Consequentialism and Deontology

Consequentialism suggests that whether an action is good or right depends on its consequences. The best-known consequentialist theory is utilitarianism, which states that actions are right insofar as they maximize happiness or pleasure and minimize the opposite¹. If, for instance, it seems likely that Mrs Jones will kill herself because of her depression and we have good grounds to believe that she will enjoy her life again if she were to receive appropriate treatment, then treating her would seem to be the ethically right thing to do, even against her wishes. But this depends upon a careful assessment, because although compulsory treatment would seem to maximize happiness, such treatment must not be so unpleasant or upsetting as to cause her permanent discontent.

We can see immediately, therefore, how complicated things might become in pushing forward this argument. What if, for instance, it could be known for certain that Mrs Jones would never be happy again? Should she then be left untreated or at least not treated against her will? A legal issue, about her ability to make decisions for herself, arises and reflects the Law’s emphasis on the rights of competent persons to control what happens to their bodies under normal circumstances. Generally speaking, it is only when a person is not ‘of sound mind’ that others are allowed and required to make decisions on the person’s behalf.

To return to the case of Mrs Jones, just as utilitarians might argue that it is best to have a rule that people like Mrs Jones should be treated because this is more likely to maximize happiness (i.e. rule utilitarianism, as opposed to a focus on particular and individual acts, which is called act utilitarianism) so too we could more simply argue that we have a duty (deon) to treat Mrs Jones. We quite often speak of a duty of care, for instance, which carries with it the idea that this is something we must do – and the difference between this and utilitarianism is shown by the fact that we add ‘whatever the outcome’. In deontology the consequences are not the main issue. What is at stake is how people should behave as rational agents in the world. Given some of our typical concerns as human beings – that we should have a basic level of certain sorts of good (warmth, clothing, food) – it can be argued in deontological mode that there is a duty, for those who are able, to provide these goods to people who lack them. Duties are sometimes thought of as being corollaries of rights. Hence, if a person has a right to be told the truth about his condition, we have a duty to be honest with him. A right to basic standards of care carries with it a duty to provide such care. A right to privacy entails a duty not to invade the person’s privacy, to confidentiality a duty to maintain confidences.

Four Principles

In clinical ethics it has become commonplace, partly in order to avoid the complexity of the arguments that emerge in discussions of consequentialism and deontology, to use the four principles of medical ethics². These provide an easy way to access the relevant arguments in connection with health care decisions. Autonomy, often regarded as the main principle, stresses self-rule: the person with dementia should still be able to make decisions for him- or herself. But the second and third principles, beneficence and non-maleficence, stress the need for carers to seek to do good for those they care for and to avoid them coming to harm. So, at some point, doing good for the person with dementia may involve taking over certain decisions in order to avoid harm. Perhaps, because of cognitive impairment, the person’s money now needs to be controlled by someone else to avoid financial abuse. Finally, the principle of justice stresses the need to treat people fairly. So resources to help people with dementia should be distributed evenly, or at least in a fair manner (albeit what is considered fair in one political system may not be considered fair elsewhere).

The principles of medical ethics give us a framework within which to discuss moral dilemmas. One of the complaints about these principles, however, is that they do not give us a way to decide between them. Perhaps someone thinks Mrs Jones should be left to make her own decisions about whether or not she commits suicide (i.e. her autonomy should be respected), while someone else feels that compulsory treatment would do her good (i.e. beneficence) and avoid her coming to unnecessary harm (i.e. non-maleficence). The difficulty of deciding between principles seems intractable.

Ethics of Care

In response to the messiness of moral decision-making in the real world, a new approach to ethics has emerged from practice³. Whereas the more traditional theories stress calculations of pleasure, rules and principles (they also seem to hold out the possibility of definitive answers), the newer approach stresses context and the nature of our relationships within contexts of care. The move from rules to relationships has been regarded as a key feature of feminist ethics. But there have been several such approaches – communicative ethics, narrative ethics, hermeneutic ethics, situation ethics – all of which stress the importance of person-to-person interactions and the nature of our interdependency^1,3. For any given situation the key elements in deciding the right thing to do will be the nature of the communication, the way in which the stories of those concerned (the actors) interact, the meaning of the events viewed from different perspectives with different interpretations, and so forth. This can lead to the conclusion that there are no definite answers in ethics, because (for any given case) we shall always be told that it depends on the details of the context and the perspective. But, to my mind, this is too relativist, as if anything goes and nothing can be called right or wrong. Rather than say that no ‘definite’ answers can be given, I should rather say that the answers are not ‘definitive’ in the sense that they are not final and unconditional. They are revisable and open to new interpretation.

Casuistry

Being open to appeal in the light of new evidence is the approach of casuistry, which considers matters case by case, where the factual details of the case must be understood and those making decisions must immerse themselves in them, but where cases are then compared to sentinel or paradigm cases, where decisions have already been made⁴. Appeal is then made to appropriate moral principles to explain the important moral distinctions between cases, but it is always left open that decisions might be revised in the light of alternative information. Thus, the casuistic process underpins law, allowing a development of legal thought in response to new cases, but with reference to established principles. The same holds for clinical decisions, which tend to be (at one and the same time) both practical and ethical. As with other types of care ethics, casuistry pays attention to the fine-grained details of individual circumstances, which will have a determining effect on our judgements about what might seem either right or wrong in a given case.

Virtue Theory

Virtue ethics draws on a long tradition going back to Aristotle and is based on the idea that the right or good thing is that which the virtuous person would do⁵