SECTION 2: CONSEQUENTIALIST AND DEONTOLOGICAL THEORIES

'Both horns of a dilemma are usually attached to the same bull' ¹

2.1 JUSTIFICATION OF ETHICAL PRINCIPLES

In the examples that we considered in Section 1, we saw that there are four main principles appealed to in ethical decision making:

1. Principle of Beneficence,
2. Principle of Autonomy,
3. Principle of Non-malfeasance and
4. Principle of Justice.

In the following example, three of these principles are considered.

The Cancer Example

An individual has cancer and asks a member of the health-care team, in this case a nurse, what is wrong with him. The nurse knows from close relatives of the cancer sufferer that he will be overcome by depression if he knows the true diagnosis. He has the prospect of a few more months of life with some pain that could be alleviated by drugs. It seems reasonable to suppose that the quality of life of the sufferer in these last few months will be better if he does not know the truth of his diagnosis. Should the nurse tell him what is wrong with him?

The Principle of Autonomy is clearly relevant here. The right to be told one's true medical condition would appear to he an area over which an individual has a right to be self-governing. This knowledge might affect how the individual would like to conduct the last few months of his life. For example, there might be certain things that he would choose to say to those who have been close to him. Also, he might choose to spend the last few months at home, if this was possible, rather than in hospital.

However, it might be argued that application of the Principles of Beneficence and Non-malfeasance favor not telling this individual the true diagnosis. It might be assumed that harm would be done to the individual if he knows, since then he will be overcome by depression. Since the Principle of Non-malfeasance states that one ought not to do harm, application of this principle would appear to favor non­disclosure. Put positively, the Principle of Beneficence is applicable since the duty to benefit here might be assumed to be accomplished by not telling the individual the truth. Therefore, in this case it would appear that application of the Principle of Autonomy favors a different action to that which would result from applying the Principles of Beneficence and Non-malfeasance. Although we have a clearer understanding of the nature of our dilemma by making explicit the principles that are only present implicitly in the description of the case, we have not been able to determine which course of action the nurse should take.

What we need is a further understanding of how these principles can in turn be justified. We need to know what considerations fundamentally underpin the way that we look at ethical dilemmas. For instance, in this example we might say that what we are fundamentally trying to achieve is the best outcome in this case. We want to reach a decision that will yield the best results or consequences for the individual concerned, his relatives and others such as health-care workers involved with his case. This is the essence of consequentialist ethical theories (see ET1008: Section 12: 3.1 and  3.2).

2.2 CONSEQUENTIALIST ETHICAL THEORIES

The view that what is important is that the best consequences are achieved has been formulated by Parfit as:

‘. . . there is one ultimate moral aim: that outcomes be as good as possible.‘ ²

Therefore, in the ‘cancer example', we should be asking: ‘What will produce the best outcome in this situation?' This is the fundamental question that we need to ask when we look at ethical dilemmas.

2.2.1 Act consequentialism

There are different ways in which we might seek to answer the question of what will produce the best outcome in ethical dilemmas. In the ‘cancer example' we might ask directly: ‘What is the right action for the nurse to perform?' and not make any reference to the three principles mentioned above. If we did this, we should only consider the consequences on the individual, relatives and other members of the health-care team of the nurse's action of telling or not. The consequentialist view of what would make her action right would be that an action is right if it produces the best possible outcome.

If we approached the question in this way, we would first of all have to determine what is the best outcome and then from this it would follow what is the right action to perform. The right action would be that one which would, on this occasion, produce the best consequences. What is to count as the right action therefore becomes something that is dependent on the ethical decision about what is the best outcome. Thus, rightness is defined in terms of what produces good outcomes.

2.2.2. Rule consequentialism

In order to avoid what might turn out to be a lengthy examination in each separate case of what is going to yield the best outcomes, it might be suggested that certain principles or rules could be justified on consequentialist grounds. If this could be done, then when a principle with a consequentialist justification is applicable in a certain case, we would know that adoption of this principle is likely to lead to good outcomes. Instead of applying the consequentialist justification directly to acts, we should be using it to justify certain rules or principles. Thus we have a rule is right if it produces the best outcome possible.

In Sections 4, 5 and 6 we shall consider how the Principles of Autonomy, Beneficence, Non-malfeasance and Justice might be justified on consequentialist grounds.

Other rules might also be considered as justifiable on consequentialist grounds. Thus, in the ‘cancer example', it might be the case that the rule, ‘One ought to tell the truth,' has a consequentialist justification. Acting in accordance with this rule is likely to produce the best consequences. If this is the case, the right action to perform from this point of view would be for the nurse to tell the truth. The right action is the one that is in conformity with the rule which has a consequentialist justification.

This way of applying the consequentialist, doctrine is indirect, as opposed to the direct application considered in the act consequentialist approach. We are not considering the consequences of an individual action but evaluating an action as right because it falls under a rule that has a consequentialist justification. In the 'cancer example', we are not considering directly the consequences of the nurses action in this particular case. Rather, we are evaluating the nurse's action of telling the truth as being right because the rule, ‘One ought to tell the truth', has a consequentialist justification.

What are good outcomes?

Whichever of these two approaches is adopted, the doctrine that outcomes be as good as possible does not give us a complete ethical theory. We need to know what are to count as good outcomes in order to apply either our act or rule consequentialist doctrine. We need to attach a value theory to our consequentialist claim which will tell us what are good consequences.

There are many different views about what are to count as good consequences. These views all claim that what is good is fundamental. That is, no further justification can be given for what is taken to be a good outcome; it just is good. Another way of making the same point is to say that what is good has intrinsic worth. It is not good because of something else that it might yield, it is good in itself.

These views are still described as consequentialist theories but differ in the view they take about what has ultimate value. In looking at these different value theories that can be combined with consequentialism, we do not discuss whether the particular author is applying consequentialism to individual actions or to rules. Our concern will simply be to examine the value theory that is being proposed. Application of these theories to the four principles is considered later.

2.2.3 Hedonistic consequentialism (utilitarianism)

The classic consequentialist doctrine is that put forward by Bentham ⁴ and later by Mill ⁵. Although they put forward different accounts, they agree on the fundamental point that what has ultimate value is happiness. Good outcomes are those that yield happiness. This view has a certain initial plausibility that makes it worth examining. If we take the ‘cancer example', we are trying to achieve as much happiness as possible for the individual and others affected in the situation.

Mill wrote:

‘The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in Proportion as they tend to produce happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. ' ⁶

This is clearly a consequentialist theory since what is right is being determined by the consequences of an action and the consequences that are taken to be good are those that produce happiness. In this initial formulation at least, happiness is being equated with the sensation of pleasure and the absence of pain.

Because consequentialism is here being combined with a theory that states that good outcomes are those that produce happiness, it is called hedonistic conse­quentialism. Indeed, this phrase is often what is meant by the term utilitarianism and that is how I shall use this term. Mill describes his theory as utilitarianism. He clearly intends to capture by this term that it is both a consequentialist doctrine and one that gives intrinsic value to happiness. However, sometimes the term utilitarianism is used synonymously with consequentialism. This should not cause any undue problems since the context of the use usually clarifies which sense is intended.

One of the obvious features in favor of this sort of approach to ethical problems is that it reduces all issues of value to one common currency of pleasure and the absence of pain This should, in principle, make it easier to arrive at a solution to ethical problems. The right action to perform will just be that action which produces the greatest balance of pleasure over pain. However, this seeming simplicity masks many problems. How exactly are we to measure these sensations of pleasure and pain? Mill himself argues later in the essay that there are different sorts of pleasure. He describes these as intellectual and sensual and claims that the intellectual pleasures are more valuable than the sensual ones. How are pleasure and pain to be recognized in those individuals who cannot express their experiences?

Mill recognized some of the difficulties with his initial formulation of the doctrine where he equates happiness with the sensation of pleasure and the absence of pain . Indeed, towards the end of the essay he starts to describe happiness as ‘a concrete whole' ⁶ which comprises the concrete things that individuals desire. The individual is happy then in proportion to the amount of his or her desires are satisfied, in proportion as he or she has what he or she prefers. It should be noted, however, that this sort of position is in direct opposition to earlier parts of Mill's essay where he specifically distinguishes happiness from satisfaction or contentment.⁷

However, this move away from taking happiness to refer to some mental state of pleasure and the absence of pain to considering it as a reflection of desire satisfaction is what is reflected in contemporary consequentialist theories. These theories, then, are also consequentialist adhering to the claim that outcomes be as good as possible. However, they combine this with a different view about what constitutes a good outcome.

Interest or preference consequentialism

Recent formulations of consequentialist theories take the interest or preference satisfaction of those affected to be what counts as a good outcome. Singer advocates the former view in his book Practical Ethics ⁸ and the latter position is argued for by Hare in his book Moral Thinking ⁹. Interests are taken to encompass anything that individuals desire. Singer, for example, lists the following interests:

‘. . . the interest in avoiding pain, in developing one's abilities, in satisfying basic needs for food and shelter, in enjoying warm personal relationships, in being free to pursue one's projects without interference. ' ¹⁰

One of the obvious questions with this sort of account is what sort of beings can he said to have interests and are there some interests, for example, in the continuation of one's own existence, that some beings cannot possess? If we consider the beginning of life, can the fetus at all stages of its development be said to possess interests? Even if it can possess some interests, do these include an interest in the prolongation of its life? If the interests of the fetus conflict with the interests of other individuals, how are these conflicting interests to be weighed in order that the maximum satisfaction of interests be achieved?

These difficulties will be raised later when the adoption of interest or preference consequentialism is considered in particular cases. Interest or preference consequentialism is arguably preferable to hedonistic consequentialism, since there are many problems associated with the measurement of the sensation of pleasure which are apparent in the hedonic calculus proposed by Bentham ¹¹.

2.3 DEONTOLOGICAL ETHICAL THEORIES

If we return to the ‘cancer example', we might say that what is important to consider here is not what will cause the best outcome. Rather, certain features of the situation make certain actions right or wrong in themselves. For example, one such character­istic in this example might be telling the truth. Although this might sometimes be overridden, the rightness of telling the truth is something intrinsic to truth telling itself and is not dependent on truth telling resulting in good consequences. This is to take a deontological approach, which can be contrasted to the way that the rule consequentialist viewed truth telling (rule consequentialism, above) where the rightness of truth telling was justified in terms of it being instrumental to achieving the best outcome.

Perhaps the major point of difference between deontological ethical theories and consequentialist ethical theories is that the former take rightness to he primary. As we have seen, for consequenialists, what is right does not have any independent standing but is defined in terms of what produces good outcomes. It is then this latter notion that receives an independent explanation. In the case of deontological ethical theories, certain actions are intrinsically right and their rightness is not dependent on some further claim such that they are productive of the best outcomes. In fact, the best outcome will be achieved, in deontological terms, if the right action is performed. This is because the right action determines what is the best outcome. Clearly, if a view like this is held, then some account is necessary of what makes certain characteristics right. Why should something like telling the truth be regarded as something that is intrinsically right? The following deontological theories provide answers to this question.

2.3.1 Kant's deontological ethical system

Just as Bentham and Mill provide the classic statement of a hedonistic consequentialist view, so Kant's ethical theory contains the classic statement of a deontological theory. Kant proposed a test called the ‘Categorical Imperative' which could be used to test whether a certain rule, such as one ought to tell the truth, was really a duty (see page 16). The Categorical Imperative is first formulated by Kant as:

'Act only on the maxim through which you can at the same time will that it should become a universal law. '¹²

What does this mean? To begin with, what is a maxim? An example of a maxim that we might adopt is that we shall always do the shopping on a Friday. Another one might be that we will always take anything that we want even if it does not belong to us. From these examples, we can see that a maxim is a subjective principle of action. It is a principle that we have decided to adopt to govern our lives. In order to see if our maxims are duties, we shall then have to see if they pass the test incorporated in the Categorical Imperative.

So what exactly is involved in this test? As a minimum requirement for a maxim to be capable of becoming a universal law, a law applicable to everyone, it must not contain contradictions when stated in its universal form. Kant gives an example of a maxim which, if universalized, would be self-contradictory. Let us suppose that we decided to have as one of our subjective principles of action the maxim of making promises which we had no intention of keeping. This could be a very useful maxim for us. For example, I could borrow some money from you and promise to pay it back even though I had no intention of doing this. However, Kant argues that such a maxim could not become a universal law since it would be self-contradictory. He writes:

‘How would things stand if my maxim became a universal law? 'I then see straight away that this maxim can never rank as a universal law of nature and be self-consistent, but must necessarily contradict itself^, ' ¹³

The contradiction present if this maxim is universalized is that the practice of promise keeping would disappear. This is because no one could rationally believe anyone's promises since they would be aware that the other person had no intention of keeping them. To make a promise implies having the intention of keeping it and hence it is contradictory to both have and not have this intention. Indeed, it is difficult to see how there could be these insincere or lying promises unless there were a practice of promise keeping. This is because they derive what success they achieve from the existence of the institution of promising. That is, from the fact that most people make promises with the intention of keeping them.

Although lying promises fail this test incorporated in the Categorical Imperative there are some maxims that are not contradictory when universalized but are still not duties. This is because they fail the second part of the test incorporated in the Categorical Imperative. If we have as one of our subjective rules of action that we shall just look after our own interests and not help others who might be in need of our assistance, could this become a universal law? Kant writes:

‘. . . it is impossible to will that such a principle should hold everywhere as a law of nature. For a will which decided in this way would he in conflict with itself, since many a situation might arise in which the man needed love and sympathy from others’ ¹⁴

The suggestion here appears to be first that there is no formal contradiction in everyone adopting the policy of just looking after their own interests and not helping others in distress. However, we shall find that we cannot both have this as one of our maxims and at the same time want it as a universal law. That is, we would not choose this maxim and also hold that everyone else should just look after their own interests. The merits of Kant's argument about this point are hotly debated but it is clear that Kant is suggesting a two-part test in his Categorical Imperative since even if a maxim, when universalized, is not contradictory, it does not automatically follow that it can become a law. It has also to pass the second part of the test and be such that we can will it both as a subjective principle and as a universal law.

The necessity of being able to universalize our maxims, of acting as if you were legislating for everyone, is not the only feature incorporated in Kant's account. In formulating principles of action that pass this test we need to recognize that other human beings are also ends in themselves and must not be treated as a means to a further end. If we make a promise with no intention of keeping it then we are using someone as a means towards an end which we desire but which they do not share. Finally, other rational beings as well as ourselves will formulate principles and recognition of this will impose restrictions on what maxims can pass the test of the Categorical Imperative. These last two points are discussed in further detail in Section 4.2.2  when we consider Kant's justification of the Principle of Autonomy.

If we return to the ‘cancer example', the maxim of telling the truth would appear to pass the test incorporated in the Categorical Imperative. When this maxim is universalized and applied to everyone, there is nothing self-contradictory in everyone telling the truth. In addition, if we want to tell the truth ourselves we shall want other people also to tell us the truth. This maxim therefore passes both tests and is thus a right-making characteristic (see ET1008: Section 12.3.2).

One of the major problems with Kant's deontological system is that there might well be situations where more than one thing is our duty. This in itself is not problematic except where these duties conflict in the sense that it is not possible to perform an action which is in conformity with both. Arguably, this situation might be said to arise in the ‘cancer example' where it might be claimed that the two duties of telling the truth and not harming someone are in conflict.

2.3.2 Ross' deontological ethical system

An account that could remedy this problem was put forward by Ross in two books published in the 1930s called The Right and the Good¹⁵  and The Foundations of Ethics'. Ross proposed that certain duties such as fidelity, beneficence and justice be regarded as what he called prima facie duties. These duties are those that we just, from our ordinary moral convictions, regarded as duties. He recognized that in some situations these could conflict and the duty that was finally decided to be applicable in the particular situation would be regarded as our absolute duty in that situation.

If we return to the ‘cancer example' again, Ross might have argued that there are two prima facie principles involved, the principle of non-malfeasance, that is, the non­infliction of harm, and the principle of telling the truth. Our ordinary moral intuition reveals that these are prima facie duties and where they conflict, we must somehow find the greatest balance of right over wrong in order to discover what is our absolute duty in this case.

2.4  EVALUATION OF CONSEQUENTIALIST AND DEONTOLOGICAL THEORIES

Throughout this course, we shall see in detail the implications of adopting one or other of these approaches, but I will make a few points now about these competing theories.

Consequentialist theories have what seems, on the face of it, to be an advantage since there is only one thing that is claimed to have intrinsic value. For Mill this was happiness and for other philosophers it was preference or interest satisfaction. Everything of value can be reduced to the one common currency of happiness or interest satisfaction. Consequently, everything of value can be directly compared since all value issues are explicable in terms of one currency. This would appear to make moral dilemmas more easy to solve and less intractable. In the ‘cancer example' we would just have to consider the interests of the individuals affected in this situation and the right action to perform will be that action which maximizes interest satisfaction.

However, one might have an initial feeling that not all values are indeed commensurable and that any account that claims they are is not reflecting the sophistication of moral thought. Also, despite its apparent simplicity, any account which evaluates actions or rules in terms of consequences is going to have to weigh probabilities of certain consequences against the amount of good that those consequences might yield . Therefore, any calculation might be very difficult to undertake.

Perhaps the most fundamental criticism that can be leveled at consequentialist theories is that separate individuals are no longer of paramount importance in their account. The maximization of happiness or interest satisfaction is the goal to be achieved. If this is achieved by an unequal distribution of happiness between individuals, then nothing can be done about this. We shall see how this ultimately leads them to give an unsatisfactory account of the Principle of Justice in Section 6.

An initial advantage of deontological theories is that they appear to advocate as right what is generally recognized by the majority of people as being right. However, what characterizes a moral dilemma is that this is usually a situation in which these prima facie duties conflict. It might be felt that deontological theories do not provide a decision procedure to deal with these sorts of cases. Any talk of ‘weighing' the various prima facie duties against one another is not descriptive of a method at all. However, maybe this is all that can be hoped for and after the situation has been suitably clarified, we shall in some sense see what course of action will be right.

The fundamental advantage that deontological theories have over consequentialist theories is their recognition of the importance of individuals. It is not legitimate to sacrifice individuals for the sake of a particular favorable outcome. Our argument is for the importance of this claim throughout the book.

REFERENCES

1.    Kohn, R.M.H. (1970) Perspectives in Biology and Medicine, Sumner Press, p633.

2.    Parfit, D. (1984) Reasons and Persons. Clarendon Press, Oxford, p24.

3.    Bentham, J. 'An Introduction to the Principles of Morals and Legislation'. In M. Warnock (ed.) (1968) Utilitarianism. Fontana Library Glasgow.

4.    Mill, J.S. 'Utilitarianism'. In M. Warnock (ed.) (1968) Utilitarianism. Fontana Library Glasgow.

5.    Ibid, p257.

6.    Ibid, p 291.

7.    Ibid, p260.

8. Singer, P. (1933) Practical Ethics, (2nd edn). Cambridge University Press, Cambridge.

9.    Hare, R.M. (1981) Moral Thinking.• Its levels, Method and Point. Oxford University Press, Oxford.

10. Singer, op.cit., p31.

11. Bentham, op. cit., pp 64-5.

12. Kant, 1. ‘Groundwork of the Metaphysic of Morals'. In H.J. Paton (ed.) (1948) The Moral Law. Hutchinson University Library, London, p84.

13. Kant, op.cit., p85.

14. Kant, op.cit., p86.

15. Ross, W.D. (1930) The Right and the Good. Oxford University Press, Oxford.

16. Ross, W.D. (1939) The Foundations of Ethics. Oxford University Press, Oxford.