Ethical Issues in Dentistry: Introduction I. Introduction to Moral theory. A. Basic Concepts and Problems

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Ethical Issues in Dentistry:

I. Introduction to Moral theory.
A. Basic Concepts and Problems.
1. Morality and ethical theory
Morality: A social institution, concerned with social practices defining right and wrong. It’s composed of a set of standards which is pervasively acknowledged by a culture or a people.
Ethical Theory: an activity in which one engages in reflection on the nature and justification of right actions.
2. Morality and Prudence
Prudence: Self interest (don’t touch the stove, brush your teeth—not moral rules)
Morality: Is not reducible to prudence. Prudence is self-interest whereas morality extends to others. Prudence and morality may coincide, but that which is prudent may not be moral, and that which is moral may not be prudent.

3. The Rule of Conscience
Let your conscience be your guide. Certainly, conscience is not the end all and be all of morality. People’s consciences will tell them very different things in very similar circumstances. Yet, should you ever do what your conscience tells you is the wrong thing? Ethicists disagree.
4. The Common Morality
Those of us who are committed to morality share a set of norms, even though these norms may be very general. We all agree at least that any of the norms that we hold apply to all people, or to all who are members of the moral community. We cannot arbitrarily exclude any of those we may not like, or who may not like us. The common morality applies to everyone.
The basics of common morality are best expressed, perhaps, in the three basic factors of morals: the good, the right, and the virtuous. The first factor contemplates ends or outcomes; the second with duties and obligations, the third with character formation.

5. Moral dilemmas and suggestions for solving moral disagreements
Genuine moral dilemmas are real and difficult. The Tarasoff case (p. 45-49) is a good example. It’s a moral dilemma because there are very good reasons for mutually exclusive alternatives. If one set of reasons is acted upon, events will result that are desirable in some respects but undesirable in others.
Resolving moral disagreements:
a. Obtain objective information

b. Provide definitional clarity

c. Adopt a code

d. Use examples and counter-examples

e. Analyze arguments
6. The Problem of Relativism
Cultural Relativism: Cultures vary in the values that they hold. That is, values are relative to a culture.
Distinction: Between a relativity of judgment and a relativity of standards. We clearly have the former, but does the latter hold?
Cultural Normative Relativism: What is thought to be right in one culture is really right for that culture, regardless of what another culture thinks about it.
Individual Normative Relativism: What is thought to be right for one individual is really right for that individual, regardless of what another individual thinks about it.
Criticisms of both views:

7. Moral Diversity and Moral Disagreement
Why do we disagree, morally speaking?

  1. Factual disagreements (for example, over the benefits of a particular procedure)

  2. Scope disagreements about who should be protected by a moral norm (what degree of autonomy for children?)

  3. Disagreements about which values are relevant to a particular moral dilemma

  4. Disagreements about appropriate specifications

  5. Disagreements about the weights of conflicting norms

  6. Disagreements about balancing norms

  7. The presence of a genuine moral dilemma

  8. Insufficient information or evidence (very common!!)

B. Normative Ethical Theory
First, a distinction: All ethical theories can be classed as one of two kinds: teleological (consequentialist) or deontological. The former says that the morality of an action is completely determined by its consequences. The latter says, no, they’re not; there are other relevant considerations.
1. The importance and role of professional standards: Are they sufficient?
2. Utilitarianism

  1. basic concepts:

i) The principle of utility: Maximize the good. We ought to act in such a way as to maximize value over disvalue.
ii) The Standard of Good. Since morality consists in maximizing the good, we must describe what we mean by good. John Stuart Mill is a hedonist. His version of the Principle of Utility, which he calls the Greatest Happiness Principle: Actions are right in proportion as they promote happiness and wrong as they produce the reverse of happiness. By happiness is intended pleasure and the absence of pain. Other utilitarians will have different theories of good: e.g., satisfaction of desires, satisfaction of preferences, or some plurality of goods. Further, utilitarians also hold that goods are quantifiable. That is, goods are measurable and comparable.
iii) The principle implies consequentialism (the morality of an action is completely determined by its consequences)
iv) and impartiality/universalism (everyone matters equally).
b. Act and rule utilitarianism: According to act utilitarianism, every deliberation requires that we calculate the consequences by appealing to the principle of utility. Rule utilitarianism says that we appeal first to relevant secondary principles (don’t lie, don’t steal, etc). The principle of utility justifies these principles and it settles conflicts between them.
c. Problems with utilitarianism: 1) Problems accounting for the dignity of the individual (The patient in room 605). 2) The real difficulty in quantifying pleasures or even goods of any kind. 3) The difficulty of the distinction between act and rule utilitarianism.

3. Kant and deontology

  1. basic concepts

Kant puts forth a Supreme Principle of Morality, which he calls The Categorical Imperative. It’s a Categorical Imperative as opposed to a Hypothetical Imperative.

Motives are very important for Kant. You must not only do what you believe is right, but you must do so for the right reason, that is, you act from the motive of duty. For Kant, good actions only follow from a good will, and a good will is the ONLY thing in the universe that is good in and of itself. Every other good is corruptible and is only instrumentally good. But, from a good will only flows good actions. The motive for the action comes from an appeal to a universal rule. In order to determine our duty, Kant supplies us with the Categorical Imperative, his Supreme Principle of Morality:
The first version:

  1. The Categorical Imperative: Always act in such a way that you can at the same time will that the maxim of your action to be a universal law of nature. In other words, Don’t make exceptions for yourself!

The second version:

  1. The Categorical Imperative: Always treat humanity, whether in the person of yourself or another, always as an end in themselves, and never as a means only. In other words, don’t use people!

  1. Problems with Kantian deontology: 1) Seems to ignore the importance of consequences. Can they be so unimportant? 2) Leaves little room for virtue. One can be a perfect Kantian and be sorely lacking in virtues, such as compassion.

4. Virtue ethics: Descends from the classical Hellenistic tradition represented by Plato and Aristotle. Here, the exclusive emphasis on duty, obligation, and rules is misguided. Instead of looking at rules of obligation, we should be focusing on making good people, cultivating people of good character. Moral virtues are understood as morally praiseworthy character traits, such as courage, compassion, sincerity, reliability, etc. The focus is on the ideal person, while action is of secondary importance. Acquiring virtues is much like acquiring other skills, such as cooking and carpentry. You become just by behaving justly.

However, virtue ethics is more than purely habitual training. One must also have a correct motivational structure. Thus, a person who is compassionate, not only has a disposition to act compassionately, but a morally appropriate desire to be such.

Consider a dentist who meets moral obligations but hates her job, etc. We need virtue to fill out the morally ideal person.
5. Care ethics
a) The impartiality of traditional moral theory (esp. Kant and Mill) are inadequate guides to action. Abstract formulations take us away from the concrete situation and from the relevant social and historical facts which characterize that situation.
b) Impartiality undermines respect for the individual because it treats individuals impersonally, as interchangeable moral agents without any uniqueness. In many situations, impartiality is a vice, not a virtue.
c) Kantian and utilitarian impartiality leave little room for virtues--empathy, compassion, love, etc.
d) Rather than focusing on individuals, care ethics focuses on relationships. They totally reject the idea that ethics is based on our being autonomous agents who make our choices in a free and equal manner. Their rethinking claims that social cooperation (and ethics) are unchosen, intimate, and among unequals. Traditional models fail to see this.
e) We need a change of metaphor. Many traditional metaphors have been war and sports oriented. The shift to family metaphors would make a significant difference.

C. Ethical Principles—distinction between rules and principles. Basically, rules tell us specifically what to do or what not to do. Principles offer guidelines for how to make decisions.
1. Autonomy—based in Kant. Refers to basic self-governance. For many, the most fundamental principle of any medical ethics

2. Beneficence—above all, do no harm
William Frankena’s description of beneficence:
a. One ought not to inflict evil or harm (nonmaleficence)

b. One ought to prevent evil or harm.

c. One ought to remove evil or harm.

d. One ought to do or promote good.

3. Justice:
Distributive Justice deals with the question: how ought the goods and responsibilities of society be distributed among its members? In other words, what is fair?
Formal Principle: Treat equals equally
Material principles have been proposed. Here is a good list:
a. to each person an equal share

b. to each person according to individual need

c. to each person according to acquisition in the free market

d. to each person according to individual effort/performance

e. to each person according to societal contribution

f. to each person according to merit
Utilitarian theory: seeks to maximize overall value with little (or no) emphasis on the individual. Any arrangement that maximizes overall good is acceptable.
Egalitarianism: less tolerant of inequalities. In the above list, (a) is radical egalitarianism. A more mitigated one would accept inequalities only in so far as those inequalities contribute to everyone’s advantage.
Libertarians (generally c and d above) tend to value economic autonomy over any sort of equality. As long as we play by the rules and don’t cheat, any economic distribution is fine, even if it is radically unequal.
Some Concluding Notions:
*Our principles can and do conflict. How do we resolve such conflicts? One proposal by W. D. Ross is promising.

Grounded in the Common Morality, obligations arise simply because we live together and interact. They are not grounded in Kant or Mill, or rights. Examples of such obligations: “Promises create obligations of fidelity;” “Wrongful actions create obligations of reparation.”

Prima facie nature of principles: A prima facie duty is one that is always to be acted upon unless it conflicts on a particular occasion with an equal or stronger duty. It is conditional, then, on not being overridden by a stronger duty.

*Morality and Law—Law and Morality are NOT identical!

*Legal and Moral rights
Legal Rights: sanctioned by law

Moral Rights: held regardless of law
Negative rights: rights of non-interference

Positive rights: a right to be provided with some good

*Law, Authority, and Autonomy
Liberty limiting principles:
a. The Harm Principle: A person’s liberty is justifiably restricted only to prevent harm to others caused by that person.
b. The Principle of Paternalism: A person’s liberty is justifiably restricted to prevent harm to self caused by that person.
c. The Principle of Legal Moralism: A person’s liberty is justifiably restricted to prevent that person’s immoral behavior.
d. The Offense Principle: A person’s liberty is justifiably restricted to prevent offense to others by that person.
*Remark on case studies and ethical theory

*The domain of ethics

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