PHILOSOPHICAL

ETHICS: AN
INTRODUCTION
INTRODUCTION

‘This book explores some key issues in health care ethics. Health care ethics is a topic
within the broader field of normative ethics. Normative ethics is concerned, in large part,
with general theoretical questions such as what makes acts morally right or wrong, what
states of affairs are desirable or undesirable, what constitutes a good life for the person
who leads it, which character traits are virtuous and which are vicious, and, most generally,
how one ought to live. Philosophers have developed a number of normative ethical theor-
ies in an effort to address these questions. Ihe principal goal of this chapter is to introduce
you to some of the most important and influential ethical theories and to explain their
major strengths and weaknesses. A grasp of these ethical theories is helpful, if not essen-
tial, for thinking about moral problems that arise in health care.

LEARNING OBJECTIVES
After completing this chapter, you should be able to do the following:

e Distinguish between metaethics, normative ethics, and descriptive ethics

e Explain ethical relativism and its problems
e Define classical act utilitarianism, explain objections to it, and give utilitarian re-
sponses to those objections
e Describe Kant’s distinction between an action’s having moral worth and an action’s
being morally right
e Understand and apply the universal law version and the humanity version of Kant’s
categorical imperative
e Outline the main strengths and weaknesses of Kant’s moral theory
e Describe W. D. Ross's distinction between prima facie duties and duties, all things
considered
e Explain Ross's moral theory, and describe its strengths and weaknesses
e Define what justifies moral rules according to social contract theory
e Explain why John Rawls’s theory ofjustice is called justice as fairness

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18 DEBATING HEALTH CARE ETHICS

e Qutline the strengths and weaknesses of Rawls’s theory and of social contract theor-
ies in general
e Recognize how virtue ethics differs from other approaches to ethics
e Describe Aristotle’s concept of moral virtue and his doctrine of the mean
e Identify the strengths and weaknesses of virtue ethics
e Explain various feminist approaches to ethics
e Point out the strengths and weaknesses of the ethics of care

THREE TYPES OF ETHICAL INQUIRY

We begin by explaining normative ethics and distinguishing it from descriptive eth-

ics and metaethics.’ As suggested above, normative ethics addresses general theor-
etical questions about what sorts of things matter, morally speaking. When considering
whether an act is right or wrong, for example, should we look only at its consequences?
Or are other things important—for example, a person’s motives? But normative ethics
is also concerned with practical or applied issues. Here the concern is to try to resolve
concrete moral problems, such as whether mercy killing is sometimes morally permissible,
whether cloning human beings is immoral, and what obligations people have to non-
human animals and the environment. What is distinctive about normative ethics is that
it is prescriptive: It is concerned with what ought to be, not with what is the case. ‘[hus,
to say that health care ethics is an area of inquiry within normative ethics, or more nar-
rowly, within practical ethics, is to say that it is concerned with how one ought to act, the
character traits one ought to develop, the policies that ought to be adopted, and so forth,
when dealing with ethical problems that arise in and around the practice of health care.”
It is helpful to distinguish normative ethics from descriptive ethics. Descriptive eth-
ics is concerned with the examination of a given population's beliefs about a particular
moral issue. For example, we might ask, “What percentage of the Canadian population
believes that abortion is sometimes morally acceptable?” Descriptive ethics seeks to de-
scribe what is the case; for instance, it seeks to describe what people actually believe about
particular moral issues. Descriptive ethics also is concerned with questions of why people
believe what they believe about ethics and how they come to hold their particular moral
beliefs and attitudes. Comparisons between different cultures’ moral beliefs, and ques-
tions of what people in the past have believed about various ethical issues, also belong to
descriptive ethics. So, while descriptive ethics is a rich and interesting area of inquiry, it is,
for the most part, an area that properly belongs to the social sciences: Careful empirical
investigation is the key to doing descriptive ethics well.
But since normative ethics is essentially prescriptive, it differs importantly from de-
scriptive ethics. Thus, for example, in doing health care ethics we want to know what
Canadians (or people, in general) should think about the moral acceptability of abortion,
and we are much less concerned about what people happen to think. Here there is the

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 Chapter 2. PHILOSOPHICAL ETHICS: AN INTRODUCTION 19

recognition that people’s actual moral beliefs and society’s laws, policies, and professional
ethical codes can be mistaken (recall that prevailing moral beliefs, and many of society’s
laws and policies, used to favour whites over non-whites, men over women, and so forth),
and we attempt to move toward moral beliefs, laws, policies, and ethical codes that are
justified.”
While descriptive ethics requires careful empirical study, the key to doing normative
ethics well is good reasoning.” In other words, normative ethics is a matter of rational in-
vestigation. To be sure, this requires an awareness of the relevant facts, but it also requires
the defence of various moral principles and careful argumentation from these moral prin-
ciples and the relevant facts to conclusions about what ought to be done.
One of the most important steps in arguing for one’s position in normative ethics is
to begin by clearly defining the key concepts one is investigating. For instance, if we want
to determine when, if ever, abortion is morally permissible, we should first determine
what “abortion” involves. For instance, is it an abortion if one removes the premature fetus
to save the pregnant woman's life, knowing that the premature fetus will die as a result?
And is it an abortion if one prevents a fertilized ovum from implanting in the uterus (say
by using an intrauterine device or the so-called morning-after pill), or is this just a form
of contraception? And what about the nearly 50 percent of fertilized eggs that end up
being discarded at in vitro fertilization clinics—should we view the destruction of these
unused fertilized eggs as abortions?” Obviously, defining the concept one is debating
can be a tricky matter, but it is terribly important to get it as clear as one can so that one
knows exactly what one is investigating.
Also, when thinking about problems in normative ethics, it is very important to clar-
ify relevant facts. For instance, on the topic of abortion, we will presumably need to know
such things as when does pregnancy begin; when are fetuses able to survive if born; when,
if ever, are fetuses conscious; and, in general, what changes go on throughout pregnancy
as the fetus develops. We will also want to know the effects of pregnancy on a woman,
for example, what health risks does she face in pregnancy, what health risks arise from
abortion, what percentage of pregnancies are not consensual, what are the consequences
to families and society of having unwanted children, and what effects would there be on
women's lives if access to abortion was heavily regulated or even banned.
Finally, once key terms are defined and the relevant facts identified, the next step is
to consider whether the act in question is supported (or opposed) by moral principles or
moral considerations that we are willing to accept after careful reflection. For instance, we
might propose the moral principle that a person should be free to do what she chooses
provided that she does not violate others’ rights and provided that she is competent to
make her own decisions. We might then argue that abortion can be freely chosen by
competent persons without violating anyone's rights, and, therefore, abortion is morally
acceptable in these situations. Alternatively, we might put forward the moral principle
that it is morally wrong to intentionally kill innocent human beings, and since abortion
involves intentionally killing innocent human beings, it is morally wrong. We then need

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20 DEBATING HEALTH CARE ETHICS

to examine each of these arguments, and any others that can be brought to bear on this
topic, to see whether they are (deductively) sound. (Arguments that are not deductive
should be checked for inductive strength and for the truth of the premises.) ‘There is no
mechanical method for determining whether any given argument is sound or strong;
instead, we have to carefully examine each premise (both the factual claims and the moral
principles) and consider whether it is true or vulnerable to criticism. We also need to
consider the logical structure of the argument to determine whether the premises, taken
together, adequately support the conclusion. If a flaw can be identified either in one (or
more) of the premises or in the logic of the argument, then we ought to reject the argu-
ment as rationally unpersuasive.
‘The process of developing, examining, and revising arguments is at the heart of nor-
mative ethics, health care ethics, and, indeed, all substantive areas of philosophy—it re-
quires creativity, a sharp critical mind, and a sense of fairness. ‘Ihe goal is to find the best
arguments on a particular topic and to understand why rival arguments fail. On occasion,
on truly difficult issues, one may be unable to tell which argument is best—they may
all appear problematic, or there may be opposing arguments that look equally good. In
such cases, the appropriate thing to do is to admit that one does not know what to think.
Even in difficult cases such as these, the investigation itself can be fruitful: For, at a min-
imum, one will better understand the debate around a moral issue—the arguments for
and against, their strengths and their weaknesses—and why the issue is so difficult.
Finally, normative ethics should also be distinguished from metaethics. Metaethics
concerns the rational investigation into the nature of morality. Here, the focus is on ques-
tions about morality rather than questions within morality, such as “Are moral judgments
capable of being true or false?” and “What are the meanings of moral terms?” For in-
stance, one might ask, “What does it mean to say that something is morally wrong or that
something is morally right?” Is this merely a report about the speaker's feelings or an ex-
pression of emotion, or is it a statement that can be objectively true or false?° Metaethics
is a rich area of philosophical research; however, because this is a book on health care
ethics, not metaethics, we will not be able to explore these issues in depth here.’
One of the main purposes of this book, then, is to suggest a number of solutions
to some problems that arise in health care ethics by reasoning about them. This will in-
volve defining key terms; clarifying relevant facts; identifying, explaining, and defending
relevant moral principles and values; and then drawing conclusions about these moral
problems. In reading this book, you will see how arguments are formed, criticized, re-
formulated, and debated again. You will see how there can be progress in an ethical debate
and how informed and intelligent disagreement sometimes remains. We hope that you
will join our debates, reflect on the merits of the arguments presented here, and develop
your own arguments for your views on these issues. [hus, in addition to attempting to
shed light on some difficult problems in health care ethics, this text aims to improve your
critical reasoning skills and to prompt you to develop your own arguments on these top-
ics. We believe that such a process is intellectually exciting and rewarding. Thus, we also

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 Chapter 2. PHILOSOPHICAL ETHICS: AN INTRODUCTION 21

hope that in reading this book you will see how challenging these problems are and how
stimulating it can be to think philosophically about these problems.

SKEPTICAL CONCERNS: ETHICAL RELATIVISM

Before we explore questions in health care ethics, and normative ethics generally, it is im-
portant to address and allay some of the skepticism about the entire enterprise of moral
philosophy. [here is a long and important minority point of view in the history of philoso-
phy that claims there is no objective truth in ethics. Instead, it is suggested that right and
wrong are simply relative to a given individual or group. For instance, some may suggest
that right and wrong are merely culturally shared attitudes or that right and wrong are
just a way for an individual to communicate her particular preferences or feelings about
an issue—for example, if a person says something is wrong, it just means she does not like
it, and if she says something is right, it just means she likes it. Although each of the above
views represents a slightly different understanding of the nature of morality, they share
in common a general skepticism about morality: Specifically, they deny that there can be
objective truths in ethics, that is, they deny the existence of ethical claims that are true in-
dependently of whether some particular group or individual wants, believes, or feels that
they are true. Let’s call this basket of views moral or ethical relativism.°
Because this is not a text in metaethics, we cannot do justice to the issues raised by
ethical relativism; however, a serious difficulty with this point of view is worth mention-
ing, namely, that there are dramatic costs to believing in ethical relativism. One such
cost is that ethical relativism conflicts with the widely held common-sense belief that
individuals or groups can be mistaken in their moral judgments. Most of us believe that
some of our past moral judgments have been mistaken. Likewise, it seems clear that some
previous prevailing moral beliefs (and practices) in our culture have also been wrong. And,
if we are honest with ourselves, most of us would admit that some of our present moral
views, and some of our culture's present prevailing moral views, could also be wrong; how-
ever, if one is an ethical relativist, it is impossible to believe these things. ‘This is because
in order to believe in the fallibility of one’s own or one’s culture’s moral views, one would
have to believe what the relativist denies, namely, that there is some standard of right and
wrong that is not based on what the individual or culture happens to think. Once it is
pointed out that ethical relativism implies that an individual's or group’s moral views can
never be mistaken, ethical relativism loses much of its appeal, for few are prepared to say
that their own moral views, much less the moral views of their culture, are incapable of
error. For ease of reference, let’s call this the problem of moral infallibility.
Moreover, because the relativist denies that there are standards of right and wrong
that are independent of what individuals or cultures happen to think, the relativist is in
the uncomfortable position of being unable to view one person's or groups moral views as
objectively better than another’s.
[he individual relativist must be willing to say something

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