Foundations of Bioethics: Ethical Theories,

Moral Principles, and Medical Decisions

Introduction
The branch of philosophy concerned with principles that allow us
to make decisions about what is right and wrong is called ethics
or moral philosophy.
Bioethics is specifically concerned with moral principles and
decisions in the context of medical practice, policy, and research.
Moral difficulties connected with medicine are so complex and
important that they require special attention. Medical ethics gives
them this attention, but it remains a part of the discipline of
ethics.
Thus, if we are to answer the question as to whether there are
any rules or principles to use when making moral decisions in the
medical context, we must turn to general ethical theories and to
a consideration of moral principles that have been proposed to
hold in all contexts of human action.

Introduction
This chapter reviews several major ethical
theories which attempt to supply basic
principles that we can rely on in making moral
decisions. Those theories are:

Utilitarianism
Deontology Kants version and Rosss version
Rawlss Theory of Justice
Natural law ethics
Virtue ethics
Care ethics

Introduction

The chapter also reviews several broad

principles that cut across some or all of
the ethical theories examined. These
principles are:
Non-maleficence
Benevolence
Utility
Rules of distributive justice
Autonomy

Utilitarianism
According to Utilitarianism, a person should perform
those action actions which conform to the Principle
of Utility.
The Principle of Utility says: a person should choose
that action which produce the greatest good for the
greatest number of people affected by the
alternatives open to him.
The rightness or wrongness of actions is determined
by the goodness or badness of the actions
consequences, not by the actions themselves.

Utilitarianism
Because the morality of an action, according to
utilitarianism, rests on its consequences,
utilitarianism is called a consequentialist theory
of ethics.
There are different views as to what make a
consequence good or bad.
According to the classical or hedonistic
version, what makes a consequence good or bad
is its effect on peoples happiness.

Utilitarianism
Roughly, a consequence is bad if it reduces
happiness, good if it increases happiness.
Happiness, in turn, is understood to mean:
an increase in pleasure and/or decrease in
pain.
Because of the emphasis on happiness,
Utilitarianism is sometimes called the
greatest happiness principle.

Application to bioethic
In August 2000, conjoined twins, named Mary and Jodie were born
in a hospital in Manchester England. Their spines were fused, and
they had one heart and one pair of lungs between them. Jodie,
the stronger one, was providing blood for her sister.
The prognosis was that without intervention, both girls would die
within six months. The only hope was an operation to separate
them. This would save Jodie, but Mary would die immediately.
Thus, there were two options:

(a) Not intervene and see both babies die

Or
(b) Intervene and save one life, Jodie.

Application to bioethics
What is the acceptable course of action?
According to utilitarian, we need to decide
which course of action will produce the
greatest good for the greatest number of
people affected by the action.
It is plausible to interpret utilitarianism as
supporting alternative (b). Surely it is better
to save one life rather than not.

Deontology
As noted earlier, consequentialist theories of
ethics find the basis for an actions morality in the
consequences produced by the action rather than
in the action itself.
Deonological theories of ethics, argue that it is
features of the action itself, apart from
consequences, which determine its morality.
When an action has the relevant features then we
can say it is our duty (or obligation) to perform it.

Deontology
It is this emphasis on duty that earns
them the name deontological,
which is derived from the Greek word
for duty or obligation.
There are different versions of
deontology. We examine two of them,
those of Immanuel Kant and W. D.
Ross.

Kant
According to Kant, we have an obligation
to perform an action if it satisfies what he
called the categorical imperative.
Kant formulated three versions of the
imperative. Though differing in wording
and emphasis, he understood them as
three different views of the same
overarching principle. They are:

Categorical imperative
Act only according to that maxim by which you can at the
same time will that it should become universal law.
Act so that you treat humanity, whether in your own person
or in that of another, always as an end and never as a
means only.
Every rational being must so act as if he were through his
maxim always a legislating member in the universal
kingdom of ends.
We shall restrict ourselves to the first two versions, starting
with the first.

First version
If you decide to have an abortion and go through
with it, it is possible to view your action as
involving a rule.
You can be thought of as endorsing a rule to the
effect Whenever I am in circumstances like
these, then I will have an abortion. Kant calls
such a rule a maxim.
In his view, all reasoned and considered actions
can be regarded as involving maxims.

First version
The maxims in such cases are personal or
subjective, but they can be thought of as being
candidates for moral rules.
If they pass the test imposed by the categorical
imperative, then we can say that such actions
are right. Furthermore, in passing the test, the
maxims cease to be merely personal and
subjective. They gain the status of objective
rules of morality that hold for everyone.

First version
Kant calls the principle categorical to
distinguish it from hypothetical
imperatives. These tell us what to do if we
want to bring about certain consequences
such as happiness.
A categorical imperative prescribes what
we ought to do without reference to any
consequences. The principle is an
imperative because it is a command.

First version
The test imposed on maxims by the categorical
imperative is one of generalization or
universalizability. The central idea of the test is
that a moral maxim is one that can be generalized
to apply to all cases of the same kind.
That is, you must be willing to see your rule
adopted as a maxim by everyone who is in a
situation similar to yours. You must be willing to see
your maxim universalized, even though it may turn
out on some other occasion to work to your
disadvantage.

First version
The best way to illustrate the first version of the category
imperative is to consider a possible instance where an
action fails the test.
Suppose, for example, that I am a physician and I tell a
patient that he has a serious illness, although I know that
he doesnt. This may be to my immediate advantage, for
the treatment and the supposed cure will increase my
income and reputation.
The maxim of my action might be phrased as,
Whenever I have a healthy patient, I will lie to him and
say that he has an illness.

First version
Now suppose that I try to generalize my maxim (apply
the first version of the categorical imperative). In
doing so, I will discover that I am willing the existence
of a practice that has contradictory properties.
If Whenever any physician has a healthy patient, she
will lie to him and say he has an illness is made a
universal law, then every patient will be told that he
has an illness. Trust in the diagnostic pronouncements
of physicians will be destroyed, while my scheme
depends on my patients trusting me and accepting
the truth of my lying diagnosis.

First version
It is as if I were saying, Let there be a rule of
truth telling such that people can assume that
others are telling them the truth, but let there
also be a rule that physicians may lie to their
patients when it is in the interest of the
physician to do so.
In willing both rules, I am willing something
contradictory. Thus, I can will my action in a
particular case, but I cant will that my action be
universal without generating a logical conflict.

First version
If we return to the Mary and Jodie example introduced earlier, we can
see that Kants approach to evaluating the alternatives (allow both to
die or save one but sacrifice the other) would be different from that of
utilitarianism. Kant would reject the idea that we should look at the
consequences of the two options.
Instead we should ask if something like the following rule could be
universalized (that is, avoid contradiction):
Save one life in situations where failing to do so will result in the loss of
life of two.
Can it be universalized? On the face of it, there is no obvious
contradiction in trying to do. As a result, the Kantian and the Utilitarian
could well agree on the morality of the action but for different reasons.

Second version
Act so that you treat humanity, whether in your
own person or in that of another, always as an
end and never as a means only.
This version illustrates Kants notion that every
rational creature has a worth in itself.

This worth is not conferred by being born into a

society with a certain political structure, nor
even by belonging to a certain biological species.

Second version
The worth is inherent in the sheer possession of
rationality. Rational creatures possess what Kant calls an
autonomous, self-legislating will.

That is, they are able to consider the consequences of

their actions, make rules for themselves, and direct their
actions by those self-imposed rules. Thus, rationality
confers upon everyone an intrinsic worth and dignity.
So, we are treating a person (including ourselves) as an
end (and not just a means to an end) when we act
towards him in such a way that recognize his rationality or
autonomy.

Second version
A non-bioethical example illustrates his meaning:
You need money and you want a loan but you know you
cant pay it back. It occurs to you to ask a friend for the
money with the promise of paying it back. You are
proposing to lie to the person and, in so doing, you are
treating them merely as a means to one of your goals.

On the hand, imagine the same situation except this time

you explain the situation to your friend, hoping still, of
course, to get the money. But now you are allowing your
friend to make his own free and fully-informed decision to
give you the money or not. You have recognized and
engaged the friend as a rational agent. You have
respected his dignity.

Second version
Recall again the example of Mary and Jodie. How might we
apply the second version of the categorical imperative to
this case. Here is one possible way to phrase the question:
If we elect to save Jodie and allow Mary to die, have they
both been treated as ends? One answer might be no
because Mary has been sacrificed to allow Jodie to live
she is being treated merely as a means to Jodies survival.
If this is the correct conclusion then a question arises as to
whether it is consistent with the apparently correct
conclusion to the first version of the imperative, that there
is no inconsistency in universalizing the rule: save one life
when the alternative is to see two die.

W. D. Ross
W. D. Ross attempts to incorporate aspects of
utilitarianism and aspects of Kantianism.
Ross rejected the utilitarian notion that an action is
made right by its consequences alone, but he was
also troubled by Kants view, if a rule passed the
categorical imperative (and became a duty to follow),
it could have no exceptions, it was absolute.
He saw not only that such rules fail to show
sensitivity to the complexities of actual situations, but
also that they sometimes conflict with one another.

Prima facie duties

Like Kant, Ross is a deontologist, but he believed (as
Kant apparently did not) that moral duties can conflict,
in which case their relative merits had to be weighed
and the chosen action based on the outcome of that
weighing.
Because duty A might be outweighed by another duty
B in a situation where the two conflict, it might seem
inappropriate to call A a duty in the first place. Aware
of this concern, Ross describes A and B as prima facie
duties. They are duties we have all things being
equal. But in a situation only one of them will turn
out (after weighing) to be our actual duty.

Prima facie duties

When is something our duty? Ross does not propose any general
test of obligation like Kants categorical imperative. Instead, Ross
falls within the tradition of ethical intuitionism. After a careful
examination of the facts surrounding a case, he believes that we
then are able to intuit the appropriate duty.
Ross claims that our experience with such cases puts us in a
position to come to know our prima facie duties with the same
degree of certainty as when we grasp the mathematical truth that a
triangle has three angles.
Furthermore, according to Ross, our experience of many individual
cases puts us in a position to recognize the validity of a general
statement like It is wrong to cause needless pain. We come to
see such rules in much the same way that we come to recognize
the letter A after having seen it written or printed in a variety of
handwritings or typefaces.

Prima facie duties

Ross offers a list of duties that he considers binding on
all moral agents. (He did not claim that the list is
exhaustive).
1. Duties of fidelity: telling the truth, keeping actual and
implicit promises, and not representing fiction as
history
2. Duties of reparation: righting the wrongs we have
done to others
3. Duties of gratitude: recognizing the services others
have done for us

Prima facie duties

4. Duties of justice: preventing a distribution of pleasure or
happiness that is not in keeping with the merit of the
people involved
5. Duties of beneficence: helping to better the condition of
other beings with respect to virtue, intelligence, or pleasure
6. Duties of self-improvement: bettering ourselves with
respect to virtue or intelligence
7. Duties of non-malfeasance: avoiding or preventing an
injury to others

Bioethical example
Recalling the example of Mary and Jodie, Ross
would answer the question of whether it is right or
wrong to separate the twins by first seeing which of
the prima facie duties are applicable and, in the
event there is a conflict, examine the non-moral
facts of the case, and with these facts as
background, weigh the duties against one another.
In considering the case, the duties of nonmalfeasance and beneficence seems relevant and
it is plausible to read them as implying that there is
an obligation to separate the twins.

Rawlss theory of justice

The theory of justice formulated by the philosopher John
Rawls can be understood as attempting to combine the
strengths of utilitarianism and deontology while avoiding
the weaknesses of each view.
For Rawls, the central task of government is to preserve
and promote the liberty and welfare of individuals. Thus,
principles of justice are needed to serve as standards for
designing and evaluating social institutions and practices.
Rawls position has direct relevance to such bioethical
issues as who should have access to health care, how
donated organs should be distributed, and who should pay
for societys medical costs.

Principles of justice
Rawls argues that there are two fundamental
principles of justice:
1. Each person is to have an equal right to the most
extensive total system of equal basic liberties
compatible with a similar system of liberty for all.
2. Social and economic inequalities are to be arranged
so that they are both
a) to the greatest benefit of the least advantaged
b) (b) attached to offices and positions open to all under
conditions of fair equality of opportunity.

Principles of justice
For Rawls, these two principles are taken to govern
the distribution of all social goods: liberty, property,
wealth, and social privilege.
The first principle has priority. It guarantees a system
of equal liberty for all. The second principle governs
the distribution of social goods other than liberty.
Though Rawls overall position has relevance to
individual medical decisions, its most important
application is to the social institutions and practices
of medical care and research.

Bioethical example: consent

According to Rawlss principles it is wrong to exploit
one group of people or even one person for the
benefit of others.
Thus, experiments in which people are forced to be
subjects or are tricked into participating are ruled
out.
A person has a right to decide what risks she is
willing to take with her own life and health. Thus,
voluntary consent is required before someone can
legitimately become a research subject.

Bioethical example: health

care
The implication of Rawls position seems to be that everyone
is entitled to health care.
First, it could be argued that health is among the primary
goods that Rawlss principles are designed to protect and
promote. (Primary goods are the rights, opportunities,
powers, wealth, and such that are both worth possessing in
themselves and are necessary to securing the more specific
goods people may want.)
Second, it could be argued that the inequalities of the
health care system can be justified only if those in most
need can benefit from them. Since this is not obviously the
case with the present system, Rawlss principles seem to
call for a reform that would provide health care to those
who are unable to pay.

Natural law ethics

Natural law theories of ethics share the general idea that the
rightness of actions is something determined by nature itself,
rather than by the laws and customs of societies or the
preferences of individuals.
The most well-known, and fully articulated, version of natural law
is that formulated by St. Thomas Aquinas and endorsed by the
Catholic Church.
Borrowing from Aristotle, the Thomistic version of natural law sees
the universe organized in a teleological way. That is, the universe
is structured in such a way that each thing in it has a goal or
purpose. Thomism importantly add that this teleological structure
was brought about by God so that the purposes found in the
Universe are a reflection of Gods purposes.

Natural law ethics

For example, when conditions are right, a tadpole will
develop into a frog. In its growth and change, the tadpole
is following the law of its nature. It is achieving its goal.
Humans have a material nature, just as a tadpole does,
and in their own growth and development they, too, follow
a law of their material nature.
But humans also possess a trait that no other creature
does: reason. Thus, the full development of human
potentialitiesthe fulfillment of human purposes or ends
requires that we follow the direction of the law of
reason, as well as being subjected to the laws of material
human nature.

Natural law ethics

We rely upon reason to determine what our
ends are and how we can achieve them. In
particular, reason directs us toward our good as
the goal of our action, and what that good is, is
discoverable within our nature.
The human good is built into human nature in
the way that, in a sense, a frog is already built
into a tadpole. Thus, the good is that to which
we are directed by our natural inclinations as
both physical and rational creatures.

Natural law ethics

These built-in inclinations are the basis for our moral
duties. For example:
Like other creatures, we have a natural inclination to
preserve our lives; consequently, reason imposes on us
an obligation to care for our health, not to kill ourselves,
and not to put ourselves in positions in which we might
be killed.
We realize through reason that others have a rational
nature like ours, and we see that we are bound to treat
them with the same dignity and respect that we accord
ourselves.

Natural law ethics

When we see that humans require a society to make their full
development possible, we realize that we have an obligation
to support laws and practices that make society possible.
We have a natural inclination to propagate our species
(viewed as a natural good), so reason places on us an
obligation not to thwart or pervert that inclination (by for
example using condoms or masturbating).
As the examples illustrate, according to natural law ethics,
through the application of reason, it should be possible to
establish a body of moral principles and rules. These are the
doctrines of natural law.
Following are two principles especially relevant to bioethics.

Principle of double effect

A particular kind of moral conflict arises when
the performance of an action will produce both
good and bad effects. On the basis of the good
effect, it seems it is our duty to perform the
action; but on the basis of the bad effect, it
seems our duty not to perform it.
What are we obligated to do in this situation?
The principle of double effect is intended to help
in the resolution of these kinds of conflicts.

Principle of double effect

The principle holds that such an action should be performed only if
the intention is to bring about the good effect and the bad effect
will be an unintended or indirect consequence. More specifically,
four conditions must be satisfied:
1. The action itself must be morally indifferent or morally good.
2. The bad effect must not be the means by which the good effect
is achieved.
3. The motive must be the achievement of the good effect only.
4. The good effect must be at least equivalent in importance to the
bad effect.

Double effect example

The principle might be illustrated by the example of Mary and
Jodie:
The doctors wanted to save the life of Jodie, a morally good
action.
The death of Mary was a bad consequence of saving Jodie but
it was not the means; it was a foreseen but unintended byproduct of saving Jodie.
The doctors intended to save the life of Jodie, it was not to kill
Mary.
Saving the life of Jodie is morally as significant as the death of
Mary.

Principle of totality
This principle says that an individual has a right to dispose
of his or her organs or to destroy their capacity to function
only to the extent that the general well-being of the whole
body demands it.
Thus, it is clear that we have a natural obligation to
preserve our lives, but, by the Roman Catholic view, we
also have a duty to preserve the integrity of our bodies.
This duty is based on the belief that each of our organs
was designed by God to play a role in maintaining the
functional integrity of our bodies that each has a place
in the divine plan. As we are the custodians of our bodies,
not their owners, it is our duty to care for them as a trust.

Principle of totality
The principle of totality has implications for a great
number of medical procedures.
Strictly speaking, even cosmetic surgery is morally
right only when it is required to maintain or ensure
the normal functioning of the rest of the body.
More important, procedures that are typically
employed for contraceptive purposes vasectomies
and tubal ligationsare ruled out since such
procedures involve mutilation and the destruction
of the capacity of the organs of reproduction to
function properly.

Virtue ethics
Virtue ethics is ethics based on character. Its
fundamental idea is that a person who has acquired
the proper set of dispositions will do what is right when
faced with a situation involving a moral choice.
Thus, virtue ethics doesnt involve invoking principles
or rules to guide actions.
The virtuous person is both the basic concept and the
goal of virtue ethics. The virtuous person is one who
acts right, because she is just that sort of person.

Virtue ethics
Right actions flow out of character, and the
virtuous person has a disposition to do the right
thing. Rules need not be consulted, calculations
need not be performed, abstract duties need not
be considered.
In medical contexts, virtue ethics calls attention
to the central role which such virtues as courage,
loyalty, integrity, compassion, and benevolence,
along with determination and intelligence,
should play in the practices of medical providers.

Care ethics
Care ethics is an outgrowth of feminist ethics or, perhaps more
accurately, is a particular strand of feminist ethics.
Care ethics is not a unified doctrine that can be captured in a set of
abstract statements. It is perhaps best characterized as a family of
beliefs about the way values should be manifested in character and in
behavior.
It is unified by a set of shared concerns and commitments, as well as
by the rejection of the traditional philosophical view that ethics can be
adequately represented by rules and principles.
As the name implies, the sentiment of caring is taken as a central
consideration in deciding what to do. In medical ethical contexts this
perspective is perhaps exemplified by how a doctor looks at his or her
patient: is this a problem to fix or is this a person whose health I care
about?

General moral principles relevant to

bioethics
The following are thumbnail sketches
of a number of principles which most,
if not all, of the ethical theories
considered endorse in one form or
another. They all have relevance to
bioethical issues.

Principle of Non-maleficence
Above all, do no harm is perhaps
the most famous and most quoted of
all moral maxims in medicine. It
captures in a succinct way what is
universally considered to be an
overriding duty of anyone who
undertakes the care of a patient.

Principle of beneficence
The principle of beneficence can be
stated in various and different ways.
Here is one formulation: We should
act in ways that promote the welfare
of other people. That is, we should
help other people when we are able
to do so.

Principle of utility
The principle of utility can be formulated in this way: We
should act in such a way as to bring about the greatest
benefit and the least harm.
The principle is the very foundation of the moral theory of
utilitarianism. However, the principle need not be regarded
as unique to utilitarianism.
It can be thought of as one moral principle among others
that present us with a prima facie duty, and, as such, it need
not be regarded as always taking precedence over others.
In particular, we would never think it was justified to deprive
someone of a right, even if by doing so we could bring
benefit to many others.

Rules of distributive justice

We expect (and can demand) to be treated justly in
our dealings with other people and with institutions.
The following rules reflect this basic sentiment.
They are best understood in terms of John Rawls
position summarized earlier.
From a bioethical perspective, they have clear
relevance to questions about, for example, access
to health insurance, the distribution of organs, and
who should shoulder the burden of health care
costs.

Rules of distributive justice

Equality
According to the principle of equality, all benefits and burdens are to
be distributed equally.
Need
The principle of need is an extension of the egalitarian principle of
equal distribution.

If goods are parceled out according to individual need, those who

have greater needs will receive a greater share. However, the
outcome will be one of equality.
Since the basic needs of everyone will be met, everyone will end up
at the same level. The treatment of individuals will be equal, in this
respect, even though the proportion of goods they receive will not be.

Rules of distributive justice

Contribution
According to the principle of contribution,
people should get back that proportion of social
goods that is the result of their productive labor.
Effort
According to the principle of effort, the degree
of effort made by the individual should
determine the proportion of goods received by
the individual.

Principle of autonomy
The principle of autonomy can be stated this way:
Rational individuals should be permitted to be selfdetermining. According to this formulation, we act
autonomously when our actions are the result of
our own choices and decisions.
Autonomy is significant not only because it is a
condition for moral responsibility, but because it is
through the exercise of autonomy that individuals
shape their lives. Autonomy is a significant
consideration when thinking about euthanasia and
abortion.