5.5
Dimensions of Ethics
The following can be considered as the dimensions of ethics:
First, ethical decisions can be made on the basis of one of several schools of ethics or ethical traditions
— that is, sets of basic and necessarily quite general substantive principles.
Second, ethical decisions can be made at a variety of levels, ranging from the individual to the societal and even the trans-national.
Third, ethical decisions can be made based on standards that are specific to a particular domain of human activity, such as business or education.
Major Schools of Ethics
There are numerous schools of ethics, or ethical traditions. Some of them are as follows:
Utilitarianism
Utilitarianism holds that the ethically best decision, or in some variants of utilitarianism the best rule for making decisions, is the one that will produce the greatest good for the greatest number. Utilitarianism is the most familiar example of a general approach to ethics that is called consequentialist, because it judges the ethical acceptability of actions or policies based on their consequences. However, the approach taken to consequences can be much broader; the consequences that are considered to be of ethical importance can be environmental, social or even spiritual. It is important to be clear in any form of consequentialist argument about the values that define what counts as a benefit or as a harm. What is the greatest good, and how do we measure it? An influential variant of utilitarianism that is sometimes applied to public policy is cost-benefit analysis, which tries to identify the greatest good and ease the problem of comparing different people’s conceptions of the good (what philosophers call the problem of interpersonal comparisons of utility) by attaching dollar values to all the consequences of a particular policy choice; the preferred policy option is simply the one showing the highest ratio of benefits to costs.
Kantian
Kantian or obligation-based ethics, named after the philosopher Immanuel Kant, with whom it is most closely associated, holds that the ethically acceptable decision is one that conforms to certain fundamental principles. For Kant, the most important of these principles was the “categorical imperative,” which has two formulations. In the first, to be ethically acceptable, one should conduct oneself according to principles that one could wish to see universally applied to everyone. In other words, before deciding to commit fraud or make promises we have no intention of keeping, we must ask whether it even makes sense to think about a society in which everyone acted as we propose to act. The second formulation requires that we avoid treating other people exclusively as means to an end, rather than as ends in themselves. Kantian ethics is the most familiar example of a more general category of ethics known as deontological ethics, whose key characteristic is that some actions are held to be inherently or intrinsically right or wrong — that is to say, right or wrong independent of their consequences.
A particularly influential form of Kantian argument is John Rawls’s attempt to define principles of distributive justice based on an intriguing application of the categorical imperative: asking how we would want the society to be organized if we had to make that choice from behind a “veil of ignorance” that prevented us from knowing in advance whether we were to be born rich or poor, male or female, athletic or physically disabled. Paradoxically, the Rawlsian approach to distributive justice shows that many Kantian ethical judgments cannot be easily isolated from consideration of their consequences.
Rights-based
Rights-based ethics, familiar because of Anglo-American legal systems’ recent emphasis on individual liberty and their much older tradition of the primacy of property rights, is organized around a set of claims (such as freedom of speech, freedom of assembly, and the ownership of private property) that individuals are presumed to have with respect to one another and to society. Rights-based ethics is embodied in the reference to “protection life and personal liberty” in the Fundamental Rights that is an integral part of the Indian Constitution.
The question “where do rights come from?” can be answered in different ways. Sometimes, as in the case of the U.S. Declaration of Independence, rights are held to be “self-evident”; at other times, they are justified with reference to more basic principles such as respect for persons, or to the idea of a contract among members of the society. In the latter respect rights-based and Kantian ethics overlap.
Contractarian
The idea of a contract is central to what many philosophers regard as a distinct school of ethics:
Contractarian ethics, which tries to derive principles of morality from the idea of a (hypothetical) contract entered into by members of a society. Implied consent to the terms of such a contract becomes the source of both rights and duties. Some variants of contractarian ethics have strongly Kantian elements: Rawls, for example, bases his analysis on the kind of contract individuals (actually, heads of households) would rationally enter into from behind the veil of ignorance. Both rights-based and contractarian ethics are characterized by what might be called intense individualism. In direct contrast, communitarian ethics, which is often defended partly with reference to limitations of the idea of rights, focusses less on individuals’ rights than on the importance to individual well-being and fulfilment of membership in a community. In the words of one of the leading contemporary communitarians, “if we are partly defined by the communities we inhabit, then we must also be implicated in the purposes and ends characteristic of those communities . . . the story of my life is always embedded in the story of those communities from which I derive my identity.”
It may be possible to define a middle ground between the intense individualism associated with the idea of a contract and the relative unconcern with the individual that is associated with many statements of communitarianism. At least one author has explored the idea of a covenant among individuals as the defining basis for moral obligations; unlike a contract, a covenant is not motivated primarily by considerations of self- interest, and can include a notion of obligation arising from sources other than individual human will or consent. A rather awkward neologism covenantial ethics has been coined to describe this middle ground.
Ethics of Care
The ethics of care, which according to many accounts originated with psychologist Carol Gilligan’s efforts to describe women’s orientation to ethical decision making as “in a different voice,” resembles communitarian ethics in that rather than starting from a conception of human beings as isolated individuals, it emphasizes their relationships with one another. However, the ethics of care tend to be suspicious of claims about the welfare of the community, partly because such claims have often been used to justify women’s inferior status within a society. It is strongly egalitarian in its conception of how people ought to treat one another, and is especially sensitive to inequalities of power. At the same time, writers in this school or tradition emphasize the limitations of rights-based or contractual conceptions of an ethical point of view toward others, pointing out that in many situations just leaving people alone is not enough, and that in some relationships (like those between mothers and children) a strictly rights-based conceptions of respect for others make no sense.
As its description implies, character ethics, or the ethics of virtue, focusses on the character of those making ethical decisions. Virtuous people (that is, those who act according to such motives as generosity, compassion or fidelity to their obligations) are those most likely to make ethically acceptable decisions. Ethical acceptability is thus determined at least in part by one’s motives for acting in a certain way, as well as by principles and consequences. Ethical acts are not necessarily those carried out by following rules, but from motives like doing good or fulfilling obligations. This formulation is especially attractive in situations where people are faced with a set of choices imposed by circumstances outside their control, all of which are ethically repugnant in different
ways, or when the consequences of a particular action simply cannot be known. This school sometimes carries out ethical analysis starting with the premise that people have a right to fulfill their obligations to others, for instance, parents to decide for their young children on medical treatment.
Casuistry
Casuistry is an ethical tradition or style holding that we are too concerned with principles. For the casuist, ethical decisions can be made only on a case-by-case basis, although the decisions made in previous cases can provide a source of wisdom to draw upon; indeed, ethical judgments can be made when there are no principles to draw upon, or when disagreement on principles is profound. An appropriate analogy may be with the operation of precedent in the legal system. Particularly in biomedical ethics, which often have to focus on individual cases in a clinical setting, there has recently been a revival of interest in casuistry as a response to what is viewed as excessive preoccupation with abstract principles in that field.
The preceding schools of ethics deal primarily with the relationships among human beings. Although many people are concerned about problems like pollution primarily because of their effects on human beings, it is also possible to argue that environmental ethics is now a distinct school of ethics, because many variants explicitly hold that human beings have duties and obligations not only to each other, but also to non-human beings and to the natural environment as a whole. One line of thought in environmental ethics, for instance, holds that preservation of “ecological integrity” is a principle that should take precedence over all others.
Key Points about the Differences among Schools of Ethics
This listing of schools of ethics is not a comprehensive one, and may even be termed as oversimplifications. In addition, there is considerable overlap between many of the schools, which are not mutually exclusive approaches separated by clear boundaries. For example, the overlap between rights-based and Kantian ethics, and environmental ethics may be deontological, consequentialist or a combination of both.
We can think of the different schools of ethics as various prisms or conceptual lenses through which a decision or situation can be viewed. When the situation looks similar through all the prisms or lenses, governments are likely to find their choice relatively simple to make. However, different schools of ethics will often want to treat a situation quite differently. For instance the issue of contract pregnancy (or as it is more often but less accurately called, surrogate motherhood) looks quite different through the prisms of a rights-based ethics and of the ethic of care. Choices about how thoroughly to treat industrial pollutants that may threaten human health, or about where to locate hazardous waste landfills, look quite different through a Kantian or Rawlsian prism than they do when made on the basis of a cost-benefit analysis. Philosopher Will Kymlicka has observed that: “Moral philosophers have not yet discovered a knockout argument for or against these different theories.” When making choices about the ethical acceptability of courses of action or of public policies, we normally and appropriately incorporate elements from several schools of ethics, rather than relying exclusively on a single one. For instance, particular policies might be acceptable on strictly utilitarian grounds, but be judged ethically unacceptable because they would harm certain vulnerable members of the community — an invocation of justice, of the ethics of care, or perhaps even of communitarian ethics (a community’s fabric is threatened when it harms its most vulnerable members). Conversely, various infringements of rights are justified, in ethics, with reference to the good of the community, or the protection of certain kinds of valued relationships. The tradeoff between equity and efficiency in economic policy is another commonly mentioned example.
In response to the possibility of disagreement among schools of ethics, one approach is to seek what has been called “mid-level principles” to govern decision making. It has four “clusters of principles”: respect for autonomy, non-maleficence (not doing harm), beneficence (doing good), and justice. These are now widely applied in both research and clinical settings, largely because people who disagree about whether (for instance) utilitarianism or rights-based ethics is ultimately more defensible may nevertheless be able to agree on these principles as the basis for ethical decision making. This does not mean ethical decision making in such settings has thereby become easy or routine; far from it. None of the four principles can be regarded as binding in all cases; since situations in which applicable principles conflict are relatively common, the best that can be done is to treat each principle only as prima facie binding — in other words, binding in the absence of more compelling moral considerations involving a competing principle. In addition, the four principles illustrate that any principle broad
enough to cover the spectrum of relevant cases will remain abstract enough so that judgment and interpretation on the part of the relevant decision maker(s) will invariably be involved, most notably about what is ethically relevant to decisions in a particular case.
Micro, Meso, Macro and Megaethics
In ethics we sometimes do an analysis at three different levels. It’s very simple: micro-level, meso-level — which is institutional or group level — and macro-level, which is governmental or societal level.
The micro level refers to interactions between individuals, whether they are members of families, strangers or people whose roles carry a particular institutional meaning (for example, doctor and patient). The meso level involves ethics within the group, institution or organization (such as a hospital, university or government department). The macro level involves ethics at the society-wide level, for example, as reflected in the decisions of provincial or national governments about domestic policy. To this list, we can add mega-ethics, which refers to ethics at the transnational or cross-cultural level. Human rights is an illustration of a mega-ethical concept, although it has applications at other levels and indeed is probably most meaningful when applied to specific policy situations at the micro, meso or macro-levels.
Table 1 illustrates these four levels as they play out in analyzing various issues related to medicine and health care, and suggests the interplay among different levels of analysis. It may be useful to take a single example — access to costly and therefore scarce therapy —and to work through the issues and tensions, in a way that is necessarily a bit dogmatic.
Source: Making Ethically Acceptable Policy Decisions by Ted Schrecker
At the micro level, not only is it entirely appropriate for a physician to seek the best treatment for his or her patient, but on many accounts the physician is obliged to do so, and for him or her to make decisions about treatment options based on other priorities, like cost containment, is almost certainly unethical. At the meso level, however, an institution confronted with scarce resources must organize a basis for making such choices as which candidates will receive transplant organs or bypass surgery, or for that matter whether priority should be given to expanding the transplant unit, the cardiac surgery unit or the provision of some other service. The institution cannot get away from these choices; as in many other situations, making no decision is a decision in itself. Such choices can be and have been made in a variety of ways and more than one principle for doing so (including the apparent non-principle of first-come, first-served, which is really a variant of the lottery principle) may be ethically defensible. What is probably not defensible is leaving the decisions to be made on the basis of whichever patient has the most effective, most persistent or loudest advocate in the form of his or her physician.
Also not defensible, however, are meso level policies that interfere with the physician-patient relationship and the ability of the physician to act as an advocate for the patient, for instance by prohibiting physicians under contract to a particular health management organization (HMO) from telling patients about treatments that the HMO will not cover. A basic macro level choice, which exists in every country and affects the choices available at all the other levels, is how the health care system should be financed, and how access will be governed. A number of resource allocations may all be ethically acceptable, but there will probably also be some clearly unacceptable ones — for example, locating a new unit in a remote area where utilization rates will be low, but which happens to elect a member of Cabinet. As suggested in the Table resource allocations that have the effect, even if not the intent, of discriminating on the basis of age should probably also be judged ethically unacceptable.
Dimensions of Ethics
The following can be considered as the dimensions of ethics:
First, ethical decisions can be made on the basis of one of several schools of ethics or ethical traditions
— that is, sets of basic and necessarily quite general substantive principles.
Second, ethical decisions can be made at a variety of levels, ranging from the individual to the societal and even the trans-national.
Third, ethical decisions can be made based on standards that are specific to a particular domain of human activity, such as business or education.
Major Schools of Ethics
There are numerous schools of ethics, or ethical traditions. Some of them are as follows:
Utilitarianism
Utilitarianism holds that the ethically best decision, or in some variants of utilitarianism the best rule for making decisions, is the one that will produce the greatest good for the greatest number. Utilitarianism is the most familiar example of a general approach to ethics that is called consequentialist, because it judges the ethical acceptability of actions or policies based on their consequences. However, the approach taken to consequences can be much broader; the consequences that are considered to be of ethical importance can be environmental, social or even spiritual. It is important to be clear in any form of consequentialist argument about the values that define what counts as a benefit or as a harm. What is the greatest good, and how do we measure it? An influential variant of utilitarianism that is sometimes applied to public policy is cost-benefit analysis, which tries to identify the greatest good and ease the problem of comparing different people’s conceptions of the good (what philosophers call the problem of interpersonal comparisons of utility) by attaching dollar values to all the consequences of a particular policy choice; the preferred policy option is simply the one showing the highest ratio of benefits to costs.
Kantian
Kantian or obligation-based ethics, named after the philosopher Immanuel Kant, with whom it is most closely associated, holds that the ethically acceptable decision is one that conforms to certain fundamental principles. For Kant, the most important of these principles was the “categorical imperative,” which has two formulations. In the first, to be ethically acceptable, one should conduct oneself according to principles that one could wish to see universally applied to everyone. In other words, before deciding to commit fraud or make promises we have no intention of keeping, we must ask whether it even makes sense to think about a society in which everyone acted as we propose to act. The second formulation requires that we avoid treating other people exclusively as means to an end, rather than as ends in themselves. Kantian ethics is the most familiar example of a more general category of ethics known as deontological ethics, whose key characteristic is that some actions are held to be inherently or intrinsically right or wrong — that is to say, right or wrong independent of their consequences.
A particularly influential form of Kantian argument is John Rawls’s attempt to define principles of distributive justice based on an intriguing application of the categorical imperative: asking how we would want the society to be organized if we had to make that choice from behind a “veil of ignorance” that prevented us from knowing in advance whether we were to be born rich or poor, male or female, athletic or physically disabled. Paradoxically, the Rawlsian approach to distributive justice shows that many Kantian ethical judgments cannot be easily isolated from consideration of their consequences.
Rights-based
Rights-based ethics, familiar because of Anglo-American legal systems’ recent emphasis on individual liberty and their much older tradition of the primacy of property rights, is organized around a set of claims (such as freedom of speech, freedom of assembly, and the ownership of private property) that individuals are presumed to have with respect to one another and to society. Rights-based ethics is embodied in the reference to “protection life and personal liberty” in the Fundamental Rights that is an integral part of the Indian Constitution.
The question “where do rights come from?” can be answered in different ways. Sometimes, as in the case of the U.S. Declaration of Independence, rights are held to be “self-evident”; at other times, they are justified with reference to more basic principles such as respect for persons, or to the idea of a contract among members of the society. In the latter respect rights-based and Kantian ethics overlap.
Contractarian
The idea of a contract is central to what many philosophers regard as a distinct school of ethics:
Contractarian ethics, which tries to derive principles of morality from the idea of a (hypothetical) contract entered into by members of a society. Implied consent to the terms of such a contract becomes the source of both rights and duties. Some variants of contractarian ethics have strongly Kantian elements: Rawls, for example, bases his analysis on the kind of contract individuals (actually, heads of households) would rationally enter into from behind the veil of ignorance. Both rights-based and contractarian ethics are characterized by what might be called intense individualism. In direct contrast, communitarian ethics, which is often defended partly with reference to limitations of the idea of rights, focusses less on individuals’ rights than on the importance to individual well-being and fulfilment of membership in a community. In the words of one of the leading contemporary communitarians, “if we are partly defined by the communities we inhabit, then we must also be implicated in the purposes and ends characteristic of those communities . . . the story of my life is always embedded in the story of those communities from which I derive my identity.”
It may be possible to define a middle ground between the intense individualism associated with the idea of a contract and the relative unconcern with the individual that is associated with many statements of communitarianism. At least one author has explored the idea of a covenant among individuals as the defining basis for moral obligations; unlike a contract, a covenant is not motivated primarily by considerations of self- interest, and can include a notion of obligation arising from sources other than individual human will or consent. A rather awkward neologism covenantial ethics has been coined to describe this middle ground.
Ethics of Care
The ethics of care, which according to many accounts originated with psychologist Carol Gilligan’s efforts to describe women’s orientation to ethical decision making as “in a different voice,” resembles communitarian ethics in that rather than starting from a conception of human beings as isolated individuals, it emphasizes their relationships with one another. However, the ethics of care tend to be suspicious of claims about the welfare of the community, partly because such claims have often been used to justify women’s inferior status within a society. It is strongly egalitarian in its conception of how people ought to treat one another, and is especially sensitive to inequalities of power. At the same time, writers in this school or tradition emphasize the limitations of rights-based or contractual conceptions of an ethical point of view toward others, pointing out that in many situations just leaving people alone is not enough, and that in some relationships (like those between mothers and children) a strictly rights-based conceptions of respect for others make no sense.
As its description implies, character ethics, or the ethics of virtue, focusses on the character of those making ethical decisions. Virtuous people (that is, those who act according to such motives as generosity, compassion or fidelity to their obligations) are those most likely to make ethically acceptable decisions. Ethical acceptability is thus determined at least in part by one’s motives for acting in a certain way, as well as by principles and consequences. Ethical acts are not necessarily those carried out by following rules, but from motives like doing good or fulfilling obligations. This formulation is especially attractive in situations where people are faced with a set of choices imposed by circumstances outside their control, all of which are ethically repugnant in different
ways, or when the consequences of a particular action simply cannot be known. This school sometimes carries out ethical analysis starting with the premise that people have a right to fulfill their obligations to others, for instance, parents to decide for their young children on medical treatment.
Casuistry
Casuistry is an ethical tradition or style holding that we are too concerned with principles. For the casuist, ethical decisions can be made only on a case-by-case basis, although the decisions made in previous cases can provide a source of wisdom to draw upon; indeed, ethical judgments can be made when there are no principles to draw upon, or when disagreement on principles is profound. An appropriate analogy may be with the operation of precedent in the legal system. Particularly in biomedical ethics, which often have to focus on individual cases in a clinical setting, there has recently been a revival of interest in casuistry as a response to what is viewed as excessive preoccupation with abstract principles in that field.
The preceding schools of ethics deal primarily with the relationships among human beings. Although many people are concerned about problems like pollution primarily because of their effects on human beings, it is also possible to argue that environmental ethics is now a distinct school of ethics, because many variants explicitly hold that human beings have duties and obligations not only to each other, but also to non-human beings and to the natural environment as a whole. One line of thought in environmental ethics, for instance, holds that preservation of “ecological integrity” is a principle that should take precedence over all others.
Key Points about the Differences among Schools of Ethics
This listing of schools of ethics is not a comprehensive one, and may even be termed as oversimplifications. In addition, there is considerable overlap between many of the schools, which are not mutually exclusive approaches separated by clear boundaries. For example, the overlap between rights-based and Kantian ethics, and environmental ethics may be deontological, consequentialist or a combination of both.
We can think of the different schools of ethics as various prisms or conceptual lenses through which a decision or situation can be viewed. When the situation looks similar through all the prisms or lenses, governments are likely to find their choice relatively simple to make. However, different schools of ethics will often want to treat a situation quite differently. For instance the issue of contract pregnancy (or as it is more often but less accurately called, surrogate motherhood) looks quite different through the prisms of a rights-based ethics and of the ethic of care. Choices about how thoroughly to treat industrial pollutants that may threaten human health, or about where to locate hazardous waste landfills, look quite different through a Kantian or Rawlsian prism than they do when made on the basis of a cost-benefit analysis. Philosopher Will Kymlicka has observed that: “Moral philosophers have not yet discovered a knockout argument for or against these different theories.” When making choices about the ethical acceptability of courses of action or of public policies, we normally and appropriately incorporate elements from several schools of ethics, rather than relying exclusively on a single one. For instance, particular policies might be acceptable on strictly utilitarian grounds, but be judged ethically unacceptable because they would harm certain vulnerable members of the community — an invocation of justice, of the ethics of care, or perhaps even of communitarian ethics (a community’s fabric is threatened when it harms its most vulnerable members). Conversely, various infringements of rights are justified, in ethics, with reference to the good of the community, or the protection of certain kinds of valued relationships. The tradeoff between equity and efficiency in economic policy is another commonly mentioned example.
In response to the possibility of disagreement among schools of ethics, one approach is to seek what has been called “mid-level principles” to govern decision making. It has four “clusters of principles”: respect for autonomy, non-maleficence (not doing harm), beneficence (doing good), and justice. These are now widely applied in both research and clinical settings, largely because people who disagree about whether (for instance) utilitarianism or rights-based ethics is ultimately more defensible may nevertheless be able to agree on these principles as the basis for ethical decision making. This does not mean ethical decision making in such settings has thereby become easy or routine; far from it. None of the four principles can be regarded as binding in all cases; since situations in which applicable principles conflict are relatively common, the best that can be done is to treat each principle only as prima facie binding — in other words, binding in the absence of more compelling moral considerations involving a competing principle. In addition, the four principles illustrate that any principle broad
enough to cover the spectrum of relevant cases will remain abstract enough so that judgment and interpretation on the part of the relevant decision maker(s) will invariably be involved, most notably about what is ethically relevant to decisions in a particular case.
Micro, Meso, Macro and Megaethics
In ethics we sometimes do an analysis at three different levels. It’s very simple: micro-level, meso-level — which is institutional or group level — and macro-level, which is governmental or societal level.
The micro level refers to interactions between individuals, whether they are members of families, strangers or people whose roles carry a particular institutional meaning (for example, doctor and patient). The meso level involves ethics within the group, institution or organization (such as a hospital, university or government department). The macro level involves ethics at the society-wide level, for example, as reflected in the decisions of provincial or national governments about domestic policy. To this list, we can add mega-ethics, which refers to ethics at the transnational or cross-cultural level. Human rights is an illustration of a mega-ethical concept, although it has applications at other levels and indeed is probably most meaningful when applied to specific policy situations at the micro, meso or macro-levels.
Table 1 illustrates these four levels as they play out in analyzing various issues related to medicine and health care, and suggests the interplay among different levels of analysis. It may be useful to take a single example — access to costly and therefore scarce therapy —and to work through the issues and tensions, in a way that is necessarily a bit dogmatic.
Source: Making Ethically Acceptable Policy Decisions by Ted Schrecker
At the micro level, not only is it entirely appropriate for a physician to seek the best treatment for his or her patient, but on many accounts the physician is obliged to do so, and for him or her to make decisions about treatment options based on other priorities, like cost containment, is almost certainly unethical. At the meso level, however, an institution confronted with scarce resources must organize a basis for making such choices as which candidates will receive transplant organs or bypass surgery, or for that matter whether priority should be given to expanding the transplant unit, the cardiac surgery unit or the provision of some other service. The institution cannot get away from these choices; as in many other situations, making no decision is a decision in itself. Such choices can be and have been made in a variety of ways and more than one principle for doing so (including the apparent non-principle of first-come, first-served, which is really a variant of the lottery principle) may be ethically defensible. What is probably not defensible is leaving the decisions to be made on the basis of whichever patient has the most effective, most persistent or loudest advocate in the form of his or her physician.
Also not defensible, however, are meso level policies that interfere with the physician-patient relationship and the ability of the physician to act as an advocate for the patient, for instance by prohibiting physicians under contract to a particular health management organization (HMO) from telling patients about treatments that the HMO will not cover. A basic macro level choice, which exists in every country and affects the choices available at all the other levels, is how the health care system should be financed, and how access will be governed. A number of resource allocations may all be ethically acceptable, but there will probably also be some clearly unacceptable ones — for example, locating a new unit in a remote area where utilization rates will be low, but which happens to elect a member of Cabinet. As suggested in the Table resource allocations that have the effect, even if not the intent, of discriminating on the basis of age should probably also be judged ethically unacceptable.
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