Purtilo & Doherty (2011) Chapter 4 Ethical Theories and Approaches:

1. Purtilo & Doherty (2011) Chapter 4 Ethical Theories and Approaches: Conceptual Tools for Ethical Decision Making Slides by W. Rose, C. Polek, P. Butler, H. Brock College of Health Sciences and College of Arts and Sciences University of Delaware

2. Chapter 4 Introduction Ethical Reasoning: A Guide for Ethical Reflection Caring Response: Using Theories and Approaches to Guide You Story or Case Approaches Ethics of Care Approach Virtue Theory Principal based approaches Deontology and Teleology College of Health Sciences

3. Introduction • Box of tools for ethical problem solving • Example • Cast: • speech pathologist Elizabeth Kim • student Max Diaz • mother Melinda D • school principal Michael Leary • EK recommend device despite ML’s request not to. Weeks after submitting report, EK asks ML when IEP mtg will be. ML says not sure & he hopes not soon. Months later EK runs into MD who says ML has told her not to worry about having IEP mtg. EK tells MD she is entitled to prompt IEP mtg. EK feels something is wrong. College of Health Sciences

4. Ethical Reasoning: A Guide for Ethical Reflection • Clinical Reasoning • The thought process clinicans use during therapeuetic interactions (P&D) • Reasoning used to plan, direct, perform, & reflect on patient care (Schell) • Used to guide action • Used to analyze & synthesize information gathered in care of a patient • Provides the answer to “Why?” College of Health Sciences

5. Ethical Reasoning: A Guide for Ethical Reflection • Modes of Clinical Reasoning • Scientific reasoning: diagnostic and procedural • Narrative reasoning: patient’s past, present, and future; influence of culture, condition, and experiences • Pragmatic reasoning: practical issues that impact care • Interactive reasoning: understanding the patient as a person • Conditional reasoning: based on the moment to moment treatment revision of the patient’s current and future • Ethical reasoning: focus on what should be done College of Health Sciences

6. Ethical Reasoning: A Guide for Ethical Reflection • Ethical Reasoning • Concerns norms, values, right & wrong • What is the morally correct action to take for this patient • Good ethical reasoning identifies what is good and bad and why • Other modes of reasoning complement and inform ethical reasoning College of Health Sciences

7. Ethical Reasoning: A Guide for Ethical Reflection • Metaethics, normative ethics, applied ethics • Metaethics: • Study of the origin and meaning of ethical principles • “tries to discover the nature and meaing of ethical reasons we propose as valid for making judgements about morality” P&D 2011 • Normative ethics: Development of moral standards (ethical norms) to regulate behavior • Applied ethics: The application of ethical norms (morals) to specific situations, such as abortion, euthanasia, etc. • P&D 2011 combine normative and applied under the “normative” heading College of Health Sciences

8. Ethical Reasoning: A Guide for Ethical Reflection • Metaethics, normative ethics, applied ethics • Examples of metaethical questions (Stanford Ency of Phil) • Is morality more a matter of taste than truth? • Are moral standards culturally relative? • Are there moral facts? • If there are moral facts, what is their origin? • How is it that they set an appropriate standard for our behavior? • How might moral facts be related to other facts (about psychology, happiness, human conventions…)? • How do we learn about the moral facts, if there are any? College of Health Sciences

9. Caring Response: Using Theories and Approaches to Guide You • Approaches emphasizing personal qualities, relationships • Story or Case Approaches • Ethics of Care Approach • Virtue Theory • Approaches “geared to ethical conduct itself” (P&D p.74) • Principal based approaches • Deontology • Teleology College of Health Sciences

10. Story or Case Approaches • Narrative Approaches • “Morally relevant information is embedded in the story” • “Good moral judgment must rely on the analysis and understanding of narratives” • “Narrative ethics requires attention to the details of the story and that all voices be considered before the situation is assessed for its moral significance” College of Health Sciences

11. Story or Case Approaches • Appoaches emphasizing relationships • “ethical issues are embedded in the relationships, not just the individual’s situation” • Patient centered understanding • Girls and young women conceptualize ethical problems differently than males • “Girls had a high sensitivity to how various actions would affect their important relationships” P&D about Gilligan 1982 • Girls’ “awareness of the connection between people gives rise to a recognition of responsibility for another” • “Ethical reflection requires recognition of the powerful influence of each player’s and some groups’ socially assigned “place” in society”… P&D p.77 College of Health Sciences

12. Ethics of Care Approach • “The major question is “What is required of a health professional to be best able to express ‘I care’?” • Focused on well-being of the whole person • Requires making real contact with the patient as a person • Fosters trust College of Health Sciences

13. Ethics of Care Approach • “The major question is “What is required of a health professional to be best able to express ‘I care’?” • Focused on well-being of the whole person • Requires making real contact with the patient as a person • Fosters trust College of Health Sciences

14. V. Ethics of Care Approach “… an accent on the silver thread of care may deflect attention from injustices woven into the basic warp and woof of the health system…” P&D 2011 p.78 College of Health Sciences

15. “… it seemed as if this were the Loom of Time, and I myself were a shuttle mechanically weaving and weaving away at the Fates. There lay the fixed threads of the warp subject to but one single, ever returning, unchanging vibration, and that vibration merely enough to admit of the crosswise interblending of other threads with its own. This warp seemed necessity; and here, thought I, with my own hand I ply my own shuttle and weave my own destiny into these unalterable threads. Meantime, Queequeg's impulsive, indifferent sword, sometimes hitting the woof slantingly, or crookedly, or strongly, or weakly, as the case might be; and by this difference in the concluding blow producing a corresponding contrast in the final aspect of the completed fabric; this savage's sword, thought I, which thus finally shapes and fashions both warp and woof; this easy, indifferent sword must be chance--aye, chance, free will, and necessity--nowise incompatible--all interweavingly working together. The straight warp of necessity, not to be swerved from its ultimate course--its every alternating vibration, indeed, only tending to that; free will still free to ply her shuttle between given threads; and chance, though restrained in its play within the right lines of necessity, and sideways in its motions directed by free will, though thus prescribed to by both, chance by turns rules either, and has the last featuring blow at events.” Herman Melville, Moby Dick College of Health Sciences

16. Virtue Theory • Historical roots • Hippocrates & his school (460-370 BCE) • Aristotle’s Nichomachean Ethics (330 BCE) • Aquinas’s Summa Theologica (1265 CE) • Maimonides Guide for the Perplexed (1200 CE) • Character traits and moral character • Character traits and caring response College of Health Sciences

17. Virtue Theory • Historical roots • Character traits and moral character • Disposition or readiness to act in certain ways • “Some character traits are supportive of high ethical standards” • “certain traits enable you to be the kind of person you want to be as a caregiver” • What virtues to cultivate? • Honesty, courage, compassion… • How to cultivate? • Experience matters • Attend to emotions • We grow into virtue by acting in accordance with what virtue cousels us to do • A community is vital for discerning virtue College of Health Sciences

18. Virtue Theory • Historical roots • Character traits and moral character • Character traits and caring response • “Professionals must exert high moral character through the cultivation of virtue” • “Makes good common sense when viewed through the lens of the professional’s moral task of achieving an outcome consistent with a caring response” College of Health Sciences

19. Principal based approaches • Based on recognition that guidelines are needed for ethical problem-solving • Principals versus elements • “Principals provide general moral guidelines in the search for a course of action that wil result in an outcome consistent with a caring response” P&D p.89 College of Health Sciences

20. Principal based approaches • Nonmaleficence • Primum non nocere: First, do no harm • Beneficence • Provide a benefit, make things better • Autonomy • Patients are entitled to self-determination • JS Mill: We should be free until our free action could harm another • Is autonomy a right? What about relationships? John Donne: No man [or woman] is an island • Fidelity • Veracity • Paternalism • Justice College of Health Sciences

21. Principal based approaches • Nonmaleficence • Beneficence • Autonomy • Fidelity • Faithfully meeting a patient’s reasonable expectations • Respect (e.g. modesty) • Competency • Professionalism • Follow rules & laws • Live up to agreements • Veracity • Paternalism • Justice College of Health Sciences

22. Principal based approaches • Nonmaleficence • Beneficence • Autonomy • Fidelity • Veracity = honesty • Paternalism • Caregiver’s judgment of what’s best diverges from patient’s wishes • Acting as a parent: in loco parentis • See for example this • Justice College of Health Sciences

23. Principal based approaches • Nonmaleficence • Beneficence • Autonomy • Fidelity • Veracity = honesty • Paternalism • Justice • “Ensures proper distribution of burdens and benefits when there are competing claims, not all of which can be met fully” P&D p.88 • Scarce resources • Priority of access • Discrimination College of Health Sciences

24. Principal based approaches • Nonmaleficence • Beneficence • Autonomy • Fidelity • Veracity = honesty • Paternalism • Justice • “Ensures proper distribution of burdens and benefits when there are competing claims, not all of which can be met fully” P&D p.88 • Scarce resources • Priority of access • Discrimination College of Health Sciences

25. Deontology and Teleology • Deontology (Kant) • Teleology (Bentham and Mill) • Utilitarianism: You should do what will produce the greatest good for the greatest number College of Health Sciences

26. Deontology and Teleology • Deontology (Kant, 1785) • Onto = being, existence • Ontogeneny recapitulates philogeny • Dei + onto = necessary (required) + existence => Duty • Deontological ethics = ethics based on duty • Ethical acts are acts that conform with our duty – regardless of the results that may result. • The ends do not justify the means College of Health Sciences

27. Deontology and Teleology • Deontology (Kant, 1785) • Categorical Imperative: “I am never to act otherwise than so that I could also will that my maxim should become a universal law.” Fundamental Principles Of The Metaphysic Of Morals, trans T. Abbott. • Duties • Absolute • Prima Facie • Conditional College of Health Sciences

28. Deontology and Teleology • Deontology (Kant, 1785) • Categorical Imperative: “I am never to act otherwise than so that I could also will that my maxim should become a universal law.” Fundamental Principles Of The Metaphysic Of Morals, trans T. Abbott. • Kant in three • Duties • Absolute • Prima Facie • Conditional College of Health Sciences

29. Deontology and Teleology • Deontology (Kant) • Teleology (Bentham and Mill) • Utilitarianism: You should do what will produce the greatest good for the greatest number • Dilemma: Kill one to save five. • Leads to rule-based utilitarianism College of Health Sciences