Utilitarian and deontological ethics in medicine

Abstract

Medical ethics is a sensible branch of moral philosophy and deals with conflicts in obligations/duties and their potential outcome. Two strands of thought exist in ethics regarding decision-making: deontological and utilitarian. In deontological approach, outcomes/consequences may not just justify the means to achieve it while in utilitarian approach; outcomes determine the means and greatest benefit expected for the greatest number. In brief, deontology is patient-centered, whereas utilitarianism is society-centered. Although these approaches contradict each other, each of them has their own substantiating advantages and disadvantages in medical practice. Over years, a trend has been observed from deontological practice to utilitarian approach leading to frustration and discontentment. Health care system and practitioners need to balance both these ethical arms to bring congruity in medical practice.

Ethics is a crucial branch in medicine guiding good medical practice. It deals with the moral dilemmas arising due to conflicts in duties/obligations and the faced consequences. They are based on four fundamental principles, i.e., autonomy, beneficence, nonmaleficence, and justice. Much of the modern medical ethics deals with the moral dilemmas arising in the context of patient's autonomy and the fundamental principles of informed consent and confidentiality. Ethics deals with choices, decisions/actions based on the choice and the duties and obligations of a doctor to the best interest of the patient. Ethical practice is a systematic approach toward the institution of these principles to approach an appropriate decision-making. While these definitions are clear to express, exceptions arise in each of these principles during clinical practice. For example, when a doctor owes a duty to both patient and society, situations of breech in confidentiality may arise. Similarly, the practice of fundamental principles of autonomy and informed consent may be breeched in the care of newborn, mentally handicapped or patients in the permanent vegetative state. In practical ethics, two arms of thoughts exist in decision-making: Utilitarian and deontological. In utilitarian ethics, outcomes justify the means or ways to achieve it, whereas in deontological ethics, duties/obligations are of prime importance (i.e., end/outcomes may not justify the means).

In the utilitarian approach, decisions are chose based on the greatest amount of benefit obtained for the greatest number of individuals. This is also known as the consequentialist approach since the outcomes determine the morality of the intervention. This approach could lead to harm to some individuals while the net outcome is maximum benefit. This approach is usually guided by the calculated benefits or harms for an action or intervention based on evidence. A few examples of utilitarian approach in medical care include setting a target by hospitals for resuscitation of premature newborns (gestational age) or treatment of burns patients (degree of injury) based on the availability of time and resources. There are two variants of utilitarianism: Act utilitarianism and rule utilitarianism. Act utilitarianism deals with decisions undertaken for each individual case analyzing the benefits and harms promoting overall better consequences. Every action/decision arrived for each patient is confronted with the measurement of balance of the benefits and harms, without examining the past experience or evidence. This method would lead to enormous wastage of time and energy in decision-making and are prone to bias. In rule utilitarianism, no prediction or calculation of benefits or harms is performed. These decisions are guided by preformed rules based on evidence and hence provide better guidance than act utilitarianism in decision-making. According to rule utilitarianism, morally right decision is an action complying moral codes/rules leading to better consequences.[1] Although these concepts look appealing patients feels constrained when clinicians make the decisions, affecting the fundamental ethical principles. These ethical issues can be accommodated when dealing with patients who are competent to play a role in decision-making, while posing moral dilemmas in patients who are incompetent, e.g., in patients who are brain-dead (permanent vegetative state), decision-making with regards to withdrawal of life-sustainment/organ donation, etc. In the above scenario, dilemmas can be dealt ethically and legally if the patients had made advance decision directives about their life similar to decisions on wealth.[2,3]

In contrast to the utilitarian concept, deontology is ethics of duty where the morality of an action depends on the nature of the action, i.e., harm is unacceptable irrespective of its consequences. This concept was introduced by a philosopher, Immanuel Kant and hence widely referred as Kantian deontology. The decisions of deontology may be appropriate for an individual but does not necessarily produce a good outcome for the society. The doctor-patient interaction or relationship is by nature, deontological since medical teaching practices inculcate this tradition, and when this deontological practice is breached, the context of medical negligence arises. This tradition drives clinicians to do good to patients, strengthening the doctor-patient bond. The deontological ideologists (doctors and other medical staffs) are usually driven to utilitarian approach by public health professionals, hospital managers, and politicians (utilitarian ideologists). From a utilitarian perspective, health care system resources, energy, money, and time are finite and are to be appropriately accommodated to achieve the best heath care for the society. These are executed with furnished rules and guidelines. While achieving good for the greatest number, few harm (iatrogenic) is acceptable by utilitarian ideologists. For example, few cases of vaccine-induced paralytic polio after oral polio vaccination. From a deontological perspective, utilitarians generalize the guidelines or rules while there may be exceptional cases where the guideline may not apply. Deviation of action from the guidelines contributes to medical negligence to utilitarians. Such conflicts in approach are commonly encountered in the current health care systems. Similarly, the involvement of third party payment systems (health insurance) affects the confidentiality between the doctor-patient relationship.[4]

Traditional moral analytical studies (Greene's dual process model) revealed that deontological and utilitarian inclinations are mutually exclusive while recent studies utilizing the process dissociation moral analytical approach revealed that an inclination toward an ideology may occur due to the absence of inclination to another. These studies also reported the association of deontological inclinations with empathy, religiosity, and perspective-taking, while moral concern and reduction in the cognitive load being associated with utilitarian inclinations.[5] In conclusion, both utilitarian and deontological perspectives have their own importance in medical ethics. In the current scenario, we get to see utilitarian perspective countermanding the deontological perspective and hence most ethical and moral dilemmas. A balance between these two perspectives would bring better harmony and justice to medical practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.