It's hard to deny that some things are morally right and others wrong. Those claiming they don't believe in objective morality soon backtrack when a perceived injustice is done to them! Moral realism is the view that ethical claims report facts and are true claims if they get those facts right.

In practice, ethical decisions are often made based on many factors such as feelings, social pressure, conscience, or predicted outcomes. Acting on such factors may or may not lead to appropriate ethical responses but in medicine we need to make ethical decisions in a grounded way. This whistle-stop tour explores the best-known ethical models, followed by a Christian appraisal.

historic ethical frameworks

There are three major historical ethical frameworks

virtue ethics

Virtue ethics dates back to Aristotle (384-322 BC). Virtue ethics, rather than focusing specifically on what is the 'right' thing to do, instead asks what sort of moral character we ought to cultivate in order to flourish as human beings. It focuses on the motive for our actions rather than on the actions themselves.

Aristotle's view of the virtues was that they always lay in a 'mean' between two extremes of corresponding vices. For example, in the case of courage, the vice of deficiency is cowardice, while the vice of excess is recklessness.

Aristotle's concept of virtue as the 'golden mean', however, only works for the limited number of virtues. What would be the extremes, for example, of the virtue of love? Nevertheless, virtue ethics emphasises that we can get a good outcome from actions arising from our ethical decisions, and yet still have unethical motives. Doctors' motives for better care of some patients rather than others can have a similar spectrum of motivations. Virtue ethics emphasises that motives matter in ethics.

deontological ethics

Deontological (meaning rule-based rather than God-based) ethics is associated with Immanuel Kant (1724-1808) a Prussian polymath, best known for his formulations of the famous Categorical Imperative (CI). The most frequently well-known expression of Kant's CI is the formulation of Universal Law which is (in my own paraphrase), 'Act on the principle that at the same time, you can will everyone else to act upon as well'.

This principle is often misapplied in contemporary medical ethics. For example, Kant considers suicide is unethical because, even if you yourself desire it, you cannot also reasonably want everyone else in the world to kill themselves as well. Sometimes appeals to Kant's CI are made to justify assisted suicide and euthanasia on the grounds that if I were suffering intolerably, I would want to die in this way, and thus I could also will it for everyone else who feels the same way. This, however, is to focus on feelings rather than reason. Also, to introduce a caveat such as 'if they were suffering unbearably', is in Kantian thought, a hypothetical rather than a categorical imperative. Hypothetical imperatives always have an explicit or implied 'if' in their formulation. Suicide, murder, and lying are always wrong for Kant; the formula of 'Universal Law' is exactly that — it must always apply across the board.

utilitarian ethics

Most contemporary medical moral decision-making, especially in resource allocation, is utilitarian in nature. Rather than asking 'What is the rule?' most contemporary bioethicists focus on 'What is the outcome?'

The ethics of utility is usually attributed to Jeremy Bentham (1748-1832). The central idea is that 'the greatest happiness of the greatest number' [1] is the measure of right and wrong. Whilst at first this sounds reasonable, and certainly appealing, it soon runs into obvious difficulties, as not all forms of pleasure are of equal value to everyone. Bentham's follower, John Stuart Mill (1806-1873), recognising this, introduced the concept of 'higher and lower pleasures', famously stating that, 'It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied...'.[2]

principlism

All three of the previous three foundations of ethics were eclipsed in 1977, when the first edition of Beauchamp and Childress' Principles of Biomedical Ethics was published and soon became the bible of Western bioethics. With its four key principles of autonomy, beneficence, non-maleficence, and justice the system as a whole is known as Principlism. Within Principlism, the concept of autonomy is understood in terms self-rule and personal choice. Beneficence and non-maleficence are 'doing good' and 'not-doing harm' respectively, and justice in Principlism is often, though not exclusively, solely regarded as distributive justice.

The widespread adoption of Principlism is not hard to explain. It is easy to understand (certainly in comparison to Kantianism) and therefore easy to teach. It does not require any metaphysical beliefs so can be used by atheists and religious believers alike and it is easily applied to medical ethical dilemmas. One of its main problems is there is no clear way to decide what to do when application of one of the four principles conflicts with one or more of the others.

a biblical appraisal of ethical theories

Elements of each of the previous systems find support from scripture.

virtues:

motivated by Christ's love

Living virtuously is obviously vital for those Peter encourages to 'make every effort to supplement your faith with virtue'[3] and instructs 'to proclaim the virtues of him who called you out of darkness into his wonderful light.'[4] The fruit of the Spirit — love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control[5] — could be considered as a list of Christian virtues. As could Paul's other list of things on which we should focus our thoughts — honesty, being honourable, justice, purity, loveliness, excellence — all of which he clearly states as praiseworthy virtues.[6]

rules:

obedient to Christ's commands

Christians are 'not under law, but under grace,'[7] and hence are not motivated merely by obedience to rules but out of love for Christ. Nevertheless, Jesus says that if we love him, we will keep his commandments.[8] As the Scriptures, including the Old Testament, contain the things concerning Christ,[9] so Christians looking to make ethical decisions Christianly need growth in familiarity with biblical teaching, which helps to form the mind of Christ in his followers.[10]

consequences:

conforming to Christ's wisdom

Though Christians may consider utilitarianism the least likely framework to deliver consistently ethical outcomes, Jesus' saying that 'wisdom is proved right by all her children'[11] should give pause for thought. Furthermore, in the parable of the unjust steward,[12] the commendation is related to the outcomes which demonstrated how savvy the steward was (note that though Jesus does not say the master commended the steward for his dishonesty, but rather for his shrewdness). Outcomes were clearly important to Christ.

principlism:
holding together in Christ

All four principles of Principlism are present in the Bible. That is one reason why it works so well in many cases. God has given us autonomy and the responsibility of exercising it wisely.[13] The Gospels are full of examples of how Jesus 'went about doing good'[14] and the New Testament commands his followers to do likewise.[15] Jesus never acted maleficently in word or deed,[16] and taught his disciples to speak and act likewise.[17] Finally, justice is a major foundational theme running throughout the entire Bible.[18]