Critical care decisions in fetal and neonatal medicine: ethical issues
The role of ethical analysis in considering practical problems
2.2 The critical discipline of ethics or moral philosophy investigates the underlying reasons or justifications for specific moral beliefs or moral codes. It does this by various means: it seeks clarity in the uses of important terms, such as ‘quality of life’; and it requires consistency in the practical application of moral claims or values. Ethics also requires coherence in the defence of any moral framework, that is, a demonstration of how it conforms to other beliefs held to be true. This requirement leads to the formulation of ethical theories, which aim to give a systematic explanation of how arguments about moral issues can be resolved, through appeals to some general criterion according to which moral claims can be assessed.
2.3 Ethics or moral philosophy may not appear to be immediately helpful to those seeking practical solutions to the kind of dilemmas which may arise in fetal and neonatal critical care. Philosophers, like others in society, disagree over which philosophical theories are most appropriate to apply to any given situation. There are a range of competing theories, the principal ones being consequentialism, most commonly known in the form of utilitarianism; deontology or duty-based theory; and virtue ethics or character-based theory. While within each of these theories there are many nuanced positions, broadly, consequentialists judge actions according to their outcomes taken as a whole, whether good or bad. This means that they would usually assess decisions and policies in critical care in the light of the predicted outcomes for the majority of babies. In contrast, a deontological approach would hold to fundamental duties or principles in medical care that must not be breached, whatever the consequences. A rights-based theory holds that individuals have interests which are sufficiently important to justify enforcing others to respect those interests in the performance of duties. It is therefore a form of deontological theory. Rights-theorists disagree on a number of matters, including the question of who should possess rights.2For the virtue ethicist, what matters most is the character of the parents and professionals who are making the decisions. Another approach, termed the ethics of care,3 also has relevance to critical care decisions. From this perspective, the focus should be on the special situation of pregnant women and mothers with an emphasis on the interconnectedness of needs, the role of emotions and social relationships.
2.4 Those who subscribe to different ethical theories may nevertheless arrive at the same basic moral judgements about the rightness or wrongness of certain actions. A consequentialist, a deontologist, advocates of a rights-based approach, virtue theory or the ethics of care could all agree that a particular action, such as a gratuitously cruel infliction of injury, was wrong, but would have reached this view for different reasons derived from their basic theoretical commitments. However, on some matters these different commitments will lead to the making of different and incompatible moral judgements.
2.5 A comprehensive discussion of the different theoretical approaches to morality is outside the scope of this Report. Nevertheless, it is important to be aware of them as we examine the primary areas of concern for ethics in fetal and neonatal medicine. For, underlying the strongly held disagreements between people about what should be done in practice are often very different views on morality. This holds true for the Working Party itself. Although we have been able to agree on a number of substantive conclusions and recommendations that are informed by ethical analysis, we were not always in agreement about the frameworks by which we reached our conclusions. In addition, it is important to acknowledge at the outset that there are some issues on which different members of the Working Party would, if asked as individuals, present different judgements. We cannot and should not expect complete unanimity on issues of such fundamental moral concern. Instead we must acknowledge that there is a plurality of moral beliefs and assumptions and that each has the function of providing tools for examining the moral permissibility of certain acts. At the same time, we should try to seek agreement on substantive matters wherever possible, even if we disagree about the reasons behind these shared conclusions.
2.6 Given these differences in moral outlook, is the critical analysis of moral philosophy or ethics of any practical use? We believe that it is for the following reasons:
- First, by carefully examining the concepts used within different ethical theories, ethical analysis can help to clarify their scope and validity. A better understanding of the strengths and weaknesses of those concepts can reduce ambiguities and confusion. It may also reveal that there is more agreement among people than they might think.
- Secondly, by demanding consistency, ethical analysis can reveal ways in which people may be responding instinctively or with a ‘gut reaction’ to some situations, rather than examining them in terms of their general moral beliefs.
- Thirdly, by insisting that reasons or justifications for our decisions are provided, ethical analysis can lead to a shift in our views, as we come to appreciate the basis on which those with different opinions make their judgements.
Thus moral philosophy can aid informed and measured dialogue between people about morality, an essential feature, we would claim, of the genuinely moral life and of decisionmaking processes in critical care (see paragraphs 2.44–2.57).
2.7 We recognise that moral decision making is not simply a matter of detached rationality. However, the Working Party would not go as far as some proponents of an ethics of care approach who claim that drawing on emotions allows one to exercise specific superior capacities to solve moral problems.4Nevertheless we recognise that emotions play an important part in our everyday moral decision making. Decisions frequently have to be made by parents and clinical staff with little time to consider the clinical options, and often in very stressful circumstances. In our view it is essential that any discussion of ethical issues, no matter how controversial, should seek to be dispassionate, impartial and have practical relevance to those making decisions. Equally, the discussion should acknowledge the great personal significance and the very difficult choices that sometimes must be made in critical care, and consequently, the strong feelings of all who are involved. We now turn to consider the first of four areas of particular significance, the value of human life.
Footnotes
2 Some, for instance, would deny that young children and the newborn can be rights-holders. There is also disagreement as to the scope or comprehensiveness of rights that people may have. All could agree, for instance, that every adult has a right to life but not all will agree that everyone has a right to the best possible healthcare. Rights-based theorists may disagree as to when, if ever, it is morally permissible to override rights. Could, for instance, avoiding very great harms befalling a very large number of people be a good enough reason to override the rights of a single person?
3 See Gilligan C (1982) In a Different Voice: Psychological theory and women’s development(Cambridge, MA: Harvard University Press). It should be noted that there is disagreement on whether the ethics of care should be understood as an independent normative theory, as a type of normative theory, such as virtue ethics, or merely as a supplement or critical commentary to existing normative theories. For a selection of various understandings of the ethics of care see Held V (Editor) (1995) Justice and Care: Essential readings in feminist ethics(Boulder, CO: Westview Press).
4 For further details, see Tong R (2003) Feminist Ethics, Stanford Encylopedia of Philosophy, available at:
http://plato.stanford.edu/entries/feminism-ethics/, accessed on: 11 Sept 2006.