3.9 Acting ethically: tools for analysis
Do the usual principles underpinning conventional health care ethics provide an adequate or acceptable framework for the discussion of ethics in the CAM relationship? Most bioethics teaching in medical schools in the UK and USA draws on the principles-based approach to considering ethical dilemmas. To recap, the four principles are:
respect for autonomy
the duty to benefit (beneficence)
the duty not to harm (non-maleficence)
respect for justice.
As well as principles, practitioners need to be aware of the three types of ethical theory. Ethical theories are ways of judging whether an action is right or wrong. Two of the main theories were touched on earlier in this chapter: they are duty-based ethics and consequence-based ethics. The third theory is virtue ethics. Some ethicists believe that the practitioner's moral character is the most important basis for making good ethical decisions. According to this theory the focus is less on the facts of the particular scenario and more on the moral qualities required of the ethical practitioner. Virtuous practitioners, they argue, are inclined to make right decisions.
The ethical theories are described in Box 5.
Box 5 The three ethical theories
1 Duty-based ethics
The duty-based theorist (or ‘deontologist’) believes that an action is ethically right to the extent that it conforms with rules or duties. This theory prioritises certain duties, most notably, the duty to respect people's autonomy by treating people not as a means to an end but as an end in themselves. Within this theory, when a duty is considered to be important, it must be applied in all situations, regardless of the outcome. If, for example, a practitioner has a duty to respect confidentiality, this duty must be applied absolutely, in all situations. A duty-based theorist would not consider it acceptable to breach confidentiality even where this is necessary to protect the life or wellbeing of a third party. In health care ethics, the professional duties set out in a code of ethics are considered to be an important source of duties which the practitioner must comply with. For the duty-based theorist, the four principles become ‘duties’ which the practitioner has to apply absolutely.
2 Outcome-based ethics
An outcome (or ‘consequence’) based theorist believes that an action is ethical to the extent that it brings about a good rather than a bad outcome. Put another way, an action is good to the extent that it maximises happiness and minimises suffering. You may have heard this theory described as the theory of ‘the greatest good for the greatest number, at the cost of the least suffering’. Unlike a duty-based theorist, an outcome theorist may sometimes override duties to an individual, if doing so would create a greater good. The outcome theorist is not compelled to apply a duty in the same way in every situation, if this would cause harm (for example, an outcome theorist might decide that it is ethically acceptable to breach the confidentiality of a sex offender who has threatened to attack a third party if breaching confidentiality will protect that person from harm). For the outcome-based theorist, the four principles provide a starting-point for moral deliberation, but a principle can be waived if its application would cause more harm than good. Since the outcome theorist judges an action to be right or wrong on the basis of anticipated risks or benefits, it is important to ascertain all relevant facts in advance.
3 Virtue ethics
Virtues are habituated character traits that predispose people to act in accordance with worthy goals and the role expected of them. Virtues include candour, fidelity, compassion, discernment and integrity. Virtues are an important component of ethical decision making:
Principles do not provide precise or specific guidelines for every conceivable set of circumstances. Principles require judgment, which in turn depends on character, moral discernment, and a person's sense of responsibility and accountability. Often what counts most in the moral life is not consistent adherence to principles and rules, but reliable character, moral good sense, and emotional responsiveness.
(Source: adapted from Beauchamp and Childress, 1994)
It is hard to quantify the extent to which any of these theories are applied in real-life situations. Generally, health practitioners are not expected to justify the basis for every decision they make. Motives are not usually questioned unless something has gone wrong. For this reason, it may not necessarily be known whether a decision was made because of the practitioner's assessment of risks and benefits (outcome-based decision making), or because of the practitioner's perceived sense of duty towards the parties involved (duty-based theory), or because of what sort of person the practitioner is (virtue-based decision making). Medical decision making is no different from the ethical decisions that ordinary people make in everyday life. Sometimes ethical decisions are made through gut instinct, although if scrutinised in greater detail, even gut instinct involves a complex interplay of ethical decision making. Few people would be happy if the basis of their decision making was questioned, and most people are defensive when asked to justify why they behaved in a certain way. Trainee practitioners may believe they will know intuitively what to do in an ethically contentious situation. This may make health care students reticent about being taught how to make ethical decisions formally. Some practitioners may regard any instruction in professional ethics as an affront to their own personal sense of morality and a slur on their sense of propriety. This is misguided, since the obligations health professionals owe to their users go beyond normal moral obligations. Whereas everyday life usually requires nothing more than common decency, the health care relationship requires practitioners to consider their users' best interests at all times. This involves respecting the wishes about treatment of users who can participate in the decision-making process and acting in the best interests of users who cannot give consent for themselves.