AMU Wk1 Considering Moral Philosophies and Principles Discussion Forum 1–Chapters 1 & 2: Describe some of the administrative/ organizations challenges tha

AMU Wk1 Considering Moral Philosophies and Principles Discussion Forum 1–Chapters 1 & 2: Describe some of the administrative/ organizations challenges that managers must consider when looking to solve ethical problems (1 full page of text minimum with a minimum of 2 references in proper APA format). Post in Forum. Read a minimum of two of your classmates postings and respond to a minimum of two of the postings (minimum 300 words each and a minimum of 1 reputable reference each in proper APA format).Your initial posting is due by Wednesday, while all peer postings are due by Friday. This allows time for other students to respond to your initial response. I highly recommend you submit the initial post to Turnitin.com prior to submitting it through the Forum Portal. CHAPTER 1
CONSIDERING MORAL PHILOSOPHIES AND
PRINCIPLES
hat sources guide us in ethical decision making? How do they help us identify and act on
the morally correct choice? Philosophers, theologians, and others grapple with such
questions. The clearest tradition of ethics in Western medicine dates from the ancient Greeks.
Throughout the 20th century and into the 21st century, managers and nurses have formally
sought to clarify, establish, and, sometimes, enforce ethical standards. Their codes and
activities incorporate philosophies about the ethical relationships of providers to one another,
to patients, and to society. For managers, the appropriate relationship with the organizations
that employ them is an added dimension of their codes.
A natural starting point for discussing ethics and understanding how to resolve ethical
problems is to review the moral philosophies that have had a major influence on Western
European thought and values. Among the most prominent of these philosophies are utilitarian
teleology; Kantian deontology; natural law as formulated by St. Thomas Aquinas; and the work
of the 20th-century American philosopher John Rawls. The latter part of the 20th century saw
renewed interest in casuistry and virtue ethics. Its emphasis on the individual makes virtue
ethics especially helpful in guiding action for managers. In addition, the ethics of care is
considered briefly.
Principles derived from these moral philosophies provide the framework or moral
(ethical) underpinnings for delivery of health services by organizations. These principles will
assist managers (and health services caregivers) in honing a personal ethic. The derivative
operative principles are respect for persons, beneficence, nonmaleficence, and justice. Virtue
ethics stands on its own as a moral philosophy; also, it helps supplement the principles when
they lack rigor in analyzing or solving ethical problems.
The following case about Baby Boy Doe is true. State and federal law would prevent it
today. Its simplicity and starkness make it a useful paradigm against which to apply the moral
philosophies and derivative principles discussed in this chapter.
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W
Baby Boy Doe
In 1970, a male infant born at a major East Coast medical center was diagnosed with mental retardation and duodenal atresia
(the absence of a connection between the stomach and intestine). Surgeons determined that although the baby was very small,
the atresia was operable, with a high probability of success. The surgery would not alter the baby’s mental retardation, but
would permit him to take nourishment by mouth.
The baby’s parents decided to forego the surgery—something they had the legal right to do—and over the course of the
following 2 weeks, the infant was left to die from dehydration and starvation. No basic determination of the extent of mental
impairment had been made, nor could it have been, at the time the infant died. Neither hospital personnel nor state family and
social services sought to aid him.
Darr, Kurt. Ethics in Health Services Management, Fifth Edition, Health Professions Press, Inc., 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=4816403.
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This case sends a shudder through most people. Feelings or emotions, however, are
insufficient. If managers are to be effective in addressing and solving—or, preferably,
preventing—such problems, they must identify and understand the issues involved, know the
roles of staff and organization, and apply guidelines for ethical decision making. Following a
discussion of moral philosophies and ethical principles, the case of Baby Boy Doe is analyzed.
MORAL PHILOSOPHIES
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Utilitarianism
Utilitarians are consequentialists: They evaluate an action in terms of its effect rather than the
action’s intrinsic attributes. Synonymous with utilitarians are teleologists (from the Greek
telos, meaning end or goal). Utilitarianism has historical connections to hedonism
(Epicureanism), which measured morality by the amount of pleasure obtained from an act or a
rule as to how to act—greater pleasure was equated with greater morality. This theory was
refined by two 19th-century English philosophers, Jeremy Bentham and John Stuart Mill.
Mill’s elaboration of utilitarianism was the most complete. Unlike Bentham, Mill sought to
distinguish pleasures (the good) on qualitative grounds. Questions about the superiority of
certain pleasures, such as listening to a piano concerto, were to be answered by consulting a
person of sensitivity and broad experience, even though requiring such judgments diminished
the objectivity of utilitarianism. Mill stressed individual freedom. In On Liberty, he noted that
freedom is requisite to producing happiness and that this makes it unacceptable for the rights of
any group or individual to be infringed in significant ways.
In determining the morally correct choice, utilitarians ignore the means of achieving an end
and judge the results of an action by comparing the good produced by a particular action to the
good produced by alternatives or the amount of evil avoided. Modified utility theory is the
basis for the cost–benefit analysis commonly used by economists and managers. “The greatest
good for the greatest number” and “the end justifies the means” are statements attributable to
utilitarians. However, these statements are only crude gauges of utilitarianism, inappropriately
applied without qualification.
Utilitarianism is divided into act utility and rule utility. Both measure consequences, and
the action that brings into being the most good (understood in a nonmoral sense) is deemed the
morally correct choice.
Act utilitarians judge each action independently, without reference to preestablished
guidelines (rules). They measure the amount of good, or (nonmoral) value brought into being,
and the amount of evil, or (non-moral) disvalue avoided by acting on a particular choice. Each
person affected is counted equally, which seems to assign a strong sense of objectivity to this
moral philosophy. Because it is episodic and capricious, act utilitarianism is incompatible
with developing and deriving the ethical principles needed for a personal ethic, organizations’
philosophies, and codes of ethics. Therefore, it receives no further attention.
Rule utilitarians are also concerned only with consequences, but they have prospectively
considered various actions and the amount of good or evil brought into being by each. These
assessments are used to develop rules (guidelines) for action, because it has been determined
that, overall, certain rules produce the most good and result in the least evil or “un-good.”
Darr, Kurt. Ethics in Health Services Management, Fifth Edition, Health Professions Press, Inc., 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=4816403.
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Therefore, these rules determine the morally correct choice. The rules are followed for all
similar situations, even if they sometimes do not produce the best results. The rule directs
selection of the morally correct choice. Rule utilitarianism assists in developing moral
principles for health services management. Following Mill, however, it must be stressed that
the underlying context and requirement is that liberty be maximized for all.
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Deontology
Deontologists adhere to a formalist moral philosophy (in Greek, deon means duty). The
foremost proponent of deontology was Immanuel Kant, an 18th-century German philosopher.
Kant’s basic precept was that relations with others must be based on duty. An action is moral if
it arises solely from “good will,” not from other motives. According to Kant, good will is that
which is good without qualification. Unlike utilitarians, deontologists view the end as
unimportant, because, in Kant’s view, persons have duties to one another as moral agents,
duties that take precedence over the consequences of actions. Kantians hold that certain
absolute duties are always in force. Among the most important is respect, or the Golden Rule
(“Do unto others as you would have them do unto you”). Kant argued that all persons have this
duty; respect toward others must always be paid.
Actions that are to be taken under the auspices of this duty must first be tested in a special
way, a test Kant termed the categorical imperative. The categorical imperative requires that
actions under consideration be universalized. In other words, if a principle of action is thought
to be appropriate, a determination is made as to whether it can be consistently applied to all
persons in all places at all times. There are no exceptions, nor can allowances be made for
special circumstances. If the action under consideration meets the test of universality, it is
accepted as a duty. The action fails the test if it is contradictory to the overriding principle that
all persons must be treated as moral equals and, therefore, are entitled to respect. Truth telling
is a prominent example of a duty that meets the categorical imperative. Because the categorical
imperative tests the results (ends) of actions, Kantian deontology must be considered
teleological (ends-based).
For the Kantian deontologist, it is logically inconsistent to argue that terminally ill persons
should be euthanized, because this amounts to the self-contradictory conclusion that life can be
improved by ending it. Similarly, caregivers should not lie to patients to improve the efficiency
of healthcare delivery; such a policy fails the test of the categorical imperative because it
treats patients as means to an end—efficiency—rather than as moral equals. The Golden Rule
is the best summary of Kant’s philosophy. Having met the test of the categorical imperative,
Kantian deontology does not consider results or consequences. This does not mean that
managers must ignore consequences, but that the consequences of an action are neither included
nor weighed in ethical decision making using Kantian deontology.
Natural Law
Mill defined morally right actions by the happiness or nonmoral value produced. Kant rejected
all ethical theories based on desire or inclination. Unlike Mill and Kant, natural law theorists
contend that ethics must be based on concern for human good. They also contend that good
Darr, Kurt. Ethics in Health Services Management, Fifth Edition, Health Professions Press, Inc., 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=4816403.
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cannot be defined simply in terms of subjective inclinations. Rather, there is a good for human
beings that is objectively desirable, although not reducible to desire.1 Natural law holds that
divine law has inscribed certain potentialities in all things, which constitute the good of those
things. In this sense, the theory is teleological because it is concerned with ends. Natural law is
based on Aristotelian thought as interpreted and synthesized with Christian dogma by St.
Thomas Aquinas (1225–1274).2
The potentiality of human beings is based on a uniquely human trait, the ability to reason.
Natural law bases ethics on the premise that human beings will do what is rational, and that
this rationality will cause them to tend to do good and avoid evil. Natural law presumes a
natural order in relationships and a predisposition by rational individuals to do or to refrain
from doing certain things. Our capability for rational thought enables us to discover what we
should do. In that effort, we are guided by a partial notion of God’s divine plan that is linked to
our capacity for rational thought. Because natural law guides what rational human beings do, it
serves as a basis for positive law, some of which is reflected in statutes. Our natural
inclination directs us to preserve our lives and to do such rational things as avoid danger, act
in self-defense, and seek medical attention when needed. Our ability to reason shows that other
human beings are like us and therefore entitled to the same respect and dignity we seek. A
summary statement of the basic precepts of natural law is “do good and avoid evil.” Using
natural law, theologians have developed moral guidelines about medical services, which are
described in Chapters 10 and 11.
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Rawls’s Theory
The contemporary American moral philosopher John Rawls died in 2002. Rawls espoused a
hybrid theory of ethics that has applications in health services allocation and delivery. His
theories were expounded in his seminal work, A Theory of Justice, originally published in
1971. They are redistributive in nature, and the philosophical construct that he used results,
with some exceptions, in egalitarianism in health services.
Rawls’s theory uses an elaborate philosophical construct in which persons are in the
“original position,” behind a veil of ignorance. Such persons are rational and self-interested
but know nothing of their individual talents, intelligence, social and economic situations, and
the like. Rawls argues that persons in the original position behind a veil of ignorance will
identify certain principles of justice. First, all persons should have equal rights to the most
extensive basic liberty compatible with similar liberty for others (the liberty principle).
Second, social and economic inequalities should be arranged so that they are both reasonably
expected to be to everyone’s advantage and attached to positions and offices open to all (the
difference principle).3 According to Rawls’s theory, the liberty principle governing political
rights is more important and precedes the difference principle, which governs primary goods
(distributive rights), including health services.
Rawls argued that hypothetical rational and self-interested persons in the original position
will reject utilitarianism and select the concepts of right and justice as precedent to the good.
Rawls concluded that rational self-interest dictates that one will act to protect the least welloff because (from the perspective of the veil of ignorance) anyone could be in that group. He
Darr, Kurt. Ethics in Health Services Management, Fifth Edition, Health Professions Press, Inc., 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=4816403.
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termed this maximizing the minimum position (maximin).
When applied to primary goods, one of which is health services, Rawlsian moral theory
requires egalitarianism. Egalitarianism is defined to mean that rational, self-interested
persons may limit the health services available to people in certain categories, such as
particular diseases or age groups, or limit services provided in certain situations. It is also
rational and self-interested for persons in the original position not to make every good or
service available to everyone at all times.
Rawls’s theory permits disproportionate distribution of primary goods to some groups, but
only if doing so benefits the least advantaged. This is part of the difference principle and
justifies elite social and economic status for persons such as physicians and health services
managers if their efforts ultimately benefit the least advantaged members of society.
Casuistry and the Ethics of Care
Casuistry Many historical definitions of casuistry are not flattering. They include a moral
philosophy that uses sophistry and encourages rationalizations for desired ethical results, uses
evasive reasoning, and is quibbling. Despite these unflattering definitions and a centuries-long
hiatus, advocates of casuistry see it as a pragmatic approach to understanding and solving
problems of modern biomedical ethics. Casuistry can be defined as a kind of case-based
reasoning in historical context. A claimed strength is that it avoids excessive reliance on
principles and rules, which, it is argued, provide only partial answers and often fall short of
comprehensive guidance for decision makers.
A significant effort to rehabilitate casuistry was undertaken by Jonsen and Toulmin,4 who
argued that
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Casuistry redresses the excessive emphasis placed on universal rules and invariant principles by moral philosophers. .
. . Instead we shall take seriously certain features of moral discourse that recent moral philosophers have too little
appreciated: the concrete circumstances of actual cases, and the specific maxims that people invoke in facing actual
moral dilemmas. If we start by considering similarities and differences between particular types of cases on a
practical level, we open up an alternative approach to ethical theory that is wholly consistent with our moral practice.
At its foundation casuistry is similar to the law, in which court cases and the precedents they
establish guide decision makers. Beauchamp and Walters5 stated that
In case law, the normative judgments of a majority of judges become authoritative, and . . . are the primary normative
judgments for later judges who assess other cases. Cases in ethics are similar: Normative judgments emerge through
majoritarian consensus in society and in institutions because careful attention has been paid to the details of particular
problem cases. That consensus then becomes authoritative and is extended to relevantly similar cases.
In fact, this process occurs in organizations when ethics committees, for example, develop a
body of experience with ethical issues of various types—their reasoning uses paradigms and
analogies.
Clinical medicine is case focused. Increasingly, cases are being used in management
education. This development has made it natural to employ a case approach in health services.
Traditionally, ethics problem solving in health services has applied moral principles to cases
—from the general to the specific, or deductive reasoning. Classical casuists, however, used a
kind of inductive reasoning—from the specific to the general. They began by stating a
paradigm case with a strong maxim (e.g., “thou shalt not kill”) set in its most obvious
Darr, Kurt. Ethics in Health Services Management, Fifth Edition, Health Professions Press, Inc., 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=4816403.
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relevance to circumstances (e.g., a vicious attack on a defenseless person). Subsequent cases
added circumstances that made the relevance of the maxim more difficult to understand (e.g., if
defense is possible, is it moral?). Classical casuists progressed from being deontologists to
teleologists and back again, as suited the case, and adhered to no explicit moral theory.6
Jonsen7 argued that modern casuists can profitably copy the classical casuists’ reliance on
paradigm cases, reference to broad consensus, and acceptance of probable certitude (defined
as assent to a proposition but acknowledging that its opposite might be true). Casuistry has
achieved a prominent place in applied administrative and biomedical ethics. Increasing
numbers of cases and a body of experience will lead to consensus and greater certainty in
identifying morally right decisions.
Ethics of Care Medicine is based on caring, the importance of which is reflected
historically and in contemporary biomedical ethics. Care focuses on relationships; in clinical
practice, this means relationships between caregivers and patients. E…
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