UTILITARIANISM AND BIOETHICS

In bioethics the influence of utilitarianism as an applied ethical theory is widely felt, both positively and negatively. On almost all substantive issues in the area, utilitarianism anchors one of the contending positions. Yet, it is the object of fierce criticism, nearly always to do with the challenges it poses to ordinary or conventional morality, especially in cases involving the taking of life, and to the distinctions that are supposed to carry the weight of that morality.

Classical Utilitarianism

Classical or act-utilitarianism is the view that an act is right if its consequences are at least as good as those of any alternative. In this form the view is consequentialist, welfarist, aggregative, maximizing, and impersonal, and the principle of utility that it endorses what might be called the utilitarian goal.

The view is consequentialist, in that it holds that acts are right or wrong solely in virtue of the goodness or badness of their actual consequences. This view is sometimes called act-consequentialism, or, here, for reasons of brevity, simply consequentialism. It is matters to do with consequentialism, and the conflicts that consequentialist thinking is supposed to engender with ordinary morality in bioethics (and elsewhere), that has made the present topic one of note in contemporary bioethics. The view is welfarist, in that rightness is made a function of goodness, and goodness is understood as referring certainly to human welfare but also, perhaps, to animal welfare as well. The view is impersonal and aggregative, in that rightness is determined by considering, impersonally, the increases and diminutions in wellbeing of all those affected by the act and summing those increases and diminutions across persons. The view is a maximizing one: One concrete formulation of the principle of utility, framed in the light of welfarist considerations is "Always maximize net desire-satisfaction."

The act-utilitarian goal, understood in the light of the above characterization, then, is to maximize (human) welfare. The crucial question to which this goal gives rise is how best to go about achieving it, and some contemporary actutilitarians have come to think that the best way of going about maximizing (human) welfare overall may be to forego trying to maximize it on each occasion. It is this insight, in some form or other, that has spurred the most important developments in act-utilitarianism today—developments, however, that have not for the most part featured in bioethics, where the utilitarianism discussed and criticized remains classical or act-utilitarianism, with its embedded consequentialism.

Act-Utilitarianism v. Moral Intuition: The Opposition View

What has driven and continues to drive much of the opposition to act-utilitarianism has been the thought that some alternative view can better account for a number of our moral intuitions. Our moral intuitions, it is said, frown upon murdering or torturing someone, upon enslaving people or using them as means, upon acting in certain contexts and so using people in certain ways for mere marginal increases in utility, all of which act-utilitarianism is supposed to license. It is supposed to license these things because of its constituent consequentialism: If such acts were to have better consequences than the actual consequences of any alternative, then the act-utilitarian would be compelled to call such acts right. And this, allegedly, conflicts with our moral intuitions or ordinary moral convictions or what some people think of as commonsense morality.

This is familiar territory in past debates over utilitarianism generally, though it is no more settled for all that, and it raises directly the question of whether our moral intuitions have probative force in ethics. This is an important issue in its own right, separate from the fate of any form of utilitarianism, but far too broad and complex an issue to be gone into in any detail here. For those inclined to the view that moral intuitions do have probative force in ethics and utilitarianism can be rejected if it produces clashes with those intuitions, the problem has been to make it appear that certain of our intuitions are more secure than others—so secure, in fact, that we believe them to be more correct or true than any normative ethical theory that contended otherwise could be. Obviously those who adopt this line need to identify which these crucial intuitions are, and various ways of doing this have been suggested. Today reflective equilibrium methodologies are perhaps the preferred way, though some relatively straightforward intuitionists still survive, as do some who seek for the preferred intuitions or convictions in their religion. Even with the back and forth movement between intuition and principle that reflective equilibrium methodologies involve, however, it is clear that some intuitions survive and remain intact. Thus, in A Theory of Justice, Rawls appears to think that, if a moral/political theory gave the result that slavery was justified, that would be enough to demand from us amendment and/or abandonment of the theory. His intuition on this score needs no revision. Other writers privilege other of their moral intuitions either about particular acts or classes of acts. Of course the more people that are found, whether in our own or another culture, to differ over these crucial intuitions, the more difficulty there is in selecting just which the crucial ones are. Thus reflective equilibrium methodologists on the one hand and straightforward intuitionists on the other seek ways to discount variation in these crucial intuitions, or, at the very least, to reduce the scope and depth of variations.

The Taking of Life: A Prime Example

Whatever the scope and depth of variations, however, the assumption that certain intuitions survive critical scrutiny has been the springboard from which assaults upon actutilitarianism have nearly always begun. In cases involving the taking of life, this has been especially true, so that, for example, the topics of abortion, infanticide, euthanasia, suicide, and physician-assisted suicide have become battlegrounds for the playing out of certain kinds of consequentialist reasoning over intending and causing or bringing about death. Of course, other issues in bioethics have been contentious between consequentialists and their opponents, and those involving genetic engineering and therapeutic cloning promise to become intense in the near future; but it is the cases of taking life that have pressed upon the opponents of consequentialism. Four points may be used to illustrate the clash:

1. Can a genuine distinction be drawn between intending death and merely foreseeing death as a side-effect of one's act and, if such a distinction can be drawn, whether it can be used to mark off moral differences between cases? This issue haunts the taking-life cases; it has been one of the main bones of contention over the viability of the doctrine of double effect; and it is, when allied with a whole array of concerns having to do with whether the act/omission, acting/refraining, and active/passive distinctions are morally significant ones, part of the killing/letting die debate. On the whole, consequentialists attack the moral significance of these distinctions. Thus with a patient who has required ever larger doses of a pain-killer, a physician now proposes to administer the minimum dosage necessary to relieve pain, in the knowledge, however, that the drug at that dosage will prove fatal or at least hasten death. Is the doctor's act permissible? According to some it is permissible, since the physician intends the relief of pain, not death, and only foresees as a side effect of the act that death will ensue or be hastened. Were the doctor to intend the death, either as end or as means, the act would be, not tantamount to, but in fact murder. In this way, then, some want to distinguish morally between the doctor's intentionally killing the patient and his knowingly bringing about the patient's death. Consequentialists, on the whole, have doubts that any such moral distinction can be drawn on this basis: In both cases, the patient ends up dead as the result of causal steps that the doctor takes. Suppose the doctor chooses to administer the drug and knowingly brings about the patient's death: What is one to say about this bringing about? One cannot say that it was the result of negligence or recklessness or of accident or mistake. In fact the death is in part the result of choice or decision on the part of the doctor, and it is an integral part of the case that the doctor is a causal agent in the patient's death. Certainly the choice or decision by the doctor to administer the drug cannot be ignored in describing what happened in the patient's case, since that choice or decision in part determines what happened to the patient. This is true, moreover, even if it is true that the patient's death forms no part of the doctor's intention. It is simply false that the only way morality can be injected into the doctor's case is through what is intended; for that fails to take account of the fact that the patient's death is brought about by the doctor, in the sense described. Unplugging ventilators and turning off machines, among other acts, are all things that the doctor does, in the course of bringing about the patient's death. (The causal account requires complication in a case involving an omission; but the injection of morphine is not an omission.)
2. In this regard, withdrawing treatment or food and hydration is something the doctor does as well. It is sometimes held that a doctor may not permissibly supply the means of death to a competent, informed patient who is terminally ill, who has voluntarily requested the doctor's assistance in dying, and whose request has survived depression therapy. Yet the very same doctor, it is held, may withdraw food and hydration if, for example, the patient makes a valid refusal of further treatment. Not all withdrawal cases take this form, since things other than food and hydration can be withdrawn from a patient's treatment; but consequentialists on the whole have difficulty in seeing what the morally relevant differences are between these cases. The doctor can supply a pill and produce death, he can withdraw feeding tubes and produce death; how can one be permissible and the other impermissible? Causally he appears to be a factor in the patient's death in both cases. Nor will the consequentialist allow the case to be made out to be one in which, by his valid refusal of further treatment, the patient is to be regarded as the sole actor present, as if the doctor who will withdraw feeding tubes were not there and did not act. The patient's autonomous, voluntary decision to forego further treatment is not the only morally or causally relevant fact to the situation: Death is only produced if the doctor withdraws feeding tubes. Notice, importantly, that the case cannot be reduced to one in which it is claimed that the patient is permitted or allowed by the doctor to die and that it is the underlying disease which kills him, which is what is usually claimed in the cases of omissions; for in the withdrawal of feeding tubes, it is starvation, not the patient's underlying condition, that kills him. What one causes in the world is relevant to the issue of one's moral responsibility. One may want the doctor to take seriously the autonomous, voluntary decision of the patient to refuse further treatment, but this does not settle the issue of whether withdrawing feeding tubes helped cause death by starvation. Withdrawal of feeding tubes is not an alternative to physician-assisted suicide, so far as causality is concerned: In both cases, the doctor takes an essential step in the production of death.
3. In the withdrawal case, if the doctor does not withdraw feeding tubes, then he fails to honor the patient's right to refuse treatment, but if he fails to provide the pill, there is no violation of the patient's right to refuse further treatment. Nor does a right to refuse treatment entail a right to be provided with the means of death. So why is there not a moral difference between the withdrawal and pill cases, in that not prescribing the pill does not violate the patient's rights, whereas not withdrawing the feeding tubes does. But this lands the opponent of consequentialism with another problem: While to insist upon one's right to refuse treatment is one way of committing suicide, taking the pill is another way of committing suicide. Why, if suicide is permissible, is one way of committing suicide, the doctor withdrawing feeding tubes, more acceptable than another way of committing suicide, the doctor supplying a pill that the patient takes? It is necessary to identify some reason to think that, if suicide is morally permissible for terminally ill patients, having a doctor withdraw feeding tubes is acceptable but having the doctor provide a pill is not, when both are seen by the patient and by the rest of society as means of committing suicide. If one refuses to allow that suicide is permissible in such cases, then there will be no moral difference between the withdrawal and the pill cases and so the one cannot be used by way of contrast to the other. Of course, in the withdrawal case, those who want to find a difference between it and the pill case may point to the fact that the law allows the doctor to withdraw feeding tubes but not, for example, the patient's son to withdraw those tubes. But it would be a mistake to treat this as if it were identical with the claim that, if the son withdraws the tubes, the withdrawal causes death, whereas if the doctor withdraws them, the withdrawal does not cause death. In either case the cause of death is starvation through the removal of feeding tubes; it is just that the law frowns upon the son's act in a way that it does not the doctor's act, in the relevant circumstances.
4. There is an issue that intersects this discussion of alleged moral differences between cases that turns the debate in another direction. Consequentialists on the whole accept a quality of life view of the value of a life. The value of a life is a function of its quality, and quality of life is a function of a life's content. In this regard, some lives lack the scope and capacities for richness of life that confer on other lives untold blessings, and this regard for content can reach the desperate levels involved in the cases of anencephalic infants and those in a permanently vegetative state, where even the very capacities for having a rich life are impaired or missing. The result is that such lives are judged on a quality of life view to be deficient in quality, with the result that their value is less than the lives of ordinary humans. This view enrages some people, for whom the thought that all lives are equally valuable, whatever their quality, is a stance or intuition or principle that is paramount and to remain unchallenged. This view is difficult in some ways to credit; for there are some lives so deficient in quality that one would not wish to live them and would not wish those lives on even enemies. To be fully in the progressive grip of amyotrophic lateral sclerosis is to have a life the quality of which seems progressively to plummet; indeed, some of those condemned to such lives often ask for relief from them through the earlier discussed examples of physician-assisted suicide. It is not society who is judging their lives adversely that prompts them to seek help; they themselves so judge their lives. It seems hard, therefore, to think of such lives on all fours with ordinary ones, and the quality of life view of the value of life reflects this fact.

It doubtless strikes some as repugnant and offensive to think of human lives as of different values. The old view would have been that all human lives were equally valuable in the eyes of God, but today this view cannot be assumed to be prevalent in all medical contexts, even when it could be agreed that people ought to base value claims about lives on the assumption of God's existence, religious tenets, or the like. So what is to replace God in this claim about lives? One can make assumptions about, say, equal worth being apart from value, but are these more than assumptions? And does society not use quality of life judgments about lives all the time in hospitals and medical settings, to decide all kinds of issues, from who gets what resource to how much of it they get? And there all the while, of course, is the plain fact that the content of some lives inspires an overwhelming sense of tragedy, of what lives once were or could have been but of what they have become. How can this sense of tragedy and dire outcome represent equal value?

Of course, in many lives, say, where certain physical handicaps are present, there does not exist this sense of overwhelming tragedy, and people cope very well with misfortune. But where a life begins to plummet disastrously in quality, equal value appears harder to defend. Unequal value, however, implies that some are at greater risk than others: If one could save either a life of very high quality or a life of very low quality; if in hospitals medical intervention is likely to produce in one case a life of ordinary dimensions and in another a life of radically reduced dimensions, and a doctor can only make one such intervention; which life should be choosen?

r. g. frey

SEE ALSO: Autonomy; Care; Casuistry; Communitarianism and Bioethics; Consensus; Contractarianism and Bioethics; Emotions; Ethics: Normative Ethical Theories; Human Rights; Obligation and Supererogation

BIBLIOGRAPHY

Beauchamp, Tom L. 1986. "Refusals of Treatment and Requests for Death." Kennedy Institute of Ethics Journal 6: 371–381.

Beauchamp, Tom L., ed. 1996. Intending Death: The Ethics of Assisted Suicide and Euthanasia. Englewood Cliffs, NJ, Prentice-Hall.

Brock, Dan. 1993. Life and Death: Philosophical Essays in Biomedical Ethics. Cambridge, Eng. and New York, Cambridge University Press.

Dworkin, Gerald; Frey, R. G.; and Bok, Sissela. 1998. Euthanasia and Physician-Assisted Suicide. Cambridge, Eng. and New York, Cambridge University Press.

Frey, R. G., and Wellman, Christopher, eds. 2003. The Blackwell Companion to Applied Ethics. Oxford, Eng., and Malden, MA: Blackwell.

Glover, Jonathan. 1977. Causing Death and Saving Lives. Harmondsworth, Eng.: Penguin.

Harris, John. 1985. The Value of Life. London: Routledge Kegan Paul.

Kamm, Frances. 1993. Morality, Mortality, Vol. 1. New York: Oxford University Press.

Rachels, James. 1986. The End of Life: Euthanasia and Morality. New York: Oxford University Press.

Rawls, John. 1971. A Theory of Justice. Cambridge, MA: Harvard University Press.

Singer, Peter. 1993. Practical Ethics. Cambridge, Eng., and New York: Cambridge University Press.

Singer, Peter. 1996. Rethinking Life and Death: The Collapse of Traditional Ethics. New York: St. Martin's Press.

Singer, Peter, and Kuhse, Helga. 2002. Unsanctifying Human Life. Malden, MA: Blackwell.