1. “A good will is not good because of what it effects or accomplishes…Thus the moral worth of an action does not lie in the effect expected…”
2. The representation of an objective principle …is called a command, and the formula of the command is called an imperative. All imperatives are expressed by an ought…”
3. “… if the action would be good merely as a means to something else the imperative is hypothetical; if the action is represented as in itself good, …then it is categorical.”
4. “There is therefore only a single categorical imperative and it is this: act only in accordance with that maxim through which you can at the same time will that it become a universal law.”
5. “All rational beings stand under the law that each of them is to treat himself and all others never merely as a means but always at the same time as ends in themselves.”
6. “Duty is that action to which someone is bound…To assure one’s own happiness is a duty.”
7. “Be an honourable human being…Do not wrong anyone.”
8. “Freedom (independence from being constrained by another’s choice), insofar as it can exist with the freedom of every other in accordance with universal law, is the only original right belonging to every man by virtue of his humanity.”
9. “The greatest violation of a human being’s duty to himself …is the contrary of truthfulness, lying …a lie…does not require what jurists insist upon adding for their definition that it must harm another…for it always harms another… inasmuch as it makes the source of right unusable.”
10. “…beneficience is the maxim of making others’ happiness one’s end… To be beneficient, that is to promote according to one’s means the happiness of others in need, without hoping for something in return, is everyone’s duty.”
11. “Every human being has a legitimate claim to respect from his fellow human beings and is in turn bound to respect every other.”
Immanuel Kant was a rational purist – to him morality was binding in the sense of being an absolute, “categorical” imperative which a pure rational free will finds to be a duty. The will is authentic when absolutely free from self-interest and all other internal or external influences except pure practical reason; pure practical reason makes the free will good by making it transcend self-interest and all other influences into universal commitment in a logically consistent way, for the mere duty of pursuing “good will.” This for Kant was the nature, sum, and process of morality. Morality to him was purely a rational deduction of its own type: acting under a consistent maxim that one could will to be universal, derived through a process of pure practical reason by a perfectly free will, as an autonomous agent. A maxim that is purely rational, consistent, and universal is, of course, categorical in that it derives from a perfectly free “good will” and aims for nothing other than the “universalizable.” Kant recognized other values, but separates them from the moral one. Understandably, his model of reason is like that in mathematics – maxim-based, ultrapure, and rigorous. For him, moral value can occur only in the context of morality as described above. Since morality is an abstract concept, it can be derived only by pure practical reason, not emotion, feeling, tradition, or consequences of following moral imperatives. Maxims derived from any of the mentioned factors or any other factor than pure practical reason would be hypothetical (Kant 1978, 1993, 1996).
To Kant, humans are moral agents because they are capable of pure practical reasoning to discern what moral maxims ought to be and have the freedom of will to choose them. So, humans ought to act as autonomous moral agents. On this rests their moral dignity and why they should never be used as mere means to an end but as ends in themselves, which is another maxim of his. Morality is a pure duty owed by humans as autonomous rational agents with wills free from all other influences.
Kant’s abstract system based on idealized purist suppositions about reason and experiential freedom of the will has more of the purity of reason than reality or practice. This is obvious in health care settings. However, it overcomes the weaknesses of utilitarianism in respecting individuality and justice and extolling the values of rationality, freedom, equality, and independence. It focuses on “autonomy”“respect for persons,” and integrity, primary responsibility, or duty. Later workers based on Kant’s contributions, called Kantians, have extracted, adapted, and redeployed these concepts, sometimes in ways that are far from but reminiscent of Kant’s usage (Secker 1999). For instance, in principlism, autonomy or respect for persons is now specified in the act of informed consent and also relates to maintenance of privacy and confidentiality. Kantian analysis of common medical problems can shed useful light on the morally ambiguous issues at hand (Bernstein and Fundner 2003; Bernstein and Brown 2004).
Pearl
The two dominant ethical theories are utilitarianism and deontology. Their difference can be simplistically demonstrated using the “life boat scenario.” A ship sinks and 12 people find themselves in a lifeboat, but it is only safe to hold 10 for the time needed to get to shore. Utilitarians would invite two persons to leave so that two die but ten are saved. Deontologists would insist that none should leave so all 12 would die. Even though the outcome is worse, the duty to do the right thing, and not take a life, is honored.
2.4.4 Kantian Contractarianism
There are two main social contract theories: Hobbesian and Kantian. Contractarianism is an effort at formalizing society especially with respect to the content of social obligations and the motivation for fulfilling them. It is based on the mythical contract we have made with each other which we are morally obliged to keep. Only Kantian contractarianism will be discussed here. Kantians have extracted and reapplied in more practical ways, some of the terms and concepts used by Kant. One such Kantian in contractarian moral theory was developed by John Rawls whose consistent concern was more societal than individual. His starting assumption was that since as Kant said, we are all ends in ourselves, we are then all of equal moral status and should be treated as being equal, with fairness in society. His myth or model therefore starts from a presumed state of ignorance, where each and all are ignorant of their present or would be social advantages and those of others. In such a state, ordinary self-interest would dictate that one decides to give the best possible to everyone being considered, since any lot might end up as one’s own (Rawls 1971). Rawls then went on to advocate equality of liberty, opportunity, and distribution of resources in that order of priority. In distribution of resources, he proposed that inequality in distribution of resources should only be such as is required by circumstances and as would make everyone happy. Rawls considered that behind the veil of ignorance, every rational being would be fair. This means that every situation in ethics (and in everything!) should be analyzed and judged without preknowledge about the stakeholders or preconceived notions by the evaluator – this way absolute fairness prevails. Rawls aimed at the goal of “justice as fairness” in his works where “justice” (and “right”) precedes “goodness.” Significantly, freedom, justice, and fairness are moral values which are usually considered important and relevant in health care services especially in respect of access to care and resource allocation (Beauchamp and Childress 2001; Arras et al. 1999; Kant 1978).
2.4.5 Rights-Based Theory
This is “liberal Individualism.” It has old traces but has been worked into the fabric of present-day lives with implications for the health care sector.
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