SH5000 Ethics and Research in Professional Contexts
Analysing the Case-Studies:
When thinking about moral decision-making in professional contexts you may approach your analysis of a given dilemma by going through the following steps:
Case study —- Mrs K is a 37-year-old woman with four children. She consults her doctor for irregular periods. She had been using a diaphragm as contraception, having stopped taking birth control pills because of their side effects.
Her doctor tells her that she is pregnant. She does not want another child. She says she already has as many children as she can cope with. Mrs K suffers from depression. Her doctor considers her circumstances fall within the Abortion Act 1967 and refers her to a clinic.
Mr K disagrees with abortion.
Did the doctor do the right thing?
Professional Ethics resources
Here are some web links for professional ethical codes of conduct in Health and Social Care and in Youth Work:
QALYfying the Value of Life: https://jme.bmj.com/content/medethics/13/3/117.full.pdf
The QUALY method – using utilitarianism in practice:
Harris, J, “QALYfying the Value of Life”, Journal of Medical Ethics 13, 1987, pp. 117-123.
Moral status of the fetus: Fetal rights
Abortion Act 1967
abortion doctors and the law
diaphragm as contraception
Utilitarianism and Consequentialism
Bentham, J (1789), An Introduction to the Principles of Morals and Legislation, (edited by J. H. Burns and H. L. A. Hart (1970), London: Athline Press).
Mill, J.S. (1861), Utilitarianism (various editions, e.g. R. Crisp, (ed.) 1998, New York: Oxford University Press.
Criticism of utilitarianism:
Williams, B. “A Critique of Utilitarianism” in J.J.C. Smart & Bernard Williams, (eds.) (1973) Utilitarianism: For and Against, Cambridge, UK: Cambridge University Press.
The Four Principles Approach:
Beauchamp, T.L. and Childress JF (2001) Principles of Biomedical Ethics (5th edition). Oxford: Oxford University Press.
The QUALY method – using utilitarianism in practice:
Harris, J, “QALYfying the Value of Life”, Journal of Medical Ethics 13, 1987, pp. 117-123.
Characterising the ethical professional: virtue, care, narrativity, paternalism.
Aristotle, Nicomachean Ethics (Book 2, on virtues…it can be viewed online here: http://classics.mit.edu/Aristotle/nicomachaen.2.ii.html)
The Ethics of Care:
Gilligan, Carol (1982) In A Different Voice. Cambridge: Harvard UP (esp. the Jake and Amy example, pp. 26-28)
V.Held, (2005) The Ethics of Care, Oxford: Oxford University Press.
Narrativity and ethics:
4 Principles approach:
Beauchamp & Childress (2008), Principles of Biomedical Ethics. 6th edition.
The normative theory that gives the ‘Principle of Respect for Autonomy’ is Kantian Deontology. See:
Kant, I. (1785) Groundwork of the Metaphysic of Morals, trans. Gregor, Mary, J, (1998), Cambridge, (pp.7-16, 25-39 – the sections on the ‘Good Will’ & the ‘Categorical Imperative’).
On consent and capacity:
Sayers, G.M., Schofield, I & Aziz, M, ‘An Analysis of CPR Decision-making by Elderly Patients’, in Fulford, et al, (2002),Healthcare Ethics & Human Values, pp. 304-311
The UK Mental Capacity Act 2005 – URL: http://www.legislation.gov.uk/ukpga/2005/9/contents
Eyal, Nir, “Informed Consent”, The Stanford Encyclopedia of Philosophy Online (Fall 2012 Edition), Edward N. Zalta (ed.) URL: http://plato.stanford.edu/entries/informed-consent/#Aca
Faden, Ruth R., and Tom L. Beauchamp. 1986. A History and Theory of Informed Consent. New York: Oxford University Press
Utilitarianism and Beyond:
SH5000 Ethics & Research in Professional Contexts Week 1 Handout important information
Part one: Ethics
In Part One of this module we will study various ethical theories, and explore how they might be applied to moral dilemmas in professional contexts relevant to your degree pathways. We will look at how far, if at all, ethics can inform and guide the making of moral choices and the consequent performance of actions for professionals in health and social care, youth work, and other social professions.
Here are some key terms that you will need to become familiar with:
Ethics – the theory of right and wrong conduct
Morals – the practice of right and wrong conduct (behaviour)
Moral Philosophy – inquiry into the idea of moral conduct; the attempt to come up with a rationally defensible theory of right and wrong conduct.
Meta-ethics – inquiry into the meaning of moral statements (e.g. “it is wrong to lie,” or “killing humans is always wrong ”), their truth or falsity, and the existence of any moral facts that may underlie them. Normative Ethics – systems of moral belief that assume certain ethical norms as the basis for making moral judgments (e.g. “it is good to be happy” or “ it is right to do one’s duty”), and which explain the use (but not the meaning) of moral terms in moral statements as a result. Normative ethical systems clarify the values and reasoning that lie behind moral choices, and provide means of moral justification in accordance with certain specified rules and/or principles.
Applied Ethics – the application of normative ethical theories to moral problems or dilemmas, often hypothetically, with the aim of arriving at a solution or an appropriate moral understanding of the issues. Practical Ethics – the practical use of moral theories when deciding how to act in everyday situations, where moral choices need to be made and actions performed.
Personal ethics – the level at which moral choices are made in accordance with personal beliefs about what is morally valuable.
Professional ethics- the level at which moral judgments are made in accordance with certain professional codes of conduct, within the context of performing one’s professional duties appropriately. N.B Our studies will involve examining the way moral judgments are arrived at, not legal or religious ones. Where these may seem to be importantly related we will attempt to clarify and explain the connection, but our focus throughout will be on ethical and not legal or religious theoretical positions. Some questions to bear in mind:
What makes a choice a moral as opposed to a non-moral one?
Why be moral? (i.e. Why ought I to do what morally I ought to do?)
Shall I act on personal impulse or intuition, or is there any objective guidance that can help me to decide what is the right thing for me to do?
Why might it be valuable for social professionals to study ethics?
Can you think of examples of problems or choices that professionals in your areas might be faced with that can be classified as moral dilemmas? Can ethics help to solve them?
What makes a choice a moral, as opposed to a non-moral, one?
Is there a distinction to be made between moral dilemmas and other kinds of dilemmas that humans may be faced with? If so, what exactly is it?
You may believe that many choices we are faced with during our lives are pretty straightforwardly matters of personal preference. That is, you may accept that often, when you find yourself in the position of having to make a decision about what to do next, the choice is ultimately yours alone and can be made in any way you wish. In these types of cases what we actually do as a result of the choices that we make can be said to be neither moral nor immoral.
For example, I may have woken up this morning and found myself wondering whether to wear my blue jumper or my green jumper today. This choice seems to be one of personal preference. I may think: “well, it’s up to me!” I may believe that I am free to choose to wear whatever I want, on the basis of whatever I wish. Perhaps green is my favourite colour, so I’ll choose the green jumper. Or perhaps I feel like trying blue for a change, etc.
However, we can query whether or not the action that results from my making a choice between my two jumpers (i.e. the picking up and putting on of one or other of the jumpers) could actually constitute a moral choice. We could describe it as a right or a wrong action, a good or a bad one, or claim that we ought or ought not to have performed it. And, we can wonder whether it really is a case of choosing being simply up to me.
Suppose that I live in a community where wearing blue clothes is commonly taken to signify membership of a particular cultural/religious/political group, with particular values? Wearing the blue jumper because I intend to signify my group membership, or resulting in people responding to me favourably or unfavourably because they believe I am a group member, or to reflect my values as a
group member, all render my choice a moral and not simply a personal one. The choice becomes one that is significant to me and to others – it somehow socially matters.
Moral dilemmas, then, involve people having to make choices to perform actions where their intentions, the results of their actions, and the values reflected in their choice are significant – they matter, and not just to the individual performing them.
Ray Billington in his book Living Philosophy (Routledge, 1993), suggests that we can distinguish between the following 5 features of moral choices:
no single, definite and final solution;
A Further Distinction:
The decisions we take when faced with choices result in behaviour that can be classified as moral, immoral or even amoral. That is, they result in the practice of what we may call right or wrong conduct, or perhaps simply conduct.
But on what basis are we to judge whether the conduct is moral, immoral or amoral? One thing we can attempt to do is to evaluate the behaviour/conduct/action with reference to ethics (the theory of right and wrong conduct). We can judge the action in terms of certain ethical norms and/or principles in order to try to determine its rightness or wrongness. So, whether or not you believe that a particular action is moral or immoral or even amoral will depend upon the values that you hold and the ethical arguments that you use to decide what is right and wrong. There are different forms of justification in ethical theory, and we will look at some examples.
Although there is much disagreement amongst ethicists about what the proper basis for moral decision- making ought to be, they all agree on one thing – that we ought to be moral. They all say that we ought to do what morally we ought to do. Do you agree? Why/why not?
A Central Meta-Ethical Debate: Are there any Moral Facts?
A puzzle that will probably crop up during the course is one that has engaged ethicists since ethics was first clarified as an area of inquiry (in western philosophy with Plato & Aristotle in the 5th Century B.C.). This puzzle centres around the question of whether or not there are any moral facts, and asks, if there are such facts, whether or not we can know them. This is not something we will spend much time examining (there’s a vast literature on this topic that goes beyond the limits of our course), but it’s important for you to consider whether or not you take morality to be a matter of mind-independent facts or whether you take it to be a matter of socially constructed knowledge, because this will have repercussions for your approach to arriving at solutions to moral dilemmas. If there are certain moral truths (perhaps it is true that it is wrong to kill, for example), and we can discover these truths, then you might believe that working out what to do in any given case involves finding out (using some method) what the relevant moral fact is & then acting in accordance with it. However, if you hold that morality is rather about creating socially desirable or useful norms, and acting in accordance with these, then your approach to solving dilemmas will probably involve some process of determining what is desirable or useful for a particular society, and working from there to create moral prescriptions.
How will we proceed?
We will be studying the central tenets of some of the most well-known and commonly used western normative ethical theories, e.g. Utilitarianism and Deontology, Virtue Ethics and Care Ethics.We will consider the significance of these theories for practical choice-making by attempting to apply them to a selection of dilemmas (expressed as case-studies from professional contexts – you will be given case- studies to work with on the module, and you will also be encouraged to bring in case-studies to discuss from your own experience, or from newspapers, books, television, the internet or other media).
We will take into account relevant laws, policies and professional codes of conduct and issues of rights and morality in these cases, and we will also look at what the relationship between morality and cultural and religious difference might be. But our focus will be on thinking about how far ethical theory is of practical use in helping us come to make decisions about how to act when faced with moral dilemmas in professional practice.
Cook, M. Bioedge, (27.10.12) – http://www.bioedge.org/
§ immediate situations § possible future ones
With the aims of:
Billington, R. (1993) Living Philosophy, Routledge
Systems of moral belief that assume certain ethical norms/standards as the basis for making
moral judgments (e.g. “it is good to be happy”, or “ it is right to do one’s duty”).
Normative ethical systems clarify the values and reasoning that lie behind moral choices, and provide means of moral justification in accordance with certain specified rules and/or principles.
The application of normative ethical theories to
concrete moral problems or dilemmas, with the aim of arriving at a solution or an appropriate moral understanding of the issues.
What’s the distinction between morals & ethics? Theory – ethics can inform
action/behaviour/practice – being moral
The practical use of ethical theories when
deciding how to act in concrete situations, where moral choices need to be made and actions performed.
Very important context
WHAT IS A RIGHT?
freedom or entitlement;
N.B. Moral rights are distinct from legal rights. Legal rights involve formal agreements that there are such rights. RIGHTS IN THEORIES
2 traditions of rights: (references on reading list)
John Locke (1680)– human rights as natural & inherent to all humans, equally. Inalienable (you are born with them; they cannot be taken away).
Jeremy Bentham (1816) – inalienable rights as ‘nonsense on stilts’; rights must be justified in terms of the Principle of Utility, & can be revoked or overridden if doing so maximises utility. Rights are meaningless unless legally enforceable, & specific.
WHAT ARE ‘HUMAN RIGHTS’?
Ò They are sometimes legally guaranteed by human rights law,
e.g. in the UK: Human Rights Act, Sex Discrimination Act, Race Relations Act, Equal Opportunities Act, Mental Capacity Act, Children Act, etc.
THE UNIVERSAL DECLARATION OF HUMAN RIGHTS (1948)
Articles relevant to health care:
POSITIVE AND NEGATIVE RIGHTS
Ò Negative rights protect people from physical and mental abuse – non-interference. Passive duties.
Ò Positive rights permit a substantive claim to be made. For instance, they may recognise the right to receive health care. Active duties.
Ò Is there a right to health? – recent debates (see references The Lancet & work by Amartya Sen).
RIGHTS OF HEALTH-CARE PRACTITIONERS
RESPONSIBILITIES OF HEALTHCARE PRACTITIONERS
Ò To inform patients of their options;
Ò To offer to treat patients; Ò To respect patient
Ò To respect patients’ decisions.
Ò The duty of care
RIGHTS & DUTIES OF PROFESSIONALS
Patients have a right to information about their condition & the treatment options available to them, so they can consent or refuse.
The right confers a duty on healthcare professionals to provide relevant information in a clear, non-coercive manner, suited to the patient.
Informed Consent seen as crucial in the moral doctor-patient relationship. Why?
Valuing autonomy (self-determination)…
(Article 3) right to life, liberty, security of the person…
But is the right to consent an absolute right?
Difficult to see how it can be – too many factors making it likely that fully informed, truly voluntary consent will be hard to achieve.
Not an absolute right in UK law.
Is this moral? What should the limit be?
CONSENT & CONFIDENTIALITY
If it’s not absolute when can the right to informed consent be breached?
Example: Public health & infectious disease control. In order to protect the public from contagious infectious diseases, The Public Health Act (1984) regulates notification of diseases and mandatory treatment of conditions like tuberculosis (TB).
The individual’s right to consent is restricted in two areas:
Firstly information about the patient’s diagnosis has to be given to the relevant authorities. The patient should be informed. It is mandatory for a medical practitioner to disclose personal details of the patient and the diagnosis to the relevant authorities even if the patient does not agree to this.
Secondly patients suffering from communicable diseases can be forced to take their
medication by supervised administration or involuntary inpatient treatment.
If a patient confesses a crime or a planned crime to a doctor, it is left to her to decide whether to pass on this information to the police. This decision requires careful weighing up whether the right to consent on passing on information is more important than the right of the public to be protected.
GMC guidance (Confidentiality: Protecting and Providing Information, 2004) gives general advice on disclosure, but leaves the ultimate decision with the medical practitioner…
What moral guidance/reasoning can help here?
BALANCING RIGHTS – THE ABORTION DEBATE
What happens where a right is interpreted differently by different parties?
Example: the right to life of a fetus vs the right to choose the use of her own body of a pregnant woman in the case of abortion.
UK – 1967 Abortion Act – medical justification.
UK – 1991 Human Fertilisation & Embryology Act (24 weeks rule).
USA – 1973 historic Supreme Court decision in the Roe v. Wade case which effectively made abortion legal in the US – privacy justification..
please use the key words to explain the case study for example using words like deontology virtue ethic more virtue and example why you are using this to describe your point……… and so on.
THE ETHICAL PROFESSIONAL: VIRTUE, CARE, NARRATIVITY.
PROFESSIONAL ETHICS & MORAL CHARACTER
These are standard in professional codes of conduct
But being ethical is not just about performing right or good actions…..
addressed by Virtue Ethics, Care Ethics, Narrative Ethics
DEONTOLOGY & UTILITARIANISM
morality as primarily a following of certain action-guiding principles
morality as primarily the cultivation of certain
dispositions or character traits
BEING MORAL – ACTIONS OR PERSONS?
ARISTOTELIAN VIRTUE ETHICS
Aristotle 5th Century B.C. Athens: The Nicomachean Ethics This theory focuses on the goodness of persons, not the
A person is good or bad depending on whether or not they possess certain virtues or vices.
aim for excellence of character; strive to be ideally virtuous
We can say: persons ought to have a virtuous personal character if they are to treat others well and behave responsibly
goodness of actions.
THE MORAL VIRTUES
Ò Aristotle claims there are certain moral virtues which humans can & ought to try to develop, in order to become as moral as possible.
Ò Courage; patience, honesty, kindness, etc.
Ò Eudaimonia – a sense of living well, flourishing (not the same as utilitarian happiness/well- being…)
Ò Virtue is moral knowledge. Practical wisdom.
Ò The virtuous person just knows how to act – she doesn’t need to follow rules. No decision- making procedure as such.
Ò The mean between extremes – e.g. not too cowardly, but equally not too courageous as this could be risky/rash.
VIRTUE VERSUS DEONTOLOGY
Both look at the motive of the agent.
But rather than looking at the person’s reasons & intentions for their action, as in deontology,..virtue theory looks at the character trait which motivates the action
VIRTUE VERSUS UTILITARIANISM
Unlike utilitarianism, virtue theory does not look at the consequences of an act to evaluate the act….
…it only looks at the character of the agent
HOW VIRTUE THEORY DIFFERS FROM DEONTOLOGY AND UTILITARIANISM
QUESTIONS/CRITICISMS OF VIRTUE ETHICS
Who is virtuous?
Someone who acts virtuously.
But which acts are virtuous acts?!
In order to say which is a right act, don’t we need objective guidance (i.e. rules, norms)?
Collapses back into evaluating acts not persons!
Ò Newer theory based on the work of Gilligan, C. (1982) In a Different Voice: Psychological Theory & Women’s Development, Harvard .
Ò Similar to virtue theory in some respects
Ò Emphasis on empathy, care, emotion, connectedness/relationships, considering concrete persons, as part of moral reasoning.
Ò focus on resolving conflicts & peacemaking to preserve relationships wherever possible
Gilligan identifies 2 different modes of moral reasoning.
Ò Feminine mode – emphasises care, emotion, compassion, particular situations, experience, relationships. Private.
Ò Masculinemode–emphasises reason,impartiality, principles, justice, rights. Public.
Ò Historically, the masculine mode has been seen as superior & more morally mature
The Jake and Amy example (pp.26-28 in Gilligan).
Care ethics says these 2 modes are
and both can lead to morally right actions. Can be complementary
We need both justice and care
This theory emphasises gender relations…but makes no claims about the essential nature of men or women. (Indeed, Gilligan found the care mode expressed by both genders within disadvantaged groups.)
PLURAL VALUES…WHAT SHALL I DO?
Shall I act on personal impulse or intuition, or is there any objective guidance that can help me decide what is the moral thing for me to do?
Ò Normative ethical theories specify norms/standards of right & wrong behaviour.
Ò Principles of normative ethics can motivate & justify actions & policies in professional practice – used in codes.
Ò Different theories give different methods for reasoning to moral actions.
A Consequentialist theory – actions are not good or bad in themselves; the consequences are what count.
Teleological – aims at a telos(goal) & evaluates the morality of an action in terms of progress towards that goal.
The right act is the means to a good consequence. No act is intrinsically wrong. Ends justify the means. So…what is the good consequence for utilitarianism?
WHAT WOULD THE CONSEQUENTIALIST DO?
Dr X has a patient with a persistent cough. X rays suggest incipient lung cancer, but are inconclusive. The tests need to be repeated in order to confirm the diagnosis. The patient is anxious, and the doctor is reluctant to alarm her unnecessarily.
Dr X considers lying to his patient and saying the X-rays need to be repeated purely for administrative purposes
Ò J. Bentham (1748-1832) Ò J.S.Mill (1806-1873)
Ò Bentham – we are governed by our capacity for pleasure & pain.
Ò Mill’s Utilitarianism (1861) the classic text.
Bentham’s Principle of Utility. Hedonic calculus
Mill – Actions are right to the degree that they tend to promote the greatest good for the greatest number.
What is the ‘greatest good’?
Bentham – maximise the quantity of pleasure
Mill – maximise the quantity of high quality pleasure.
(b.) weak rule utilitarianism, where (a.) states the rules must never be broken & (b.) allows for rule- breaking on utilitarian grounds..
2 FORMS OF UTILITARIANISM
WHICH ENDS SHOULD WE PURSUE?
maximise pleasure/happiness/wellbeing minimise suffering/pain
Are these the main goals of human lives?
As in the film, The Matrix, you have the option to wire your body up to a machine which will provide a ‘virtual’ life of total happiness, in which every preference and desire will be satisfied. Your body will remain inert, and your ‘life’ will simply be a series of computer- generated illusions.
Would you choose this rather than live a ‘real’ life with the risk of suffering and pain?
MORE PROBLEMS WITH UTILITARIANISM
SOME CONCEPTUAL CHALLENGES
Ò The organ lottery
One person’s organs can save five lives. Should
we sacrifice that one to save the others?
Ò Jim and the Indians
An evil dictator is holding 10 Indians hostage. He is about to kill all of them, but says if Jim kills one, he wll let the other 9 go free.
A 3rd form:
Preference utiltarianism – take into account people’s subjective preferences when calculating the greatest overall amount of pleasure. It allows for individuals themselves to state what for them constitutes pleasure or pain, & prevents any one criterion of these to be imposed.
But some argue that certain actions are just plain wrong, regardless of people’s preferences.
UTILITARIANISM IN PRACTICE
Decisions about the allocation of healthcare resources are often made using a utilitarian QALY (Quality Adjusted Life Year) model.
“The essence of a QALY is that it takes a year of healthy life expectancy to be worth 1, but regards a year of unhealthy life expectancy as worth less than 1. Its precise value is lower the worse the quality of life of the unhealthy person (which is what the ‘quality adjusted’ bit is all about).“