An Introductory Philosophy of Medicine

Chapter 12. Origins of Bioethics and Normative Ethics

Medical ethics has a long and rich tradition (Cantrell, 1997; Jonsen, 2000). "Physicians, occupying a special place in society, have always faced ethical challenges," observes Robert Cantrell, "and many of them have studied ethics and strived to develop ethical standards and to live by them" (1997, p. 447). As medicine developed over the centuries, so did the complexity of the ethical issues associated with its knowledge and practice.

Mirroring this development in ethical complexity was a development in the expressions to denote the nature and role of ethics in medicine. These expressions include-to name a few-medical or clinical ethics, bioethics, biomedical ethics, and healthcare ethics. Each of these expressions was introduced into the literature at specific moments in medical history because of particular events and circumstances, although there is considerable overlap in their usage. In general, medical or clinical ethics covers an earlier time period, with bioethics, biomedical ethics, and healthcare ethics representing a more recent time period.

In this chapter the rise of bioethics is reconstructed first, followed by a discussion of the various normative ethical theories as they relate to medical practice. Normative ethics is a twentieth century notion, which under went considerable develop during the century. For example, G.E. Moore (1873-1958) positioned normative ethics between casuistry and metaethics and focused on the question of the kinds of the good rather than on questions of the particular good or on the meaning of the good (Solomon, 2004). Today, normative ethics is more expansive in scope. For example, it involves "substantive proposals concerning how to act, how to live, or what kind of person to be" (Kagan, 1998, p. 2).

How a person should act is based on the moral values and principles that a person holds. By understanding what is of value morally or to what moral principles a person subscribes, why and how a person acts as he or she does and why or how a person should act can be better explored and understood. Moreover, these values and principles are often used to justify morally a person's actions. Because actions are under girded by different values and principles there are a variety of ethical theories, each with its own particular advantages and problems. Finally, ethical theories are key to addressing the quality-of-care crisis since much of that crisis has an ethical or a moral basis.

12.1 Origins of Bioethics

Bioethicists trace their roots back to the Greeks, especially to Hippocrates (460 BC-370 BC), whose Oath in some form is still recited by graduating medical school students (Amundsen, 2004a; Ficarra, 2002; Jonsen, 2000).' The Oath, although not thought to be authored by Hippocrates, is the social contract-at least in contemporary American medicine-that defines the ethical dimensions of medical practice. However, comparison of the ancient text with modern versions reveals considerable differences in the texts (Graham, 2000). The Oath was typical for the times in which it was written: "it begins by calling the divinities of health as witnesses, makes a promise of fidelity to one's teachers, lists six behaviors that the oath taker binds himself to avoid, and ends with acceptance of the rewards and punishments entailed by observance or violation of the precepts" (Jonsen, 2000, p. 4).

Other ethical injunctions are found in the Hippocratic corpus. The most widely recognized is found in the Epidemics I, which is thought to be authored by Hippocrates. In that text, the following statement is made: "As to diseases, make a habit of two things-to help and not to harm" (Jonsen, 2000, p. 2). This moral maxim is a command, which also represents the style of the Oath: "The tone of the maxim is clearly deontological: it issues an order" (Jonsen, 2000, p. 3). The Hippocratic tradition was important for the development of medical ethics until the late medieval ages, when it was combined with Christian values (Amundsen, 2004b, c). Although the tradition did not have a significant impact during the Renaissance, there was a revival of it during the Enlightenment (Cook, 2004; Smith, 1979).

The Hippocratic tradition was clearly important for the development of early ethical codes for medical practice. And those codes were concerned with ethical issues that arose from the bedside and the physician's character and behavior. "However, if we wish to understand the development of specifically modern codes of medical ethics," according to Ivan Waddington, "we must look not to ancient Greece, but to nineteenth-century England, and in particular, to the work of Thomas Percival [1740-1804], whose Medical ethics, published in 1803, marks an important break-point between ancient and modern medical ethics" (1975, p. 36).2 Percival's motivation for composing an ethic was "that the official conduct, and mutual intercourse of the [medical] faculty, might be regulated by precise and acknowledged principles of urbanity and rectitude" (1975, p. 65). To that end, he devised principles of conduct for general practice, as well as for hospitals and ancillary institutions. In his medical ethics, Percival characterized ethical practice in terms of a contract between physicians as caregivers and the larger community (Haakonssen, 1997).

In the United States, physicians adopted and modified Percival's code; and, in 1847 the newly formed American Medical Association (AMA) used it to develop a national ethical code of practice (Jonsen, 1998). That code was revised several times again in the early twentieth century. During each revision, the ethical rules and principles became fewer in number, until the code became an instrument for maintaining "professional cohesion and respectability" rather than ensuring the patient's welfare (Jonsen, 1998, p. 8). During the late nineteenth century, the AMA attempted to establish the primacy of its brand of medicine. By the early twentieth century, it succeeded through supporting legislation to control medical practice and drug sales. "Medical ethics during this area appeared to some critics," according to Cantrell, "to be more concerned with limiting the practice of medicine to `orthodox' physicians and to establishing a medical monopoly rather than with regulating behavior" (1997, p. 448).

The AMA was successful in establishing its "orthodox" monopoly, with emphasis on scientific medical knowledge and practice, but at the expense of ignoring the physician's character and behavior. The results have been disastrous, even though many medical miracles were developed during the twentieth century. For example, in Tuskegee, Alabama, a study was conducted to follow the natural history of syphilis (Jones, 1981). Around 400 African American men diagnosed with the disease were left untreated, even though antibiotics were later available. The study ran from 1932 to 1972, when it was abruptly ended after a governmental committee ruled the study unethical. The publicizing of the study in the early 1970s profoundly affected the American public. "The revelations," according to Jonsen, "seemed to bring the horrors of the Nazi medical experiments, which many had judged as impossible in the United States, into our benign scientific and medical world. The ethics of research, which had been under quiet scrutiny for a decade, burst forth into public view" (2000, p. 109).

In the early 1970s the term "bioethics" appeared under two very different contexts that gave rise to two diverse connotations.' Besides the abuses in medical research, such as the Tuskegee study, a number of other medical advances, especially in terms of manipulating conception and reproduction and of delaying death, inspired the development of a new ethics to help guide the application of these technological advances 4 "By the late 1960s," according to Judith Swazey, "an important element in the changing social context of biomedical research was a diminishing of the once strong conviction that such research would be an unqualified good for human health and welfare. A variety of biomedical research analysts and commentators, journalists, members of Congress, and in turn the general public," she adds, "began expressing concerns about the possible negative social, ethical, legal, economic, and political implications of new and prospective advances in areas such as behavioral control, genetic engineering, and human experimentation, as well as organ replacement" (1993, p. S5).

Indeed a number of people felt the need for ethical reflection on modern medical advances, which were developed under the aegis of the biomedical model. As David Thomasma explains: "modern medical care conceals a dangerous ethic that encourages treating persons as [objective] things" (2002, p. 335). The response to this dangerous ethic was felt so keenly by so many, that bioethics sprung up at a variety of institutions. Probably the best known are the Institute of Ethics, Society and the Life Sciences, founded in 1969, and now known as the Hastings Center, and the Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics, founded in 1971, and now known as the Kennedy Institute of Ethics (Jonsen, 2000; Reich, 1996).

The cancer biologist Van Potter developed a second rather broad conception of bioethics, which, according to commentators, did not have an immediate impact on the development of bioethics as a discipline. Potter's concern was for an ethic that connects humans to their natural environment, a concern he acquired from the ecologist Aldo Leopold (1887-1948). Potter called for a "science of survival" in which biological facts and ethical values are fused through wisdom for the common good. "A science of survival," according to Potter, "must be more than science alone, and I therefore propose the term `bioethics' in order to emphasize the two most important ingredients in achieving the new wisdom that is so desperately needed: biological knowledge and human values" (1970, pp. 127-128).

To that end, Potter (1971) proposed a "bioethical creed" that consisted originally of five beliefs and their attendant commitments to achieve them. The creed focused on the relationship of humans to their environment and to each other, in order to enhance the survival and flourishing of all. In 1988, Potter extended his original notion of bioethics to include human health. This expanded version he called "global bioethics." "Global bioethics," according to Potter, "is proposed as a secular program of evolving a morality that calls for decisions in health care and in the preservation of the natural environment" (1988, pp. 152-153). To that end, he slightly modified the beliefs and commitments of the original creed and added the additional beliefs and commitments concerned with personal and family health.

Edmund Pellegrino divides the development of bioethics into two stages, with an initial proto-bioethics stage from 1960-1972. The proto-bioethics stage represents an effort to "humanize" medical knowledge and practice. Abraham Flexner, he notes, had earlier warned that medical education must include the humanities to temper the medical student's scientific education. The next stage is a philosophical era of professional bioethics, which lasted from 1972 to 1985. According to Pellegrino, "the subjects of discourse centered on the theoretical substratum for bioethics-principlism, deontology, utilitarianism, virtue, casuistry, feminism, caring, narrative, or some combination of these theories" (1999, p. 82). It is during this period that bioethics became a discipline and part of academia proper. The third stage, which dates from 1985 to the present, Pellegrino calls global bioethics. The term "global" conjures up Potter's early denotation of bioethics, but, according to Pellegrino, goes beyond it even in terms of scope. "The breadth of issues and the breadth of disciplines now embraced by bioethics," according to Pellegrino, "become evident in the work of committees and consultations. Here," he continues, "ethical issues are often inextricably entangled with psycho-social, economic, legal, and religious issues" (1999, p. 84).

12.2 Normative Ethics

There are a variety of taxonomies for categorizing the different normative ethical theories. For example, Beauchamp and Walters (1999) and Beauchamp and Childress (2001) divide normative theories into general and practical categories. "General normative ethics," according to Beauchamp and Walters, "attempts to formulate and defend basic principles and virtues governing the moral life" (1999, p. 2). This category contains the traditional theories, such as utilitarianism and virtue ethics. Practical normative ethics is concerned with the development of handy rules and guidelines.

David Solomon (2004), however, divides normative ethics into three categories: virtue, deontological, and consequentialist theories. They are based on the three key features of human action: agent, action, and consequences. "Virtue theories," according to Solomon, "take judgments of agents or persons as most basic; deontological theories take judgments of actions as most basic; and consequentialist theories take judgments of consequences as more basic" (2004, p. 814).

In this section, a continuum-taxonomy is utilized to categorize normative ethical theories (Honer et al., 1999). According to this taxonomy, normative ethical theories range between two poles: absolutism and relativism. Absolute ethical theories, such as deontology, divine command theory, or natural law theory, are based on reason or divine or natural law and are objective in nature. Relative ethical theories, such as ethical subjectivism, cultural ethical relativism, and ethical egoism, are based on personal feelings, cultural authority, and self-interest. Absolute theories are more or less discovered by humans, in such cases as natural law, while relative theories are constructed and represent human inventions and conventions. In between these two poles are other ethical theories, such as consequentialism and utilitarianism, and situation ethics, which have features of both poles. Finally, virtue ethics and evolutionary ethics, which are not as easily classified in terms of actions or rules, represent ethical theories that are important in medical practice.

12.2.1 Absolute Ethical Theories

At the absolute end of the pole are the objective ethical theories, such as deontology, divine command theory, and natural law theory.' Objective theories claim that there are absolute moral values and ethical norms or absolute rules that are separate and independent from personal and social perspectives. These values and norms or rules are universal and binding for all cultures and all situations: "An absolute rule is exceptionless, that is, what the rule prescribes is morally decisive and cannot be overridden by other considerations" (Boyle, 1998, p. 72). The general form of such rules is: "Actions of type T are never (always) to be performed in circumstance C" (Solomon, 2004, p. 815). For example, a physician should never exploit his or her position or authority to kill an innocent human being.

For deontological theories the sources are rational laws, while for divine commandment and natural law theories they are religious authority and natural laws, respectively. The motivation for these theories is "conscientiousness-that state of character that disposes persons to follow rules punctiliously, whatever the temptations may be to make an exception in a particular case" (Solomon, 2004, pp. 815-816). Although these theories function to determine the moral state of some actions, there is considerable debate over the ethical or moral nature of other actions, especially in medicine such as in the case of euthanasia of patients with incurable illnesses or of the sacrifice of human embryos for stem cell research. The major problem with absolute theories, except for one formulation of the divine command theory and the Thomistic natural law theory, is that they are based on a particular type of rationality from a specific historical period-the Enlightenment. In today's postmodern world that rationality does not carry the same authority as it once did. Moreover, absolute theories based on natural law and religious authority depend upon interpretation, which requires a cultural and hermeneutical context. Deontological Theories

"Deontological normative theories," according to Solomon, "take moral judgments of action as basic, and they regard the fundamental ethical task for persons as one of doing the right thing-or, perhaps more commonly, of avoiding doing the wrong thing" (2004, p. 815). Doing the right thing or avoiding the wrong thing is to perform one's duty or obligation by following an absolute rule. "Modern deontology," notes Michael Slote, "treats moral obligations as requirements that bind us to act, in large measure, independent of the effects our actions may have on our own good or well-being, and to a substantial extent, even independent of the effects of our actions on the well-being of others" (2004, p. 796). In other words, deontological theories are nonconsequentialist ethical theories and the moral worth of an action is defined by whether it is performed from a sense or by reason of duty (deon) rather from an agent's desire to achieve a particular end or goal.

Kant (2002) developed the most widely recognized and influential deontological ethical theory. He utilized reason rather than one's emotions or desires to justify absolute moral rules, which he called the categorical imperative. These rules are categorical in that they admit no exceptions and are imperatives in that they represent commands. Kant contrasted the categorical with the hypothetical, in that the latter pertains simply to the conditions that must be met to achieve a particular desired end or goal. The hypothetical imperative, then, claims that if a person wants to achieve a particular end or goal then that person must take a specified course of action. Kant's categorical imperative eliminates the conditional antecedent. A person must take this course of action regardless of one's desired goal or end. For example, a physician must treat patients not to win their business or praise but simply because it is the right thing to do.

There are several problems with Kant's deontological ethics. First, he provided no means by which to adjudicate among moral absolutes when they conflict with one another. Kant's categorical imperative "is [simply] too rigid to be realistically used in everyday life" (Card, 2004, p. 30). For example, should a physician confronted by a person who wants to commit suicide because of a fatal illness, which is causing untreatable and intolerable pain and anguish, help that patient? On the one hand, there is the Kantian categorical imperative not to commit suicide; but, on the other hand, there is the command to respect a person as an end and not as a means to a particular categorical imperative like not committing suicide.

Another problem with Kant's deontological ethics is whether absolute rules should be followed constantly or absolutely. For example, if a physician feels that telling a patient the truth about his or her illness condition would jeopardize the patient's wellbeing then should the physician obey the absolute rule not to lie? Finally, morals may depend more on emotions or the heart than on duties or the head: "patients do not want caregivers to view them simply as `duties' for whom they are responsible as professional... [but rather] as unique persons for whom caregivers have some genuine human feeling" (Tong, 2007, p. 16). Divine Command Theory

Whereas deontological theories, like Kant's, are motivated by reason, religious-based absolute theories, especially illustrated by the divine command theory, are not. According to proponents of the divine command theory: "Moral status M stands in dependency relation D to divine act A" (Quinn, 2000, p. 53). This dependency relation is generally expressed in terms of divine commands. In other words, it is a divinity or God who determines what is morally right or wrong and communicates this to humans through ethical commands: "Whether something is right or wrong is a perfectly objective matter: it is right if God commands it, wrong if God forbids it" (Rachels, 1986, p. 41). Through commandments, then, like the Decalogue found in the Old Testament, God provides a moral standard for how a person is to act and behave morally.

Traditionally, there are two broad formulations of the divine command theory based on Plato's analysis of the notion of the pious in the Euthyphro: "Is the pious being loved by the gods because it is pious, or is it pious because it is being loved by the gods?" (1997, 10a). The first formulation is a strong version of the divine command theory, which states that actions are right because God commands them. The problem with the strong version of the divine command theory is that morality ends up being capricious and vacuous: "God's judgments are based on `raw' approval, meaning that God has no reasons for commanding what He commands apart from the fact that He commands it!" (Card, 2004, p. 13). Or, God may have reasons but we are not privy to them. In any case, morality then is not based on an action's nature or on any particular reason.

The second formulation of the divine command theory is a weaker version, which states that God commands the actions because they are right, or, at least, "what God commands is coextensive with what is right" (Wierenga, 1983, p. 387). In other words, morality and ethical standards are independent of God. Harris (2003) calls this formulation the "Shared Moral Universe of God and Humanity" and provides several interpretations of it, in that God's commands are-or even God's will is-not necessary and sufficient conditions for morality. He also provides an epistemic interpretation, which states that there is some possible moral knowledge apart from God's commands. Finally, Harris articulates a more robust version of this formulation: "Not only is morality totally independent of God, but God is bound by it: He ought not to do or command what is immoral" (2003, p. 22). In other words, God created the moral structure of the world and chooses not to act contrary to it.

Although the weaker version of the divine command theory appears to avoid the problem of the first formulation, by conferring a moral acceptability onto an act not through its being commanded but through the inherent nature of the act, a significant problem with this version arises: the moral nature of the act itself transcends the very nature of God. But, if God is all knowing and perfect then this formulation is inconsistent with the nature of God. So, there is a dilemma with these two formulations of the divine command theory: either the moral standards depend upon God's command and humans must obey regardless of reason, or the moral standards are supreme and God is less than perfect. The dilemma is avoided by proponents of the divine command theory by claiming that "if perfection is of God's essence, then God wills perfectly in accord with the correct moral principles" (Card, 2004, p. 15). In other words, God is not subordinate to moral principles and still their author. Natural Law Theory

While rejecting the divine command theory, proponents of natural law theory take advantage of that theory's second formulation: that there is a natural goodness built into the universe. For example, Thomas Aquinas claimed that God created the universe, including morality, with a natural purpose or design to achieve a particular end or telos 6 "The divine plan," according to Daniel O'Conner, "pre-exists and controls the world as the architect's plan pre-exists and controls the construction of the building he has designed. The eternal law is thus," he concludes, "God's wisdom directing the movements and actions of his creatures in their appropriate ways" (1967, p. 59). The natural law is then a reflection of this eternal law, as it serves God's ends and purposes.

Natural law theory is teleological in nature (Card, 2004). God endowed humans with practical reason, in order to determine these natural purposes or laws: "Just as nature operates in conformity with natural laws-'laws of nature'-so there are natural laws that govern how we should behave" (Rachels, 1986, p. 45). The task of moral philosophy is to determine or identify the natural/moral laws that govern human actions. Moral philosophy, then, is guided not by capricious divine commands but by the purpose or end that God built into the natural world.

Contemporary natural law proponents develop natural law ethics based not on an explicit religious belief in God who created natural law but rather on specific basic human goods that are used to define the morally right. The fundamental principle of this version of natural law ethics is an absolute proscription of actions directed against one of these basic goods. For example, John Finnis (1980) provides a list of goods that includes life, knowledge, play, aesthetic experience, sociability (friendship), practical reasonableness, and "Religion." These goods are not moral goods per se, but rather they are important for what he calls "human flourishing" (Finnis, 1980). Germain Grisez (1983) also provides a list of goods, which he divides into two categories.' The first represents the reflexive or existential goods, which include, e.g. self-integration and religion or holiness. The second category denotes the nonreflexive or substantive goods, which include life itself, knowledge of truth and appreciation of beauty, and activities of skillful work and of play.'

The fundamental issue for natural law ethics is how to move from the basic human goods to specific moral choices. According to Grisez, that task is accomplished through what he calls the "first principle of morality": "In voluntary acting for human goods and avoiding what is opposed to them, one ought to choose and otherwise will those and only those possibilities whose willing is compatible with a will toward integral human fulfillment" (1983, p. 184). Derived from this principle are "modes of responsibilities," which are prohibitions to limit oneself in order to achieve fulfillment vis-a-vis the basic goods.' These modes function as a bridge from the fundamental moral principle to act in accord with the basic goods to everyday ethical concerns and problems. The outcome is the formation of a moral life in terms of integral human fulfillment, "in which all the human goods would contribute to the fulfillment of the entire human community" (Grisez, 1983, p. 222).

Russell Hittinger (1987) offers an insightful analysis and criticism of what he calls the "Grisez-Finnis natural law system"10 His major concern is with the teleological nature of contemporary natural law ethics based on human goods. "Grisez and Finnis would have us strike an alliance with the goods," according to Hittinger, "even though there is no good reason to believe that either the goods or humanity itself enjoys an overarching telos" (1987, p. 178). His next concern is with the "fullness" of the Grisez-Finnis theory in terms of basic human goods. Grisez and Finnis do not develop a complete or comprehensive theory of the goods, in that they do not develop "a nonarbitrary principle for coordinating the goods," with the effect that "morality is subject to mere ad hoc arrangements" (Hittinger, 1987, p. 181).

Hittinger also asserts, contra Grisez and Finnis, that "the human subject is something more than the sum of the parts of the goods which are pursued" (1987, p. 185). The reliance of Grisez and Finnis on a truncated notion of the self is inadequate to justify the self's openness towards God. "At the very least," according to Hittinger, "we need a theory of the moral subject, and its capacity for self-transcendence, as a propaedeutic to the problem of supernaturality" (1987, p. 185). Finally, Grisez and Finnis take too many short cuts in the development of their natural law ethics: "A natural law theory must show how nature is normative with respect to practical rationality. This has not been accomplished by the Grisez-Finnis method" (Hittinger, 1987, p. 192).

12.2.2 Relative Ethical Theories

At the relative pole are the theories of ethical subjectivism, cultural ethical relativism, and ethical egoism. Ethical subjectivism is a system based on the relative values of a specific individual, while cultural ethical relativism is based on the relative values of a particular culture. According to Tong, "subjectivists and cultural relativists are driven to their respective positions by their desire not to be ethical `know-it-alls' or cultural imperialists who mistaken their particular moral views for the absolutely right moral views for everyone, everywhere" (2007, p. 7). In other words, how one should act is determined either by one's feelings or by what the culture says. Ethical egoism is relative to one's self-interest.

The fundamental problem with relative ethical positions is that the truth of a value does not necessarily follow from a person's or a society's feeling or belief, or from a person's self-interest. The assumption that a person or a society knows the right course of action is essentially indefensible. History is replete with examples of persons and societies who thought they acted ethically but did not. Also, Tong rejects these positions as "wrong headed" and claims that the refusal of relativists to make an ethical judgment, e.g. the abuse or torture of children as wrong or immoral, as a "deleterious conversation stopper" (2007, p. 7). Ethical Subjectivism

Ethical "subjectivism works from the basic belief that morality is not grounded in reasoning, and therefore states that a person's feelings or beliefs are the only possible means for morally justifying an action" (Card, 2004, p. 6). The individual person is the ground for his or her ethical stance; there is no higher authority. Thus, if a physician believes that it is right to lie to a patient, e.g. concerning the state of a patient's illness, then lying is morally justifiable. There is no external standard by which to judge whether an action is morally acceptable; rather, there is only that standard internal to a person's ethical sensibilities.

There are two types of ethical subjectivists: existentialists, who stress the individual's experience, and linguistic theorists, who stress an emotive theory of values (Honer et al., 1999). Existentialists claim that value judgments cannot be justified but simply asserted, while linguistic theorists claim that value judgments reflect the emotional use of moral terms.

There are several problems with subjectivism (Card, 2004). First, subjectivists do not criticize ethical decisions according to a moral code: "The only possible way that a person's actions are judged as wrong on ethical subjectivism is if he acted in a way inconsistent with his own beliefs" (Card, 2004, p. 7). Another problem is that a subjectivist need not be tolerant of another's ethical position, if he or she does not feel like being tolerant. This is paradoxical in that ethical subjectivism stresses the primacy of the individual but cannot guarantee it for others.

Finally, ethical subjectivism is ineffectual for providing a comprehensive explanation for morality. In other words, it cannot justify one action over another. For example, a physician who participates in assisted suicides simply because he or she feels it is the decent thing to do cannot justify such action morally. In conclusion, "While our feelings about the morality of performing an action posses some importance, the implications of considering them as the basis of morality are deeply problematic and hence ethical subjectivism is an unacceptable moral perspective" (Card, 2004, p. 7). Cultural Ethical Relativism

Cultural relativists claim that ethical values depend upon social authority and that there are no universal values true for all cultures; rather, values are justified by what that culture believes or asserts. In other words, "This view holds that an action is morally right if it accords with the norms of that person's culture, and morally wrong if it does not" (Card, 2004, pp. 7-8). For example, if a physician engages in assisted suicide and if such activity goes against that physician's cultural norms, especially in the United States, then the physician acts immorally according to his or her culture. However, if the physician moves to another culture or country, such as the Netherlands or Belgium, where such activity is moral and legal, then he or she acts morally. The advantage of cultural relativism over subjectivism-particularly from an objectivist's position-is that at least a person's action may be judged immoral, if it does not conform to the person's cultural standard of acceptable moral behavior.

Although cultural ethical relativism does permit some type of moral judgment, there are still problems with it. The major problem is how to define a culture. A culture is generally heterogeneous in nature and there may be significant variation in terms of moral codes within any given culture. Moreover, a professional society may have ethical norms that vary with other subcultures within a society or with the larger society itself. The issue here is the autonomy and authority of a particular subculture, like medicine. For example, abortions were performed illegally for decades in the Untied States until legalized. And yet within that society there are those who would like to overturn the legality of abortion. Are these reformers immoral? According to cultural relativists, they are. But can a society's legal system or even its majority rule define what is morally acceptable given the diverse subcultures within a society, especially the pluralism now present in the United States? The simplicity of the cultural relativists view cannot address the moral nuances or complexity of this question: "Cultural ethical relativism lacks the resources for dealing with conflicting practices within a culture stemming from multiple cultural memberships" (Card, 2004, p. 11). Thus, most ethicists have rejected this moral system. Ethical Egoism

Ethical egoism, like ethical subjectivism and cultural ethical relativism, is close to the relativistic pole and, like subjectivism, focuses on the self for justifying its ethics. However, whereas ethical subjectivists claim that ethical choices are justified by what a person endorses, ethical egoists claim that these choices are justified by what profits or benefits a person (Card, 2004; Rachels, 1986; Regis, 1980). In other words it is based on self-interest, which a person generally attempts to maximize. Ethical egoists do not claim that everyone acts in terms of self-interest, which is the position of psychological egoism, but that everyone should act in terms of one's self-interest. The fundamental principle of this ethical position is to do what is best for the individual self, regardless of what happens to others because of those actions.'

Kurt Baier (1991) distinguishes between a strong and a weak form of ethical egoism. The strong form states that it is "always right (moral, praiseworthy, virtuous) to aim at one's own greatest good, and... never right, etc., not to do so," while the weak form states that it is "always right to do so, but not necessarily... right not to do so" (Baier, 1991, p. 201). In other words, according to the strong form it is morally good to maximize one's self-interest and morally wrong not to do so, while according to the weak form it is again morally right to maximize one's self-interest but not necessary morally wrong not to do so. Finally, ethical egoism is often contrasted with ethical altruism, which states that a person's actions should benefit the other even if it is to the detriment of one's own wellbeing.

A major problem with ethical egoism, as with ethical subjectivism and cultural ethical relativism, is that the truth or practicality of an ethical choice does not necessarily follow from one's self-interest, in that it is to some extent arbitrary (Rachels, 1986). For example, behaving in such a way to maximize one's self-interest in the short run may have deleterious results in the long run. Proponents of a weak form of ethical egoism argue that one's actions can benefit another incidentally. For example, Thomas Hobbs (1588-1679) embraced such a form of ethical egoism in which a person acts to benefit others because in the long run it is beneficial to that person, even though in the short run it may not be.

A second major problem is the "paradox of egoism": "unrestricted pursuit of self-interest by everyone produces a state of affairs contrary to the egoist's selfinterest" (Harris, 2007, p. 65). In other words, ethical and moral chaos is the result of everyone acting in one's own best interest. Take for example a pharmacist who dilutes cancer drugs in order to amass a multi-million dollar fortune (Card, 2004). What is really problematic for ethical egoism is that both the moral rightness and wrongness of the pharmacist's action are defensible. Another major criticism is that ethical egoism leads to an inability to resolve conflicting self-interests, which often require some type of moral guidelines or rules (Baier, 1958; Rachels, 1986). Moreover, ethical egoism is inconsistent with the helping professions, such as medicine, since obviously "a highly self-interested attitude would not serve one well in these professions" (Thiroux, 1998, p. 41).

Edward Regis (1980) identifies another crippling problem with ethical egoism: it fails to satisfy the constraint on seeking self-interest that does not result in harm to others. According to Edwards, a more robust form of ethical egoism should meet three conditions: "(a) it must emphasize pursuit of self-interest... (b) it must neither require such pursuit to be the exclusive or only end of action, nor that one do all those actions which might be to one's interest... and (c) it must deny that positive action for the good of others is morally obligatory" (1980, p. 60).

Edwards next proposes an ethical egoism that he claims satisfies these conditions: "the view which holds both that one ought to pursue one's well-being and happiness, and that one has no unchosen moral obligation or duty to serve the interests of others" (1980, p. 61). His form of ethical egoism does involve self-interest that is not necessarily one's only main goal and that rejects the need to further others' self-interest. Although Regis' ethical egoism leaves open the problem of unintended harm, it is constrained by the ethical egoist acknowledging that everyone is an "end-in-themselves" and that their rights as such must be respected.

12.2.3 Consequentialism and Situationism

There are two other normative ethical theories that fall in between the two poles of absolutism and relativism-consequentialism, and the related theory of utilitarianism, and situationism (Honer et al., 1999). Consequentialism exhibits features of both absolute and relative ethical theories. It is absolute since it requires that the level of satisfaction be empirically determined or tested, while it is relative since the values that support it depend on subjective human satisfaction. However, it is more aligned with the absolute rather than the relative theories, since it is primarily dependent on empirical determination of the level of satisfaction. The best known form of consequentialism is utilitarianism, which takes happiness for the greatest number to be the greatest moral good.

Situationism or situation ethics also exhibits both features of absolute and relative ethical theories. It is absolute since most situational theories subscribe to a single moral rule, while it is relative since it is culturally or socially dependent for its context. However, situationism is more aligned with the relative rather than the absolute theories, since it is primarily dependent on the social context. In this section consequentialism and utilitarianism are discussed first, followed by situationism or situation ethics. Consequentialism and Utilitarianism

Traditionally, "Consequentialism is a moral perspective that holds that only the consequences or results of one's actions matter intrinsically" (Card, 2004, p. 24). In other words, for consequentialist theories the value of the consequences of one's actions justifies their moral worth. Moreover, these actions should benefit not just the person performing them but must also benefit as many persons as possible. The consequentialist's "crucial ethical task is to act so that one will bring about as much as possible of whatever the theory designates as most valuable" (Solomon, 2004, p. 816). Morally, the "whatever" is the good, which can either be instrumental or intrinsic. The intrinsically good is that which is good per se because of what it is, while the instrumentally good acts to bring about the intrinsically good.

Consequentialist theories are concerned with maximizing the intrinsically good for the greatest number of people. Although the instrumentally good may help at times to bring about the maximal amount of the good, it may at times do so immorally such as in the case of a trivial lie. Moreover, consequentialist theories are generally divided into act or rule types. Act consequentialism states that a person should perform an action that results in the greatest good for the greatest number of people, while rule consequentialism states that a person should follow those moral rules that maximizes the greatest good for the greatest number.

The best known and highly recognized form of consequentialism is utilitarianism (Thiroux, 1998). Utilitarianism is generally associated with John Stuart Mill (1806-1873), who wrote a short book entitled Utilitarianism, although Jeremy Bentham (1748-1832) formulated the first modern adaptation of the utilitarian principle for revising the British legal system. James Mill (1773-1836), John Stuart's father was a supporter of Bentham and John Stuart read Bentham works and also became a supporter (MacKinnon, 2007). Utilitarianism is derived from the word "utility," which means usefulness towards a specific end. The traditional principle of utilitarianism, as formulated by Bentham and later developed by Mill, claims that the ethical or the good is what produces the greatest utility or usefulness for the greatest number of people. In other words, utilitarians claim that whatever maximizes utility is morally right.

Bentham defined utility specifically as the "property in any object, whereby it tends to produce benefit, advantage, pleasure, good, or happiness.. .or. . . to prevent the happening of mischief, pain, evil, or unhappiness to the party whose interest is considered" (MacKinnon, 2007, p. 61). Bentham then articulated the principle of utility as the "principle which approves or disapproves of every action whatsoever, according to the tendency it appears to have to augment or diminish the happiness of the party whose interest is in question" (MacKinnon, 2007, p. 61).

Mill later revised and clarified Bentham's principle as a moral standard to include not just the agent's utility or happiness in question but that for the greatest number of people: "for that standard is not the agent's own greatest happiness, but the greatest amount of happiness altogether; and if it may be possibly doubted whether a noble character is always the happier for its nobleness, there can be no doubt that it makes other people happier, and that the world in general is immensely a gainer by it" (MacKinnon, 2007, p. 68).

The substantiation of utilitarianism depends upon what John Dewey (1859-1952) calls the "test of consequences," i.e. an act must be justified by the empirical evidence (Honer et al., 1999). To that end, utilitarians attempt to measure the amount of utility or happiness an act produces. Calculation of utility depends on a number of factors, including "the net amount of happiness, its intensity, its duration, its fruitfulness, and the likelihood of any act to produce it" (MacKinnon, 2007, p. 52). The decision between two acts vis-n-vis its morality depends upon calculating which act results in the greatest amount of happiness for the greatest number.

For Bentham, the quantity of utility was sufficient to determine the moral nature of an act, while for Mill the quality of the utility must also be considered in the calculation. According to Mill, people would rather be a person dissatisfied than a pig satisfied. "The point of the argument," claims MacKinnon, "is that the only reason we would prefer a life of fewer net pleasures (the dissatisfactions subtracted from the total satisfaction of a human life) to a life of a greater total amount of pleasures (the life of a pig) is that we value something other than the amount of pleasure; we value the kinds of pleasure" (2007, p. 54).

There are several problems with utilitarianism, as evident from some very troublesome questions critics have raised about it. For example, how does one define human utility or happiness that is acceptable to a majority? And then how does one calculate optimal utility? The calculation of utility assumes realistically a great many variables, besides the factors listed above, such that "no one can consider all of the variables that utilitarianism requires us to consider" (MacKinnon, 2007, p. 54). In other words, utility is a complex notion that must take into account not only objective factors but also subjective ones. Moreover, does not the definition of utility or happiness depend on the values of a specific group? What type of empirical evidence can be obtained that defends a particular value that is not already laden with that value? Also, the question arises as to whether one should sacrifice one's own happiness or pleasure for the common good; for, "not to give some preference to ourselves is an affront to our personal integrity" (MacKinnon, 2007, p. 55). Moreover, does one give to the poor to such an extent that one becomes impoverished?

A final, troubling question is whether the end always justifies the means. Since utilitarians justify an act (means) in terms of the consequences (ends), it is conceivable that one can morally justify an end even though the means is immoral. Take for example a medical experimentation in which researchers used mentally challenged children to test the effectiveness of an immunization protocol for hepatitis (Harris, 2007). Although the researchers obtained permission from the children's parents, they divided the children into groups in which both received the hepatitis virus but one with optimal immunization treatment and the other with suboptimal treatment. The suboptimally treated group contracted hepatitis but survived after the disease ran its course. When the study was published, the public reaction was outrage. The researchers justified their actions, claiming that the knowledge gained from the study would benefit a great number of children who would be exposed to the virus. But this rationalization did not appease the public outcry: "Many people objected that the children had been `used' in a morally unacceptable way" (Harris, 2007, p. 120). Critics of utilitarianism argue that the end, although beneficial for children who might contract hepatitis, could not be justified by the means, using mentally challenged children.

In response to this problem, many utilitarians distinguish between act and rule utilitarianism. "Act utilitarianism," according to Harris, "judges the morality of an action by whether the action itself produces the most utility, or at least as much utility as any other action" (2007, p. 127). The problem, as noted above, is that an act might be immoral, such as lying or stealing, but is tolerated because of the large amount of utility it generates for the greatest number of people. Rule utilitarianism is proposed to rectify this problem by advocating moral rules to determine the morality of an action. "Rule utilitarianism," according to Harris, "judges the morality of an action by whether the moral rule presupposed by the action, if generally followed, would produce the most utility, or at least as much utility as any other rule" (2007, p. 127). One of the major problems with this type of utilitarianism is whether it is possible to formulate rules that apply to every situation without exception (Thiroux, 1998). Situation Ethics

Situation ethics or situationism is concerned not with the agent performing an action, or the action itself, or even the action's consequences, but with the context or situation in which the decision to act is made. "It claims," according to Solomon, "that one should approach the resolution of particular moral problems by eschewing all general action guides in favor of concentrated attention to the details of the particular situation" (2004, p. 822). In other words, situationism claims that ethical and moral choices depend upon the context or situation in which people find themselves. In that respect, it is relative.

On the other hand, situationism is absolute in that ethicists such as Joseph Fletcher, the best known advocate of situationism, claim that there is one absolute moral value-love. According to Fletcher, "situation ethics has only one norm or principle or law (call it what you will) that is binding and unexceptional, always good and always right regardless of circumstances. That is `love'-the agape of the summary commandment to love God and the neighbor" (1966, p. 30).

Although love is the principle upon which Fletcher bases all ethical choices and decisions, it is not used to produce a static ethical system but rather a dynamic and developmental one, especially since situations can change and morph dramatically. Moreover, situationists welcome change in their ethics, rather than resisting it, with love as the guiding principle: "Each person, therefore, must make a personal decision in situations of moral importance and do the best she can with the knowledge and experience at her command to act as a concerned, loving person" (Honer et al., 1999, p. 167). In other words, situation ethics or the "new" morality, as Fletcher called it, is more flexible than the "old" morality or legalism based on traditional moral rules. However, it is not as relative in nature as antinomianism; rather, it is situated in between these two positions (Fletcher, 1966).

Fletcher distinguished six propositions or principles, for the situationist, which are at the center of ethical decision making. The first is: "Only one `thing' is intrinsically good; namely, love: nothing else at all" (Fletcher, 1966, p. 57). Love is the end-value towards which all other values are means-values. The next proposition is: "The ruling norm of Christian decision is love: nothing else" (Fletcher, 1966, p. 69). For Fletcher love "replaces" the law, and he quoted Augustine (354-430) to defend his position: "Dilige et quod vis, fac (Love with care and then what you will, do)" (1966, p. 79). The third is "Love and justice are the same, for love is justice distributed, nothing else" (Fletcher, 1966, p. 87). Love requires prudence and careful thought to ensure its actions are just.

The fourth principle is: "Love wills the neighbor's good whether we like him or not" (Fletcher, 1966, p. 103). Love is not sentimentality but rather an attitude that takes into consideration the neighbor's good. The next proposition is: "Only the end justifies the means; nothing else" (Fletcher, 1966, p. 120). For a situationist, like Fletcher, "to will the end is to will the means," even if it leads to an immoral act under the "old" morality (1966, p. 133). The final proposition is: "Love's decisions are made situationally, not prescriptively" (Fletcher, 1966, p. 134). In other words, the morality of an action is not located within the action itself but rather in its context.

Situation ethics caused a considerable public stir during the late 1960s and early 1970s, especially with the publication of Fletcher's book. Many of the critics took exception to Fletcher's six propositions. For example, Robert Fitch claimed that love and justice are two separate principles. Christianity's commandments discriminate love from justice, while situationism "liberates like a demolition bomb more than it gives birth like an act of creation" (Fitch, 1968, p. 118). Fitch fainted at the evil committed in the name of love, throughout history.

The proposition to come under severest criticism, however, was number 5. John Montgomery, in a public debate with Fletcher, charged that: "If a situation ethicist, holding to the proposition that the end justifies the means in love, tells you that he is not lying, can you believe him?" (Fletcher and Montgomery, 1972, p. 32). Moreover, others argued that "a good and `loving' intention does not guarantee a good and desirable outcome" (Davis, 1990, p. 2). For example, although the intention of physicians, who treated pregnant women with thalidomide in the early 1960s, was good the result was disastrous.

Finally, critics claimed that the contextual flexibility of situation ethics is nothing more than simple relativism, since love is too ambiguous a notion to act as a moral guide (Honer et al., 1999). Moreover, Augustine's dictum on "love and do what you will" fails to recognize that Augustine did not consider love as a sufficient condition for moral action, since some actions per se are immoral (Outka, 1998). By the 1980s the debate over situationism subsided, although there are some who claim that valuable lessons may still be learnt from this ethical position (Outka, 1998).

12.2.4 Alternative Ethical Theories

Besides these ethical systems that focus on the ethical acts and rules, there are alternative ethical systems that must be examined, especially because of their use by bioethicists. These theories include virtue ethics and evolutionary ethics. Each of these theories focuses more on the agent, whether its character or its phylogeny. Virtue Ethics

Virtue ethicists focus on the character or virtue of a moral agent. The issue is not so much which moral rule or value to follow in what particular context or even the consequences of one's actions, but rather it is what kind of person one wants to become or what kind of traits or virtues would a moral agent have or exhibit.

Virtue ethics was initially developed by the Greeks, especially Aristotle who, in the Nicomachean Ethics, divided virtues into intellectual and moral. He identified various intellectual virtues, including sophia or theoretical wisdom and phronesis or practical wisdom. The moral virtues include such virtues as bravery, justice, prudence, and temperance. For Aristotle, a virtue is a mean between two extremes: "Now it is a mean between two vices, that which depends on excess and that which depends on defect" (2001, 1107a3). For example, compassion is the mean between heartlessness on the one hand and lenience on the other. The result of leading a virtuous or moral life, according to Aristotle, is eudaimonia or a state of flourishing. Finally virtues are the result of well formed habits, which society nurtures. The result is a person who by habit of character wants to live a moral life.

Virtues loomed large in ethical understanding, especially during the middle ages with Thomas Aquinas, until the Enlightenment, when ethicists began to focus on the act rather than the person. The two dominant approaches to ethics in the ensuing centuries were consequential and deontological ethics (Oakley, 1998). However, in 1958 Elizabeth Anscombe challenged, in her influential article "Modern moral philosophy," the hegemony of these two approaches. She argued that consequential and deontological ethics are inadequate to ground ethics. Rather, she made a clarion call for grounding ethics and morality on virtues. Other philosophers, such as Alasdair Maclntyre and Philippa Foot took up the challenge.

The contemporary virtue ethics project involves two programs (Louden, 2006). The first is a critical program, in which virtue ethicists criticize the consequential and deontological approaches. The criticisms focus on the over dependence of these approaches on legalism, rationality, and formalism for making moral choices. The second program is constructive in nature and focuses on issues surrounding the defining, justifying, and applying of virtues to moral situations.

What then is virtue ethics? Virtue ethics "holds that the character of the moral agent, the virtue he or she has, [is] of fundamental importance to ethical conduct" (Jansen, 2000, p. 262). Although there are a variety of contemporary virtue ethics, Justin Oakley (1998) identifies six common features that define them and distinguishes them from consequential and deontological ethics. The first is that a right or moral action is determined or justified by what the virtuous person would do in a given situation. The next feature is that what constitutes the good of a specific action or in a particular situation must first be established before what is moral or right can be determined.

The third feature of virtue ethics is that the "intrinsic goods embodied in the virtues cannot be reduced to a single underlying value, such as utility, but are plural" (Oakley, 1998, p. 90). The next feature is that virtues are objectively good in that their goodness is determined by human characteristics. The fifth feature is that virtues are agent-relative rather than agent-neutral, as for consequential ism. The final feature is that "acting rightly does not require agents to bring about the very best possible consequences they can. Rather," claims Oakley, "many virtues ethicists argue that we ought to aspire to a level of human excellence" (1998, p. 91).

A common critique of virtue ethics is that virtues depend upon a specific culture or a particular ethical system; thus, it is to a large extent relative (Honer et al., 1999). In other words there is no single virtue or set of virtues that can be applied to all situations, within a given context. Moreover, given the ambiguity of the notion of virtue it is unclear whether virtue can function to provide the necessary guidance to decide the morality of a situation. For example, two virtues may compete with one another, as when a friend asks about an article of clothing. One may be honest and tell the friend it is not flattering, or one may be kind and say it looks fine not wanting to hurt the friend's feelings. Rachels and Rachels call this the problem of incompleteness. "The admonition to act virtuously," they claim, "does not, by itself, offer much help. It only leaves you wondering which virtue takes precedence" (Rachels and Rachels, 2007, p. 189).

Besides the problematic nature of virtues, there is also the problematic nature of the virtuous agent as moral: "there is a plurality of virtuous character traits, and not all virtuous people seem to have these traits to the same degree, so virtuous people might not always respond to situations in the same way" (Oakley, 1998, p. 93). Moreover, appeal to a virtuous moral agent is insufficient for justifying the moral nature of an act. Take for instance the "benevolent" physician who withholds the truth about a patient's terminal cancer and asks the family to participate in the deception.

Virtue ethics is enthusiastically appropriated for both bioethics and medical practice. For example, Rosalind Hursthouse (1987) utilizes virtue ethics to analyze the moral issues associated with abortion. P. Gardiner (2003) champions virtue ethics for resolving medical moral dilemmas, such as the sale of organs or the traditional Jehovah's Witness case involving blood transfusion. Peter Toon (2002) also advocates virtue ethics for medical practice, in general: "virtues are the qualities needed to flourish in the practice of medicine" (2002, p. 695).

Not all commentators are enthusiastic about virtue ethics for bioethics and medical practice. In response to Toon, for example, Diane Reeves (2002) claims that virtue ethics is inadequate for medical practice and for resolving medical dilemmas. She notes that Toon relies on moral rules to resolve medical problems. Lynn Jansen (2000) is also less than sanguine about the application of virtue ethics to medicine. Jansen argues that although virtues play a role in medicine it is subsidiary to the role of duties and rules." Virtue ethicists make traditional ethicists uneasy, since no context-independent ground is available to stand on rather only a slippery slope. Evolutionary Ethics

Evolutionary ethics has a rather ignoble past (Ruse, 1993). Although Charles Darwin (1809-1882) provided a robust mechanism for biological evolution, in terms of natural selection, the application of this mechanism to ethics has been less than successful. One of Darwin's enthusiastic supporters, Herbert Spencer (18201903) utilized a Darwinian adaptation known as "survival of the fittest" to promote Social Darwinism. Spencer based his evolutionary ethics on laissez-faire individualism and progressivism. "He believed," according to Michael Ruse, "that liberty is a moral good because it will promote happiness and, therefore, one has an obligation to maximize liberty inasmuch as one can" (1993, p. 136).

The mechanism of Social Darwinism depends on non-interference from government with a society's liberty and its progress. This cashes out in removing social programs that aid the non-fit, at the expense of the fit. The non-fit, as Social Darwinists fear, reverses progress rather than supports it. Critics such as Thomas Huxley (1825-1895) argued vigorously against Social Darwinism; but its greatest critic, G.E. Moore, asserted that it commits a "naturalistic fallacy." In other words, one cannot move, as David Hume (1711-1776) argued, from "is" to "ought"

Evolutionary ethics or Social Darwinism fell into disrepute during the first-half of the twentieth century, especially after the atrocities of the Second World War, only to be revised in the second-half by sociobiologists (Ruse, 1993, 2006). For example, Edward Wilson makes a clarion call for ethics to be "biologicalized" (1975, p. 27). Wilson champions a program to account for ethics or why humans do the good, or even should be good, in terms of natural selection, especially at the level of genetic selection. In other words, morality is the result of natural selection in that it confers a selective advantage for survival.

Although the natural bent of an organism is towards selfishness, especially in terms of food and sex, co-operativeness allows humans to fair even better than going it alone. This co-operativeness, according to sociobiologists, is then parsed out in terms of morality, nothing more. As Ruse argues for this "new" evolutionary ethics: "ethics might be simply a collective illusion of our genes, put in place by natural selection to make humans into good cooperators" (2006, p. 480). Anthony O'Hear (1997) takes exception to the "new" evolutionary ethics, claiming that ends such as truth and beauty have little to do with selective adaptation and may even interfere with it.

To date evolutionary ethics is not widely applied to medicine, for various reasons. Kenneth Calman (2004), for example, argues that values are critical for medical ethics and practice. For Calman, the issue of evolutionary ethics involves the type and degree of changes in these values. He claims, for instance, that the core values, like human rights, are not changing, even though there is substantive change in peripheral values that influence medical ethics and practice. For example, he cites changes in peripheral values pertaining to genetic cloning and screening and in organ transplantation that are reshaping the medical landscape. "In essence," according to Calman, "new knowledge indicates what we can and could do. The question which is raised," he challenges, "is whether we ought and should do it" (2004, p. 368).

Enthusiasts of evolutionary ethics address the above challenge, especially in terms of changes in the core values of medicine that reflect the changes in society's core values. Evolutionary ethicists are critical of those who fail to analyze the changes in the social values that then define medical practice. Not to do so, would be to expose the profession to the blind forces that shape and define society. For Calman, however, core values are essential in that they define the nature of medicine: "Values give coherence to professional groups and give a sense of purpose, and a way of seeing and monitoring standards. They define the profession" (2004, p. 370). To change these values, if at all, requires careful consideration so as not to loose the compassion and care patients require.

12.3 Summary

A major problem with the various competing ethical theories is how best to determine which one is adequate for bioethics and medical practice, especially in terms of the quality-of-care crisis. For example, some ethicists champion one of the consequentialist theories that endorses the patient's welfare as the primary aim in ethical deliberations and medical practice, while other ethicists prefer one of the deontological theories that promotes a duty or rule to the exclusion of consequences. Moreover, other biomedical ethicists promote one of the other ethical theories for specific reasons germane to that theory. However, there is no consensus as to which ethical theory could meet the needs for deliberating over bioethical conundrums. That solutionat least for some-came in the form of principlism, the topic of the next chapter.

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