Bio ethics PHI-324

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SHOULD that ethicists disagree about the answer to this question. The current debates about abortion, nuclear warfare, homosexuality, and euthanasia remind us that ethicists often disagree about ethical matters. We will begin, however, not with the disagreements emerging from the various definitions of ethics, but with the similarities they all share. DEFINING ETHICS Despite their differences, most ethical theories include the following features. Ethics Is about Choices Here we make but two points, one requiring some explanation, the other needing only a brief statement. First, ethics is concerned with what we choose to do intentionally or on purpose. Ethics is not concerned with what people do accidentally or unintentionally, even if these behaviors cause bad things. If I am getting into a crowded elevator and accidentally step on your foot despite trying to be careful, this is not really an ethical matter. Although I may say "I'm sorry," and thus imply that I did something intentionally, in reality I did not intentionally step on your foot, and nothing unethical or immoral was involved. The situation becomes more complex if I had stepped on your foot in the process of pushing and shoving my way into the crowded elevator. In this instance I would have to admit some degree of ethical responsibility. True, I did not intend to step on your foot, but I did intend to push my way into the crowded elevator, and thereby I did intentionally choose behavior known to entail a high risk of stepping on someone's foot under these. Tremendous debates have existed for centuries in psychology, philosophy, and legal theory about whether human beings are able to choose freely or whether their actions are totally determined mined by biological, psychological, or sociological factors. These debates need not detain us here. We do know, with the wisdom of everyday experience and of a long criminal justice tradition, that we make choices in life and are therefore responsible in some degree for what we do. To deny this is to deny that a jury could ever find a person guilty of a criminal action. Philosophers and scientists may question our ability to make choices, and some have advanced powerful arguments for explaining our behavior in terms of some form of determinism. But these arguments have not yet convinced us to abandon our experience of choice or to abolish a legal system that holds people responsible, and responsibility implies the person need not have done the deed but indeed chose to do it. It is important to note that choice embraces what we choose not to do as well as what we choose to do. Choice is about omissions as well as actions. Choosing to do nothing in a situation where we could do something is just as much of a choice as the choice to do something. We are responsible both for what we freely choose to do and for what we freely choose not to do but could do. Second, although ethics is about choice, not every choice is ethically significant. The only choices of concern in ethics are those giving rise to significant good or bad in the world. Many choices we make in life are too remote from the sphere of good or bad to be of ethical concern. I might very carefully choose what shirt or blouse to wear today, but this choice does not ordinarily give rise to significant good or bad in the world, and so it is not an ethical choice. My choices of what to wear are not usually ethically significant, nor are my choices of what to eat for.dinner, of the color of my new car, of computer software, of a television program, and the like. The recognition that ethical choices are concerned with significant good and bad features in life brings us to the second common theme in ethics-the effort to distinguish what is good from what is bad. Ethics Is about Evaluation Ethics inevitably employs determinations and judgments about values. In their simplest form, determinations and judgments about values are differentiations between the good and the bad. Every ethics tells us that certain things are morally good and other things are morally bad and encourages us to choose the good and avoid the bad. Sometimes the differentiations between good and bad are clear and uncontroversial-nothing nothing bad is involved in the choice of the good, and nothing truly good is involved in the choice of the bad. I take care of my children, for example, or I abuse them. Caring for my children is clearly and simply good; abusing them is clearly and simply bad. Again, I send money to a local charity, or I embezzle money from the local charity. In normal circumstances, contributing to a charity is simply good; stealing from it is simply bad. Other ethically significant choices, however, are complex in the sense that they involve both good and bad. One and the same action brings about damage and suffering to myself or others but also brings about some good. Euthanasia destroys a human life but brings a quick and peaceful end for a suffering patient dying a slow and painful death. The complex ethical choices, those embracing both good and bad, are the actions and omissions that generate the great controversies in ethics. Some ethicists distinguish between two types of evaluation: "good or bad" and "right or wrong." They advocate evaluating actions as right or wrong and all other morally significant factors-persons,

character traits, consequences, and the like-as good or bad. Although there is some merit to distinguishing evaluations of "good or bad" from "right or wrong," this is not the approach we adopt in this text. One reason for not using two types of evaluations (good or bad and right or wrong) is that all ethical evaluations can be expressed in the basic terms of good or bad. Doing the right thing is always good, and doing the wrong thing is always bad. More important, whenever we distinguish between actions and all other relevant moral aspects in ethics, an unfortunate tendency develops. The distinction inclines us to isolate moral actions from other morally important features, such as feelings, character traits, and the impact of the actions on ourselves and others. The result is an ethics focused on actions considered by themselves selves and neglectful of the way feelings, intentions, habits, and personal character affect, and are affected by, our actions. As one important contemporary author, William Frankena, put it in two remarks he made in the opening pages of his widely read book titled Ethics, (i) "We must not let our decision be affected by our emotions," and (2) "the only question we need answer is whether what is proposed is right or wrong; not what will happen to us, what people will think of us, or how we feel about what has happened." Frankena is typical of many contemporary ethicists in that he distinguishes the evaluation of actions from the evaluations of other factors. He proposes two kinds of moral judgment: "judgments ments of moral obligation," which evaluate actions in terms of right and wrong according to principles, ples, and "judgments of moral value," which evaluate motives, intentions, character traits, and consequences in terms of good or bad. He calls this a "double-aspect conception of morality." Although Frankena proposes that

we should regard the morality of principles and the morality of character traits and the other considerations as complementary, he insists that the principles are the basic aspect of morality and that other considerations are secondary. The character acter traits, for example, are viewed as supporting the principles and are understood in light of them. Frankena tells us that character traits support moral principles four ways. First, they support us in moments of trial when we are tempted to act contrary to the principles. Second, they sustain us when we have to determine what principle it is our duty to follow when two or more principles conflict. Third, they sustain us when we are trying to revise the working rules of actual duty. Fourth, they allow us to recognize excuses and extenuating circumstances when a person did not act according to the principles but at least tried to do the right thing. In other words, the character traits are considered important only when we need help to carry out the obligations indicated by the principles, or need to resolve conflicts between them, or need to revise rules derived from them, or need to excuse or understand others who have failed to follow the principles. The complementariness riness of the double-aspect morality is not a complementariness of equals; the principles are basic, and the character traits play a supporting role. As will become clear in the course of this chapter, the position developed in this book is contrary to that suggested by the two remarks of Frankena. Because virtue pertains to feelings, virtuous feelings will affect our decisions, and rightly so. Second, in an ethics of the good, the most important question in ethics is precisely what will happen to us if we do, or do not, behave in a certain manner. The "only question we need answer" in ethics is not whether our actions are right or wrong but whether our actions, feelings, and character traits are making our lives good lives. Judgments about our actions in an ethics of the good are very much concerned with what happens to us. Actions are good when they help us live well but bad when they undermine our living well. In an ethics of the good, the virtues and the prudential reasoning needed to establish them in each situation are basic, not the principles. Action-guiding principles enter the picture only when they are helpful, as they often are, in reinforcing the virtues. Evaluating moral features as good or bad implies, of course, some standard of evaluation. Any ethicist making evaluative judgments about good and bad is employing a criterion or norm. Judgments presuppose standards, and this brings us to our next point-ethical norms. Ethics Is Normative Some authors make a distinction between descriptive ethics and normative ethics. This distinction is misleading if it implies that ethics is not normative, thatis, if it implies that ethics is a description of what people believe is right or wrong and of how they reason morally. In the long tradition of moral philosophy and ethical theory, ethics has never meant this. Ethics was never understood simply as research into what beliefs people actually hold or how they actually solve moral dilemmas. Ethics was always understood to be normative. It recognized that there were good beliefs, behaviors, iors, and ways of reasoning morally and that there were bad beliefs, behaviors, and ways of reasoning soning morally. It would be better to call the important work done in descriptive ethics moral psychology or moral anthropology because it is not ethics in the traditional sense. It is moral psychology and not ethics, for example, when researchers interview people to ascertain how they reason morally or what their values are. A well-known example of moral psychology is the work of Lawrence Kohlberg and his colleagues, who developed first six, and then seven, stages of moral reasoning from their research on children as they grew into adults. Another example is the work of Carol Gilligan, who pointed out imbalances in Kohlberg's analyses. Other examples of moral psychology or moral anthropology include programs of values clarification and studies of the moralities actually embraced by people of different racial, sexual, cultural, ethnic, and religious backgrounds. In health care, surveys of what nurses or physicians think is ethical regarding certain options-decisions about the withdrawal of feeding tubes, for example-fit into this category of moral psychology. The key factor in descriptive ethics is that researchers discover, usually by extensive interviews, views, what people value or what people think is good or bad. The research is important and no good ethicist would want to be without it, but it is not really ethics in the traditional sense because the work is purely descriptive and empirical. Ethicsthe traditional sense always included a normative component. Ethicists strove to determine not simply what people thought was good but what was good; not simply what people did in fact value but what was truly valuable; not simply how people reasoned morally but how best to reason morally. The oldest ethical text we have, the stone tablet recording the Code of Hammurabi (now preserved in the Louvre Museum in Paris), is not simply descriptive of what the Babylonians around 1800 B.C.E. thought was morally good or bad behavior; it is a normative code backed by the authority of the king. Moses did not first interview his people around 1200 B.C.E. to find out what they thought was moral or immoral behavior; he introduced the Ten Commandments as God's laws and made them normative. And Aristotle did not accept what many people of his day (around 350 B.C.E.) thought was the way to live and act but insisted there was a norm for judging the morality of our feelings, habits, and behaviors-and the norm was whether or not these contributed to our living well. Ethics is not about someone's belief that x is good and that y is bad. Ethics begins when we ask someone why he thinks x is good and why he thinks y is bad. Ethics begins when we begin giving reasons why something is good or bad, and the appeal to the reasons why something is good or bad is an appeal to something normative. When a person gives reasons why stealing is bad, she is appealing to norms. Perhaps she will say stealing is wrong because it violates God's law, or the natural law, or a person's natural right to his property, or the duty of justice as conceived by Kant, or the greatest happiness principle of Mill. If she is following the older tradition of ethics typified by Aristotle, she may say stealing is ultimately wrong because it threatens to undermine the thief's good life and happiness as both an individual and a social being by violating the virtue of justice, and the virtues are what we

need to live well and happily. Ethicists and moral philosophers disagree on what might serve as the normative basis of moral judgment, but they do not disagree on the need for something normative. The fact that a person believes something is right or wrong is not enough; the moral philosopher insists that those beliefs must be justified by something normative and that the exploration of what is normative for our behavior is the work of ethics. Ethics is not simply about reality-the positions people actually hold as moral-but about norms that enable us to say (to the extent that it can be verbalized) which positions are morally good and which positions are morally bad. This point about the normative component of ethics is important because some published work in professional journals associated with health care frequently refers to purely descriptive research into what people think is right or wrong as "ethics." Empirical research in ethics, however, is not ethics or moral philosophy in the traditional sense unless it also evaluates the findings in terms of something morally normative, be that norm rights, principles, laws, rules, or human fulfillment fillment and happiness. The important normative component in ethics introduces our next topic-reasoning. Ethics Includes Reasoning Faced with the challenges of life, we have to determine what is truly good for ourselves and what is truly bad. The ethical wisdom embedded in our traditions is a rich source for discerning what is good or bad, but it is not enough. Sometimes moral traditions misguide us; our tradition found slavery morally acceptable for centuries but now condemns it. Sometimes, and this is especially true in health care, our moral traditions fail to guide us because our predecessors never experienced or even When responding to the moral questions created by new techniques and technology such as ventilators, artificial hearts, transplantation, cardiopulmonary resuscitation, medical feeding, and medically assisted reproductive interventions, for example, we are very much on our own because we are the first generation to encounter these situations. Following moral traditions, the moral responses given by previous generations, although important, simply will not do. Aristotle correctly identified what we do in ethics-"All people seek the good, not the way of their ancestors." This means we have to think and reason about what will achieve a good life and not simply adopt the ready-made judgments of a moral tradition constituted by our predecessors. Discerning what is truly good or bad can be difficult for several reasons. First, some things seem good for us but really are not, and some things seem bad but really are good. The pint of ice cream in the freezer looks good to the overweight person with high cholesterol and heart disease but really is not, and fasting from food and fluids for many hours seems bad if we are hungry and thirsty, but it is really good for us if we are about to undergo surgery. Second, good things are often mixed with bad things. Surgery often brings life-prolonging benefits, yet it also brings the burdens of risk, pain, and physical mutilation. When the good and bad are inextricably entwined, as they often are in health care situations, reasoning can only figure out how best to enhance one's good life and reduce what undermines it. Third, our ability to figure out what is good and what is bad is always distorted to some extent by psychological and social biases beyond our control. Our view is always a point of view, the view of a particular person or persons, in a particular place, at a particular time, with a particular history, and in a particular social, cultural, and (perhaps) religious matrix. This means that theconclusions of our moral reasonings are never absolute but always relative in some degree to our historical and psychological perspectives. It is also helpful to recognize that the reasoning we encounter in ethics appears on three different levels. The first and most immediate level is the personal level. Here I find myself faced with a situation where I must not only decide what is good but actually do or be affected by what I decide. I am the moral agent. For example I am of advanced years and in declining health, and I need a lung biopsy. I have to decide whether or not it would be better for me to allow physicians to attempt cardiopulmonary resuscitation in the event of a cardiac or pulmonary arrest during the biopsy. As the result of my decision, an order not to attempt resuscitation will, or will not, be written for me. Another example: I am a physician, and a patient suffering from acquired immune deficiency syndrome (AIDS) has asked for medications I know he intends to use to commit suicide in the future. I have to decide whether it would be better to write the prescription or to refuse a dying man what he considers a reasonable request. Figuring out what I will actually decide in a particular situation where I am personally engaged is the kind of reasoning the earlier ethics of Aristotle and Aquinas (an ethics we will retrieve in this book) called prudence. The second level of ethical reasoning is judgmental. Here I also find myself considering a particular situation and want to know what will achieve the good in the circumstances, but I am not actually going to do, or be significantly affected by, what I decide. I am not the moral agent. Making ethical judgments on this level is far less personal than practicing prudence because someone else is confronted with the ethical question. In the examples given above I might be a friend of the person wrestling with the decision about

cardiopulmonary resuscitation, or I might be a colleague helping the physician decide whether or not he should give the patient with AIDS access to medications that will probably be used for suicide. Some ethicists do not make a distinction between the personal reasoning of the person actually confronted with the ethical challenge and the judgmental reasoning of the person considering the case but not so engaged that she will carry out or be significantly impacted by whatever decision is made. They consider both the personal and judgmental levels of reasoning as instances of moral judgment about what should, or should not, be done. In a sense, this is true. There are important similarities between the personal reasoning about what is good or bad when I am faced with doing and being affected by what I decide and the moral judgments I make about what is good or bad for others to do. Despite the similarities between these two levels of moral reasoning, however, there are reasons for noting the difference between them. The person faced with making a decision about something she will do or be affected by has an important existential perspective not shared by those judging behaviors they will not actually pursue. Her personal reasoning is a part of her life, her story, her future, and these existential and historical factors introduce an important context not shared by anyone else. She is not looking on as a judge; she is the principal involved in the case. In the last analysis, the final moral decision rests with the moral agent faced with doing or being affected by what she decides, and her position is unique. This uniqueness is better preserved by distinguishing the personal and the judgmental levels of moral reasoning, a distinction reminiscent cent of that previously made in theological ethics between following one's conscience even when everyone else's ethical judgments might indicate one should do otherwise. In this book we will not be operating on the personal level of ethical reasoning because you and I are not actually going to carry out, or be affected by, the evaluative decisions we make in the cases we study. When we study the cases we will be operating on the level of judgmental reasoning, not prudence or personal reasoning, just as we do when we try to help friends figure out what is good or bad, or when we review cases in ethics committee meetings at a hospital or nursing home, or when we make moral judgments about particular cases reported in the media, and so forth. At the same time, since the personal and judgmental levels are similar, experience in reasoning soning on the judgmental level will ideally help us to make better personal decisions in our lives when we are actually faced with ethical challenges similar to those we study in this book. These challenges are ones that practically nobody can avoid. Most of us will be making morally

significant health care decisions for ourselves and for others, most likely our parents, spouse, or our own children. The third level of ethical reasoning is theoretical. Here we study carefully and critically what others have written and said about ethics, and we attempt to develop some sort of theoretical account that explains the nature of ethics. If I try to show that biomedical ethics is fundamentally a matter of obligations derived from principles and rules, or if I try to show that biomedical ethics is fundamentally not a matter of obligation but of following our natural inclination to achieve a good life and to live well, I am reasoning on the theoretical level. Also on the theoretical level are the attempts to develop an ethics based on divine law (as found in the Hebrew, Christian, and Islamic traditions), and the attempts to base an ethics on natural law, on natural rights, on the greatest happiness principle, and on the respect-for-persons principle that obliges us to treat every person as an end and not merely as a means. The theoretical study of the nature of ethics, its concepts, and its language is the work of ethicists-the moral philosophers and moral theologians. They try to explain what ethics is all about and to clarify the thoughts and language we use in our judgments and personal decisions. It is very important and very demanding work that requires extensive study. There is a large body of important ethical literature stretching from Plato, Aristotle, the Stoics, and early Hebrew and Christian texts, through Cicero and Augustine, Aquinas, Spinoza, Locke, Hume, Kant, Hegel, Bentham, and Mill, to the seminal authors of our own century. It all must be understood to some extent if one is to enter the conversation about ethics on the theoretical level. Although the theoretical study of ethics-moral philosophy and moral theology-seems far removed from our personal ethical reasoning about what to do in a particular situation, it is not

.Ethical theory does have an impact on our lives, although its role is often unnoticed until we undertake a serious and critical examination of our moral beliefs. Hence, the academic or theoretical ical work we do in ethics, no less than the cases on which we form judgments, has the same practical goal as does our personal deliberation when we are confronted with a situation where we have to decide what to do. That goal is learning how to live well. Since this volume is not intended for the specialist, the emphasis is not on the theoretical level. Nonetheless, some theoretical background is necessary, and we will present some theoretical considerations in the early chapters of the book. Most of the time, however, we will work on the judgmental level of ethical reasoning. We will try to make our judgmental reasonings as close as possible to the personal reasoning of a moral agent engaged in an existential situation by looking at actual cases from the different perspectives of the patient, the proxy, the physicians, the nurses, the attorneys, the administrators, and the judges. In this way the ethical analysis of each case will approximate the prudential reasoning each of us practices in life as we strive to live well. The work on the theoretical and judgmental levels will enrich our ability to discern and to do what actually will better achieve the good in our lives. All the work we do in ethics, even the theoretical work, has the same attractive goal of achieving personal happiness in our lives. We turn next to a description of the two kinds of ethics we find in our cultural tradition. Two KINDS OF ETHICS The major ethical theories in our cultural background fall into two general groups. The theories of the first group are related by the emphasis they place on moral obligation, or duty. Behavior in accord with our moral obligation is considered morally right; behavior not inaccord with our moral obligation is considered morally wrong. Underlying these theories is the assumption that people do not naturally tend and desire to live well. If this assumption is embraced, it makes sense to say that people must be obliged to live well and that the morality of behavior is a morality of duty. Moralities of obligation are moralities of law, where law is understood as a system of precepts or rules people are obliged to follow. Moralities of law appear in different forms. Some rely on divine law, others on natural law, still others (Kant, for example) on the moral law we give to ourselves. Today the morality of law appears most frequently as an ethics based on principles, rules, and rights, where the principles, rules, and rights are understood as action-guides that we have a moral obligation or duty to observe and respect. The theories of the second group are related by the emphasis they place

accord with our moral obligation is considered morally wrong. Underlying these theories is the assumption that people do not naturally tend and desire to live well. If this assumption is embraced, it makes sense to say that people must be obliged to live well and that the morality of behavior is a morality of duty. Moralities of obligation are moralities of law, where law is understood as a system of precepts or rules people are obliged to follow. Moralities of law appear in different forms. Some rely on divine law, others on natural law, still others (Kant, for example) on the moral law we give to ourselves. Today the morality of law appears most frequently as an ethics based on principles, rules, and rights, where the principles, rules, and rights are understood as action-guides that we have a moral obligation or duty to observe and respect. The theories of the second group are related by the emphasis they place on the good of the person performing the action. Behavior making our lives good is considered virtuous, and behavior making our lives bad is considered worthless and a vice. These theories of the good assume that most everyone naturally seeks to live well, and they make this desire for a good life the starting point of ethics. The key notion of modern ethics-obligation-is scarcely present in the theories of this group. It makes little sense to say people are obliged to seek what they already want. Instead of obligation, the key notion in an ethics of the good is virtue. Virtues are the feelings, habits, and behaviors that do in fact create a good life. The two kinds of ethics, of course, are not totally unrelated. After all an ethics encouraging people to live up to their obligations implies it is good for them to do so, and an ethics encouraging people to live well implies living up to their obligations. Yet the differences between an ethics of obligation and an ethics of the good are important, and they result in two significantly distinct approaches to ethics. An example from a seminal work that has influenced many American ethicists reveals clearly the difference between an ethics rooted in obligation and duty and an ethics rooted in the good and virtue. At the end of his important book The Right and the Good, W. D. Ross wonders whether duty or love would be a better motivation for moral actions. In other words, which actions are morally superior-those done for duty or those done for love? His conclusion is consistent with his preference for what is right over what is good: "The desire to do one's duty is the morally best motive." He acknowledges that many will question this and argue that actions springing from love are morally superior to actions springing from duty, but he argues that they are wrong. When a genuine sense of duty conflicts with any other motive (even love), the sense of duty takes precedence. And if, Ross tells us, both love and duty incline us to one and the

better if we act from the motivation of duty rather than from the motivation of love: "We are bound to think the man who acts from sense of duty the better man." This kind of ethics suggests that parents caring for their children act in a morally superior way when they care for them because it is their duty, rather than because they love them. It suggests that a partner in a marriage behaves in a morally superior way when he supports his wife because it is his duty, rather than because he loves her. It means a physician or nurse acts in a morally superior way when his interaction with patients is motivated by the duties of the clinician-patient relationship rather than by the love of neighbor. It is precisely this priority of duty over love that separates sharply the moralities of obligation from the moralities of the good. In the ethics of Aristotle and Aquinas retrieved in this text, love is the major virtue whereby we constitute and create our lives as good lives. Aristotle devoted more space to love in the Nicomachean Ethics than to any other virtue, and Aquinas made love the crowning virtue of his moral philosophy and theology. There is, then, a kind of fundamental option in health care ethics today-the option between an ethics based on obligation and duty, with its principles, rules, and rights that we must obey and respect, and an ethics based on living well, with its virtues that create a good life. The ethics of obligation has appeared in many forms in our ethical tradition. We turn next to its major historical manifestations. HISTORICAL VERSIONS OF THE ETHICS OF OBLIGATION We can identify five major versions of theories based on obligation. The first two versions originated nated over two thousand years ago, the remaining three emerged only in the past few centuries.Divine Law Theories These influential theories originated in the land recognized today as Iraq but known in ancient times as Babylonia and Mesopotamia. Here a nomadic patriarch named Abraham was born and grew up about four thousand years ago. Consistent with the Semitic cultures in this area of West Asia, Abraham and his people believed that God gives commandments to his people. God's law creates the moral obligations in our lives; human beings are obliged to follow the laws of their Creator. The divine law theories continue today in the Jewish, Christian, and Islamic religious traditions, tions, for these are the three major world religions tracing their lineage to Abraham and his God. Most people in our culture became familiar with the divine law theory when they first heard of the "Ten Commandments," a set of laws Moses promulgated to his people over three thousand years ago. These commandments, along with hundreds of other divine laws, are preserved in the early books of the Hebrew Bible, which many Christians call the Old Testament. Natural Law Theories Plato is widely recognized for his efforts to develop an ethics based on metaphysical norms (that is, on otherworldly, transcendent, eternal, unchanging "Ideas" or normative "Forms") that the wise person must grasp in order to know what is good or bad behavior in the particular situations of this temporal and changing world. At the end of his life, however, after wrestling with numerous difficulties about the famous metaphysical Ideas or Forms, Plato began to speak of physical nature in a morally normative way. He began to argue that actions were virtuous if they were "according to nature" and not virtuous if they were "contrary to

Most ancient people, for example, believed with Job and Sophocles that bad things happen to good people without reason and that tragedy can destroy a good life. The Stoics were popular because they assured people that this was not so, that "everything thing happens for the best" in a universe permeated by rational order. According to some scholars, these two Stoic notions-the logos of nature and acting "according to nature"-were independently developed into "acting according to the natural law" by two important figures, Cicero of Rome and Philo of Alexandria. Both of these major figures may have been influenced by a common source, Antiochus of Ascalon (ca. 13o-68 B.C.E.), whose doctrine trine represented a transformation of early Stoicism's "according to nature" to an inchoate notion of "according to the law of nature." Cicero studied in Greece and wrote extensively on Greek ethics in Latin during the last century before the common era. In his treatments of the Stoics he sometimes freely translated the "logos of nature" as the "law of nature," and "according to nature" as "according to the law of nature." Greek philosophy had almost always distinguished nature and law, physis and nomos (although Plato's remarks in The Laws are an exception to this), but Cicero tended to obliterate the distinction. He wrote in his Laws: "The highest reason (logos in Greek, ratio in Latin) implanted in nature is law, which commands what ought to be done, and forbids the opposite" (I, v, 18). Cicero put the moral law into nature and thus presided at the birth of natural law theories. With him, the transition from "according to nature" to "according to the law of nature" and "according to natural law" became reality. His ideas were later developed at length by Roman jurists looking for a theoretical foundation for civil law, by Christian canonists eager to provide a foundation for Church law, and byIn the past few centuries many ethicists have moved away from the claim that our moral obligations arise either from divine law or from natural law. In place of these older theories, they have created several new approaches. The major ones are natural rights, utilitarianism, and a universal moral law we give to ourselves. Natural Rights

Some ethicists, following political philosophies developed by Thomas Hobbes and John Locke, say that our moral obligations come from individual rights possessed by all people. People are thought to have natural or human rights, chiefly the right to life, the right to choose, and the right to property, and our obligation is to respect these rights. These theories of obligation are called rights-based based theories. Rights-based theories of moral obligation explain the tendencies to justify ethical judgments on the basis of such rights as the right to health care, the right to life, the right to choose, the right to refuse treatment, the right to die, and so forth. If someone has a right to die, a rights-based theory obliges us to respect that right; if a fetus has a right to life, the theory obliges us to let the fetus live; if a woman has a right to choose abortion, the theory obliges us to let her have it; if a person has a right to health care, the theory obliges someone to provide it. Utilitarianism Some ethicists, following Jeremy Bentham and John Stuart Mill, say that our moral obligation arises from what will benefit the most people. We are obliged to act on behalf of the greatest happiness for the greatest number. These theories are called utilitarian because our obligation is to use whatever means are useful for achieving the greatest happiness. Although it is misleading to say simply that utilitarianism is a philosophy whereby the end, the greatest happiness for the greatest number, justifies the means, this caricature does help us to grasp in a preliminary way the basic dynamic of the moral theory. Today, most utilitarian theories are rule utilitarianisms; that is, our moral obligation is to follow the rules that will result in the greatest happiness for the greatest number. For example most utilitarians accept the rule stating that it is immoral to kill an innocent person intentionally. They argue that I amAutonomous Moral Law By autonomous moral law we mean a moral law that comes neither from God nor from nature but from ourselves. The Greek roots of "autonomous" are "self" and "law." Each ancient Greek city was autonomous (that is, it made its own laws), and this is why the cities were called city-states. In this moral theory of autonomy, we constitute the moral law for ourselves. This may sound like pure subjectivism or even anarchy, but it is not. The originator of this powerful moral theory, the eighteenth-century German philosopher Immanuel Kant, insisted that any maxim that we propose as a moral law for ourselves must be universally desirable (that is, the maxim must condone the behavior that we would want everyone to do). Hence, if I find myself in a tight spot and need a lie to escape, I might consider giving myself a moral maxim that permits lying. But no moral maxim can condone lying because no reasonable person would want such a maxim to be universal (that is, to be a maxim that would apply always and everywhere). And why not? Because a universal moral maxim permitting lying would make life impossible. Such a maxim would make it morally right for the bank to lie about the balance in my account, for the airline to lie about the destination of my flight, for the surgeon to lie about my need for surgery, and for the professor to lie about the quality of my work in the course. Kant's theory is an example of a deontological theory of obligation. Deontological theories oblige us to avoid certain actions without exception. The proscribed actions are always immoral regardless of good intentions, of extenuating circumstances, or of the

Supplement the prima facie principles and duties. The deductive component begins when we apply one of the general norms-a divine or natural law, or a human right, or an action-guiding moral principle-to a particular situation. By applying the law, right, or principle to the particular situation, we are able to make a moral judgment ment that reveals our moral obligation in the particular case. For example if we begin with a human right as a general norm-the right to life, for instance-and apply it to a particular situation involving a feeding tube sustaining the life of a permanently unconscious patient, then we could easily judge that the withdrawal of the tube is unethical because it violates the patient's right to life. This moral judgment would then oblige us to continue the feeding tube. The inductive component of the deductive-inductive reasoning is what gives rise to the general norms and allows us to modify them. It does this chiefly in two ways. First, from our inherited social practices and rules we can generate general norms and, if necessary, subsequently revise them. The general norms are then applied to future situations. Second, from the judgments we make in particular cases we can develop general principles and rules and then apply them (sometimes in a modified way) to future analogous cases as these occur. This latter form of induction tion is often called casuistry. The deductive-inductive model of moral reasoning can be sketched as follows. If the moral reasoning makes the theory and norms foundational and then applies the norms to particular cases to

Divine Law Theories These influential theories originated in the land recognized today as Iraq but known in ancient times as Babylonia and Mesopotamia. Here a nomadic patriarch named Abraham was born and grew up about four thousand years ago. Consistent with the Semitic cultures in this area of West Asia, Abraham and his people believed that God gives commandments to his people. God's law creates the moral obligations in our lives; human beings are obliged to follow the laws of their Creator. The divine law theories continue today in the Jewish, Christian, and Islamic religious traditions, tions, for these are the three major world religions tracing their lineage to Abraham and his God. Most people in our culture became familiar with the divine law theory when they first heard of the "Ten Commandments," a set of laws Moses promulgated to his people over three thousand years ago. These commandments, along with hundreds of other divine laws, are preserved in the early books of the Hebrew Bible, which many Christians call the Old Testament. Natural Law Theories Plato is widely recognized for his efforts to develop an ethics based on metaphysical norms (that is, on otherworldly, transcendent, eternal, unchanging "Ideas" or normative "Forms") that the wise person must grasp in order to know what is good or bad behavior in the particular situations of this temporal and changing world. At the end of his life, however, after wrestling with numerous difficulties about the famous metaphysical Ideas or Forms, Plato began to speak of physical nature in a morally normative way. He began to argue that actions were virtuous if they were "according to nature" and not virtuous if they were "contrary to nature." In his last work, The Laws, Plato had the "Athenian stranger" (undoubtedly Socrates) say that there is an "unwritten law" against incest recognized by everyone. The Athenian stranger then argues that legislators ought to mold public opinion in such a way that people will recognize that this unwritten law should be extended to all sexual behavior that is not "according to nature" (that is, all sexual behavior not appropriate for reproduction in marriage). Homosexuality, fornication, and masturbation were explicitly condemned by Plato, in addition to incest, as being not according to nature. Homosexuality also received a stronger prohibition: It is not simply not according to nature-it is "contrary to nature," a transgression of nature. Although "according to nature" is not an exact equivalent of "according to natural law," Plato's use of the phrases "unwritten law," "according to nature," and "contrary to nature" is obviously ously normative. He believed that sexual actions not in accord with nature are immoral and should become the subject of legal prohibitions. Early Greek Stoicism (a philosophy inaugurated by Zeno, who had studied at Plato's Academy in Athens more than a half century after Plato's death) also stressed "according to nature" as morally normative. Following Plato, the Greek Stoics did not explicitly speak of natural law, but they did view nature as permeated by a rational order (logos) and then concluded that ethics is living and acting "according to rationally ordered nature." The Stoic influence on ancient thought was immense. Stoicism played a dominant role in the moral thinking of the ancient world until late in the fourth century of the common era, when Christianity replaced it after the Roman emperor made Christianity the official religion of the vast empire in southern Europe, northern Africa, and the Middle East. Many Stoic ideas continue anonymously in our culture to this day.rights,him. Autonomous Moral Law By autonomous moral law we mean a moral law that comes neither from God nor from nature but from ourselves. The Greek roots of "autonomous" are "self" and "law." Each ancient Greek city was autonomous (that is, it made its own laws), and this is why the cities were called city-states. In this moral theory of autonomy, we constitute the moral law for ourselves. This may sound like pure subjectivism or even anarchy, but it is not. The originator of this powerful moral theory, the eighteenth-century German philosopher Immanuel Kant, insisted that any maxim that we propose as a moral law for ourselves must be universally desirable (that is, the maxim must condone the behavior that we would want everyone to do). Hence, if I find myself in a tight spot and need a lie to escape, I might consider giving myself a moral maxim that permits lying. But no moral maxim can condone lying because no reasonable person would want such a maxim to be universal (that is, to be a maxim that would apply always and everywhere). And why not? Because a universal moral maxim permitting lying would make life impossible. Such a maxim would make it morally right for the bank to lie about the balance in my account, for the airline to lie about the destination of my flight, for the surgeon to lie about my need for surgery, and for the professor to lie about the quality of my work in the course. Kant's theory is an example of a deontological theory of obligation. Deontological theories oblige us to avoid certain actions without exception. The proscribed actions are always immoral regardless of good intentions, of extenuating circumstances, or of thesupplement the prima facie principles and duties. The deductive component begins when we apply one of the general norms-a divine or natural law, or a human right, or an action-guiding moral principle-to a particular situation. By applying the law, right, or principle to the particular situation, we are able to make a moral judgment ment that reveals our moral obligation in the particular case. For example if we begin with a human right as a general norm-the right to life, for instance-and apply it to a particular situation involving a feeding tube sustaining the life of a permanently unconscious patient, then we could easily judge that the withdrawal of the tube is unethical because it violates the patient's right to life. This moral judgment would then oblige us to continue the feeding tube. The inductive component of the deductive-inductive reasoning is what gives rise to the general norms and allows us to modify them. It does this chiefly in two ways. First, from our inherited social practices and rules we can generate general norms and, if necessary, subsequently revise them. The general norms are then applied to future situations. Second, from the judgments we make in particular cases we can develop general principles and rules and then apply them (sometimes in a modified way) to future analogous cases as these occur. This latter form of induction tion is often called casuistry. The deductive-inductive model of moral reasoning can be sketched as follows. If the moral reasoning makes the theory and norms foundational and then applies the norms to particular cases to

supplement the prima facie principles and duties. The deductive component begins when we apply one of the general norms-a divine or natural law, or a human right, or an action-guiding moral principle-to a particular situation. By applying the law, right, or principle to the particular situation, we are able to make a moral judgment ment that reveals our moral obligation in the particular case. For example if we begin with a human right as a general norm-the right to life, for instance-and apply it to a particular situation involving a feeding tube sustaining the life of a permanently unconscious patient, then we could easily judge that the withdrawal of the tube is unethical because it violates the patient's right to life. This moral judgment would then oblige us to continue the feeding tube. The inductive component of the deductive-inductive reasoning is what gives rise to the general norms and allows us to modify them. It does this chiefly in two ways. First, from our inherited social practices and rules we can generate general norms and, if necessary, subsequently revise them. The general norms are then applied to future situations. Second, from the judgments we make in particular cases we can develop general principles and rules and then apply them (sometimes in a modified way) to future analogous cases as these occur. This latter form of induction tion is often called casuistry. The deductive-inductive model of moral reasoning can be sketched as follows. If the moral reasoning makes the theory and norms foundational and then applies the norms to particular cases todetermine what we are obliged to do, then it is primarily deductive, and the morality is usually described as applied normative ethics. If the moral reasoning stresses the origin of the norms in particular judgments coalescing over time into a common shared morality giving rise to general rules obliging us in analogous cases, then it is primarily inductive and is sometimes called casuistry. If the moral reasoning moves with ease from the general norm to the particular and from the particular to the general norm, it is thought of as coherentist, and its dynamics is sometimes described as an ongoing reflective equilibrium. Coherentism is a term describing the effort to develop a coherence between the general norms and the particular judgments by constantly adjusting each as experience develops. In practice, however, most coherentists tend toward the path staked out by Frankena; that is, the principles are primary. The deductive reasoning in the deductive-inductive model is analogous to the reasoning we find in geometry. Certain geometrical axioms are given, and from them we can deduce certain truths about particular figures-circles, triangles, rectangles, and so forth. The axioms are true by definition, and if they are applied to a particular figure correctly through deductive reasoning, the conclusions about the particular figure will be true. Moralists disagree on where the analogues to the axioms-the principles or laws-come from. Some say they precede or transcend our experience, ence, as in the theories of divine laws or Kantian moral law; others say they come from a universal common morality. Once established, however, they tend to operate deductively; the principles and laws are norms employed to determine what people are obliged to do. Sometimes the geometrical flavor of contemporary moral theory emerges explicitly. John Rawls, an advocate of reflective equilibrium, nonetheless wrote in his landmark book ,4 Theory of Justice: "The argument aims eventually to be strictly deductive.... Clearlyarguments from such premises can be fully deductive, as theories in politics and economics attest. We should strive for a kind of moral geometry with all the rigor which this name connotes." What follows are some extremely simplified examples of deductive moral reasoning in health care ethics using the rights-based and principles-based approaches. When you look at these examples, ples, set aside your opinions; that is, pay no attention to whether or not you agree with the conclusions. sions. Focus instead on the structure of the reasonings. Notice how they employ a general principle or a right that everyone is believed to have, and then apply it to a particular situation in order to generate a conclusion. Remember also that we are leaving aside questions about where the general principles or rights originated; it makes no significant difference in these reasonings whether the principles or rights were derived from a transcendent or transcendental source such as divine law or Kant's pure reason, or from shared moral tradition, a common morality we inherited much as we inherit a language. i. The general principle is that we must always do what will result in the greatest happiness for the greatest number; this withdrawal of life-sustaining treatment will bring the greatest happiness ness for the greatest number; therefore, this withdrawal is morally justified. 2. The general principle is that we must always treat another person as an end and never merely as a means; this cesarean section is treating the woman merely as a means because its sole purpose is to let a resident practice the surgery; therefore, this surgery is not morally justified. 3. The most fundamental right is the right to life; withdrawing nutrition and hydration will cause loss of life by starving the person to death; therefore, withdrawing CONTRASTING THE ETHICS OF OBLIGATION WITH AN ETHICS OF THE GOOD The basic idea in an ethics of the good can be expressed in three relatively simple assumptions. First, it is taken as uncontroversial that people do not simply want life, but a good life; that people do not simply want to live, but to live well. Second, it is also taken as uncontroversial that achieving a good life, living well, depends to some extent on the choices we make in life. Finally, it is taken as uncontroversial that intelligent choices, choices that constitute rather than undermine living well, require thought and reasoning. Ethics clarifies the goal we all seek-a good life-and determines, mines, to the extent it can be determined, the choices we need to make to achieve it. Clarifying what truly constitutes a good life and deliberating thoughtfully about how to achieve it in the actual and varied situations confronting us in life constitute the subject matter of ethics in an ethics of the good. It is important to understand that the good life or living well is not something we should or ought to seek, but something we in fact do seek. Aultimate and underlying goal of every human being. Nobody in his right mind would strive to live a bad life, to live badly. It is also important to understand that the good life I seek in this ethics is my own happiness and good. What I seek is my good, a good life for myself. Rightly understood, this is not, as we will see, selfishness. My good is inextricably interwoven with the good of others, especially those who are my family, friends, and members of my communities. This ethics of the good, no less than the ethics of obligation, is a normative ethics. The norm is a good life, a life of fulfillment and flourishing. The feelings, habits, and behaviors that constitute living well are precisely the feelings, habits, and behaviors that are ethical; those that undermine living well are unethical. In an ethics of the good, the reasoning is not an effort to deduce moral judgments from rights, principles, or rules. Rather, the person first acknowledges that the overarching goal of life is to live well, and then he figures out what will achieve this goal. The feelings, habits, and actions contributing to a good life are called the virtues; those that undermine a good life are worthless and can be called the vices. The deliberation or practical reasoning called prudence does not lead to a moral judgment that I am obliged to obey whether I want to or not but to a moral decision that I want to execute because the behavior will make my life good. RETRIEVING THE ETHICS OF THE GOOD The ethics of the good has not been fashionable for centuries. One reason why it fell out of favor was the difficulty in clarifying just what constitutes a good life. In this section we need to give a brief account of what we mean by a good life and also to explainwhy it is important to include a figure such as Aquinas in our retrieval of the ethics of the good from Aristotle. In chapter six we will develop the notion of what constitutes one of us; that is, a notion of what it means to be considered a member of the human population. We will suggest that the notion of "psychic body," what many refer to as sentience, is key for understanding when one of us exists. A human body becomes psychic when it becomes even minimally aware, and a human body ceases to be psychic when it can no longer be even minimally aware. A fetal human body becomes one of us when it begins to feel; and a totally unconscious human body ceases to be one of us when it suffers irreversible loss of all awareness or feeling. If we consider each one of us a psychic or sentient body, then our question about what constitutes a good life is a question about what is good for a psychic human body. This is, after all, what each of us is, regardless of our age, race, gender, and so forth. For purposes of analysis we can distinguish several major natural inclinations each one of us-each psychic body-possesses. Although it is somewhat arbitrary to separate the interwoven strands of any existing psychic body, three important sets of inclinations characterize human psychic chic bodies. First, some inclinations are markedly biological in nature, and satisfying them contributes to a good life. Living well means we have adequate food, shelter, health, and so forth. Second, some inclinations are markedly psychological in nature, and satisfying them contributes butes to a good life. Living well means we have satisfying emotional and cognitive lives and the freedom or liberty to exercise some choice over how we live and what we do. Third, some inclinations are markedly social in nature, and satisfying them contributes to a good life. Living well means we have healthy interpersonal relationships of love and friendship, contractual agreements with others rooted in justice, and relationships with the political community nity constituting the society in which we live. Living well means living in supportive political and institutional environments that help people flourish. Human existence is always a coexistence, an existence with others, and this coexistence is sometimes interpersonal, sometimes contractual, sometimes communitarian, and, thought Aristotle, always political. Each of us has inclinations to forge relations with loved ones and friends, to enter into agreements with others, and to live in just and peaceful communities that we help to build. The political community is not a social contract we establish for the protection of our individual rights; our very existence is fundamentally communal as well as personal. Building community is building a good life for ourselves because living in a well-ordered society working toward peace and justice contributesthe right to self-determination, the right to life, the right to die, and the right to health care, create obligations binding on others is very strong. Still strong, also, is the idea that both utilitarianism and Kantian deontology, different as these two theories are, somehow generate or at least defend a common set of normative principles (autonomy, beneficence, justice, and nonmalificence) that serve as general guidelines for formulating lating more specific rules that we are obliged to follow in practice. More recently the idea of a universal "common morality" containing rules of obligation applicable to all people in all places at all times as well as character traits that are universally admired has been gaining attention. Some say that this common morality, and not any moral theory, is what provides the four initial foundational tional norms or principles for bioethics that develop through a process such as reflective equilibrium into a coherent set of more specific rules for guiding our behavior If you are at all familiar with the dominant vocabulary of American bioethics, you are undoubtedly aware that it is an ethics based on principles, most notably the principles of autonomy, beneficence, justice, and nonmaleficence. People involved in health care, especially physicians and nurses, are expected to observe rules and rights derived from these general principles to determine what they are morally obliged to do in particular situations. If the principles clash, as they often do, then they must be balanced against each other to determine which one obliges or they must be adjusted to preserve coherence in the system. In the minds of many, making moral decisions and judgments in health care ethics remains a process of guiding our actions in accord with the obligations tions and rights established by the general principles and the more specific rules derived from them. In chapter 14, a chapter devoted to medical research, we show how this philosophical approach, now called by some "principlism," received a major boost when Congress set up the National Commission for the Protection of Human Subjects in 1974. Congress asked the Commission sion to identify basic ethical principles and to develop ethical guidelines derived from these principles ples that could be applied to biomedical and behavioral research. In 1979 this Commission issued its final report, known as the Belmont Report, in which it dutifully identified three basic principles: respect for persons (autonomy), beneficence, and justice. It described a basic ethical principle as a "general judgment that serves as a basic justification for particular prescriptions and evaluations of human actions." The theoretical background of basing ethics on principles that oblige, however, was established lished decades before the National Commission. It goes back to several prominent moral philosophers phers who developed the ethics of duty to a high degree. One such influential philosopher was William Ross, whom we have already mentioned. A brief consideration of ethics of obligation, which has influenced many prominent American bioethicists, will help us to understand something of the background of the National Commission and of American bioethics. Unlike Kant, who had proposed that some duties deriving from his single basic principle of morality were so strict that no exceptions could be tolerated, Ross suggested a cluster of prima facie duties. For Ross the term "prima facie duty" referred to the characteristic of the kinds of action that we would be obliged to perform if the action in the particular case would not be in conflict with another prima facie duty. For example, the prima facie duty of fidelity requires me to keep my promises, but if I had promised to take my son for ice cream at three o'clock and he breaks his arm at two-thirty, then the prima facie duty of beneficence (taking him for medical treatment) overrides the prima facie duty of fidelity that obliges me to keep my promises. Ross named six basic prima facie duties: beneficence, justice, not injuring others, self-improvement, improvement, gratitude, reparation, and fidelity. Today Ross's prima facie duties, and the exercise of balancing or weighing them when they are in conflict, have reappeared in American bioethics as prima facie principles, most notably the prima facie principles of autonomy, beneficence, nonmaleficence, leficence, and justice. These principles are normative principles, and it is our duty to abide by them. However, and this is what makes them prima facie, whenever these principles conflict, we have to balance them against each other to determine which one prevails in the particular situation. Hence, although these principles are normative (that is, more than rules of thumb), they are not absolute because they can be overruled by other principles. Most of the textbooks on health care ethics published in the last two decades of the twentieth century-the books designed to help medical and nursing students learn about health care ethics-relied relied chiefly on a handful of basic principles and rules derived from them as the basis for moral judgment. The ethics of principles is an ethics of obligation; it is never far from the idea that ethics is about our duties and not about the natural desire to live well. More recently, however, some of the new editions of health care ethics textbooks, largely as a result of the influence of an increasing interest in virtue ethics and in the ethics of care often associated with feminist ethics, now complement their ethics of principles and rules with elements borrowed from virtue ethics. For example, some ethicists who propose a universal "common morality" as the foundation and source of their principles expand the concept of "common morality" so it embraces not only principles and rules of obligation but moral character traits called virtues as well. However, as we will see in the next chapter, the notion of virtue advanced by proponents of common morality in the twenty-first century differs in substantial ways from the virtue ethics adopted in this book and from the virtue ethics found in the tradition, most notably the virtue ethics elaborated by Aristotle and Aquinas. Despite some similarities, an ethics of the good is not ultimately compatible with an ethics of obligation. An ethics of the good assumes that ethics is primarily about our natural inclination and desire to seek what is good for ourselves, and that we can figure out what is ethical by a practical reasoning called prudence, whereas an ethics of obligation assumes that ethics is primarily about our obligations and duties, and that we can figure out what is ethical by a process of deductive-inductive tive-inductive reasoning based on general principles and tempered by adjustments to achieve coherence ence or reflective equilibrium. We do have to make a fundamental choice, then, between the two approaches. In this text the choice is to adopt the ethics of the good. Seeking what is good for ourselves is not a matter of obligation