A fragment on ethics for a chapter called 'Ethics in catheter-based cardiovascular interventional therapy' co-authored with P. Lanzer, MD.
This chapter examines the ethics involved in catheter-based cardiovascular interventions as nested within iterated larger structures of ethics. The ethics of catheter-based cardiovascular interventions are a particular instance of medical ethics. Those in turn are a particular application of professional ethics. And those in turn are the application of general ethical concerns to the specific case of those subjects bound into a profession or institution. Hence the chapter starts with a thumbnail sketch of the most general context and philosophical approaches taken to it and subsequently refines this to consider the increasingly specific matters.
Glossary of Terms
Consequentialism: the view that the moral value of an ethical judgement or action depends only on whether it has good consequences
Deontology: the study of duty and obligations underpinning judgments of the compliance of an actor with deontological ethics and hence the moral status of their actions
Ethics: field of philosophical study concerned with morality, both its general nature and particular prescriptions
Morality: the standards of goodness, virtue or of right conduct. Common morality concerns shared moral standards, if they exist; applied morality concerns particular moral standards of specific human practices such as membership of a profession.
Knowledge-that: propositional knowledge of facts or of what is the case. Such knowledge is often analysed as true belief with a suitable pedigree such as justification or warrant.
Knowledge-how: knowledge required to perform actions sometimes called ‘know-how’.
Ontology: the philosophical study of what exists including most abstractly Being itself but also puzzling ‘objects’ such as numbers and values and their place in nature
Particularism: the view that moral judgements cannot be encoded in moral principles and instead answer to the objective moral values inherent in particular situations.
Principlism: the view that moral judgements can be encoded in moral principles.
Phronesis: a type of expertise directed at recognizing the practical demands and moral obligations implicit in particular situations.
Profession: a profession an activity requiring institutionalized training, specialized knowledge and standards on practice. Professionals are adequately trained, qualified and certified individuals required to adhere to professional standards. Expertise of professionals is based on exercise of specific knowledge and morality
Virtue ethics: the view that the moral value of ethical judgment depends on the character of a moral subject
CBCVI - Catheter-based cardiovascular interventions
QALY - Quality Adjusted Life Year
‘Ethics’ is the name for the philosophical study of moral standards, the standards of goodness, virtue or of right conduct. Such philosophical study divides roughly into normative ethics, on the one hand, which concern prescriptions for how to act, for example by the articulation of general rules for good conduct and, on the other hand, meta-ethics which addresses more abstract questions of what kind moral or ethical claims are. It is a metaethical question whether moral claims can be true or false and if so what makes them so. A contrasting meta-ethical view is that they merely express the feelings or emotions of a subject and do not answer to anything else. Such a view, emotivism, compares moral claims with a cry of ‘boo!’ or ‘hurrah!’ which are not even candidates for truth or falsity.
Similarly, given the former view that moral claims can be true or false; whether theyare codifiable in principles (principlism) or are essentially situation-specific judgements (particularism) and hence calling for situation-specific expertise (phronesis), is a metaethical debate (see e.g. 1).
It would be helpful if there were consistent terminology such that, for example, ‘ethics’ always referred to normative ethics and moral philosophy to meta-ethics. But sadly this is not so. Further, whilst some debates within ethics seem clearly meta-ethical or normative, there is often an overlap. For example, the debate about whether there is a common morality – a universal understanding of moral demands applicable across all times and cultures – has implications for the kind of status that moral claims have but also impacts on the nature of prescriptions that might be advanced (e.g. whether they can be advanced as anything more than local views).
Evolutionary ethics is a more recent development which has consequences for all three areas. At its most general, it aims to shed light on general ethics, the practices of making ethical claims and having moral feelings. In his book Sociobiology: The New Synthesis, Edward Wilson claims that “scientists and humanists should consider together the possibility that the time has come for ethics to be removed temporarily from the hands of the philosophers andbiologicized (2)
One reason for the relevance of evolutionary theory is that it purports to explain some of the building blocks for philosophical accounts of general ethics. “[T]he hypothalamus and limbic system ... flood our consciousness with all the emotions - hate, love, guilt, fear, and others – that are consulted by ethical philosophers who wish to intuit the standards of good and evil. What, we are then compelled to ask, made the hypothalamus and the limbic system? They evolved by natural selection. That simple biological statement must be pursued to explain ethics.” (2).
One test case for evolutionary approaches is whether they can explain how altruistic behaviour, or the ability to think that altruism is the right response in a situation, could have evolved given our ‘selfish genes’. But it is easy to see how such an explanatory project might come to have normative ethical implications if the standard of good and bad has to fit with evolutionary fitness. Further it can seem to have metaethical consequences if it is thought that ethical claims do not answer to anything external to human evolutionary history. That is, if ethical practices can be fully explained via the evolutionary advantages of, say, cooperation then that might seem to undermine the idea that moral claims answer to additional objective standards of goodness and badness. On the other hand, an evolutionary account may be of the capacity to form moral judgements in response to genuine ethical standards akin to the capacity to reason correctly about mathematics which does not reduce the apparent truths of mathematics to the contingencies of human evolution. Thus the significance of evolutionary approaches to ethics is open to debate.
There are three main competing normative ethical traditions. They are:
Consequentialism: As its name suggests, this is the view that the moral value of an ethical judgement or action depends only on whether it has good consequences. That simple characterisation hides an immediate further complexity. How should the good consequences be characterised? If the aim is to explain moral judgments, in other terms – to reduce moral to non-moral concepts, then the consequences might be, for example, defined in terms of human happiness. Thus, moral judgment would be explained as that which leads to happy consequences, morally good thus being explained using a non-moral concept of happiness. Of course, like any reductionist definition, it is open to question whether the concept of moral good can be explained using non-moral concepts. Such an approach seems to be vulnerable to G.E. Moore’s ‘open question’ objection (3). That is, because it seems to make sense to concede that an action maximizes happiness but still to question whether it is right, then goodness cannot mean maximizing happiness.
A more modest non-reductive form of consequentialism, by contrast, might instead help itself only to a morally rich notion of ‘good consequences’, or morally good consequences. This would not attempt to shed light on what is meant by ‘morality’ using independent concepts. It would not be an analysis of moral goodness in other termsbut might still help to emphasize that what matters are the effects of, rather than the motives for, moral actions.
The most famous instance of a consequentialist approach is JS Mill’s Utilitarianism which Mill summarizes as follows:
The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. To give a clear view of the moral standard set up by the theory, much more requires to be said; in particular, what things it includes in the ideas of pain and pleasure; and to what extent this is left an open question. But these supplementary explanations do not affect the theory of life on which this theory of morality is grounded- namely, that pleasure, and freedom from pain, are the only things desirable as ends; and that all desirable things (which are as numerous in the utilitarian as in any other scheme) are desirable either for the pleasure inherent in themselves, or as means to the promotion of pleasure and the prevention of pain. (4)
In medicine, utilitarianism lies at the heart of the assessment of healthcare in terms of number of years of survival; Quality Adjusted Life Year (QALY) which assesses both the quantity and quality of years lived and often forms the basis of quasi-economic assessment of competing claims for resources. The basic idea is that a year of life enjoyed with full health is given a numerical value of one. A less than fully healthy year of life scores less on a scale which reflects the experienced quality. The value of medical care can then be assessed by predicting the outcome expressed in QALY relative to the economic cost.
A central challenge for consequentialists is to reconcile the idea that the moral value of an action depends upon a kind of calculus of outcomes with our everyday ignorance of the longer term consequences of our actions. Another problem is that a utilitarian calculation may threaten individual rights if collective happiness or good sufficiently outweighs – according to consequentialist or utilitarian calculation – individual suffering. But the idea that individual rights can be so outweighed may not accord with antecedent intuitions about morality.
Deontology: On this approach, the moral value of an action is independent of the action’s actual consequences but depends instead on one or more general duties to act. Particular kinds of action are simply precluded or, contrastingly, demanded by general principles. The challenge for its supporters is thus to articulate a consistent set of principles or general duties that capture morally correct action and to explain their origin. Some duties, such as the Hippocratic injunction to do no harm, are widely and deeply held but can conflict with other equally deeply held principles to do patients well.
The most famous form of deontological theory is Kantian ethics which centres on a single high level ‘categorical imperative’ or principle:
Act only according to that maxim by which you can at the same time will that it should become a universal law. (5)
This principle flows from Kant’s argument that the key feature of morality is that moral guidance must be capable of application in any possible set of circumstances. Generality is of the essence of morality, in this view.
But even this formal constraint has content because some maxims would be self-stultifying if generalised. Kant gives the example of someone who borrows money promising to repay it but who has no intention ever to do so. If the particular case were made universal, that is if everyone behaved this way, then the institution of lending money would cease. Hence it is impossible to ‘will’ that such a principle becomes a universal law because it would undermine the possibility of satisfying the desire to borrow money. Thus, according to Kant, borrowing money with no intention to repay it cannot be a moral act. A similar example for healthcare would be selfishly deciding to benefit from blood banks, and at the same time sabotaging its very principle of blood donation. Subverting the universal maxim (blood banks are useful and needful)would conflict with the continued existence of blood banks from which one hopes to benefit, it would be self-defeating to ‘will’ it.
In addition to ruling out some actions because a maxim derived from it could not be generalised without contradiction, the first formulation of the categorical imperative also gives rise to more specific advice. Kant’s view of morality is based on a highly rationalist view. A moral agent should want to do what is good not for any subjective reasons but for an absolutely or categorically compelling end. Thus free will is a basic precondition of moral action, albeit a will to be governed by absolute principles. And if it is to be universalized, it would contradict the categorical imperative as set out above to claim that another person can be morally treated as merely a means to some end, rather than being valued intrinsically for their own sake. Hence Kant gives a further derivation of the first imperative
Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.
The main challenge to a Kantian version of deontology is to show how all the intuitively morally compelling principles can be derived from the formal requirement for universality. The challenge for any version of deontology that accepts a basic plurality of principles (such as the Four Principles Approach discussed below) is to explain away the problem that they may conflict in particular circumstances.
Virtue ethics: On this approach, the moral value of ethical judgment depends on the character of a moral subject. The fullest original statement was Aristotle’s Nicomachean Ethics (6). The central practical aim of virtue ethics is the development of a moral character. Thus, one of the Aristotle’s key tasks is to offer an account of the sort of characteristics a virtuous person has (and from which the value of ethical judgments derives). The ultimate aim of virtue ethics is eudaimonia, meaning flourishing. Thus success in ethical judgments is underpinned by a conception of a good, happy and fulfilling life. It is a matter of debate whether the concept of a good life is always morally charged or whether, by contrast, some kind of reduction of moral properties to some non-moral form of the good life is intended.
Virtue ethics seems to be an answer to a different kind of question to that to which deontology and consequentialism respond. It does not directly answer the question of what is the right thing to do in a particular circumstance except to say that it is what a virtuous agent would rightly choose to do. This is because it, unlike them, denies that moral demands can be codified in general principles. It is, in other words, particularist rather than principlist.
Even a brief summary of these three distinct general approaches reveals the conceptual and practical difficulties of normative ethics. First, the rival ethical models or theories need to be fully articulated. Second, because they can give different results, a justified choice has to be made about which to follow. A consequentialist or utilitarian approach might suggest that the consequences of Robin Hood’s actions are sufficiently good to justify stealing from the rich. A deontological approach might insist that stealing is always, as a matter of principle, wrong. Third, the ‘data’ – the full details of (e.g. clinical) situations – have to be interpreted and related to favored ethical theories. Fourth, a judgment has to be derived from the favored theory as applied to the case at hand. At each of these stages, there can be reasonable disagreement between different parties. Such judgments lack reliability in the medical sense.
Independently of existence or absence of a universal and timeless common morality at the most general level, there seem to exist subsidiary moral codes at lower and more applied levels. One such subsidiary level is represented by the existence of different forms of professional ethics. One way to think of these is that whilst the most general ethical demands appeal to rational subjects universally, the adoption of a specific professional role adds further ethical obligations contingent on that role.
Key attributes of a profession include specialized knowledge, institutionalized training and preparation, normative standards governing professional practice and core moral values not always explicitly articulated. Members of the profession are required to adhere to the professional standards defined by the responsible bodies. Typically the candidates must complete a defined training curriculum, pass the required examinations and comply with the expected norms, standards and formal regulations.
While knowledge transfer can be both, explicit and tacit, the transfer of moral values is frequently tacit and largely empirical. Thus, besides fulfilling the professional knowledge-based requirements and qualifications, the proper conduct of a professional requires embodiment of the expected moral attitudes.
It is open to question whether adopting a professional role merely makes explicit general moral demands as they apply to specific professional contexts or whether professional ethics can conflict – and even trump – more general ethical demands. To take a non-medical example, defense barristers have duties to their clients that trump the requirements on impartial investigation of, say, police officers. They must present their clients in their clients’ best light not necessarily in the most plausible light. Thus, it may be that the professional ethics of defense barristers can conflict with the requirements on honesty and rational appraisal of others in general ethics. On the other hand, it may be that this moral attitude is simply an instance of moral complexity that general ethics have to acknowledge.
Medical ethics is a further sub-species of normative professional ethics. One of its key roles is to frame tools to aid clinicians, and other participants in clinical judgements, to assess the ethical aspects of a situation. Raanan Gillon, a general practitioner and professor of medical ethics, for example, aims to demonstrate the efficacy of his favoured approach – Beauchamp and Childress’ Four Principles approach (see below) – by showing how it can simplify a range of factors that might otherwise have to be assessed individually (7). In a paper called ‘Ethics needs principles – four can encompass the rest – and respect for autonomy should be “first among equals”’ Gillon considers as an example of another ethicist’s analysis of the merits of a free market in human organs, and draws from it the following daunting list of the relevant considerations (7):
people’s rights and claims;
different sorts of interests and their relative strength;
loss of life;
what would be good or bad for people;
benefits and harms;
grief and distress;
an obligation to make sacrifices for the community;
an entitlement of the community to deny autonomy and even to violate bodily integrity in the public interest;
the system of justice;
public policy considerations;
and saving and protecting the lives and liberties of citizens. [Gillon 2003: 308]
He goes on to say: ‘my hypothesis entails that all of them can be explained and justified by one or some combination of the four principles’(7). Thus one role for a philosophical theory of medical ethics – a theory of normative ethics, of how one ought to act – is to codify and rank competing factors to guide judgement.
The four principles to which Gillon appeals are based on perhaps the most famous framework for normative medical ethical thinking; the ‘Four Principles approach’ – as it is generally called - is a deontological approach set out at length by Tom Beauchamp and James Childress in their Principles of Biomedical Ethics (8). In it, the authors set out four general principles to guide medical ethical reasoning as follows:
Autonomy: The patient or user’s perspective is fundamental and informed consent to treatment is thus a key derivative ethical aim.
Beneficence: The good of the patient is a key aim.
Non maleficence: Harm should be avoided where possible.
Justice: Benefits, risks and costs should be distributed fairly. Subjects in similar positions should be treated in a similar manner.
These four principles are supposed to capture medical ethical reasoning. The approach is indebted to the principlist approach to general ethics of the early 20th century represented by the British philosopher W.D. Ross. According to Ross (9), moral duties are encoded in general principles. Each principle imposes a ‘prima facie’ duty: a duty that would be obligatory all other things being equal, that is if no other principles were to apply. Whilst the principles encode prima facie duties, the obligation to act in a particular situation requires an actual or concrete duty: the all things considered duty imposed by the situation as a whole. This demand reflects the interplay of the principles – possibly a subset of them – that are relevant to the case. But because the different principles can pull in different directions the actual duty depends on which duty, in the situation, is the strongest.
Ross himself proposed seven such duties: fidelity, reparation, gratitude, non-injury, harm-prevention, beneficence, self-improvement and justice. Beauchamp and Childress’ Four Principles – beneficence, non-maleficence, autonomy and justice – are a smaller number of universal duties more relevant to medicine. Nevertheless, even with this smaller number, the principles can conflict. They do not derive from any single higher principle. Thus they need both ‘balancing’ and further ‘specification’ when applied to particular situations because the principles can conflict. Standardly, for example, beneficence and non-maleficence are in tension in virtually all fields of medicine including surgery, drug therapy and catheter-based interventions. In psychiatry, autonomy and beneficence are in tension in the case of involuntary treatment. The judgment of which principle should dominate in any particular context looks to be an exercise of situation specific judgment or phronesis suggesting that, ultimately, the Four Principles approach collapses into particularism. The ‘principles’ are not really principles governing a judgment but rather helpful reminders for what might be relevant for phronesis. (Ross himself does not offer an account of what determines which principle dominates in a given situation. This is the basis of a criticism of him by the contemporary moral philosopher Jonathan Dancy (10).)
Such ‘quasi-legal medical ethics’ (as Fulford calls it (11)) has come under fire from another direction. The values that should govern medical interventions are more than just explicitly ethical values (even medical professional values) but also include a wider set of preferences of those involved in treatment decisions. Hence a properly values based practice should not start with a limited set of values but rather in needs to be sensitive to a potentially open ended set of concerns and values (11).
Ethics in catheter-based cardiovascular interventions
Ethics, a traditional field of study and expertise in philosophy, has become an integral component of medicine in its myriadformats. In CBCVI, to date, issues of ethical professional conduct have as yet to be formalized. To further develop and to maintain standards of excellence in the CBCVI profession, the establishment of ethics curricula is an urgent and an important target.
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