Ethics Decision Strategies

An Introduction to Doing Medical Ethics
Michael A. Gillette, Ph.D.

Theory and Casuistry

The practice of clinical ethics can be approached from one of two possible starting points. It is possible to argue theoretically (from theory to practice), or casuistically (from practice, up to theory, and then back down to practice). If one takes the first route, the theoretical approach, the primary task is to gain an understanding of the broad range of ethical theories that are available and to understand the strengths, weaknesses, and relevance of each of those theories. The second task is to learn how to apply the theories effectively, and to evaluate their implications.

The casuistic approach is based on the idea that we must reason from experience in order to determine the general demands that we all accept. We must then generalize our understanding of the intuitive responses that we give in particular cases to help us reason through other, intuitively vague, moral cases. Both theory and casuistry have advantages and disadvantages. They do share much in common, however, and become best suited to a productive discussion of ethics when combined. The strategy that I will outline below is based on a combination of theoretical and casuistic approaches.

Theory

When discussing issues in medical ethics it is routine to mention that some particular action is wrong because it ignores someone's rights, or that some other action is obligatory because someone has a right to be treated in a certain way. We often become so engaged in the practical discussion that we take "rights-talk" for granted, without ever wondering what "rights" are, where they come from, or even if they actually exist.

There are many ethical theories that support a belief in rights. It is important to note, however, that one of the most significant and influential ethical theories has denied the existence of any sort of natural rights.

Utilitarianism is based on the view that what makes an action right is the good consequences it creates. The utilitarian believes that it is always right to do the greatest good for the greatest number. 'Good' is usually understood to mean 'happiness', so utilitarianism has often been referred to as the greatest happiness principle. If the world is a happier place, the utilitarian reasons, it is a better place. Therefore, we should always try to increase happiness and decrease unhappiness in the world. That is all there is to ethics, according to this view, and the notion that people have natural rights is incorrect.

Utilitarianism has significant strengths. It is simple, intuitively plausible, and we use it all the time. Every time we make a cost-benefit analysis we are being utilitarians. Every time a soldier dies for the greater good, or we build a new highway while knowing that traffic fatalities will result, we are judging that the sacrifice is worth making and that the greatest good will follow. Utilitarianism also allows that the ends can justify the means, however, and this seems dangerous. Are there no limits on our search for happiness? Are there no rights that we must respect regardless of the consequences?

Many have argued that utilitarianism cannot be correct since it treats people as things to be used to increase happiness. According to utilitarianism, a lie is morally justified, a killing is morally required, and intentionally causing suffering to innocent people is acceptable if, in the long run, the ends will justify these actions. This cannot be right, many have reasoned. People are more than mere things to be used, we are autonomous beings with feelings and desires that must be respected. This way of thinking has led to the development of many non-utilitarian moral views that recognize human rights that act like trump cards when pitted against utility.

Rights theories come in many varieties but one of the most popular versions is based on the dictate that we must always treat people as ends in themselves, objects with intrinsic value, never only as means to something else, like tools that can be used up and then thrown away. This way of thinking is attractive. It elevates people to a higher moral level. But is it true that we can never use other people to satisfy our needs? If we could never use other people how could we justify drafting people for war, killing in self-defense, entering into favorable business deals or even paying someone to serve us food in a restaurant? It seems that a middle-of-the-road approach between utility and rights theory is needed, and that is precisely what virtue theory attempts to offer.

Virtue theory is based on the notion that our moral obligations depend upon the relationships that we have to others. Much of what we need to do is based on the roles we play in life. Why must a ship captain go down with the ship? Why must a doctor treat the sick? Because these people have accepted the duties which their professions entail.

Virtue theory says that people must always act consistently with the roles they play in life. As citizens, family members, professionals, and friends we play certain roles that place special obligations upon us. If we can tell the stories of our lives and thus identify our own roles, we will know what it is right for us to do.

This theory is strong. But just like each of the other theories which I have described, it does have its problems. From which roles am I allowed to choose? Who defines a role? How do I know when it is time to abandon a particular role in order to satisfy another role that I play? These are just a few examples of the types of questions which a discussion of virtue theory will raise.

Additional theories are available, such as contract theory, but a full discussion of those theories is not necessary at this time. Let us move forward with an appreciation for the fact that people will operate on an ethical level by attempting to maximize the values that seem ethically most important to them. Some will want to maximize rights while others will be prone to performing cost-benefit analysis. Others will prefer to discuss professional obligations, while some may heavily weigh agreements and expectations between providers and recipients. These values are all important, and we must strive to understand when it is appropriate to apply each one. Therefore, we must develop a practical strategy for decision making that can take into account theoretically important values.

Casuistry

The Structure of Practical Moral Decision Making

When considering the process by which ethical decisions can be made, the analogy of orienteering is useful. When lost in the wilderness it is possible to find your way home with a minimum of difficulty only if you are trained in the art of orienteering. The process of orienteering involves three basic tools: a map, a compass, and a clear view of the landscape. By orienting yourself on your map after viewing the landscape, it becomes an easy matter to use your compass to plot a course to safety. This goal, of finding our way through an unfamiliar wilderness into an area of known comfort and safety, is exactly the project of ethical decision making. Our goal, therefore, is to become expert in the activity of moral orienteering.

In order to make this analogy work it is necessary to provide more detail regarding the process of orienteering. When a person orienteers, his first job is to figure out his current location. In order to do this the lost person must look around and find at least two clearly discernible landmarks. By using his compass, he must figure out where he presently sits in relation to those landmarks. If a mountain top is due west, for instance, then he can look on his map and see that on the map he must be standing somewhere on a line that is drawn from the mountain to the east. If he is due south of a bend in a river, then he knows that he must be standing somewhere on a line that is drawn on his map from that bend to the south. Knowing the location of these two landmarks and his orientation to them, he is sure that he can be nowhere in the world except at the intersection of the two drawn lines.

Orienteering in an ethical way is identical to orienteering in the physical way. If someone finds herself in a morally difficult situation, the first thing to do is to look for clearly definable features of the moral landscape. Next, she must determine how close her present situation is to those features. Once she has located herself on her moral map, she is able to plot a course to safety.

Suppose a choice must be made about withholding life prolonging care for a client. First we must find some clear intuitions in this area. We need to find an example where allowing a client to die would be clearly wrong (murder). Then we must find an example of permissible death (a Do Not Resuscitate Order for a terminally ill patient who is in pain). Next, we must determine whether the present case is more like the former or more like the latter. Finally, after comparing our present situation with the two intuitively clear cases, we must determine how the present case is similar and dissimilar to each of those examples. Armed with this information, we will be able to determine our moral location and generate an appropriate answer to our conundrum.

To complete this analogy, I should note that the basic tools of orienteering -- the map, compass, and clear view of the landscape - have counterparts in moral discourse. Our moral compass is reason. It is reason that can lead us through the confusing emotions and variation of viewpoints that are a perennial feature of ethics. Our moral map is a function of intuitions that are derived from consideration of clear cases upon which most of us agree. Although each individual moral map may be slightly different from others, there are clear social landmarks that appear on all of our moral maps. Many social expectations are inescapable and clear. It is these features that form the basis of our moral map. The clear view of the landscape which is so important to orienteering is often the most difficult tool to secure. In the physical world, it might be necessary to climb a tree or hike up a hill to gain this perspective. In the ethical world, developing a clear view of the landscape can also require effort. Only by engaging in a careful discussion of issues among numerous people with distinct viewpoints can we develop a clear sense of the issues that surround us. The ethics committee is the source of our clear view of the surrounding terrain.