Theoretical diversity in normative ethics

Introducing the theories of moral thinking is important for this thesis, because they create understanding about the theoretical diversity of ethics as a wider discipline. The different traditions of normative ethics are indirectly but noticeably echoed in the social diversity of healthcare ethics that I have studied in this thesis. I will shortly introduce the basics of central normative ethical theories to provide the reader a theoretical background for understanding the varieties of ethical reasoning. Going through the research findings later in the thesis, a careful reader will detect tracks of deontology, consequentialism, virtue ethics or care ethics.

Normative ethics as a branch of moral philosophy is directly connected to bioethics because of its theoretical and analytical frames that are useful for addressing bioethical questions. Normative ethicists seek to identify abstract principles or a principle generalizable enough to be applied in different kinds of moral contexts. Realizing how different kinds of standards have been set by normative ethicists reveals the nuanced diversity of ethics as a discipline.

Understanding this diversity brings forth the realization that—as Scottish philosopher Alasdair MacIntyre (1981 & 1988) has famously argued—there is no one “grand theory” in normative philosophy that all philosophers would or could agree on. MacIntyre claims that objectifying arguments are like masks philosophers wear to look rational, but this does not turn their ethical arguments into generally objectifiable realities. Lacking general arguments that could be shared by all philosophers, the field of ethics rather consists of traditions of thinking, such as the Aristotelian, Augustinian, Thomist or Humean thought.

Normative theories can first be distinguished into two categories. Ethical pluralism comprises theories in which ethicists seek to articulate several coexisting moral principles to guide moral action. Ethical monism, however, refers to theories that aim to determine one central, supreme ethical principle.

Ethical pluralism is a very characteristic—even though disputed—approach in bioethics and is often in practice known as principlism (Beauchamp &

Childress 2012). Principlism is a particularly practical theoretical approach for ethical decision making, because by acknowledging moral pluralism to begin

with, people are able to combine different moral epistemologies that typically are thought to be in conflict with one another. Principlism focuses on the widely shared moral principles of autonomy, beneficence, nonmaleficence, and justice as its guiding principles for ethical analysis. (Ibid.; see also Bulger 2007.)

Ethical monism—theories written with the intention of identifying one principle to guide moral action—can be classified into two great traditions of moral philosophy: deontology and consequentialism (also known as utilitarianism). Deontological theories invoke the argument that certain deeds are ethical because of principle and the inherent value of the actions. Therefore, a healthcare professional who approaches a professional ethical question with a deontological viewpoint does not reflect on the value considerations of individuals, such as what values may count and why in making the decision; rather, she looks at the situation in the light of the principles that have been determined to guide her professional action.

Deontological thinking is therefore inherently rule-based⁴. (See, for example, Darwall 2003.)

Consequentialist theories or utilitarianism, though, puts weight on the ethical value of actions in relation to the consequences of the actions.

A professional who chooses to approach an ethical dilemma with the utilitarian frame is not looking for principles; instead, she is asking, “Are people benefitting from this action and how?”. Thinking in this way, instead of looking at principles, she is aiming to find a way to act that creates the most benefit for the people involved. The normative theory of utilitarianism contains the argument that we should strive to make the world the best place we can, regardless of what kinds of rules have previously been set to guide our actions. (See, for example, de Lazari-Raek & Singer 2017.)

A timeworn example illustrating the differences between deontological and consequential ethics asks whether it would be wrong or right to pull a lever if it would mean killing one person but saving the lives of five. This

4 Etymologically, the word deontology has its roots in the Greek word deon, which means ”that which is binding; duty.” (Read online April 7, 2020, at https://www.

etymonline.com/word/deontology.) Thus, the word deontology literally refers to rules.

classical thought experiment known as the trolley problem was first discussed by Philippa Foot in 1967 (see Andrade 2019; Foot 2002). Many variations of the problem exist now, but this is the classical dilemma: Imagine there is a runaway trolley heading to a track on which there are five people tied up and unable to move. You have the option to pull the lever to save the people, while directing the trolley to head to a sidetrack where there is one person tied on the track. Would you do nothing and let the five people die, or would you pull the lever, diverting the trolley to the sidetrack and kill the one person instead?

The trolley problem is considered to have great importance in discussions on medical ethics (Andrade 2019).

Someone looking at this dilemma with a deontological viewpoint would hold that killing is wrong in principle and thus, cannot be accepted: violating this principle would be seen to corrupt the whole social shared, rule-based moral system. However, another person may take a utilitarian, consequence-oriented perspective and argue that saving the lives of five would justify pulling the lever, even though this would lead to the killing of one person.

Therefore, she would think that taking action and pulling the lever would be more ethically sound than doing nothing and watching five people die. This dilemma grasps the very epistemological conflict between deontology and consequentialism: Should we put more weight on the shared rules or, rather, on the consequences of our actions?

A different tradition under the umbrella of normative ethics is virtue ethics, a theory of ethics that emphasizes the virtues of individual people, not the governing rules or consequences of people’s actions. The theory of virtue ethics, having its foundation in Aristotle’s Ancient Greek philosophy (Aristotle 2020), emphasizes people’s characteristics to bear the burden of moral standards. The measure of moral conduct is thought to be a virtuous person who has learned to act in ways that realize high moral standards.

Considering the origins of the tradition of virtue ethics in Ancient Greece, it is perhaps no coincidence that the Greek tradition of physician’s ethics started by Hippocrates builds its normative standards heavily on the physician’s individual characteristics. “In purity and according to divine law will I carry out

my life and my art,” states the Oath⁵. Rather than focusing on how a doctor overcomes a gripping moral dilemma, a healthcare professional approaching professionals ethics from the virtue ethics point of view inquires, “What kinds of people are professionals to be, at their best, in order to carry out their work with excellence and integrity? And what kind of virtues should they cultivate to attain these qualities?” (See, for example, Devettere 2002 about virtue ethics.)

Another theory in normative ethics is care ethics, a tradition that focuses on interpersonal relations and contextual factors. A great shift toward this thinking was spurred by Carol Gilligan’s (1982) book In A Different Voice, in which Gilligan argued that women have a different way of thinking about morality than men. Care ethics was developed by feminists as a response to more traditional moral philosophy that was then criticized for setting the moral weight on individual actors, overlooking the web of social connections and the interdependence of people. Thinking in terms of care ethics, taking people’s dependence and their vulnerabilities into account are central values.

A person looking at healthcare questions from the framework of care ethics would stress responsibility, relationships and interpersonal connections to be weighed in decisions on a situational, case-by-case basis, rather than set rules and principles. (See, for example, Larrabee 2016; Brugére 2017.)

These theories demonstrate how there is no one “grand theory” of moral action, even though ethical theories pursue objectivity in their reasoning.

Ethics is, rather, a diverse field in which defining a moral action is deeply dependent on the perspective taken.

5 Read online April 6th, 2020, at https://www.nlm.nih.gov/hmd/greek/greek_oath.

html. Translated by Michael North, Library of Medicine, 2002.

3 Social constructionism as theoretical