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Ethics in Dentistry:
Introduction to Ethical Theory
Dr. Bill Myers
Basic Concepts and Problems
1. Morality and Ethical Theory:
Morality: A social institution, concerned with social practices
defining right and wrong. It’s composed of a set of standards
which is pervasively acknowledged by a culture or a people.
Ethical Theory: an activity in which one engages in reflection
on the nature and justification of right actions.
2. Morality and prudence
Prudence: Self interest (don’t touch the stove, brush your
teeth—not moral rules)
Morality: Is not reducible to prudence. Prudence is selfinterest whereas morality extends to others. Prudence and
morality may coincide, but that which is prudent may not be
moral, and that which is moral may not be prudent.
3. The Rule of Conscience:
Let your conscience be your guide. Certainly, conscience is not
the end all and be all of morality. People’s consciences will tell
them very different things in very similar circumstances. Yet,
should you ever do what your conscience tells you is the
wrong thing? Ethicists disagree.
4. The Common Morality:
Those of us who are committed to morality share a set of norms,
even though these norms may be very general. We all agree at
least that any of the norms that we hold apply to all people, or to
all who are members of the moral community. We cannot
arbitrarily exclude any of those we may not like, or who may not
like us. The common morality applies to everyone.
The basics of common morality are best expressed, perhaps, in the
three basic factors of morals: the good, the right, and the virtuous.
The first factor contemplates ends or outcomes; the second with
duties and obligations, the third with character formation.
5. Moral Dilemmas and Solving Moral Disagreements:
Genuine moral dilemmas are real and difficult. The Tarasoff
case (p. 45-49) is a good example. It’s a moral dilemma
because there are very good reasons for mutually exclusive
alternatives. If one set of reasons is acted upon, events will
result that are desirable in some respects but undesirable in
others.
Resolving moral disagreements:
• Obtain objective information
• Provide definitional clarity
• Adopt a code
• Use examples and counter-examples
• Analyze arguments
6. The Problem of Relativism:
• Cultural Relativism: Cultures vary in the values that they
hold. That is, values are relative to a culture.
• Cultural Normative Relativism: What is thought to be right in
one culture is really right for that culture, regardless of what
another culture thinks about it.
• Distinction: Between a relativity of judgment and a relativity
of standards. We clearly have the former, but does the latter
hold?
• Individual Normative Relativism: What is thought to be right
for one individual is really right for that individual, regardless
of what another individual thinks about it.
7. Moral Diversity and Moral Disagreement
Why do we disagree, morally speaking?
• Factual disagreements (for example, over the benefits of a particular
procedure)
• Scope disagreements about who should be protected by a moral
norm (what degree of autonomy for children?)
• Disagreements about which values are relevant to a particular moral
dilemma
• Disagreements about appropriate specifications
• Disagreements about the weights of conflicting norms
• Disagreements about balancing norms
• The presence of a genuine moral dilemma
• Insufficient information or evidence (very common!!)
B. Normative Ethical Theory
All ethical theories can be classed as one of two kinds:
• Consequentialism says that the morality of an action is
completely determined by its consequences.
• Deontology says, no, they are not; there are other relevant
considerations.
• Jeremy Bentham’s “Auto Icon”
Utilitarianism
Basic Concepts:
i) The principle of utility: Maximize the good. We ought to act in such a way as to maximize
value over disvalue.
ii) The Standard of Good. Since morality consists in maximizing the good, we must describe
what we mean by good. John Stuart Mill is a hedonist. His version of the Principle of Utility,
which he calls the Greatest Happiness Principle: Actions are right in proportion as they
promote happiness and wrong as they produce the reverse of happiness. By happiness is
intended pleasure and the absence of pain.
iii) The principle implies consequentialism (the morality of an action is completely
determined by its consequences),
iv) and impartiality/universalism (everyone matters equally).
A note on moral theories: A moral theory has to specify what
it takes as fundamental; that is, they must specify the object
of moral evaluation.
From general to specific:
Society—Persons—Character traits—Motives—Intentions—Behaviors
Utilitarianism takes behaviors and/or intentions as being
basic.
Act v. Rule Utilitarianism:
Act utilitarianism: every deliberation requires that we
calculate the consequences by appealing to the principle of
utility.
Rule utilitarianism: we appeal first to relevant secondary
principles (don’t lie, don’t steal, etc). The principle of utility 1)
justifies these principles and 2) it settles conflicts between
them.
Problems with Utilitarianism:
1) Problems accounting for the dignity of the individual (The
patient in room 605).
2) The real difficulty in quantifying pleasures or even goods of
any kind.
3) The difficulty of the distinction between act and rule
utilitarianism.
Kant and Deontology
Motives are central:
• You must not only do what you believe is right, but you must do so for
the right reason, that is, you act from the motive of duty.
• Good actions only follow from a good will, and a good will is the ONLY
thing in the universe that is good in and of itself. From a good will
flows good actions.
• The motive for the action comes from an appeal to a universal rule.
Kant’s Supreme Principle of Morality, or The Categorical Imperative:
• First Version: Always act in such a way that you can at the same time
will that the maxim of your action to be a universal law of nature. In
other words, Don’t make exceptions for yourself!
• Second Version: Always treat humanity, whether in the person of
yourself or another, always as an end in themselves, and never as a
means only. In other words, don’t use people!
Criticisms of Kant:
1) Seems to ignore the importance of consequences. Can they
be so unimportant?
2) Leaves little room for virtue. One can be a perfect Kantian
and be sorely lacking in virtues, such as compassion.
Virtue Ethics
Descends from Classical Hellenistic tradition:
• Instead of looking at rules of obligation, we should be focusing on
making good people, cultivating people of good character.
• Moral virtues are understood as morally praiseworthy character
traits, such as courage, compassion, sincerity, reliability, etc.
• Thus, the focus is one the ideal person.
• Acquiring virtues is much like acquiring other skills, such as cooking
and carpentry.
• Virtue ethics is more than purely habitual training. One must also
have a correct motivational structure.
Criticisms:
Virtue ethics is very useful when it comes to choosing
between right and wrong. It is less useful in dealing
with genuine moral dilemmas. More is needed.
Care Ethics
Care ethics is critical of traditional ethical theory:
• The impartiality of traditional moral theory (esp. Kant and Mill) are
inadequate guides to action. Abstract formulations take us away from
the concrete situation and from the relevant social and historical facts
which characterize that situation.
• Impartiality undermines respect for the individual because it treats
individuals impersonally, as interchangeable moral agents without any
uniqueness.
• Kantian and utilitarian impartiality leave little room for virtues-empathy, compassion, love, etc.
Rather than focusing on individuals, care ethics focuses on
relationships. They reject the idea that ethics is based on our
being autonomous agents who make our choices in a free and
equal manner. Their rethinking claims that social cooperation
(and ethics) are unchosen, intimate, and among unequals.
We need a change of metaphor. The shift to family metaphors
would make a significant difference.
C. Principles of Bioethics
The distinction between rules and principles: rules tell us specifically
what to do or what not to do. Principles offer guidelines for how to
make decisions.
• Autonomy: Based on Kantian Ethics. Refers to basic self-governance:
personal rule of self by adequate understanding while remaining free
from controlling interferences by others and from personal limitations
that prevent choice. For many, autonomy is the fundamental principle
of medical ethics.
• Beneficence—above all, do no harm
William Frankena’s description of beneficence:
a. One ought not to inflict evil or harm (nonmaleficence)
b. One ought to prevent evil or harm.
c. One ought to remove evil or harm.
d. One ought to do or promote good.
• Justice:
Distributive Justice deals with the question: how ought the goods and
responsibilities of society be distributed among its members? In other words, what
is fair?
Formal Principle: Treat equals equally
Material principles:
a. to each person an equal share
b. to each person according to individual need
c. to each person according to acquisition in the free market
d. to each person according to individual effort/performance
e. to each person according to societal contribution
f. to each person according to merit
• Utilitarian theory: seeks to maximize overall value with little (or no)
emphasis on the individual. Any arrangement that maximizes overall
good is acceptable.
• Egalitarianism: less tolerant of inequalities. In the above list, (a) is
radical egalitarianism. A more mitigated one would accept
inequalities only in so far as those inequalities contribute to
everyone’s advantage.
• Libertarians (generally c and d above) tend to value economic
autonomy over any sort of equality. As long as we play by the rules
and don’t cheat, any economic distribution is fine, even if it is
radically unequal.
When principles conflict:
Proposed by W.D. Ross: Grounded in the Common Morality, obligations
arise simply because we live together and interact. They are not
grounded in Kant or Mill, or rights. Examples of such obligations:
“Promises create obligations of fidelity;” “Wrongful actions create
obligations of reparation.”
The prima facie nature of principles: A prima facie duty is one that is
always to be acted upon unless it conflicts on a particular occasion with
an equal or stronger duty. It is conditional, then, on not being
overridden by a stronger duty.
Some Concluding Notions:
Morality and Law:
These are not identical. That which is legal might not be
moral, and that which is immoral might not be illegal.
Legal and Moral Rights:
Legal Rights: sanctioned by law
Moral Rights: held regardless of law
Negative rights: rights of non-interference
Positive rights: a right to be provided with some good
Law, Authority, and Autonomy:
Liberty limiting principles:
a. The Harm Principle: A person’s liberty is justifiably restricted only to
prevent harm to others caused by that person.
b. The Principle of Paternalism: A person’s liberty is justifiably restricted to
prevent harm to self caused by that person.
c. The Principle of Legal Moralism: A person’s liberty is justifiably
restricted to prevent that person’s immoral behavior.
d. The Offense Principle: A person’s liberty is justifiably restricted to prevent
offense to others by that person.