Ethics, medical ethics and HIV/AIDS

Ecumenical Review, The, April, 1996 by Christoph Benn, Kenneth Boyd

THEORIES AND PRINCIPLES OF ETHICS

Ethics is the systematic study of moral reasoning in theory and practice. It clarifies questions about right and wrong, but also demonstrates their complexity: most ethical theories and many moral judgments are contestable. Some norms, values or principles are sufficiently widely agreed for codes of professional practice or laws to be based on them. But no ethical theory or decision-making method yields unequivocal conclusions which convince everybody: too many different beliefs, philosophies, cultural backgrounds and life experiences influence our views of right and wrong. Meaningful and constructive discussion of practical ethical problems nevertheless is possible when conceptual frameworks developed throughout the history of ethical reasoning are used to examine the facts and values in question. Such discussions can lead to a degree of consensus, or at least to a mutual understanding of divergent views.

In health care ethics today, the conceptual framework most widely used in analyzing medico-moral questions is that of the "Principles of Bio-ethics":(1,2) these are first, respect for the autonomy of persons; second, beneficence; third, non-maleficence; and fourth, justice. Each principle represents a prima facie duty -- that is, it is morally binding unless it conflicts with one of the others. The framework does not provide a method for choosing between the principles when they do conflict, or for determining the scope of their application (for example, we have a prima facie duty to respect the autonomy of persons, but who exactly counts as a "person"). However in medical ethics in general and in ethics related to HIV/AIDS in particular, we often encounter problems characterized by the fact that there are extremely complex issues which are intrinsically ambiguous. Choices and alternative decisions must be made on issues of right or wrong, but often one can find convincing arguments supporting each of the options.

The theories or principles alone cannot solve these problems, as there might be mutually exclusive decisions each of which violates certain principles while being supported by others. This is what is called an ethical dilemma. We are often faced not with the question whether or not to violate a certain theory or principle, but which possible alternative violates it more or less. Therefore ethical principles are not, in themselves, sufficient to reach a conclusion in the case of ethical dilemmas. But they add an accessible ethical dimension to the international scientific vocabulary, and a common language in which to address, analyze and discuss medico-moral questions of cross-cultural concern.

"The final outcome may be that reasonable people will disagree, but the process of debate and scrutiny of these perspectives is likely to produce the kind of thoughtful judgment that is always more valuable than simplistic conclusions reached without the benefit of careful, sustained reflection and discourse."(3)

This framework of principles has an additional advantage: It can be employed by either of the two classic schools of thought in philosophical ethics, namely deontologists or utilitarians. It can also be accepted by the adherents of many religious traditions and faith communities. Even when those with different philosophical or religious views qualify the principles or define their scope, the common core language remains ecumenical. These particular principles, moreover, were originally identified by examining ethical codes and standards (especially of the health care professions) which had historically been deeply influenced by Christian values and perspectives. This makes them especially conducive to developing an ethical approach to HIV and AIDS which is inspired by the gospel, but is also open to any reasonable person of good will in today's pluralistic and often secularized societies.

To enter into this dialogue on ethical questions we need, apart from a comprehensive knowledge of the basic ethical principles, also sound facts and technical information about the disputed questions themselves. These two elements should then enable a thorough discussion of the issues concerned, and an ethical decision-making process which is well informed, transparent and verifiable.

A. Theories of ethics

Deontology,

The first school of thought, the theory of deontology or the doctrine of duty, is the basis of some of the oldest ethical systems in all cultures. It focuses on the intrinsic duties and values which determine our actions. These values, formulated as commandments and rules for human behaviour, are understood to be a matter of principle and as having their own undeniable justification in themselves. In fact these deontological values can be formulated and justified on the basis of different perspectives. For example, the ten commandments found in the Old Testament (Ex. 20:1-17) are an ethical code based on divine revelation. The golden rule "Do to others as you would have them do to you" (Luke 6:31) which is found in the New Testament (and in other forms also in other world religions) serves as a general guideline for the assessment of human behaviour. Deontological principles can also be explicated through philosophical reasoning. For example, Immanuel Kant's "Supreme moral law",(4) "Act only on that maxim through which you can at the same time will that it should become a universal law", is intended to convince all reasonable people by the intrinsic force of its logic. Therefore there are moral rules and values which can be regarded as universal, and as forming the basis for principles and ideals which have to be translated into concrete moral actions.