SECTION 3: WHAT CRITICAL ETHICS CAN ACHIEVE
`The opposite of a correct statement is a false statement, but the opposite of a profound truth may be another profound truth.’1
3.1 CAN ETHICAL POSITIONS BE PROVED?
Before examining the application of consequentialist and deontological approaches to ethical issues in health care, it is worth examining in more detail a point raised in Section 1. There we argued that a knowledge of the ethical codes governing practice was not sufficient for the solution of all the ethical problems encountered in health care. A critical ethical approach was needed which would examine the principles that were being implicitly or explicitly used in ethical discussions and consider what justification could be given for them. This claim might be taken to imply that it is possible to prove that certain ethical standards are correct and others are wrong in the sense that the flat earth theory would now generally be considered to he wrong. However, the adoption of a critical ethical approach to these issues does not assume that certain ethical positions are capable of being proved to be right and that others can be shown to be wrong. Some ethical theories do incorporate this claim but others do not.
It might be argued at this point that if an ethical theory does not prove that one position is right and another wrong then there is no point in adopting a critical ethical approach. After all, if it is just a matter of opinion which position is right, why do we need to examine these different theories? If it is ultimately up to us to decide what is right and this is quite compatible with someone else disagreeing, why do we need to consider the different philosophical theories that can be applied to ethical issues in health care?
3.2 COGNITIVISM VERSUS NON-COGNITIVISM
The labels for the two different views outlined above are cognitivism and noncognitivism. These views cut across the distinction between consequentialist and deontological theories since both of these theories can be combined with either cognitivism or non-cognitivism. Stated formally, cognitivism is the view that moral judgments are statements that are capable of being true or false. So just as it is true or false that you are sitting at your computer reading this course or that you are 35 years old, similarly, moral claims about what ought to be done are capable of being shown to be true or false.
Non-cognitivism is just the denial of the claim that moral judgments are statements capable of being true or false. This denial can be combined with a number of different positive views about the status of moral claims. These range from claiming that moral judgments are expressions of emotion2,3 to claiming that they indicate ultimate preferences that we wish to adopt.4, 5 For example, we might think that life is something that is valuable even if the individual is not conscious. This is a position that we wish to adopt which is indicative of a fundamental attitude. Someone else might adopt a different view arguing that only life that is capable of supporting consciousness is valuable. Therefore, according to a non-cognitivist account it is possible for there to be ultimate disagreement between people who hold different ultimate preferences or express different emotions towards ethical issues.
Mill presented his consequentialist theory as a cognitivist theory since he believed that it was possible to prove the fundamental principle of morality that he called the Greatest Happiness Principle (see Section 2.2.3). However, both Singer and Hare' adopt non-cognitivist approaches believing that it is possible for there to be disagreement between fundamental ethical positions.
Although there have been accounts recently that support a cognitivist approach 8, many consider that a non-cognitivist account is correct and that it is possible for there to be disagreement about what is right or wrong in moral questions. If you consider this to be correct, then it might appear that there is no future in undertaking a critical ethical approach to ethical issues in health care if ultimately it is up to each individual to decide what is right. If these views just reflect an individual's subjective preferences and subjective preferences differ, why embark on this sort of discussion? Indeed, what scope is there for rational discussion about ethical problems if ultimately it is up to the individual to decide what ought or ought not to be done?
3.3 RATIONAL DISCUSSION WITHIN A NON-COGNITIVIST FRAMEWORK
If a non-cognitivist view is adopted, there is still scope for the sort of rational discussion incorporated in critical ethics. We illustrate this using examples of abortion and embryo research to indicate the sort of procedure that would be employed in a critical ethical approach.
3.3.1 Isolation of principles
The first step in such a discussion is to find out what principles someone is using to justify their position.
For example, if someone holds that all elective abortions are wrong we could enquire what principle they were using to support this position. This blanket condemnation of abortion with no qualifications for, for example, pregnancies commenced as a result of rape, might be supported by appealing to the sanctity of human life. Human life has intrinsic value and it is wrong to terminate something that has intrinsic value.
3.3.2 What do the principles mean?
Having ascertained the nature of the principle that is being used to justify the ethical position that has been taken about abortion, the second step in the discussion is to seek a greater understanding of what this principle means. Why is the principle limited to human life? At this point, the supporter of the original view about abortion might claim that the principle is just an example of the wider principle that all life forms are sacred. One would then need to know what it is about life itself that makes it intrinsically valuable. Does this principle extend to plant life as well as animal life? If the principle is being restricted to human life, what makes human life valuable as opposed to the lives of other species?
We would also need to know exactly what constitutes life. When is life supposed to have begun and what counts as the end of life? In the case of abortion, is life counted as having begun at conception? Answers to these sorts of questions would provide a far greater understanding of the view that is being held. They might even occasion a change in the original view once a fuller awareness of the exact meaning of the principle that was being used was gained.
3.3.3 What are the implications of these principles?
A change in an original view taken by someone might also result from the third step which could be taken in a critical ethical discussion. Having gained a fuller understanding of precisely what the principle one is appealing to means, changes of view could result when the implications of adopting this principle are pointed out. If we remain with the issue of abortion, the view might be held that abortions are justified if the fetus is discovered to be suffering from Down's syndrome. One principle that might be appealed to in justification of this position is that the quality of life of an individual suffering from Down's syndrome and the impact on the quality of life of those individuals who will be living with and caring for this individual is such that a termination is justified. However, if this justification is advanced, then one implication of this is that, if the presence of Down's syndrome has not been detected in the fetus, but the baby that is born is suffering from Down's syndrome, then the infanticide will be perfectly justified on the basis of the principle that was used to justify an abortion in these sorts of cases. Indeed, in the UK, since screening for Down's syndrome is only offered routinely to women over 35, most Down's syndrome children are born to mothers under 35 since they have not been screened during pregnancy. It might therefore be thought perfectly justifiable to accept the implications of this principle and hence the justifiability of infanticide in the case of these babies.
3.3.4 Change or qualification of original principles
However, holders of the original position with respect to abortions might not be prepared to accept the implication that the principle they are adopting would lead to the justification of infanticide. If they are not, then a fourth step in critical ethical discussion could come into play. They will either have to change their original view about the justifiability of abortions in these sorts of cases or appeal to a different principle to justify their original view. If they wish to qualify the principle that they used in the original justification of their views about abortion they might draw a distinction between a fetus and a baby. They might argue that their original principle only justified the termination of life in fetuses and did not apply to babies. The questions they would then have to address are:
Answers to these questions might well lead again either to a modification of the original position or a change in the principle to which appeal is made. The basic demand that they are having to satisfy is that of consistency between the principles that they hold and the implications of these principles in cases other than the one under consideration.
EMBRYO RESEARCH EXAMPLE
Another example of this stage of discussion at work is apparent when we consider how the principle of the sanctity of human life might be invoked in the area of embryo research. Someone might hold the view that embryo research even only up to 14 days is wrong. The principle to which appeal is made to support this position might very well be the principle of the sanctity of human life. However, it might be pointed out in reply to this justification that at this stage of development we do not have a specific individual who could be said to have a right to life. At this stage, one fertilized egg might evolve into two individuals, two eggs into one individual or no individuals might evolve at all but instead a tumor rather than a fetus might result.
At this point the individual might well modify his or her original position and argue that what is sacrosanct is the potential for human life. Their rejection then of research on embryos would be based not on the sanctity of life of the embryo itself but in terms of its potential to become a human life and it is this that it is sacrosanct. Having modified the principle in this way, we can now appeal to the third step in critical ethical discussion (see Section 3.3.3) and consider the implications of this new principle that is being advocated. Presumably, sperm and eggs have the same potential as an embryo for developing into an individual and so this would mean that this new principle would arguably generate the judgment that all forms of reproductive control are wrong. This might well be a position that someone holding this principle does not want to accept and if this is the case, either the principle will have to be modified or rejected in favor of one that does not have this implication.
Therefore, although it might be accepted that fundamental moral principles are ultimately not susceptible to proof, this still leaves a very wide scope for the use of critical ethical discussion. Indeed, when this discussion has been undertaken, there might well be less disagreement over ultimate principles than has previously been the case. There is still much that can be done by the use of a critical ethical approach even if one adopts a non-cognitivist position where moral judgments are not taken to be statements that are capable of being shown to be true or false.
3.4 SINGER'S VIEW SUBJECTED TO CRITICAL ETHICAL DISCUSSION
The outline of the scope of critical ethical discussion that has been given can be illustrated in detail by taking an example of a non-cognitivist view and subjecting it to the sort of discussion just described. The example that I take is from Peter Singer's book, Practical Ethics.
Singer advocates a non-cognitivist consequentialist view which claims that actions are right in proportion as they maximize the satisfaction of the interests of those affected in a situations. This is clearly a consequentialist view since the value of actions lies in their consequences and what has intrinsic value is the satisfaction of interests. On the face of it, this seems an attractive view and one which many might readily accept but, as we shall see, a closer examination reveals it to be quite controversial.
3.4.1 Isolation of Singer's principle
Singer proposes that when considering a moral problem we should give equal consideration to the interests of all those affected. Interests should be treated equally regardless of who possesses them. They are to be weighed to seek the maximum satisfaction of interests and no priority can be given to one interest over another simply by virtue of who happens to have it. It is the interests themselves that are weighed, and an interest cannot have more weight merely because it is possessed by you or someone you know.
3.4.2 What does this principle mean?
The controversial aspects of this proposal begin to become apparent when we enquire what sort of beings can be said to have interests. Having ascertained what principle Singer is advocating we now take the second step in the discussion and seeking a greater understanding of what this principle means. Without this critical ethical approach, we might have assumed without reflection that the principle only applies to human beings but, as we shall see, that would be to misunderstand Singer's position.
According to Singer, a necessary condition for a being to be able to possess an interest is that the being be sentient or conscious, that is, capable of feeling. A fundamental interest would be, for example, the interest we have in feeling pleasure and avoiding pain. Therefore, we can see that life itself is not sufficient for the possession of interests since there are life forms that are not conscious. For example, plants are living but they do not have a central nervous system that would allow them to be capable of feeling.
What about fetuses? Can fetuses be said to possess interests? Singer argues that until about the eighteenth week, the fetus has an insufficiently developed nervous system to be capable of feeling and hence to be capable of having interests. Therefore, although the pre-18-week fetus is alive, it does not have interests and hence an implication of the acceptance of Singer's principle is that in moral dilemmas involving pre18-week fetuses, the fetus will have no interests to be entered into the calculation seeking the maximum satisfaction of interests.
I have stated the desire to feel pleasure and to avoid pain as being one of the fundamental interests that Singer has in mind. However, there are other more sophisticated interests than this and the question arises whether all sentient beings are capable of having all possible interests. An interest that is particularly relevant in the field of health care is the interest we have in the continuation of our lives. What characteristics must a conscious being have in order to be capable of this interest? According to Singer, the sentient being must be aware of his or her continued existence over time, that is, be self-conscious. It is only self-conscious beings that are capable of having an interest in the continuation of their lives.
Singer proposes to use the term ‘person' to refer to conscious beings who are, in addition, rational and self-conscious. Rationality involves, at the very least, the ability to make simple plans of action although many `persons' possess far more than this minimal level of rationality. It is important to remember precisely what Singer means by his definition of ‘person' since this does not correspond in all respects with the usual usage of this word. He is stipulating a definition of this word and some of his subsequent claims sound very strange unless it is remembered precisely how he uses the word `person'.
Following an argument put forward by Tooley 10, Singer continues his argument by claiming that one can only be said to possess a right to something if one is capable of having the corresponding interest. So, for example, one can only be said to have a right to life if one is capable of having an interest in one's life continuing and this interest can only be possessed by those beings that Singer labels ‘persons'.
If we draw the strands of this position together, we see the following classifications emerging. The species Homo sapiens contains three different groups according to Singer's account. The first group comprises those beings that are living but not sentient, for example, the pre-eighteen week fetus and certain beings towards the end of life. The second group is those that are conscious but not self-conscious, for example, the post-18-week fetus, young infants and those that are just conscious towards the end of life. Finally, we have those members of the species Homo sapiens are `persons' who in Singer's sense of this term, and this covers the majority of adults and children beyond immediate infancy.
3.4.3 Implications of Singer's principle
This analysis of the meaning of the principle proposed by Singer reveals at the third stage of our critical ethical discussion some rather surprising implications which conflict with many commonly held views. For example, birth is often thought to mark a morally significant dividing line in the development of an individual. By morally significant, we mean it is often thought to justify a difference in treatment between the fetus and the baby. One implication of Singer's account will be to deny this view since both before and after birth one will be dealing with a being that is sentient but not a `person'.
Another important implication of Singer's account is that it denies another commonly held belief that human life, meaning the lives of those members of the species Homo Sapiens, is of more value than the lives of other species just by virtue of their membership of this species. Species other than Homo sapiens will also have sentient members and, indeed, some species will in addition be `persons'. Chimpanzees are given as one such example based on the observations made by Jane Goodall 11. She observed evidence of chimpanzees making plans for future behavior which is one sign of the possession of rationality and self-consciousness.
Singer's distinction, which cuts across the distinction between species, has some startling implications which were not evident in the original formulation of his principle but which have become apparent during this process of critical ethical discussion. One example of the implication of ceasing to regard membership of species as morally significant can be seen in the following. Let us assume, for the sake of argument, that a horse is just a sentient being and not a 'person'. There are situations when a horse breaks a leg, in which consideration of the interests of the horse will lead to the judgment that the life of the horse ought to be terminated. The amount of pain that the horse is in is the factor that determines that the horse ought to be put down.
Compare this situation with the way we treat members of our own species who are sentient but not self-conscious. If we take the case of a severely damaged new-born infant who, even with every available technical assistance, is only likely to live for three months, it is often argued that everything should be done to insure the maximum duration of this individual's life. The amount of pain is not given the same consideration as in the case of the horse because it is being taken to be morally significant that the baby is a member of the species Homo sapiens.
Even if this position is not taken, it is often thought to be morally preferable to follow what might be called the course of passive euthanasia where nursing care alone is administered and the infant is ‘allowed to die'. However, if we adopt Singer's position and treat interests equally regardless of who possesses them then the pain of the horse, which is sentient, has to be considered in the same way as the pain of the new-born infant. If we think that the maximum satisfaction of interests is achieved if the horse is shot then it might well be the case that the maximum satisfaction of the interests of those affected will be achieved if a course of active euthanasia is adopted with the new-born infant.
3.4.4 Should Singer's principle be changed or qualified?
This critical ethical discussion of Singer's principle that we ought to seek for the maximum satisfaction of the interests involved in a situation reveals the complexity of this view, and just how much revision of ordinary implicitly held moral convictions would be necessary if we were to adopt his proposal. Of course, we might argue conversely that Singer's principle has to be changed since it conflicts with many strongly held moral convictions. The initial formulation of this principle at the start of our discussion might have led many people to accept it as sounding relatively innocuous and self-evident. However, this examination reveals how radical the proposal is. The critical ethical approach has therefore greatly advanced our understanding of this issue.
It is not to be assumed from this
discussion that we should now accept Singer's views since we might argue that
Singer needs to change his principle. For example, one could argue for the moral
significance of the species Homo sapiens on the grounds that, unlike some
other species, it is a species that can have `persons' as its members.
Alternatively, one could argue for the moral significance of the species Homo
sapiens on religious grounds. What we hope has become apparent by this
illustration using Singer's view is the advantage of subjecting ethical views to
the sort of critical analysis outlined in this course. Even if a
non-cognitivist view is accepted, a great deal can be done by rational
discussion in the ways outlined.
1. Bohr, N. `My Father' in Niels Bohr: His Life and Work. Ed. S. Rosental (1982), Wiley, New York.
2. Stevenson, C.L. (1994) Ethics and Language. Yale University Press, USA.
3. Aver, AJ. (1976) Language, Truth and Logic. Gollancz Press, London.
4. Hare, R.M. (1981) Moral Thinking• Its levels, Method and Point. Oxford University Press, Oxford.
5 Glover, J. (1977) Causing Death and Saving Lives. Penguin Books, London.
6. Singer, P. (1933) Practical Ethics (2nd edn). Cambridge University Press, Cambridge.
7. Hare, op. cit.
8. McNaughton, D. (1988) Moral Vision: An Introduction to Ethics. Blackwell, Oxford.
9. Singer, op. cit., p13.
10. Tooley, M. (1983) Abortion and Infanticide. Clarendon Press, Oxford.
11. Goodall, J. (1971) In the Shadow of Man, Boston.