Additional Theories of Ethics

Most good interview candidates will know the four pillars of medical ethics so to impress your interviewer, you can also include ethics that we get taught later in medical school. You don’t need to know these in-depth, just what they represent.

No medical decision should be based on just one form of ethics but a combination of many. This is because (as demonstrated below) all of these have flaws.

Consequentialist Ethics

“The morality of a decision is based on its consequence (or intended consequence).”

Utilitarianism

This is the most common form of consequentialism and relies on many claims. If a decision adheres to these claims, then the decision follows utilitarianism:

Consequentialism: Whether an act is morally right depends on its consequences.

Actual Consequentialism: Whether an act is morally right depends on its actual consequences (not foreseen, intended or likely consequences).

Maximising Consequentialism: The morality of an act depends on the consequence which is the best/produces the greatest net good (Net Good = Total Good - Total Bad).

Equal Consideration: There is no waiting depending on the individual. Every person is considered a person regardless of how well/unwell, moral/immoral etc. they are.

Agent-Neutrality: The net good of a consequence does not depend on who is evaluating it. The goodness of a decision would be the same regardless of the people involved (a mother doesn't have agent-neutrality towards her children when compared to other children).

Any moral decision made under these claims will be an utilitarian decision. In basic terms, the actions which promotes the most good for the most people (and avoids the most harm) is the most moral action. For example, in the famous Trolley Problem where you are on a trolley/train heading towards 5 people but you have the option to pull a lever and switch the tracks so the trolley only hits one person, a utilitarian argument would switch the lever as it is the ‘least bad consequence’. However, a utilitarian response would also support the killing of a healthy patient if their organs could be used to save 5 other dying patients. Therefore, we can’t always use this argument, and instead must also consider the morality of our actions (deontology) - not just the consequences (consequentialism).

Ethical Altruism

This is another type of consequentialism, in which the morality of a decision is based on the consequence to other individuals, regardless of the consequences to yourself. Once again it would suggest sacrificing yourself to donate your organs to 5 people would be a very ethical response, so it clearly isn’t always applicable.

Deontological Ethics

“The morality of a decision is based on its conformity to social norm. Actions are either always morally permitted or always morally forbidden”

This breaks down actions into morally permitted (actions that are moral) and morally forbidden (actions that are immoral). Instead of looking at the consequence of actions, deontologists will judge the morality of an action on its conformity to the moral norm. This means, certain actions are always morally forbidden regardless of how much good they produce (e.g killing a healthy person to transplant their organs to 5 ill people is always morally wrong as killing a person is morally forbidden). If an action contradicts the moral norm (e.g human rights), then it is morally forbidden. If an action complies with the moral norm (e.g being kind), then it is morally permitted.

In Deontological ethics there are two main deontological distinctions:

Doctrine of Double Effect: This distinguishes a difference between intending and foreseeing.

For example a doctor may overprescribe painkillers to reduce pain of a terminal patient (intention) even if you foresee that this medication will kill the patient quicker as the doctor is not intending to kill the patient. However, you must not actively euthanise a patient (killing a patient on intention alone).

Doctrine of Doing and Allowing: The distinction between doing and allowing.

For example, if you have a shortage of resources, you may divert a treatment away from 1000 people, in order to research a treatment which would save 100,000 people (doing research to save 100,000 but allowing 1000 to die.) However, if by allowing the 1000 to die, you can monitor their deterioration and use it to save 100,000 people, deontological ethics forbids this (the doing cannot be a consequence of the allowing as that is consequentialist).

However, this also means that due to deontological ethics, you must not lie, even if you foresee that it will produce the best benefit (e.g temporarily lying to a patient involved in a traumatic car crash about the nature of their family to ensure that the individual can focus on their own health before worrying about their family’s). Furthermore, you must not euthanise someone (although you can foresee it to happen) regardless if it will reduce suffering for the individual, as by doing the action, you are contradicting moral norm.

Due to the inability to consider the consequences of your actions, we can quickly see where deontological ethics fails (in the famous Trolley Problem, you must not push a large man onto tracks to save 1000 people if it means killing 1. In the Medicine experiment above, you must not allow the 1000 to die, if by doing so it would save 100,000).

Virtue Ethics

This is a very broad term to describe the ethical approach which rates morality by the character of the person, rather than the action (deontology) or consequence (consequentialism) of the action.

In simple terms, someone who acts virtuously and avoids vices (immoral behaviour), is considered a moral person. Although the characteristics that are consider virtuous have changed over time and from one philosopher to another, the traditional list of fundamental virtues are:

Prudence - possess good judgment and show care for the future. (e.g., always seek to provide the most benefit for the patient).
Justice - seek fairness in behaviour and actions. (e.g., treat people equally and without biases).
Fortitude/Bravery - encounter difficulty and adversity with courage. (e.g., whistleblow in a medical setting when something wrong is happening).
Temperance - posses self-control (e.g., refrain from drugs).

A person who acts with these virtues, (and refrains from the vices - the opposite of the virtues) would be acting morally correct. As this determines the morality of actions by their intentions, intentions must be considered when rating the morality of an action (e.g the difference between manslaughter and murder in court).

Moral Absolutism, Pluralism and Relativism

Moral Absolutism: “There is only one right answer.”

Moral Pluralism: “There is no definitive way to decide on the most moral action.”

Moral Relativism: “There is no wrong answer.”

Moral pluralism is the middle ground between the two, and often argues that a situation doesn’t have a most moral action, but rather actions can be explained using multiple theories of ethics, and are dependant on the individual. For example, if there three people are drowning at sea, and you can either save one and sacrifice yourself, or do nothing and let them die, a moral pluralist would argue that there no definitive way to conclude the most moral action. Moral Pluralism is often the case in the medical setting when resources are short, however, as a doctor, you must always treat patient in order of clinical need (the illest patient first).