What is Morality?
Morality directs people to behave in certain ways and avoid behaving in other ways.
It evaluates behavior as right or wrong and may involve measuring the conformity
of a person’s actions to a code of conduct or set of principles. Morality is “normative,”
it is concerned with how people should behave, not just how they actually do behave.
Some people use the term “ethics” for the systematic study of morality. But really
there is such looseness in the use of the terms that in the minds of many morality
and ethics are the same. Thus, “What is your ethics?” is usually taken to mean the
same as “What is your morality?”
Controversy exists in the study of morality about such questions as whether there
is a single standard of morality for all people and how we can know what that standard
Types of Acts
Though morality uses the categories of right and wrong, those two terms are not
enough to capture all that we want to say about different types of behavior. To
see this, note that while to say that an action is morally wrong means we ought
not to do it, to claim that an action is morally right fails to clarify whether
we should do it or are merely allowed to do it (that is, whether it is obligatory
or merely permissible). And what of acts that go above and beyond the call of duty?
They are morally right, but perhaps we need a term to separate them from other acts
that are right in the sense of merely permissible.
Expanding the category of “morally right” to include three different subcategories
better captures the distinctions we want:
- morally wrong
- morally right
- morally neutral
- morally obligatory
- morally supererogatory
Morally wrong acts are activities such as murder, theft, rape, lying, and breaking
promises. Other descriptions would be that they are morally prohibited, morally
impermissible, acts one ought not to do, and acts one has a duty to refrain from
Morally right acts are activities that are allowed. They include the morally neutral,
the morally obligatory, and the morally supererogatory.
Morally neutral acts are morally right activities that are allowed but not required.
One is neither obligated nor prohibited from doing them. One might call them the
"merely morally permissible." Examples of such acts include watching the evening
news on television, eating an apple instead of an orange, choosing vanilla over
chocolate, whistling while you work, thoroughly chewing your food before swallowing,
brushing before flossing instead of after, etc.
Morally obligatory acts are morally right acts one ought to do, one is morally prohibited
from not doing them, they are moral duties, they are acts that are required. Such
acts might be keeping one's promises and providing guidance and support for one's
Morally supererogatory acts are those morally right activities that are especially
praiseworthy and even heroic. They go beyond what duty requires. They aren't required,
morally, but if they are done it is an especially good thing. Examples include generous
support for worthwhile charities, volunteer work for a local nursing home, and risking
one's life to save someone from a burning building.
These four categories of acts are not always explicitly distinguished by people
but they seem implicitly incorporated into our moral distinctions and decisions.
There is, however, some disagreement about exactly what types of act fit into which
categories. Thus, for example, while everyone thinks murder to be morally wrong,
there is controversy about whether abortion is wrong; some people believe abortion
to be wrong and others believe it to be morally permissible.
Kinds of Ethics
We said that morality was concerned with normative standards of right and wrong
behavior. Actually that is one type of ethics called “normative ethics.” Besides
normative ethics, ethicists also talk of descriptive ethics and metaethics. Descriptive
ethics describes existing accepted standards of morality, normative ethics promotes
or argues for the “correct” standard of morality, and metaethics analyzes such things
as the meaning and justification of moral judgments.
Here is a link
providing some analogies to help understand
the distinction among types of ethics.
Biomedical ethicists, medical ethicists, healthcare ethicists, nursing ethicists,
bioethicists, etc. are mainly doing normative ethics, though restricted to a particular
area or domain (healthcare). Healthcare is thus engaged in what some consider a
fourth kind of ethics, applied ethics. But really it could be argued that any normative
ethics that gets away from general principles and discusses their application to
particular situations might be rightfully considered applied ethics. And so some
thinkers consider applied ethics just a type of normative ethics, not a separate
kind of ethics.
Normative Ethical Traditions
One way to do normative ethics is to focus on analyzing human acts; another way
is to focus on human character. This latter approach occurs through “virtue” ethics.
Virtue ethics seeks to ascertain the correct virtues that should be possessed by
people of strong moral character. Perhaps virtue ethics has a better chance of getting
people to do the right thing, but act-based normative ethics seems to stand a better
chance of determining what that right thing is in any given situation. In health
ethics discussions the act-based approach has been most important so we will discuss
it in more detail.
For our purposes there are two basic approaches to determining the rightness of
acts, two basic approaches to normative ethics. To understand the difference, consider
that when you do something, undertake any action, there is going to be (1) what
you actually do, and then there are going to be (2) the consequences of what you
do. For example, if I steal another person’s car, there is the act of stealing the
car, and then there are the consequences of that theft – the owner won’t have a
way to get to work, it will encourage him and others to lock things up better, I
might get caught and thrown in jail, etc.
So when looking at an act we can focus on the nature of the act itself or on the
consequences. We can say the act is right or wrong because it is a certain kind
of act, it fits in with certain principles or rules, or we can say the act is right
or wrong because it results in good or bad consequences.
To simplify the matter we’ll call the first kind of approach “deontology” and the
second kind “utilitarianism.” Other names for deontology or things like them are
“nonconsequentialism” and “path-dependent theories.” Other names for utilitarianism
or things like them are “consequentialism” and “cost-benefit approaches.”
To take up utilitarianism first, a simple way to put the basic perspective is to
say that when faced with alternative courses of possible action, morality requires
us to choose the act or choice or course of action that brings about the greatest
good (usually thought of as happiness) for the greatest number of people. The key
is that to consider only the consequences of the act, both short-term and long-term
consequences. So in the case of car theft, how much happiness is produced for everyone
by stealing the car versus the happiness from not stealing the car? Chances are
more happiness for everyone would occur from not stealing the car, so that is the
right thing to do.
You may wish to read more about utilitarianism here
The deontological approach says that consequences are important to consider but
they are not the only thing. The “path” to the consequences should be taken into
account also; some kinds of act are just wrong regardless of whether they bring
about the greatest amount of happiness overall. For example, if by murdering an
innocent person I somehow would make many people happy that doesn’t make it right
– murdering would be wrong even so, so I shouldn’t do it. What kinds of acts are
right or wrong because of the path to the consequences? Opinions vary, but there
are certain principles or rules suggested that tell us what kinds of acts are right
Deontology stresses that we have certain “duties” or obligations apart from consequences,
though often doing the right kind of act will in fact lead to good consequences
for the most people. For example, the philosopher W. D. Ross listed a number of
apparent duties we all have; they may be paraphrased as:
- Fidelity: duty to keep promises and contracts and not be deceptive
- Reparation: duty to make up for injury one caused to another
- Gratitude: duty to be grateful for favors and if possible return them
- Non-maleficence: duty not to harm others
- Beneficence: duty to do good to others
- Self-improvement: duty to improve oneself
- Justice: duty to see that pleasure or happiness is not distributed out of proportion
to what people merit
The average person in the United States has not heard Ross but he or she has heard
of another set of rules or principles from the Bible, more precisely the Old Testament
or Hebrew scriptures (in the books of Exodus and Deuteronomy); these principles
or rules are known as the “Ten Commandments.” Insofar as any of these provide moral
rules that tell us how to act and thus distinguish between right and wrong acts,
they represent a nonconsequentialist, deontological approach. Here is a paraphrase:
- Worship only the one true God.
- Do not worship idols.
- Do not make wrongful use of the name of God.
- On the seventh day of the week take a Sabbath.
- Honor you father and mother.
- Do not murder.
- Do not commit adultery.
- Do not steal.
- Do not bear false witness against your neighbor.
- Do not covet your neighbor’s wife or possessions.
Certain of these rules are religious rather than moral, but common moral rules specified
are to respect your parents and to refrain from murder, adultery, theft, falsely
accusing or testifying against another person, and being jealous of and desiring
another person’s spouse and possessions.
You may wish to read more about deontology here
Principles of Biomedical Ethics
Utilitarian reasoning occasionally surfaces in healthcare ethics, particularly when
the discussion is about the allocation of scarce resources and a cost/benefit or
cost/effectiveness approach is being used. But the most widely known approach is
a deontological approach emphasizing four principles stemming from the Belmont report
as tweaked by the ethicists Beauchamp and Childress:
- Respect for autonomy (respect for the freedom of persons)
- Non-maleficence (do no harm)
- Beneficence (do good)
- Justice (fairness)
Autonomy is the freedom of a person to make decisions that control his or her life.
In healthcare, patients deserve to have their autonomy respected in that they should
be presented with the medical situation, advised of the options and their expected
outcomes and risks, and have the freedom to make their own decisions about their
treatment rather than being misled or coerced.
Non-maleficence is a principle of ethics widely held outside of healthcare in that
each of us has the obligation to refrain from harming another person unless there
exist extraordinary circumstances such as the need for self-defense against immanent
harm. In healthcare this principle means clinicians have an obligation not to harm
patients. Temporary pain and discomfort due to tests, procedures, or other treatment
interventions should be balanced by the long-term benefit they will bring.
The principle of beneficence is also recognized outside of healthcare in that each
of us has a general moral obligation to do good for one another. But this principle
has a limited extent in that no other person has a right to demand my charity toward
them. In healthcare it becomes a principle of specific beneficence that a provider
owes to his or her patient. The patient does expect the provider will work for the
benefit of the specific patient and provide the best possible care. This is based
on the fiduciary nature (trust) that characterizes the provider-patient relationship.
The fourth principle is that healthcare should be provided with justice in allocation
of resources and in the provider allocating his or her time to patients. The usual
understanding of justice in such contexts is “distributive” justice having to do
with fair distribution. The application of this principle is not clear cut, however,
since there are differing interpretations of what fairness means – equality, based
on merit, based on need, etc.
In healthcare ethics we consider particular situations and wonder whether a proposed
course of action or inaction is morally obligatory, merely morally permissible (morally
neutral), or morally impermissible. We ask questions about what providers and clinicians
should do in certain situations. Controversies occur in healthcare ethics and in
ethics in general over the correct normative ethical approach, over whether principles,
rights, or duties are involved at all, over which principles apply in particular
situations and how they apply, and over which principles should prevail if different
principles seem to direct different courses of action.
Some “casuistic” approaches purport to eschew principles all together and claim
we should decide on a case-by-case basis using similarities with accepted decisions
from earlier cases. However, critics would question how those earlier decisions
could be justified or distinquished from mere prejudice unless one had principles
or rules to draw upon in making those initial judgments.
Metaethics asks questions such as:
- Do moral principles and judgments (“stealing is wrong,” “you ought not to steal
that,”) represent knowledge, mere opinion, or expressions of emotion that have no
- How do we know what the correct moral principles are?
- Is morality universal for all people or instead relative to culture?
Metaethics rarely enters into healthcare ethics discussions. Providers and patients
generally accept that there are right and wrong behaviors and principles or rules
that make them so, almost always without asking how we know of such principles at
It is not clear what the implications are of this lack of metaethics discussion.
Insistence on metaethics discussion in health ethics certainly would tremendously
complicate matters and perhaps even paralyze needed ethical discussion in healthcare.
However, on a theoretical level and in an academic context, discussion of metaethics
would seem to be very important in creating dialogue among people of different viewpoints
about where to get the right ethical principles.