September 1986 VIII/1
VARIOUS ETHICAL SYSTEMS
Why do different people arrive at different solutions to ethical problems in medicine, even if they begin with the same set of facts? Why, for example, do some people, whether physicians or family members, decide it is an act of mercy to remove artificial nutrition and hydration from a patient in an irreversible coma while others would maintain that the same action would be murder? One reason for disparate ethical decisions is because people use different ethical systems in reaching decisions about right and wrong actions. In this essay we shall describe briefly the various systems that people use to reach ethical decision's and evaluate these systems insofar as their effectiveness in a pluralistic society is concerned.
Ethics seeks to determine which actions will contribute to a person's fulfillment or happiness. Ethics presupposes human freedom and human responsibility. When judging which actions to perform, whether to gain money by stealing or through work, for example, a person often faces a conflict, One action is good from one point of view (stealing is an easier and often a quicker way of obtaining money), but the other action is good from another point of view (working enables one to retain personal integrity, respect the rights of others, and avoid the opprobrium associated with theft). How settle the conflict? Whether they realize it or not, people use a consistent method of ethical decision making when they are faced with such questions. The major systems of ethical decision making are:
1. Emotivism an ethical theory which relies mainly on subjective, emotional response. According to this theory, something is right or wrong because "I feel it is right or wrong." In the United States today, this method of ethical reasoning is widespread and many will defend their own or the ethical choices of others as long as the people making decisions are "sincere." This method of decision making leads to exaggerated individualism, as Robert Bellah and others demonstrate in Habits of the Heart (New York: Harper and Row, 198~). While emotions are an important factor in making good ethical decisions, by themselves emotions do not offer a sufficient basis for developing a system of shared values in a pluralistic society. Moreover, emotivism does not enable one to measure an action in accord with one's human fulfillment, unless one maintains emotional satisfaction is the same as human fulfillment.
2. Legalism an ethical system which maintains that the law determines what is ethical. In health care, this method is often used with a view toward avoiding malpractice litigation. Thus, physicians, hospital administrators, trustees, and their legal advisors often ask, "What will help us avoid malpractice," rather than, "How do we foster patient benefit (fulfillment)?" This method perverts the relationship between ethics and law. Laws should be founded upon ethical norms, but the law often falls behind ethical thinking. For-example, to assert that artificial hydration or feeding cannot be removed unless there is a law enabling people to do so ignores the essential goal of fulfillment of persons through medical care. Thus, laws are helpful if they express sound ethical norms, but laws are not the ultimate norm for ethical choices in a pluralistic society.
3. Cultural Relativism an ethical method which decrees that actions are ethical if they correspond to the customs of a society or a segment of society. Simply because people are accustomed to performing actions is not an ultimate judge of the ethical worth of the actions. Probably the most significant examples of cultural relativism for the health care professions are found in the various codes of ethics used by different professional associations. For example, the Code of Ethics promulgated by the American Medical Association approves of some actions which are in themselves unethical and disapproves of others which are not unethical. But no substantial reasons are given for the decisions offered. Does one have to follow the codes in question in order to be a good doctor? In the past, the codes of ethics for physicians have contained blatant violations of patients' rights, especially in regard to informed consent (Carlton B. Chapman's Physicians, Law, and Ethics; New York University Press, 1984). Hence, customs and codes are only worthwhile if they are subject to more basic ethical evaluation: Something is not ethical in our pluralistic society simply because "everyone does it."
4. Fideism a method of ethical decision making based upon religious faith in a church or a person. While church directives may be helpful and fulfilling for human beings, and while many churches offer worthwhile and reasonable explanations for their teachings, the ultimate motivation for accepting the teaching is religious faith. Hence, directives of churches, even though reasonable, will not be accepted in a pluralistic society by people who do not share the same faith.
5. Reasoned Analysis a method of judging ethical issues by reasoning about the effect of the action itself upon the important values of life, and the consequences of the action upon persons involved. This system seeks to discern whether or not the action and its consequences contribute to human fulfillment and happiness. This method of ethical investigation is difficult and intricate because it means we must seek some common definitions pertinent to human fulfillment and happiness and we must formulate general norms concerning human functions and human values in order to guide our decision making. While this method of ethical decision making is complicated and intricate, it has been successful in the field of health care because there are many norms that have been accepted in regard to ethical health care. For example, it is accepted by all that medical personnel should obtain informed consent before treating patients because this disposes for human fulfillment. Moreover, it is accepted that life-support systems may be removed if they are useless or involve a grave burden to human fulfillment. Likewise it is accepted that access to health care for poor people is a public concern. The many volumes published by the Commission for Protection of Human Subjects and the President's Commission on Ethics in Medicine and Biomedical and Behavioral Research are examples of the effort to do ethics through reasoned analysis. Though there is agreement in many major ethical issues in medicine, we do not mean to imply that all ethical issues are near solution. The ethical evaluation of abortion is one area in which consensus has not materialized. But we do insist that there is no possibility of reaching consensus in our pluralistic society on abortion and other con[tro]verted ethical issues unless there is a process of patient and comprehensive examination of the ethical issues through reasoned analysis. Only through this method can consensus be developed concerning actions which foster or impede human development and will we have the opportunity for consensus in our pluralistic society,
Books have been written describing the various ethical systems. This brief synopsis presents a general idea of each system and why we often differ often differ on ethical conclusions, even though we may begin with the same set of facts.
The next time you seek to make an ethical judgment or are involved in an ethical debate, analyze the method of decision making that you are using. Realize that some methods are not well-founded because they do not ask the basic questions; realize or recall that for our pluralistic society we need a method of ethical decision making which is founded upon the reasoned analysis of shared values.
Kevin O'Rourke, OP
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