Welcome back to my Medical Ethics Series for the fourth installment! This is the first part of the Normative Ethics section, where we will be going over Normative ethics, or what rules we should follow. These theories will be more familiar, as Dr. Beyda has referenced them in his talks to us. These are theories such as Utilitarianism, Deontology, and Virtue Ethics, to name a few. Today, we will be exploring briefly what normative ethics means, and then diving into Utilitarianism.
What Ought We do? (Normative Ethics)
Normative Ethics is the area of philosophy dedicated to describing what is wrong and how we go about deciding so1. To arrive here, we have to assume some form of moral motivation, and accept some form of Metaethics that we have previously discussed. For example, if we want to be Utilitarians, we have to assume that there IS a reason to act morally AND we have to assume the Metaethics of Objectivism. Normative theories are compatible with only some Metaethical theories, so it’s worth checking whether a Normative theory that sounds correct is compatible with the metaethics you have decided upon.
Utilitarianism
A theory we have all heard about, and a word people use WAY too much, Utilitarianism is the ethical concept that maximizing good (in the form of pleasure/happiness) for the most people IS the greatest good. In the words of Commander Spock, “The needs of the many, outweigh the needs of the few, or the one.” It is a form of Consequentialism, the idea that the ENDs (rather than the means) are what should be used to judge a moral action. So for Utilitarianism, the END of “maximized good” is what we care about to determine the morality of an action2. This is a rather simple and, in some ways, intuitive method of judging morality. If I take an action that saves millions of lives, such as discovering insulin, that seems pretty good! If I do something that saves one life at the cost of many others, like ignoring all my patients for one who I like more, that seems bad. But as we will see, it is not so simple!
Pros
Let’s start with the benefits of Utilitarianism. There are two main types, ACT and RULE Utilitarianism. We will explore both here.
-ACT Utilitarianism
Bentham, the grandfather of this theory, thought that if we can create a “hedonic calculus” to weigh what action is best in a situation, and we have a net positive, then this outcome is morally desirable. This is ACT Utilitarianism3. Each action has a weight we can measure, based on the type of pleasure, the intensity of pleasure, the length of pleasure, etc. Then, you subtract the suffering from it, and decide via math if the action is good. This thought process is used in medicine frequently. When you spend a certain amount of time in a patient’s room, you are weighing if you can get to all of your other patients in time and give them good care as well, and whether you’ll have to stay later because of it and not be able to feed your dog in time. You are weighing the good of extra time with one patient (an ACT) against the consequences of doing so, and measuring the overall good.
-RULE Utilitarianism
John Stuart Mill, the prodigy who followed in Bentham’s footsteps, saw some problems with ACT Utilitarianism and decided to come up with RULE Utilitarianism. This system prescribes rules to follow on a broader scope, not allowing room for individual variance like in ACT Utilitarianism. Instead of saying, “This patient needs X amount of time”, you would say, “each patient gets 30 minutes total.” The appeal here is that people do not have room to make biased or poorly calculated incorrect judgements, and because we can apply broad-based laws on a systemic level to impose this “good,” thus avoiding justifying horrible actions “for the greater good” (we will see examples of this in the Cons section)3.
Essentially, a Utilitarian gets these two main options, ACT or RULE, with the goal of maximizing the good/pleasure for the greatest number of people.
Cons
Machiavelli, a man considered by many (but not all) to be a bad person, is famous for stating that “the ends justify the means,” something many fear about Consequentialist theories such as Utilitarianism.
-ACT Utilitarianism
Although there is seeming appeal to ACT Utilitarianism, it has some large flaws that need to be discussed. The largest hole in the theory is that of how we calculate actions. This “hedonic calculus” is impossible to create;and even if it did exist, how would you employ it for each action before you take them? But even if this was not an issue, we are faced with some serious moral dilemmas. If you have a patient who is healthy, should you kill them to harvest their organs for 8 other patients who are slowly dying? It would seem that this ACT is justified because 8 people’s suffering has ended, and only one person is lost. The intensity of those 8 people’s pleasure from being alive is massive, but the suffering of the dead person is quickly resolved because they are no longer alive. This not only seems wrong, but undermines the physician-patient relationship because no patient would ever feel “safe”, creating suffering for every patient under your care in the long term. You could argue that this threatens to throw off the calculus, creating more suffering long-term, and thus would no longer be justified. But then arises the question of how you would predict this, or calculate this? As you can see, it begins to unravel from multiple angles3.
-RULE Utilitarianism
Enter John Stuart Mill, who created RULE Utilitarianism to deal with these issues. As we have seen, the dissemination of a RULE avoids the individual discretion that can lead to an inability to calculate things. It also would allow us to make a rule that “no organs can be harvested from live patients,” which avoids the dilemma seen above, where that individual action may create more good but threatens long-term relationships and abuses the current patient you have. At first blush this seems great, but it is criticized as “collapsing into ACT Utilitarianism.” The series of rules or laws we create regarding what actions are/are not okay at its core seems to be ACT Utilitarianism. Another strong critique is that it allows the converse to be true for moral acts. Yes, we can make a rule that says “never harvest organs,” but we could make a rule that says “always harvest organs,” and RULE Utilitarianism would support this if we say this is the greatest good. You might think that this wouldn’t be good because it is causing suffering, and couldn’t be a rule. Maybe, but if we did it specifically to a population with nobody to grieve for them, and saved people with large social circles, the pleasure would surely outweigh the suffering. We can go either way depending on what we decide, which makes RULE Utilitarianism in some ways more dangerous than ACT Utilitarianism3.
-What is Pleasure?
One critique I saved for its own area is the argument over what is pleasure. This applies to both forms of the theory as a problem. How do we define this? And how do we decide that this is what is good? Even if it is good, why does maximizing overall pleasure mean it is the right thing? When I have a few too many drinks I’m much happier, so should I get drunk every night? There are answers for these attacks, but it’s worth pondering if you think these issues are not truly recoverable.
Let’s Sum It Up
One of the most common Normative Ethical theories, Utilitarianism is a simple and broad-sweeping ethical theory that offers easy guidance and an answer to the feeling that our actions’ ENDs seem to carry a lot of value. We can divide it into RULE Utilitarianism and ACT Utilitarianism, depending on if we want to focus on calculating the individual ACTs pleasure creation vs. broad-sweeping RULES and their overall pleasure creation. Although they seem simple and valuable on face-value, there are some large weaknesses that are exposed when explored further, some that threaten to make medicine a dangerous field to practice, risking exploiting patients under a moral justification of removing their autonomy, beneficence, and justice. This doesn’t mean they are wrong, but the Utilitarian has to come with some strong answers to solve glaring holes we can see.
Now that we have explored Utilitarianism, a form of Consequentialism, we are going to flip to the other side of Normative theories with Deontology, a theory that considers the action itself to hold morality, regardless of consequences. I hope to see you then!
References
Travis Seideman
Travis Seideman is a member of the Class of 2026 at UACOM-P. He attended Northern Arizona University where he studied Exercise Science and Psychology. He is planning on practicing rural Family Medicine and pursuing a fellowship in Sports Medicine.