Welcome back to my Medical Ethics Series for the fifth installment! This is the second part of the Normative Ethics section, an area focused on what rules we should follow. Last time we explored Utilitarianism, and this time we turn to Deontology. Let’s get to it!
Deontology
The concept of Deontology boils down to something intuitive: some things you shouldn’t do simply because it’s wrong. The most popular philosopher associated with this is Emmanuel Kant, although similar ideas appear in the Golden Rule, the JudeoChristian 10 Commandments, and other concepts. Unlike Utilitarianism, which focuses on maximizing good/utility, Deontology is its counterpart, focusing on the individual and what rights/duties we have. In other words, Utilitarianism is the “ends justify the means,” whereas Deontology is treating people as “ends in and of themselves.”1
Foundations
Deontology is a complicated theory, despite its surface-level intuitive nature. However, there are some core concepts we can easily understand together.
–Imperatives
A Categorical Imperative is a fancy way of saying “this action is always good/bad.” The action of murder is never ok to Kant, therefore “do not murder” is Categorically Imperative. Contrast this with Hypothetical Imperatives, or things that are good/bad for something else. An example of this would be “if you want to stay healthy, you should exercise.” While a logical statement, it has no bearing on morality to him.
How do we know which things are Categorical or not? Kant’s answer: if you could not universalize it into a law of nature, then it is a Categorically Imperative to NOT do that action.1 We will see examples below in the Duties section, but for now imagine your mom asking, “what if everyone did that?”
-Duties
The imperative is the overarching rule we follow, but what exactly are these individual actions that must be followed categorically? Duties. There are two types: Perfect duties and Imperfect duties.
Perfect duties are those that IF applied universally (as a Categorical), they would be paradoxical. For example, say someone lies to the doctor. Universalize this and say that everyone lies to the doctor. Trust would collapse and doctors would disbelieve every patient, making lying impossible in the first place. Kant would therefore say you have a perfect duty to not lie to your doctor, as it’s illogical for this to be a morally acceptable action.1
Imperfect duties are those that if not followed would create a world a rational being wouldn’t tolerate. Imagine if nobody helped others’ health, we would have very sick and short lives. But if universalized, it’s not paradoxical, it’s just that no rational person wants to live like that. Unlike Perfect duties, these duties are more flexible and can be fulfilled in a variety of ways (doctor, volunteer, etc.).1
Variants
Although Deontology is most associated with Kant, his flavor isn’t the only one. One way of differentiating all the types of Deontology is breaking them down by patient-centered and agent-centered forms.
-Agent-Centered
Agent-Centered Deontology is focused on the duties of the acting moral agent. A classic example of this is the physician, who has obligations to their patients over others’ patients. One would expect them to spend more time looking into treating their own patients’ conditions as compared to their colleagues’ patients. Morality becomes personal, although to be clear, that does not mean it is subjective. The two ways of looking at Agent-centered theories are intent or action of the agent. If a doctor means to save someone but accidentally hurts them, intent theories would say they are not morally wrong. Conversely, according to the action theories, if a physician doesn’t care about their patients but helps them for prestige, as long as they are doing their duty of helping, they’re acting morally. The weaknesses jump out here, from finding intent to be an important part of morality to claiming “the road to hell is paved on good intentions.” Many people would say neither of these physicians seem to be acting in a truly morally sound way.1
-Doctrine of Double-Effect
To address intent problems, Thomas Aquinas (famous Deontologist) formulated the Doctrine of Double Effect. Here he says that an act with both good and bad effects is permissible if: (1) the act is not bad in itself, (2) the bad effect is not intended, (3) the good does not result from the bad, and (4) the good outweighs the bad.1 For example: prescribing a drug with a 90% cure and 10% mortality is moral if the intent is to cure and the other conditions are met, even if the patient dies”
-Patient-Centered
Patient-Centered Deontology is focused on the patients, or the people being acted upon. So, rather than a physician’s duty to HIS patients, he must respect the rights of ALL patients. Here, intent is not weighed, and Patient-Centered Deontology turns on whether the victim’s body, labor, or talents were used as the means for an action.1 Consider two ICU wards supplied by the same oxygen tank. Ward A has five patients in ARDS, while Ward B has one. A malfunction occurs so the tank can feed one room, and the intensivist directs oxygen to Ward A. From a patient-centered perspective, this is morally permissible because the five patients hold a right to life-sustaining oxygen. In Ward B, the lone patient’s death is simply a tragic but unintended consequence, as their body was not used as the means. Importantly, this is not a Utilitarian justification to maximize the number saved, but rather to uphold the rights of the five patients.
By contrast, an agent-centered deontologist would claim the physician has duties to each of his patients, and actively withholding oxygen from one would violate that duty, rather than passively letting them all die.
An important weakness to point out here is that patient-centered views don’t care about intent. This intensivist could WANT to kill that patient and still be morally sound, as the action he takes doesn’t use the body/labor/talents of the patient.
-Contractualism
There is a newer and complicated variant of Deontology called Contractualism. Full disclosure, this is the normative theory that I stand by, although sadly I won’t have much time to discuss it here. It’s also something I’ve happily accused Dr. Beyda of being, despite his claims of being a Virtue Ethicist (next article’s topic).
As T.M. Scanlon writes it, Contractualism considers actions that we can reasonably justify to each other to be moral. By respecting one another’s individual situation, and ignoring the aggregate (Utilitarianism), it’s a Deontological-esque theory. However, within those justifications we can consider consequences, thus making it not pure Deontology.1,2 An example of this is a shared-decision making conversation with a patient. The patient wants something, you want to respect their rights in this decision, but hope they respect your clinical expertise as well, and together you try to see what you can reasonably decide. This concept is an interesting way of trying to avoid the weaknesses in Deontology, while retaining the respect for one another’s fundamental rights. Admittedly, trying to avoid these weaknesses brings on its own host of other weaknesses (e.g. what is reasonable?). For further reading, John Rawl’s Veil of Ignorance argument3 is a famous Contractualism thought-experiment I highly encourage you to look at.
Weaknesses
I have sprinkled weaknesses throughout this article already, but there are a few doozies to address. First, this system is RIGID. A duty that is absolute (do not lie) would mean you couldn’t lie to save someone’s life. What about if I have to betray my patient’s trust to report a deadly illness? Does my duty to my patient override? Are some duties worth more than others? A second issue is the lack of consideration for consequences. Doesn’t the outcome matter? As a doctor during a mass casualty event, if I choose to save 100 patients at the cost of my own 10 clinic patients, while horrifying, that doesn’t feel morally depraved.
Let’s Sum It All Up
A popular Normative theory, Deontology focuses on duties and rights of people, rather than outcomes. We can divide it into agent-centered and patient-centered views, based on whose perspective we are considering. Agent-centered views can be further broken down by an intent or action perspective, and the Doctrine of Double-Effect tells us that we can’t try to sneak in immoral actions under the guise of being good. Lastly, Contractualism focuses more on justifying our actions to each other, trying to avoid the strict and limiting nature of classical Deontology. However, from conflicting duties, to rigid rules, there are apparent weaknesses to wrestle with in all forms of Deontology if we are to accept it. Next time, we will move to the final of the “big three” of Normative theories, Dr. Beyda’s favorite…Virtue Ethics, a theory focused on the kind of person you should be, rather than your duties or outcomes.4 I hope to see you then!
Works Cited
- https://plato.stanford.edu/entries/ethics-deontological/
- https://plato.stanford.edu/entries/contractualism/
- https://plato.stanford.edu/entries/original-position/
- https://plato.stanford.edu/entries/ethics-virtue/
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.