__________________________________________________________________ Medical Ethics for Physicians
With this information gathered, it should be apparent whether or not a value conflict exists. Many times, just the process of gathering information allows for clarification and for differences to be resolved. If an ethical dilemma ensues, the next step is to articulate the ethical principles that are opposing one another. ETHICAL THEORETICAL SYSTEMS There are numerous ethical theories. Six fundamental theories that directly concern healthcare professionals are deontologic, teleologic, motivist, natural law, transcultural, and relative/ multicultural ethical theoretical systems. These systems are each made up of principles, precepts, and rules that form a specific theoretical framework to provide the follower with general strategies for defining the ethical actions to be taken in any given situation. DEONTOLOGIC ETHICAL THEORIES Under the deontologic umbrella, an action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative in our language is viewed as a “must do,” a rule, an absolute, a black-and-white issue. This is an ethic based upon duty linked to absolute truths set down by specific philosophical schools of thought. As long as the principles dictated by these imperatives are met with dutiful compliance, one is said to be acting ethically. One of the most significant features of deontologic ethics is found in John Rawls’ Theory of Justice , which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. There are also some principles within the same ethical theoretical system that can conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can easily become an ethical dilemma when those resources are scarce. The precepts in this system of ethical decision making stand on moral rules and unwavering principles. Regardless of the situation at hand, the purest deontologic decision maker would stand fast by a hierarchy of maxims. They are as follows [13]: • People should always be treated as ends and never as means. • Human life has value. • One is always to tell the truth. • Above all in health care, do no harm. • All people are of equal value. Health professionals making ethical decisions under the deontologic ethical system see all situations within a similar context regardless of time, location, or people. It does not take into account the context of specific cultures and societies [14]. The terminology used in this system of beliefs is similar
to that found in the legal justice system. One differentiation is the enforcement of the rights and duties in the legal system that do not exist in the ethical system. A framework of legislated supportive precepts (i.e., codes of ethics) serves health professionals by protecting them in their ethical practice. However, even these systems of thought will not clearly define the right answer in every situation. Most healthcare professionals do not practice the concept of the means justifies the end if the end outcome is harmful to the patient. When duties and obligations conflict, few will follow a purist deontologic pathway because most people do consider the consequences of their actions in the decision- making process. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but is that possible when those resources are scarce? Who then decides which patient does or does not receive those resources? Theologic Ethics A well-known deontologic ethical theory is based upon religious beliefs and is known as the theologic ethical theory. The principles of this theory promote a summum bonum , or highest good, derived from divine inspiration. A very familiar principle is to do unto others as you would have them do unto you. One would be viewed as ethically sound to follow this principle within this system of beliefs. Categorical Imperative Another deontologic ethical principle is Immanuel Kant’s “Categorical Imperative.” Kant believed that rather than divine inspiration, individuals possessed a special sense that would reveal ethical truth to them. That ethical truth is thought to be inborn and causes humans to act in the proper manner. Some of the ethical principles to come from Kant will become more familiar as the principles associated with bioethics are discussed. These include individual rights, self-determination, keeping promises, privacy, personal responsibility, dignity, and sanctity of life. TELEOLOGIC ETHICAL THEORIES The teleologic ethical theories or “consequential ethics” are outcome-based theories. It is not the motive or intention that causes one to act ethically, but the consequences of the act [15]. If the action causes a good effect, it is said to be ethical. So here, the end justifies the means. Utilitarianism Utilitarianism is the most well-known teleologic ethical theory. This is the principle that follows the outcome-based belief of actions that provide the greatest good for the greatest number of people. So, rather than individual goodness or rightness, this principle speaks for the group or society as a whole. Social laws in the United States are based upon this principle. The individual interests are secondary to the interest of the group at large. There are two types of utilitarianism: act utilitarianism
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