receive the available organ.
The strength of rights-based ethics is a strong attempt to protect the individual from injury. Laws such as OSHA (Occupational Safety and Health Act) benefit society as a whole because everyone in the workplace is protected by this act. The downside to this approach is that there can be incidents of individualistic selfish behavior which is independent of the outcomes (consequences). For example, unions protect their membership while excluding the rights of the non-union members of society.
Duty-based ethics focuses on performing one’s duty to various people and institutions such as parents, employers, employees, and customers (patients). This line of moral reasoning follows the belief that our actions should be universal which means that everyone would act the same way with the same set of circumstances. For example, Americans have some duties, such as to adhere to laws enforced by government authorities. Duties also arise from our own actions. Therefore, we have a duty to keep promises, not to lie, and to make reparations to those whom we have harmed. These reparations include compensation for any damage to another person. An example is the financial compensation a medical practitioner would make if he or she caused harm to a patient.
One of the problems encountered with this moral line of reasoning is the mandate to do things out of a sense of duty regardless of the consequences. In addition, we may hear conflicting opinions about what is our “duty” or responsibility in particular circumstances. If our employer asks us to do something that we are sure is wrong or unethical, we have a duty not to perform the action. You will come across some malpractice cases later in the book that demonstrate this. However, this violates our duty to our employer. Most religions have statements that address one’s duty as a member of that faith or religion. However, many people do not accept their faith’s beliefs concerning issues such as birth control and working on the Sabbath, but do adhere to other doctrines of their religion. Many people claim that a sense of duty is not enough when dealing with ethical dilemmas. Rules do not always work. And people from different cultures may have a different sense of what “duty” means.
Justice-based ethics is based on an important moral restraint called “the veil of ignorance.” The philosopher John Rawls believed that all social contracts, such as who should receive a scarce organ donation, should be handled so that no one would know the gender, age, race, health, number of children, income, wealth, or any other arbitrary personal information about the recipient. This “veil of ignorance,” meaning we would not see the recipients of our choices, would allow the decision-makers (such as Congress or medical experts) to be impartial in their decisions. The so-called “veil of ignorance” means that no one person is advantaged or disadvantaged. In effect, the “least well off” person would then have the same chance for scarce resources and justice as the more educated and wealthy. Rawls, who equated justice with fairness, assumed that people have a self-interest when forming social contracts such as who will receive medical care. The justice-based model of ethics infers that every citizen should have equal access to medical care. For example, children with genetic diseases which would require large financial resources deserve good care simply as a matter of justice. Proponents of justice-based ethics believe insurance premium rates and risk should be spread over all members of the nation such as in a federal single-payer system.
Opponents of this theory believe it is unfair for the healthy to subsidize the unhealthy. Furthermore, under the current gigantic healthcare system and media coverage it is impossible to have the “veil of ignorance” that is demanded by this ethical model.
A moral virtue is a character trait that is morally valued. The emphasis of virtue-based ethics is on persons and not necessarily on the decisions or principles that are involved. Most people agree that virtues are just good habits, such as fairness and honesty. Other examples of virtues and good character traits are integrity, trust, respect, empathy, generosity, truthfulness, and the ability to admit mistakes.
Virtue-based ethics, or seeking the “good life,” is our legacy from the philosopher Aristotle. According to him, the goal of life, for which we all aim, is happiness. He believed that happiness is founded not solely on what we gain in life, but also on who we are. For example, the joy of being a medical professional cannot be present without having the traits or virtues that make one a good physician, nurse, medical assistant, technologist, or other healthcare professional. These virtues include perseverance, integrity, compassion, and trust. Aristotle’s theory is considered inadequate by many because it does not take into account the consequences of an action, as in utilitarianism, or the rights of others, as in rights-based ethics. In addition, there are some who believe that people might take advantage of someone who is too trusting.
While each of these five ethical theories can have positive outcomes and are useful in certain circumstances, no one ethical theory or system is perfect.
Ethical standards that relate to the medical profession are set and defined by professional organizations such as the American Medical Association. All professional disciplines, such as nursing and medical assisting, have their own organizations and standards of guiding ethical codes of conduct. Codes of ethics are discussed more fully in Chapter 5 .
In general, people believe an action is wrong or unethical if it:
· Causes emotional or physical harm to someone else.
· Goes against one’s deepest beliefs.
· Makes a person feel guilty or uncomfortable about a particular action.
· Breaks the law or traditions of their society.
· Violates the rights of another person.
No one ethical theory is perfect. The medical community and the healthcare professional use a combination of many theories to determine the correct action to take.
See Table 1.1 for comparison of the strengths and weaknesses of the five ethical theories.
TABLE 1.1 Strengths and Weaknesses of Five Ethical Theories
|The greatest good for the greatest number||· 1. Encourages efficiency and productivity|
· 2. Consistent with profit maximization—getting the most value (benefit) for the least cost
· 3. Looks beyond the individual to assess impact of the decision on all who are affected
|· 1. Virtually impossible to quantify all variables|
· 2. Can result in biased allocations of resources, especially when some who are affected lack representation or voice
· 3. Can result in ignoring the rights of some people to achieve a utilitarian outcome
|Individual’s rights to be protected||· 1. Protects the individual from injury; consistent with rights to freedom and privacy||· 1. Can encourage individualist selfish behavior that, if misinterpreted, may result in anarchy|
|Based on absolute moral rules||· 1. Absolute rules or principles help us determine what is our duty toward others|
· 2. Who determines what our duty is to one another
· 3. A mandate for respect and impartiality
|· 1. Hard to identify who should determine the rules and principles of moral behavior|
· 2. People are not treated as a means to an end
|Fair distribution of benefits and burdens||· 1. A democratic approach|
· 2. Based on a “veil of ignorance”
· 3. No one person is advantaged or disadvantaged
|· 1. Some believe it is unfair for the healthy to subsidize the unhealthy|
|Based on belief that we have a duty or responsibility to others||· 1. Based on premise that our actions are universal|
· 2. Virtuous behavior includes perseverance, courage, integrity, compassion, humility, and justice
|· 1. Concern that people can be taken advantage of if they are too complacent or tru|