Introduction 

An ethical theory is a framework for determining what morality consists in and how we ought to go about abiding by it. The focus of this section will be the dominant ethical theories of 20th/21st century bioethics because those are the ones most commonly seen in bioethics arguments. When judging an ethical theory, it is important to note whether the theory possesses internal consistency, clarity, and implications largely in line with our experiences of moral life. Many also consider it important for an ethical theory to be action-guiding, or capable of informing and directing human behavior. Note that different theories will provide both different explanations for why an action is good or bad, and even if they agree why an action is good or bad, they may disagree on the rationale. 

Consequentialism 

Consequentialism is a theory which posits that the moral evaluation of an action ought to be based solely upon the goodness or badness of its consequences for all the relevant parties. How to define what a ‘good’ or ‘bad’ consequence is, and how further to approach the calculus of weighing positive vs. negative consequences, is the subject of much debate. Some of the ways consequentialism has been historically conceived are discussed below. 

Act consequentialism vs. Rule consequentialism 

Consequentialism can be loosely divided into two overarching families of theory which approach consequentialism from different angles. 

  • Act consequentialism considers only the consequences of the particular action. Classical Utilitarianism is usually interpreted as an act consequentialism which sums the pleasure for all concerned  
  • Rule consequentialist claims that a person ought to follow the rule(s) that, if generally followed, would produce the greatest balance of good over bad, all things (and all persons) considered. 

Consider lying to a woman who is expected to die in the next few hours and is asking (in a somewhat delirious state of mind) whether her children are coming to see her. Should the attending physician (who knows her children have no intention of visiting) lie to her, given that it will ease her passage and assuming she will never know the truth? An act consequentialist might say yes, because the woman will never discover the lie and it will yield the most positive consequences for her before she dies. A rule consequentialist might question whether setting a precedent for lying to patients could undermine patient trust in medical practitioners and institutions, which may yield a net loss in terms of consequences. 

Sum vs. Average vs. Priority Views: 

The general aim of any consequentialist approach is to produce the “greatest good,” but there is ambiguity in how we are to calculate the greatest good.  

  • The sum consequentialist simply adds the total of good consequences and subtracts the total of bad consequences for all concerned and performs the action whose sum of consequences is the best. This has been criticized as being insensitive to the distribution of the consequences.  
  • The average consequentialist supports doing the action that produces the highest average consequences.  
  • The prioritizing consequentialist gives even greater significance to the consequences for a specific group, usually those who are the worst off. 

Hedonism (quantity vs. quality) vs. Preference Satisfaction (actual vs. ideal) vs. Perfectionism (list of objective goods) 

Another ambiguity in the general consequentialist approach which has bred schisms in the theory is what exactly the “good” is that we are trying to maximize. 

  • The hedonist values consequences in terms of pleasure produced, either counting only the quantity (intensity times duration) or also taking into account the quality (higher and lower) of the pleasure. 
  • The preference satisfaction theorist finds this standard too narrow because pleasure is not the only thing we prefer and instead believes that we need, in valuing consequences, to consider all the preferences that are or are not satisfied. Sometimes, they mean your actual preferences but sometimes they have in mind the preferences you would have if you were fully informed and not subject to distorting biases and emotions etc. (the difference between these two versions is very important for cases in which patients make seemingly irrational choices). 
  • The perfectionist theorist finds these accounts to be too subjective, and believes that, in valuing consequences, we should consider whether certain objective values are satisfied. Aristotelean perfectionists find these in the notion of human nature while others find these in the capacities which humans need to make choices and have a chance to obtain them (e.g., to acquire information, do means-ends reasoning, form independent values). 

Sentient Creatures vs. Human Beings vs. “Persons” 

There are different, competing views on what qualifies membership of the moral community, and accordingly, whose welfare and interests should be included in the consequentialist arithmetic. Some believe that all sentient beings capable of experiencing pleasure and preferences count. This includes many animals. Others, who are often criticized as being “speciesists,” count only human beings, regardless of whether some animals are sentient. Still others confine membership to those who are capable of higher mental functioning or those who can rightly be called “persons,” whatever their species. 

These debates lead to different notions of “moral status,” which are crucial for thinking about animal research and patients with disorders of consciousness. 

Actual vs. Future Beings 

One pressing question for any consequentialist is this: should you consider just the consequences for all those who currently exist? Or should you also consider the consequences for those who will someday exist? How this question is answered has profound implications for environmental issues and emerging genetic technologies. For example, to what extent should the present generation of existent humans be expected to sacrifice in order to preserve the planet and promote the interests of the generations to come, who will have to inherit the world we leave them? 

Deontology 

Deontology is in many ways the natural counterpart to consequentialism, as it deemphasizes consequences in favor of evaluating actions based upon their other various properties, like their intrinsic nature and conformity to moral rules (bad means which violate the moral law cannot be justified by good ends). Some forms of deontology also ascribe great moral significance to the intentions or quality of will belonging to the agent. 

Divine Command Theory (DCT) 

Divine command theory posits that actions are obligatory because God commanded us to do them and prohibited because God forbade us to do them. Permissibility rests on the sole discretion of the God(s) in charge of dictating moral law. All other actions are permissible.  

Consider a patient who subscribes to some form of divine command theory, who consequently refuses to receive a blood transfusion because he/she believes it conflicts with God’s will. (Note: simply being religious does not make one an adherent to DCT, nor does subscribing to DCT imply any particular religious persuasion). 

Nature/Natural (laws vs. rights) 

Natural law theorists believe that much as there are descriptive laws governing the physical universe, so too are there are normative laws governing behavior. They are revealed to us either as self-evident truths (See. John Locke and the founding fathers), as natural inclinations and functionings (See. Thomas Hobbes), or by reflection on the human condition (See. Hugo Grotius and Samuel Puffendorf). 

Traditionally formulated as natural laws, but in the 17th and 18th century centuries, the emphasis for many becomes laws protecting natural rights. Positive rights are entitlements to certain things and negative rights are prohibitions on what others may do to you. 

Kantianism 

  • Categorical Imperative- Actions are right only when you could consistently will that such actions would be universally performed. Consider implications for honesty and contrast with the Utilitarian. 
  • Formula of Humanity- Actions are right only if they do not treat persons as mere means but treat them as well as ends. This formulation gives content to the Kantian idea that all [rational] persons have inherent moral worth and are entitled to respect. Is providing voluntary euthanasia treating persons as ends or means? 
  • Special Obligations- Many deontological theorists postulate that we are morally bound by special moral laws in our behavior towards family members, friends, benefactors, etc. How to incorporate these special obligations into a general moral theory is a difficult problem. Consider the special obligation of fiduciary duties in medicine. 

Contractualism 

  • Actions are morally right if they are permitted by the rules that free, equal, and rational people would agree to live by. 
  • Consider implications for multiple stakeholder engagement in policy making. 

Virtue Ethics 

Virtue Theory states that the moral evaluation of an action is based solely upon whether a virtuous person would perform such an action in those circumstances. In this way, the evaluation of traits of character (the virtues and the vices) precedes the evaluation of actions. The implications for action depend, therefore, on your view of what are the virtuous traits. Some virtue theorists require that the action be done for virtuous motives while others merely are concerned with what action is performed. Among the major virtue theorists are: 

Aristotle–The virtues consist of excelling in those activities which are distinctively human, and these activities rely on exercising practical and theoretical reason. Excellent practical reason leads you to choose a pattern of action which is the golden mean between two extremes of action. For example, courage within Aristotelian ethics is properly understood as a midpoint between cowardice and foolhardiness, temperance a midpoint between overindulgence and asceticism, and so on. 

David Hume–The natural virtues consist of those character traits which our sentiments naturally approve of, and the artificial virtues consist of those character traits which we approve of because our reason shows us that they lead to results we approve of. In this way, sentiment is the foundation of ethics, not reason. Those who have emphasized such virtues as empathy and compassion, often called care virtue theorists, are working within the Humean tradition. 

Immanuel Kant–Virtue is acting in accordance with moral law because it is the moral law discovered by reason (see above). This does not mean to preclude acting out of other motives as well, so long as the agent would do the action just because it is demanded by the moral law. 

Specific Virtues Relevant to Bioethics 

  • Compassion — the habit of recognizing when a person is in pain, suffering, or distress and acting to prevent and relieve. 
  • Courage — the habit of distinguishing between what one ought to fear and what one ought not to fear; ignoring what one ought not to fear and not being excessively swayed by what one ought to fear. 
  • Integrity — the habit of living up to one’s professional and moral standards. 
  • Honesty — the habit of not telling falsehoods but rather truths and not misleading others. Allows for discretion of how/when truth is told. 
  • Fidelity — the habit of being faithful to one’s promises. 
  • Respect — the habit of recognizing individual worth and value and treating others with dignity and due regard. 

Pluralism  

Pluralism draws on multiple theories and aims to discern where they converge, or where one ought to take precedence over the others. Pluralism can be seen as a critique of the traditional theories which emphasized too narrow a set of criteria for moral rightness when taken alone. 

The major problem for a pluralistic theory is deciding how to incorporate each of these factors into a final judgment. 

Prima Facie Duties—prima facie translates as “on first appearance,” and prima facie duties are duties that are generally accepted as given unless they are outweighed by other obligations. So, for example, I may have a prima facie duty not to lie, but if I am lying to protect an innocent child from someone who would hurt them if given the truth, the duty towards the child may supersede the duty to tell the truth. 

Prima facie duties are one approach to thinking of morality on a pluralist model. W. D. Ross was one of the first contemporary pluralists. His belief grounded prima facie obligations in a priori (meaning ‘prior to experience’) intuitions. For Ross, deciding when to adhere to prima facie obligations and when to contravene them is a matter of making a considered judgment which balances the totality of our obligations. Ross’s prima facie duties include fidelity, reparation, gratitude, beneficence, nonmaleficence, justice and self-improvement. More recently, Beauchamp and Childress’ principles of bioethics have been widely utilized and discussed at length, and consist in four principles:

Autonomy  

  • Two necessary conditions: liberty (independence from controlling influences) and agency (capacity for intentional action). 
  • Some theories want more: concordance between “second order desires” and choices. 
  • But we need a theory that counts ordinary persons as deserving respect for their autonomy when they have not reflected on their preferences at a higher level; no theory of autonomy is acceptable if it presents an ideal beyond the result of normal agents and choosers. 
  • Autonomous action is analyzed in terms of normal choosers who act (1) intentionally, (2) with understanding, and (3) without controlling influences that determine their action. How much understanding and freedom from constraint? A “substantial” degree. Where “substantial” is best determined in a particular context. 
  • No inconsistency between autonomy and authority/relationships (religious, family, physician). Patients may be okay with these. 
  • Autonomy is a right not a duty. Patients do not have a duty to choose and some do not want to (e.g., studies on Korean Americans and Traditional Navajo patients). Ask patients what they want to know and who they want to decide. 
  • To respect autonomous agents involves respectful action, attitude, and requires more than just not interfering with their choices but also in building up their capacities for autonomous choice and ridding conditions that destroy or disrupt it. 
  • Practical manifestations of respecting autonomy: tell the truth, respect privacy, protect confidential information, obtain consent, and when asked help make decisions. 
  • Our autonomy-based obligations do not extend to those who cannot act autonomously or be rendered to do so (e.g., incapacitated, children). 

Nonmaleficence 

  • One ought not inflict harm. 
  • Harm: thwarting, defeating, or setting back some party’s interests. 
  • Can have harmful actions that are justifiable and so not wrong (e.g., punish a physician for incompetence). 
  • Harm is a contested concept but everyone agrees that significant bodily harms and other setbacks to significant interests are paradigm instances. Physical harms, especially pain, disability, suffering, and death, but mental harms are important too. 
  • Also obligated to not impose risks of harm. 
  • Negligence is absence of due care, a departure from the standard of care. Either done intentionally or unintentionally. 

Beneficence  

  • Contribute to patients’ welfare. 
  • The line between obligatory and ideal is often unclear. 
  • Often conflicts with autonomy. 
  • Paternalism: the intentional overriding of one person’s preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefiting or of preventing or mitigating harm to the person whose preferences are overridden. 
  • Soft Paternalism: beneficence with the goal of preventing substantially non-voluntary conduct. 
  • Hard Paternalism: interventions intended to prevent or mitigate harm or to benefit despite the fact that the person’s risky choices and actions are informed, voluntary, and autonomous. 

Justice 

  • Fair, equitable, and appropriate treatment in light of what is due or owed to persons. 
  • Distributive Justice: fair, equitable, and appropriate distribution is determined by justified norms that structure the terms of social cooperation. 
  • Fundamental Needs View, Maximize Utility View, Egalitarian (so each person can achieve a fair share of the normal range of opportunities in society—Norm Daniels), Libertarian. 

Feminist Approaches to Bioethics 

The moral evaluation of an action, policy, or institution depends on its attention to the roles (both social and political), relationships and the intersectional positioning of individuals and groups in society—this is what is important to healthcare practice and policy. “A feminist approach leads us to examine not only the connections between gender, disadvantage, and health, but also the distribution of power in the processes of public health, from policy making through to programmed delivery.” (Baylis, Kenny and Sherwin 2008) 

This cluster of approaches challenges the traditional emphasis on objectivity and individualism in mainstream bioethics, highlighting instead the ethical and epistemological importance of perspective and social connectedness. Feminist bioethics is characterized by shared theoretical and political orientations that favor certain methodological approaches, including a focus on empirical experience; attention to the effects of social, political or epistemic power; and a commitment to influencing social and political change. (Donchin 2015). 

Feminist approaches to bioethics draw from a range of conceptual tools. Care ethics seeks to place caring relationships at the center of ethical analysis (Gilligan 1993). Standpoint epistemology emphasizes the role and experiences of someone positions them as a knower, that is, gives them knowledge that reflects the particular embodied perspectives of the knower. Relatedly, there has been rich theoretical work on the social and cultural expectations of normality, and the political choices that are made in the area of prevention of and support for disabled people, contributed through feminist discussion of the norms of dependency (Kittay 1999) and vulnerability (Scully 2014) 

The idea of gendered division of labor explores the relationship between gender identity and social role. “Because women bear a disproportionate share of the associated risks and burdens, new reproductive technologies are not gender neutral, a fact frequently ignored in debates about the ethics of assisted reproduction” (Rogers 2006). 

Non-Western Approaches to Bioethics 

Myser (2003) notes the ‘normativity of whiteness’ present in mainstream bioethics discourse. Decolonization is therefore often central to non-Western approaches to bioethics. Non-Western bioethics typically centralizes local or Indigenous (both ancient and contemporary) medicines and the philosophies of health (e.g., connection between body, mind, spirit and land) that accompany them. 

Modern bioethics developed in the West and thus reflects, not surprisingly, the traditions of Western moral philosophy and political and social theory. When the work of bioethics was confined to the West, this background of socio-political theory and moral tradition posed few problems, but as bioethics has moved into other cultures – inside and outside of the Western world – it has become an agent of moral imperialism. (Chattopadhyay 2008) 

The range of these approaches is vast, including African Bioethics, Eastern Bioethics, Islamic Bioethics, LatinX/South American bioethics, and draw from a range of religious teachers and traditions, including Buddha, Confucius, Charaka, Sushruta, Shankara, Ramanuja, Chaitanya, Ramakrishna, Vivekananda, Gandhi, Gibran, Radhakrishnan, Tagore, Aurobindo, or Sri Anukulachandra. 

Some African bioethicists posit African bioethical principles, e.g., “human life invaluableness” as a means of rooting their ethic in African values (as opposed to Western values). See: Francis C. L. Rakotsoane & Anton A. van Niekerk (2017). Confucian scholars believe that any principle without compassion as a base cannot endure (Cheng-Tek Tai 2013). This reveals potentially interesting ties to virtue ethics. Alternative approaches highlight assumptions, sometimes problematic, that feature heavily in Western bioethics.  

Works cited 

The work of “de-centering” Russell, C. A. (2016) Questions of Race in Bioethics: Deceit, Disregard, Disparity, and the Work of Decentering. Philosophy Compass, 11: 43– 55. doi: 10.1111/phc3.12302. Ties to critical race theory. 

Baylis, Françoise, Nuala P. Kenny, and Susan Sherwin. “A Relational Account of Public Health Ethics.” Public Health Ethics 1, no. 3 (2008): 196–209. http://www.jstor.org/stable/26644761. 

Donchin, Anne and Jackie Scully, “Feminist Bioethics”, The Stanford Encyclopedia of Philosophy (Winter 2015 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/win2015/entries/feminist-bioethics/ 

Gilligan, Carol. 1993. In a Different Voice: Psychological Theory and Women’s Development. Cambridge, Mass: Harvard University Press. 

Kittay, Eva Feder. 1999. Love’s Labor: Essays on Women, Equality, and Dependency. Thinking Gender. New York: Routledge. 

Rakotsoane, Francis C. L., and Anton A. van Niekerk. 2017. “Human Life Invaluableness: An Emerging African Bioethical Principle.” South African Journal of Philosophy 36 (2): 252–62. https://doi.org/10.1080/02580136.2016.1223983. 

See: Tremain, Noddings, Held, Lindemann, Tong, Macklin, Kukla, Scully, Rogers, Baylis et al., Mackenzie