This Is Bioethics. Udo Schüklenk

2 ETHICAL THEORY

      2.1 In this chapter, we will give you a rough and tumble overview of major ethical theories. They are foundational for much of what follows in terms of the arguments and analyses offered when we look at specific issues in bioethics.

2.1 Virtue Ethics

2.2 One of the oldest types of ethical theories can be traced back to an ancient Greek philosopher, Aristotle¹. He developed it in his classic Nicomachean Ethics². The basic premise driving Aristotle’s account of ethics³ is tied to what he considers the highest good in our lives. He identifies that as a flourishing or a good life. There is undoubtedly some truth in this, a good life is surely what we all aspire to, and this good life is not a means to achieve some other objective, rather it is an end in its own right. According to Aristotle a virtuous life is such a flourishing life. But, lest we want to be accused of a question begging account of ethics, what exactly is a virtue? According to Aristotle, a virtue is a kind of character trait or disposition to have feelings resulting in actions that will permit us to live flourishing lives.

2.3 What kind of virtuous character traits should a good doctor have? Honesty presumably, and integrity perhaps, among others. We can find other such virtues mentioned in the Hippocratic Oath, such as the virtue of maintaining patient confidentiality. This all seems not unreasonable. Surely, we should be able to identify character traits that promote a flourishing, good life and aim to develop those. To be fair, there seems to be more than one possible flourishing, good life possible. Different people will hold different views with regard to what would make their life a flourishing life, but some features hopefully can be agreed upon by well‐intentioned, reasonable people, such as for instance living in safe neighborhoods, being in good health, and other basic necessities of life.

2.4 How are we going to decide though whether an agent acted virtuously in a particular tricky situation? Would it be virtuous for a doctor to maintain the confidentiality of the doctor–patient relationship and not disclose a patient’s HIV infection to her husband or would the virtuous doctor disclose the HIV infection to protect the husband? It turns out that virtue ethics⁴ offers space to defend both kinds of actions. The reason for this is that virtue ethics is agent‐focused rather than rule‐ or outcomes‐oriented. A virtue ethicist would be concerned about the question of whether or not the doctor possesses a virtuous character, whether or not the doctor had all the relevant information, whether or not the doctor pondered carefully about his or her preferred course of action, and so on and so forth. Whatever the doctor does is right if and only if that is what a person of good character would do. Interestingly, virtue ethics does not require the doctor to take the place of an impartial observer, unlike other ethical theories that we will be looking at in just a moment. On this account it would be quite acceptable for the doctor to prioritize her patient’s needs over those of other people who are professionally further removed from the doctor. In fact, the doctor would not necessarily be faulted for prioritizing her friends and relatives over other patients.

      2.5 This strategy to explain what makes an action right has been criticized on various counts. The only way to determine whether an action is the right action, is by looking at what a person of virtuous character would do. Evidently, this risks becoming a circular enterprise. Once we have determined that someone is a virtuous person, whatever she decided to do would then become a right course of action. But, let’s assume that our doctor is a virtuous person, how is she supposed to determine which virtue is the applicable one in this case? Is the applicable virtue the one requiring her to maintain confidentiality, or is it about preventing harm to another patient? It is not a terrible stretch to suggest that a virtuous doctor could go either way here, depending on which set of virtues is strongest. Critics of virtue ethics have expressed doubts about this approach’s ability to be action guiding.

      2.6 Virtue ethicists respond to this by saying that as far as they are concerned, even if both courses of actions were followed by different virtuous doctors, both actions could be morally acceptable actions. They do away with the idea that ethics requires necessarily that one particular course of action is right, and that all other competing courses of action must be necessarily wrong.

2.7 Another assumption made by virtue ethicists has come in for sustained criticism, too. Virtue ethics seems to assume that for every particular ethical problem a set of relevant applicable virtues exists, ready to swing into action in order to guide the virtuous character. John Hardwig has noted that the same character traits that could be considered virtuous in certain professional contexts would likely be considered vices in interpersonal relationship contexts. He writes (Hardwig 2000, 19), ‘consider, for example, impartiality and impartial justice, which are a virtue in an employer, but a vice in a father, mother, or spouse. Thus the dilemma posed by nepotism: qua employer one should treat all applicants impartially, but qua parent one is defective if one is not willing to provide special advantages to one’s children.’

      2.8 Does pointing to what a person of virtuous character would have done constitute an ethical justification? Say, if a virtuous doctor withholds from a terminal cancer patient his diagnosis in order to avoid causing distress to the dying patient, would reference to the doctor’s virtuous character truly justify the decision in a meaningful way? Justin Oakley suggests that ‘most virtues are not simply a matter of having good motives or good dispositions, but have a practical component which involves seeing to it that one’s action succeeds in bringing about what the virtue dictates’ (Oakley 1998, 95). He questions whether the benevolent character traits that motivated the doctor’s decision to deceive her patient is truly benefitting her patient. Of course, that does not actually settle the justification question, and it seems question begging. After all, the doctor in our scenario could well reply to Oakley that he does actually think the course of deception he