Abstract
Summary
While Principlism is a widely accepted consensus statement for ethics, the moral theory that underpins it faces serious challenges. This two-part paper proposes a version of virtue theory as a more grounded system of moral analysis. Part 2 examines the role of basic moral theory as the foundation to ethics and suggests how virtue theory can be used as a central framework for ethics while being inclusive of insights from deontology and consequentialism.
Introduction – is Principlism good enough?
The first part of this paper examined the moral foundations to medical ethics in general and Principlism in particular. Principlism is a generally accepted everyday tool for analysing ethical problems in medicine. 1 Although Principlism analyses medical decisions and medical actions, this may fail to capture the whole picture of the factors that are morally relevant.
Problems with post-Enlightenment moral theory
Problems with theoretical foundations
I have argued elsewhere that if morals are seen by some as part of the furniture of the world, then in the West the Judeo–Christian worldview may still represent the wallpaper. 2 It was in fact Schopenhauer who first called Kant’s bluff. 3 Without the subconscious assumptions of a theistic worldview, appealing to reason alone, why should we be bound by a duty to others, whether within a Kantian or utilitarian framework?
‘Evolutionary ethics’ can explain altruism up to a point, but only within my own social group or gene line.4,5 So why should we not be self-interested, or limit our concerns to our family, group or tribe? Many people live their lives expressing care for their family but with little regard for wider society. Perhaps the Mafia could be said to possess the courage to take this philosophy to its logical conclusion.
The dismantling of our theistic assumptions in the 20th century has been seen by some as exposing the ultimate poverty of the rational foundation of enlightenment morality. Some have argued that the disintegration of social cohesion and ‘civilised values’ in our society can be seen as a logical consequence of this philosophical embarrassment.
As for utilitarianism, shall we accept the Benthamite pure pain and pleasure variety, shall we accept Mill’s ‘higher and lower pleasures’ or shall we go for welfare utilitarianism or the recent preference utilitarianism of writers such as Harris, Glover and Singer? (These are consequentialist systems that see ‘good’ as whatever will maximise our preferences or welfare for the greatest number, with no other considerations admitted.) What shall we maximise? Having decided that who will give us the numbers to do it?
Deficiencies within deontology and utilitarianism
Deontology is inadequate in guiding my actions when my duties conflict. Utilitarianism is inadequate in obtaining justice for individuals or minorities in the face of competing demands of larger groups. Traditionally, both of these theories have been either modified (e.g. ‘rule utilitarianism’) or used selectively to utilise their strong points and minimise their downside (indeed Rawls could be seen as a way of formally achieving exactly this.) But in that case, how can one say that either is a theory that allows one to accurately understand moral principles if one then has to fix the argument in order to ensure the right result? And what faculty within us is able to tell that a particular outcome is wrong if we cannot deduce that by the use of our right moral model? If there is indeed such a faculty within, or some a priori good that we can perceive, then what is the point of these two competing enlightenment models in the first place?
Problems with hard cases
Both deontological and utilitarian models work excellently with easy cases. Should I normally steal? Should I aim to betray my friends? Should I routinely break my promises? No one after early childhood has any problem knowing the answer to such questions, but who needs deontological or utilitarian theory to work it out?
But when we come to difficult cases, such as a ‘woman's right to choose’ versus an ‘unborn child's right to life’, we find that we are dealing with conflicting duties, conflicting good and bad outcomes. We find deontology does not handle conflicting duties well. Utilitarianism promises help (so long as we are prepared to ignore minorities and issues of justice), but only by the application of a calculation where nobody knows the actual numbers to put into the equation.
In our 21st century world of mushrooming choice, reduced restraint from social convention and limited resources, such difficult cases are the norm not the exception. One must therefore ask what is the use of these two theories if they have problems with their rational foundation, if they only help us in cases so straightforward as to need no moral model, and if they routinely fail us in complex cases? The commonest escape from these problems is either a retreat to moral non-realist contractarianism or an appeal to a preference-based form of consequentialism such as that of Singer or Harris.
Virtue rides again
Previously, I asked what inbuilt intuitive judgements we use when traditional systems fail in hard cases, and the need to balance the individual's rights with the good of all. Following a seminal paper by Elizabeth Anscombe in 1958, MacIntyre made a powerful plea for recognition that an updated understanding of Aristotle’s virtue ethics offers us the only well-founded answer.6,7 MacIntyre 8 describes 20th century social life as ‘the concrete and dramatic re-enactment of 18th century philosophy’. His verdict on our modern world is that ‘the barbarians are not waiting beyond the frontiers; they have already been governing us for quite some time’. 9
MacIntyre’s call has been taken up by many medical ethicists, particularly those in general practice. 10 Rules fail, and we must look ultimately to our own moral convictions to guide us. What will inform that moral intuition?
In some respects, Aristotle’s world was surprisingly like our own. I would identify three cultural strands that defined his age and still define ours:
The post-Homeric world of a warrior society. Morally, might is seen to be right – strength is its own justification. There are obvious parallels with capitalism in the modern west. The Hippocratic (460–370 BC) world of professional practice and the ethics of care. These map across to the professional duties defined by the General Medical Council in the UK. The academic world of Socrates (469–399 BC) and Plato (c428–348 BC) – worlds of reason and new models of knowledge.
Aristotle was well aware of the different cultural strands within his society, each with their own intuitive ethic. He therefore sought to ground ethics in a unified and deeper way that did not rely on the culture of any particular social group but relied upon an account of human givens.
The strongest practical argument against virtue-based morality is that is not a guide to action. Indeed it may well be that in a particular situation two equally virtuous people may act in opposite ways. My father was a fighter pilot in the Second World War, while his friend was a conscientious objector – I believe that both acted with great courage and virtue, and they thought this too of one another. But a moment’s reflection will show that this is an example where there was not one simple right answer. There could only be better or less good answers. A simple ‘rule’ could not have given an answer that we could be confident would be right.
Virtue ethics is ethics for grown-ups living in a complex world, with far more than 50 shades of grey. As Beauchamp and Childress remark, ‘we see disunity, conflict and moral ambiguity as pervasive aspects of the moral life. Untidiness, complexity and conflict are unfortunate features of communal living …’. 11
Can we integrate three systems of moral realism?
We can see the three main secular moral systems as giving guidance at the three different levels of an act (Figure 1)
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Virtue guides our choice in the goal or motive of an act. Deontology guides our choice regarding the nature of an act itself. Consequentialism guides our choice when we take into account the specific circumstances of an individual instance of an act. The moral analysis of acts.
In the real world, we have to make judgements about acts and options that are not perfect, and these three moral theories may all help us to do this. In the real world, few acts will be perfect. If there is no clear ‘right’ option, we must use our human judgement to decide on the best of the possible options. Simple rules may not be able to give us a rigorous answer.
If we take this approach, it is rapidly clear that the three models are not of equal weight. This is obvious when I consider the issue of why we find problems with any particular moral system in the first place. For example, why should we not hang an innocent man for the common good, to use an example from Bentham? If utilitarianism is really ‘right’, why do I have a problem? When John Rawls feels the need to balance the deontological perspective with the utilitarian perspective, where does the need to balance the two come from? 13 By what method of moral reasoning have we discerned that either was not in balance in the first place? How will I know the balanced result when I see it? Surely, the only strong answer to such a question would be to see virtue-based morality as the court of ultimate appeal.
Reflection suggests that virtue-based morality actually has a place at the top of the food chain of moral reasoning. In some situations, we may well be able to get useful guidance, or be able to check out intuitions, by looking at a deontological or utilitarian perspective. Here, we will find great overlap but also a ‘tail’ of poor performance for each approach: deontology does not help with competing obligations and utilitarianism does not recognise justice per se. So I may need help in ‘adjusting’ the findings of either approach – only virtue can help me here.
Revisiting the cases of John and Jane
(See the two case descriptions in the first paper).
The case of John. Issues of human relationships are no longer in the periphery of our ethical vision but are central to our understanding. This gives us both a better way of analysing our natural human response to this case and a better way of raising the issues with John in an accessible manner. We no longer see those involved as loci for issues of autonomy versus justice, but as persons in failing relationships that threaten their flourishing. The case of Jane. Again, Jane’s distress and vulnerability can be seen directly as an ethical concern, not via intermediate steps invoking doing good or avoiding harm, which could be considered a poor fit for the issues. Compassion, instead of having to be fitted awkwardly into a category of professionalism, peripheral to ethics, becomes central as an ethical concern.
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Conclusion – the case for inclusive virtue ethics
If morals have no ultimate foundation in the world and are to be seen only as expressions of human preference, then an antirealist version of utilitarianism, looking only at whether we see consequences of an action as desirable to us, becomes likely. If we view morals as having a real claim in the human world, then virtue ethics supports a broad account of moral realism that enables us to argue the case for broadly based ethical judgements in clinical practice. Virtue ethics is rooted in the nature of what it is to be human, and thus has a natural applicability to healthcare.
Because pure virtue ethics is not always a clear guide to action, we may well use insights from consequentialism and deontology in an instrumental fashion, as heuristic tools, to inform our actions where these tools are appropriate. Our overall goals can only spring from our understanding of our own humanity and that of our patients. But are we unsure of the best specific objectives within our overall goals? Consequentialism may help us. Are we unsure as to the best methods of reaching our objectives? Deontology may help us. But as our commitment to consequentialism and deontology is instrumental and not absolute we will have no problem in abandoning them when they do not offer us a good fit with our actual problems. We will use virtue theory both as our foundational moral theory and as our court of appeal when consequences and duties appear either to conflict or to give us what we reckon to be a wrong answer.
Virtue theory will also train and strengthen my ability to choose right actions. It puts me myself, a human acting as a practitioner, squarely in the frame. Moral reasoning is not a theoretical exercise analogous to engineering. It is a human activity rooted in human givens, human transactions, human relationships and the context of our wider society.