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REVIEW ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 1  |  Page : 19-23

Deontology vs. utilitarianism: Understanding the basis for the moral theories in medicine


Department of Oral and Maxillofacial Surgery, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria

Date of Submission01-Sep-2020
Date of Acceptance26-May-2021
Date of Web Publication3-Dec-2021

Correspondence Address:
Felix N Chukwuneke
Department of Oral and Maxillofacial Surgery, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_57_20

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  Abstract 

We live in a society that functions with a system of morals that seeks to determine what is right or wrong. Each society is ruled by moral codes that guide people’s action to minimize the risk of sliding into structural dysfunction. To understand the importance of human values within which the society can live and operate in a harmonious state, many great philosophers such as Immanuel Kant and Bentham Jeremy have presented moral theories based on the principles of deontology and utilitarianism, respectively. These two ethical major streams of thought influence ethical decision-making. In utilitarian principles, outcomes justify the means or ways to achieve it and as such the focus is on the consequences of an action, whereas in deontological ethics, obligation to duty is what matters irrespective of the outcome. In medicine, deontology is patient centered, whereas utilitarianism is society centered. Practically, these two moral thoughts seem contradictory but each has its own advantages and disadvantages, which may occasionally intertwine to reach a midpoint level in a critical situation. In a well-resourced setting, the deontology approach to healthcare issues seems more practicable than the utilitarian approach because the duty of care is more focused on the individual and not necessarily on the society. As every rational being thinks of him- or herself as an end, doctors must act in such a way that they treat humanity and their patients always as an end and never simply as a means. The moral worth of a clinician’s action in patients’ management therefore depends exclusively on the moral acceptability of the rule of obligation to duty, that is, “cause no harm” irrespective of the consequences. This article highlights the fundamentals of deontology and utilitarian principles as moral theories in medicine with basic examples.

Keywords: Deontology, medicine, moral theories, utilitarianism


How to cite this article:
Chukwuneke FN, Ezenwugo AC. Deontology vs. utilitarianism: Understanding the basis for the moral theories in medicine. Int J Med Health Dev 2022;27:19-23

How to cite this URL:
Chukwuneke FN, Ezenwugo AC. Deontology vs. utilitarianism: Understanding the basis for the moral theories in medicine. Int J Med Health Dev [serial online] 2022 [cited 2022 Dec 9];27:19-23. Available from: https://www.ijmhdev.com/text.asp?2022/27/1/19/331730




  Introduction Top


Morality not only directs individuals to do what is right or wrong but also makes them do what is in the best of their conscience. Medical ethics is a branch of moral philosophy that deals with conflicts in obligations to duties and their potential outcome.[1] There are several schools of thought regarding morality. However, the ethical systems of deontology and utilitarianism as postulated by Immanuel Kant and Bentham Jeremy, respectively, significantly influence the practice of medicine regarding decision-making.[2],[3] In utilitarian principles, the end justifies the means and decisions are made based on the greatest amount of benefit obtained for the greatest number of individuals. In the deontological approach, the opposite is the case, outcomes or consequences may not justify the means to achieve it. The deontology theory deals with the principle that some features of actions other than or in addition to consequences make actions right or wrong. Kant (1724–1804), in an attempt to combat skeptical challenges to ethics, argued that morality is grounded in reason, not in tradition, laws, intuition, conscience, emotion, or an attitude such as sympathy.[4] That means humans are beings created with rational powers to resist desires as well as having the freedom to do so. Kant believed that only a creature capable of understanding reasons for and against doing something could be said to be behaving morally and therefore, morality was a possibility for rational creatures only.[5] He further maintained that the moral worth of an individual’s action depends exclusively on the moral acceptability of the rule of obligation or maxim on which the person acts. This maxim, Kant says, occasionally cannot pass a test that he calls the categorical imperative. This imperative tells us what must be done irrespective of our desire. In its major formulation, Kant states the categorical imperative as follows: “I ought never to act except in such a way that I can also will that my maxim becomes a universal law.” Kant says that this one principle justifies all particular imperatives of obligation.[6] His theory places the moral obligations on the rule that determines the individual will, where the rule is understood as a morally valid reason that justifies the action.[7] Kant was very emphatic on moral obligations. According to him, one must act not only in accordance with but also for the sake of obligation.[6] It follows that any rational person that possesses goodwill necessarily follows the categorical imperative because it mandates actions that are good in themselves. Because every rational being thinks of himself as an end in himself, as far as morality is concerned, all people must “act in such a way that they treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means.”[6] On the other hand, utilitarianism as propagated by Bentham Jeremy (1748–1832) deals with the principle that Nature has placed mankind under two sovereign masters “pain and pleasure.”[8] As a guiding principle for public policy, Bentham took a maxim that had been enunciated early in the eighteenth century by a Scots-Irish philosopher called Francis Hutcheson: “That action is best which procures the greatest happiness for the greatest numbers.” The philosophy became known as utilitarianism because it meant judging each action by its utility, that is to say its usefulness in bringing about consequences of a certain kind.[5] According to the ethical theory of utilitarianism, an action is right if it promises to produce better results than or maximize the expected utility of other action possible in the circumstances. The ethical person will act to increase the amount of pleasure or utility in the world and decrease the amount of pain by following a single principle. This is expected to promote the greatest happiness of the greatest number. An action conforms to the principle of utility if and only if its performance will be more productive of pleasure or happiness, or more preventive of pain or unhappiness, than any alternative.[6] In other words, the value of the consequences of an action is determined solely by the welfare of individuals and that the rightness of an action entirely depends on the value of its consequences. Consequentialism in essence is a marker affixed to theories holding that actions are right or wrong according to the balance of their good and bad consequences.[9] The right act in any circumstance is the one that produces the best overall result, as determined from an impersonal perspective that gives equal weight to the interest of each affected party. Utilitarian principles assert that we ought always to produce the maximal balance of positive value over disvalue. Although utilitarians share the conviction that we should morally assess human actions in terms of their production of maximal value, they disagree concerning which value should be maximized.[4] Most utilitarians are of the opinion that we ought to produce intrinsic goods such as happiness, freedom, and health that every rational person values.[10] Consequently, they try to offer many examples from everyday life to show that the theory is practicable and that one may engage in a utilitarian method of calculating what should be done by balancing goals and resources and considering the needs of everyone affected. According to Bentham, an action conforming to the principle of utility is right or at least not wrong; it ought to be done, or at least it is not the case that it ought not to be done.[10]


  Materials and Methods Top


We carried out an Internet search of relevant articles, conference proceedings, media reports, and textbooks on medical ethics locally and globally using Google Search, Google Scholar, PubMed, African Journals OnLine, Medknow, Hinari and NIH.gov, ResearchGate, and Elsevier. In addition to the relevant information obtained from the search engine, the examples and other added information are the original concepts and experiences from the authors in the field of medical ethics. The search engines yielded 20 relevant publications which, in addition to the authors’ knowledge and experience in bioethics, supported the information as presented in this article.

Autonomy

As far as individual autonomy is concerned, utilitarianism may interfere with such right to decision-making as the ideology deals with the general good of the majority irrespective of parochial and self-seeking interest. An example of interference with persons’ autonomy is that suppose a healthcare personnel who has a wealthy father needs to improve the quality of life of rural dwellers by providing health center and water supply to hundreds and thousands of people in the rural place, then without his father’s consent he/she can forge the signature of his/her father’s bank account and use the money obtained fraudulently to carry out such project. In utilitarian principle, such an action is justified even if the father did not consent as it is for the benefit of a greater number of people. On the other hand, deontologists frown at this because an individual should show moral obligation by being rational in taking action that will put another person in jeopardy in order to satisfy others. Again, to forge another person’s signature is wrong irrespective of the purpose. Reasoning and common sense will obviously tell one that it is not rational to do that, but utilitarianism would encourage that. In other words, utilitarianism more often than not is opposed to common sense and is not always the right thing. It is therefore difficult to determine the midpoint between what is right and what is wrong in the principles of utilitarianism because to them, the end justifies the means. Supposing that in the rural community where such a project is being sited that some individuals are so naive and are opposed to the project, it would have been that the autonomy of those few individuals is not considered. This poses a question: Is it not important that people be free to make decisions for themselves, even poor decisions? because that is the only way that people can develop the strength of character. From the utilitarian’s perspective, the principle of utility is the sole absolute principle. To them no derivative rule is absolute, and no rule is irreversible. Even rules against killing in medicine and refusing medical attention may be overturned or substantially revised. For example, if a 90-year-old man has kidney failure and needs a kidney transplant, one should go ahead with the treatment no matter the cost whereas in the rural environment hundreds of children are being infected by infectious diseases that could be prevented by immunization but for lack of money. In practice, the clinician has an obligation and duty to treat the old man as it is his desire and fundamental right to be given proper medical attention and treatment. To a utilitarian, it would be an unwise decision as a clinician to go ahead and do a surgical kidney replacement on the old man when the same amount of money would have been used to immunize over one hundred children. The utilitarian rule will support the idea of forgoing the treatment of the old man to providing immunization drugs for the children because of the good of the majority, whereas the deontologists argue that the quality-adjusted life years for a 90-year old after a kidney transplant cannot be compared with lifesaving immunization for young school children.

The duty of care and right to treatment

The rule of utilitarian argues that we should support rules permitting killing and denial of treatment to patients if and only if those rules would produce the most favorable consequences.[11] In the principle of deontology, you have moral obligation to treat your patient irrespective of the expected outcome. Also, the respect for patient autonomy should be paramount in our actions. The deontology principles would protect the right to treatment of the old man (autonomy) irrespective of the need to use the same amount of money to immunize children against infectious diseases in a rural community. Utilitarianism, therefore, has a way of interfering with people’s rights and way of life, whereas in essence deontology principles encourage self-centeredness. Nonetheless, one may say that utilitarianism has a very good aspect, especially in a contemporary society such as ours where resources are limited. In fact, it is actually common sense to argue that forgoing the treatment of the old man to immunizing the children is the right action. Kantians associate like John Rawls argued that vital moral considerations such as individual rights and the just distribution of goods among the individual depend on the social factors, such as individual happiness and majority interest, than on Kantian conception of individual worth, self-respect, and autonomy.[11] For Rawls, any philosophy in which the right to individual autonomy legitimately outweighs the dictates of rational moral principles is unacceptable.[12] Utilitarianism as reasonable as it may be in a rational society is very problematic in problem-solving irrespective of the consequences. If everyone believes that morality permits lying, promise-breaking, cheating, and violating the law whenever doing so led to good results, then no one could trust other people to obey these rules.[13] This means that we could not believe what others say, could not rely on them to keep promises, and in general could not count on people to act in accordance with moral rules simply because their actions will promote the general good. As a result, people’s behavior would lack the kind of predictability and consistency that are required to sustain trust.[13] This is more serious in health care. If a doctor can deny kidney transplant for a 90-year-old man in order to immunize hundreds of children against infectious diseases, then it implies that the doctor should sacrifice the old man to immunize the children. Although more good may be done by this act, it is unlikely that more overall good will be done by having a rule that allows doctors to kill their patients in this manner. If a rule were adopted that allows doctors to kill their patients when this will save more lives, the result would be that many people would not go to doctors at all.[14] An appropriate evaluation will take account of the fact that the benefits of medical treatment would be greatly diminished because people would no longer trust doctors. Apart from being competent and compassionate, patients believe that their doctor will not take advantage of them.[15] This virtue ethics in medical practice will therefore be thrown overboard.

Equality: the philosophy of objectivism

Equality in the eyes of a utilitarian is the simplest way to conceive of the goodness for the general populace in terms of happiness or personal well-being, regardless of who gets it. Such a conception is democratic in the sense that it counts every bit of your happiness as being just as important as the same-sized bits of my happiness. In essence that is a distributive justice. But one could object that in another sense, such a conception is not democratic because it does not care whether happiness is distributed equally or unequally among people. If the greatest total can be created only by exploiting the miserable to make them happy even happier, then such an outcome would seem to say that you should not do it. Hence, some philosophers see consequentialism as wrong in a matter of achieving justice and equity.[16] One may also argue that our intuitive sense of fairness is not mainly concerned with distributions of ultimate goods like happiness or well-being rather, fairness is traditionally concerned with distributions of what we might call “external goods” such as money, status, power, and political rights. To some Kantian philosophers, this portends a serious tendency for inequality in external goods to reduce the total happiness. Utilitarian would reason that when there is more equality in the main external goods, the basic conditions of people’s lives will be more similar and people will find it easier to understand and sympathize with each other.[16] Hence, actions and policies that promote equality in external goods will cause more happiness by promoting a sense of communal living. Accordingly, institutions that secure basic external equalities or that aim to protect whoever is poorest and weakest, tend to give everyone more security. Actions that promote democratic institutions, then, would tend to do the most good overall.[17] These points are the basis for promoting the ideals of the utilitarianism in a positive way such that justice will prevail in the society in line with the sense of the importance of equality. This is the principle on which access to health care is considered fundamental both individually and collectively with the understanding that good health is one of the main contributors to the well-being of every citizen. From a utilitarian perspective, governmental intervention in health coverage has the purpose to maximize the total “utility,” in this case the total welfare, of all the members of the society.[18] This approach gave origin to the so-called “universal” healthcare systems, in which health services must be allocated efficiently and distributed in accordance with equity while trying to provide health care for as many members of a community as possible.[19] Deontology constraints are essentially negative duties that specify what we cannot justifiably do to others, even in the pursuit of worthy goals; however, they do not specify any actions that we should perform for the sake of others. For example, while forcefully using the siblings’ shares of the inheritance by the eldest son to provide basic social amenities for the entire community violates deontological constraints, those constraints, however, do not tell us how to divide the wealth among the siblings to achieve equitable and fair distribution. This conception of deontological constraints or limitations highlights an obvious difference between deontologist and utilitarian such that utilitarian requires us to determine the best possible objective state of affairs, irrespective of the position of particular agents who act in those states of affairs.

Ethical dilemma in clinical care: deontology vs. utilitarianism

Kant’s theory of deontology principle judges morality by examining the nature of actions and the will of agents rather than goals achieved.[6] In other words, a deontological theory looks at inputs rather than outcomes. In the eye of utilitarian, the outcome is considered more important than the input, especially when the outcome is for the interest of the general good. To them, the end justifies the means, which propagates the principles of consequentialism. One reason for the shift away from consequences to duties in the deontology principle is that, in spite of our best efforts, we cannot control the future or expected outcome of our actions no matter the intent.[5] Consequently, we are praised or blamed for actions within our control, and that includes our willing, not our achieving. This is not to say that Kant did not care about the outcomes of our actions; he certainly would wish for good things. But his reasons were that as far as the moral evaluation of our actions was concerned, consequences did not matter.[7] According to Kantian theorists regarding the categorical imperative, if the maxim governing our action is not capable of being universalized, then it is unacceptable.[7] Kant’s point is that there should be a standard moral rule that is universal, which determines the maxim governing our actions. His view is that we should do unto others as we would have them do unto us, which is the “golden rule.” Deontological ethics is strongest in many of the areas where utilitarianism is weakest.[5] In ethics of duty, the ends can never justify the means as postulated by utilitarianism. Individual human rights are acknowledged and sacrosanct. Notwithstanding, Kantianism has a severe problem with conflicting moral obligation. Suppose as a surgeon a patient who has late-stage carcinoma was brought to me for surgery and the patient needs a highly technical surgery in which case he may or may not survive the surgery, and if it does, the chance of survival from carcinoma itself is less than 1 year. To make things worse, the relations who will bear the responsibility of paying for the surgery fee will have to go on borrowing so as to enable them to settle the bills as the patient may have to stay in the hospital for a longer time if he survives the surgery. The patient wanted an operation, whereas the family members were skeptical partly because of the financial implications and partly because of the uncertainty of recovery from surgery as well as the possible long stay in the hospital if the surgery was successful. Now, I as the surgeon have two alternatives: to carry the operation not minding the expected outcome and the prognosis or to discharge the patient and place him on palliative treatment. If I should follow the Kantian principles, then I have the moral obligation to take the patient to the theater and perform the surgery. But is my action justified? I do not think so. We, therefore, need to consider the expected outcome of our actions in our quest to obey our moral obligations. Kant’s arguments concentrate on lawful obligations, but given the limitations and realism of this theory, Kantianism occupying a central position in moral theory is questionable. Utilitarianism, on the other hand, in principle seems to permit the interests of the majority to override the rights of the minorities and, therefore, cannot adequately disavow unjust social distributions.[9] Despite these criticisms, utilitarianism has much strength that includes the acceptance of a significant role for the principle of utility in formulating public health policy. Utilitarian also offers many examples from everyday life to show that the theory is practicable and that we all engage in the utilitarian method of calculating what should be done by balancing goals and resources even in medical care.


  Conclusion Top


Moral dilemmas in medicine often arise due to conflicting obligation to duties (deontology) and the challenging consequences (utilitarianism). Considering the strength and weakness of both the Kantian principles and that of utilitarianism, there should be a middle ground in which the two moral principles will be brought together and streamlined to achieve a midpoint of reference in our quest to create a society where justice, fairness, equity, and human dignity are maintained and sustained for the betterment of the society. This no doubt has always been the guiding principles in medical practice and healthcare delivery.

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Conflicts of interest

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