The document introduces bioethics as a branch of moral philosophy that addresses ethical principles in medical practice, policy, and research. It reviews major ethical theories such as utilitarianism and deontology, explores their application in bioethical dilemmas, and discusses key principles like non-maleficence and autonomy. Notably, it includes case studies, such as that of conjoined twins Mary and Jodie, to illustrate the complexities and moral considerations involved in medical decisions.

1. Foundations of Bioethics: Ethical
Theories, Moral Principles, and
Medical Decisions

2. Introduction
• The branch of philosophy concerned with principles that allow us to
make decisions about what is right and wrong is called ethics or
moral philosophy.
• Bioethics is specifically concerned with moral principles and
decisions in the context of medical practice, policy, and research.
• Moral difficulties connected with medicine are so complex and
important that they require special attention. Medical ethics gives
them this attention, but it remains a part of the discipline of ethics.
• Thus, if we are to answer the question as to whether there are any
rules or principles to use when making moral decisions in the
medical context, we must turn to general ethical theories and to a
consideration of moral principles that have been proposed to hold
in all contexts of human action.

3. Introduction
This chapter reviews several major ethical
theories which attempt to supply basic principles
that we can rely on in making moral decisions.
Those theories are:
• Utilitarianism
• Deontology – Kant’s version and Ross’s version
• Rawls’s Theory of Justice
• Natural law ethics
• Virtue ethics
• Care ethics

4. Introduction
The chapter also reviews several broad principles
that cut across some or all of the ethical theories
examined. These principles are:
• Non-maleficence
• Benevolence
• Utility
• Rules of distributive justice
• Autonomy

5. Utilitarianism
• According to Utilitarianism, a person should perform
those action actions which conform to the Principle of
Utility.
• The Principle of Utility says: a person should choose
that action which produce the greatest good for the
greatest number of people affected by the alternatives
open to him.
• The rightness or wrongness of actions is determined by
the goodness or badness of the actions’ consequences,
not by the actions themselves.

6. Utilitarianism
• Because the morality of an action, according to
utilitarianism, rests on its consequences,
utilitarianism is called a “consequentialist theory
of ethics.”
• There are different views as to what make a
consequence good or bad.
• According to the “classical” or “hedonistic”
version, what makes a consequence good or bad
is its effect on people’s happiness.

7. Utilitarianism
• Roughly, a consequence is bad if it reduces
happiness, good if it increases happiness.
• Happiness, in turn, is understood to mean: an
increase in pleasure and/or decrease in pain.
• Because of the emphasis on happiness,
Utilitarianism is sometimes called “the
greatest happiness principle”.

8. Application to bioethic
• In August 2000, conjoined twins, named Mary and Jodie were born
in a hospital in Manchester England. Their spines were fused, and
they had one heart and one pair of lungs between them. Jodie, the
stronger one, was providing blood for her sister.
• The prognosis was that without intervention, both girls would die
within six months. The only hope was an operation to separate
them. This would save Jodie, but Mary would die immediately.
• Thus, there were two options:
(a) Not intervene and see both babies die
Or
(b) Intervene and save one life, Jodie.

9. Application to bioethics
• What is the acceptable course of action?
• According to utilitarian, we need to decide which
course of action will produce the greatest good
for the greatest number of people affected by the
action.
• It is plausible to interpret utilitarianism as
supporting alternative (b). Surely it is better to
save one life rather than not.

10. Deontology
• As noted earlier, consequentialist theories of ethics
find the basis for an action’s morality in the
consequences produced by the action rather than in
the action itself.
• Deonological theories of ethics, argue that it is features
of the action itself, apart from consequences, which
determine its morality.
• When an action has the relevant features then we can
say it is our duty (or obligation) to perform it.

11. Deontology
• It is this emphasis on duty that earns them the
name “deontological”, which is derived from
the Greek word for “duty” or “obligation”.
• There are different versions of deontology. We
examine two of them, those of Immanuel Kant
and W. D. Ross.

12. Kant
• According to Kant, we have an obligation to
perform an action if it satisfies what he called
“the categorical imperative”.
• Kant formulated three versions of the
imperative. Though differing in wording and
emphasis, he understood them as three
different “views” of the same overarching
principle. They are:

13. Categorical imperative
• Act only according to that maxim by which you can at the
same time will that it should become universal law.
• Act so that you treat humanity, whether in your own
person or in that of another, always as an end and never as
a means only.
• Every rational being must so act as if he were through his
maxim always a legislating member in the universal
kingdom of ends.
• We shall restrict ourselves to the first two versions, starting
with the first.

14. First version
• If you decide to have an abortion and go through
with it, it is possible to view your action as
involving a rule.
• You can be thought of as endorsing a rule to the
effect “Whenever I am in circumstances like
these, then I will have an abortion.” Kant calls
such a rule a “maxim.”
• In his view, all reasoned and considered actions
can be regarded as involving maxims.

15. First version
• The maxims in such cases are personal or
subjective, but they can be thought of as being
candidates for moral rules.
• If they pass the test imposed by the categorical
imperative, then we can say that such actions are
right. Furthermore, in passing the test, the
maxims cease to be merely personal and
subjective. They gain the status of objective rules
of morality that hold for everyone.

16. First version
• Kant calls the principle “categorical” to distinguish
it from “hypothetical” imperatives. These tell us
what to do if we want to bring about certain
consequences— such as happiness.
• A categorical imperative prescribes what we
ought to do without reference to any
consequences. The principle is an “imperative”
because it is a command.

17. First version
• The test imposed on maxims by the categorical
imperative is one of generalization or
“universalizability.” The central idea of the test is that a
moral maxim is one that can be generalized to apply to
all cases of the same kind.
• That is, you must be willing to see your rule adopted as
a maxim by everyone who is in a situation similar to
yours. You must be willing to see your maxim
universalized, even though it may turn out on some
other occasion to work to your disadvantage.

18. First version
• The best way to illustrate the first version of the category
imperative is to consider a possible instance where an
action fails the test.
• Suppose, for example, that I am a physician and I tell a
patient that he has a serious illness, although I know that
he doesn’t. This may be to my immediate advantage, for
the treatment and the supposed cure will increase my
income and reputation.
• The maxim of my action might be phrased as, “Whenever I
have a healthy patient, I will lie to him and say that he has
an illness.”

19. First version
• Now suppose that I try to generalize my maxim (apply
the first version of the categorical imperative). In doing
so, I will discover that I am willing the existence of a
practice that has contradictory properties.
• If “Whenever any physician has a healthy patient, she
will lie to him and say he has an illness” is made a
universal law, then every patient will be told that he
has an illness. Trust in the diagnostic pronouncements
of physicians will be destroyed, while my scheme
depends on my patients’ trusting me and accepting the
truth of my lying diagnosis.

20. First version
• It is as if I were saying, “Let there be a rule of
truth telling such that people can assume that
others are telling them the truth, but let there
also be a rule that physicians may lie to their
patients when it is in the interest of the physician
to do so.”
• In willing both rules, I am willing something
contradictory. Thus, I can will my action in a
particular case, but I can’t will that my action be
universal without generating a logical conflict.

21. First version
• If we return to the Mary and Jodie example introduced earlier, we can see
that Kant’s approach to evaluating the alternatives (allow both to die or
save one but sacrifice the other) would be different from that of
utilitarianism. Kant would reject the idea that we should look at the
consequences of the two options.
• Instead we should ask if something like the following rule could be
universalized (that is, avoid “contradiction”):
• Save one life in situations where failing to do so will result in the loss of life
of two.
• Can it be universalized? On the face of it, there is no obvious contradiction
in trying to do. As a result, the Kantian and the Utilitarian could well agree
on the morality of the action but for different reasons.

22. Second version
• Act so that you treat humanity, whether in your
own person or in that of another, always as an
end and never as a means only.
• This version illustrates Kant’s notion that every
rational creature has a worth in itself.
• This worth is not conferred by being born into a
society with a certain political structure, nor even
by belonging to a certain biological species.

23. Second version
• The worth is inherent in the sheer possession of rationality.
Rational creatures possess what Kant calls an
“autonomous, self-legislating will.”
• That is, they are able to consider the consequences of their
actions, make rules for themselves, and direct their actions
by those self-imposed rules. Thus, rationality confers upon
everyone an intrinsic worth and dignity.
• So, we are treating a person (including ourselves) as an end
(and not just a means to an end) when we act towards him
in such a way that recognize his rationality or autonomy.

24. Second version
• A non-bioethical example illustrates his meaning:
• You need money and you want a loan but you know you
can’t pay it back. It occurs to you to ask a friend for the
money with the promise of paying it back. You are
proposing to lie to the person and, in so doing, you are
treating them merely as a means to one of your goals.
• On the hand, imagine the same situation except this time
you explain the situation to your friend, hoping still, of
course, to get the money. But now you are allowing your
friend to make his own free and fully-informed decision to
give you the money or not. You have recognized and
engaged the friend as a rational agent. You have respected
his dignity.

25. Second version
• Recall again the example of Mary and Jodie. How might we
apply the second version of the categorical imperative to
this case. Here is one possible way to phrase the question:
• If we elect to save Jodie and allow Mary to die, have they
both been treated as “ends”? One answer might be no
because Mary has been “sacrificed” to allow Jodie to live –
she is being treated merely as a means to Jodie’s survival.
• If this is the correct conclusion then a question arises as to
whether it is consistent with the apparently correct
conclusion to the first version of the imperative, that there
is no inconsistency in universalizing the rule: save one life
when the alternative is to see two die.

26. W. D. Ross
• W. D. Ross attempts to incorporate aspects of
utilitarianism and aspects of Kantianism.
• Ross rejected the utilitarian notion that an action is
made right by its consequences alone, but he was also
troubled by Kant’s view, if a rule passed the categorical
imperative (and became a duty to follow), it could have
no exceptions, it was absolute.
• He saw not only that such rules fail to show sensitivity
to the complexities of actual situations, but also that
they sometimes conflict with one another.

27. Prima facie duties
• Like Kant, Ross is a deontologist, but he believed (as
Kant apparently did not) that moral duties can conflict,
in which case their relative merits had to be weighed
and the chosen action based on the outcome of that
weighing.
• Because duty A might be outweighed by another duty
B in a situation where the two conflict, it might seem
inappropriate to call A a duty in the first place. Aware
of this concern, Ross describes A and B as prima facie
duties. They are duties we have “all things being
equal”. But in a situation only one of them will turn
out (after weighing) to be our actual duty.

28. Prima facie duties
• When is something our duty? Ross does not propose any general
test of obligation like Kant’s categorical imperative. Instead, Ross
falls within the tradition of “ethical intuitionism”. After a careful
examination of the facts surrounding a case, he believes that we
then are able to intuit the appropriate duty.
• Ross claims that our experience with such cases puts us in a
position to come to know our prima facie duties with the same
degree of certainty as when we grasp the mathematical truth that a
triangle has three angles.
• Furthermore, according to Ross, our experience of many individual
cases puts us in a position to recognize the validity of a general
statement like “It is wrong to cause needless pain.” We come to
see such rules in much the same way that we come to recognize the
letter A after having seen it written or printed in a variety of
handwritings or typefaces.

29. Prima facie duties
Ross offers a list of duties that he considers binding on all
moral agents. (He did not claim that the list is
exhaustive).
1. Duties of fidelity: telling the truth, keeping actual and
implicit promises, and not representing fiction as
history
2. Duties of reparation: righting the wrongs we have done
to others
3. Duties of gratitude: recognizing the services others
have done for us

30. Prima facie duties
4. Duties of justice: preventing a distribution of pleasure or
happiness that is not in keeping with the merit of the
people involved
5. Duties of beneficence: helping to better the condition of
other beings with respect to virtue, intelligence, or
pleasure
6. Duties of self-improvement: bettering ourselves with
respect to virtue or intelligence
7. Duties of non-malfeasance: avoiding or preventing an injury
to others

31. Bioethical example
• Recalling the example of Mary and Jodie, Ross would
answer the question of whether it is right or wrong to
separate the twins by first seeing which of the prima
facie duties are applicable and, in the event there is a
conflict, examine the non-moral facts of the case, and
with these facts as background, weigh the duties
against one another.
• In considering the case, the duties of non-malfeasance
and beneficence seems relevant and it is plausible to
read them as implying that there is an obligation to
separate the twins.

32. Rawls’s theory of justice
• The theory of justice formulated by the philosopher John
Rawls can be understood as attempting to combine the
strengths of utilitarianism and deontology while avoiding
the weaknesses of each view.
• For Rawls, the central task of government is to preserve
and promote the liberty and welfare of individuals. Thus,
principles of justice are needed to serve as standards for
designing and evaluating social institutions and practices.
• Rawls’ position has direct relevance to such bioethical
issues as who should have access to health care, how
donated organs should be distributed, and who should pay
for society’s medical costs.

33. Principles of justice
Rawls argues that there are two fundamental principles of
justice:
1. Each person is to have an equal right to the most extensive
total system of equal basic liberties compatible with a
similar system of liberty for all.
2. Social and economic inequalities are to be arranged so that
they are both
a) to the greatest benefit of the least advantaged
b) (b) attached to offices and positions open to all under
conditions of fair equality of opportunity.

34. Principles of justice
• For Rawls, these two principles are taken to govern the
distribution of all social goods: liberty, property,
wealth, and social privilege.
• The first principle has priority. It guarantees a system of
equal liberty for all. The second principle governs the
distribution of social goods other than liberty.
• Though Rawls’ overall position has relevance to
individual medical decisions, it’s most important
application is to the social institutions and practices of
medical care and research.

35. Bioethical example: consent
• According to Rawls’s principles it is wrong to exploit
one group of people or even one person for the benefit
of others.
• Thus, experiments in which people are forced to be
subjects or are tricked into participating are ruled out.
• A person has a right to decide what risks she is willing
to take with her own life and health. Thus, voluntary
consent is required before someone can legitimately
become a research subject.

36. Bioethical example: health care
• The implication of Rawls position seems to be that everyone is
entitled to health care.
• First, it could be argued that health is among the “primary goods”
that Rawls’s principles are designed to protect and promote.
(“Primary goods” are the rights, opportunities, powers, wealth, and
such that are both worth possessing in themselves and are
necessary to securing the more specific goods people may want.)
• Second, it could be argued that the inequalities of the health care
system can be justified only if those in most need can benefit from
them. Since this is not obviously the case with the present system,
Rawls’s principles seem to call for a reform that would provide
health care to those who are unable to pay.

37. Natural law ethics
• Natural law theories of ethics share the general idea that the
rightness of actions is something determined by nature itself, rather
than by the laws and customs of societies or the preferences of
individuals.
• The most well-known, and fully articulated, version of natural law is
that formulated by St. Thomas Aquinas and endorsed by the
Catholic Church.
• Borrowing from Aristotle, the Thomistic version of natural law sees
the universe organized in a teleological way. That is, the universe is
structured in such a way that each thing in it has a goal or purpose.
Thomism importantly add that this teleological structure was
brought about by God so that the purposes found in the Universe
are a reflection of God’s purposes.

38. Natural law ethics
• For example, when conditions are right, a tadpole will
develop into a frog. In its growth and change, the tadpole is
following “the law of its nature.” It is achieving its goal.
• Humans have a material nature, just as a tadpole does, and
in their own growth and development they, too, follow a
law of their material nature.
• But humans also possess a trait that no other creature
does: reason. Thus, the full development of human
potentialities—the fulfillment of human purposes or ends
—requires that we follow the direction of the law of
reason, as well as being subjected to the laws of material
human nature.

39. Natural law ethics
• We rely upon reason to determine what our ends
are and how we can achieve them. In particular,
reason directs us toward our good as the goal of
our action, and what that good is, is discoverable
within our nature.
• The human good is “built into” human nature in
the way that, in a sense, a frog is already “built
into” a tadpole. Thus, the good is that to which
we are directed by our natural inclinations as
both physical and rational creatures.

40. Natural law ethics
• These built-in inclinations are the basis for our moral
duties. For example:
• Like other creatures, we have a natural inclination to
preserve our lives; consequently, reason imposes on us an
obligation to care for our health, not to kill ourselves, and
not to put ourselves in positions in which we might be
killed.
• We realize through reason that others have a rational
nature like ours, and we see that we are bound to treat
them with the same dignity and respect that we accord
ourselves.

41. Natural law ethics
• When we see that humans require a society to make their full
development possible, we realize that we have an obligation to
support laws and practices that make society possible.
• We have a natural inclination to propagate our species (viewed as a
“natural” good), so reason places on us an obligation not to thwart
or pervert that inclination (by for example using condoms or
masturbating).
• As the examples illustrate, according to natural law ethics, through
the application of reason, it should be possible to establish a body
of moral principles and rules. These are the doctrines of natural law.
• Following are two principles especially relevant to bioethics.

42. Principle of double effect
• A particular kind of moral conflict arises when the
performance of an action will produce both good
and bad effects. On the basis of the good effect, it
seems it is our duty to perform the action; but on
the basis of the bad effect, it seems our duty not
to perform it.
• What are we obligated to do in this situation?
The principle of double effect is intended to help
in the resolution of these kinds of conflicts.

43. Principle of double effect
The principle holds that such an action should be performed only if the
intention is to bring about the good effect and the bad effect will be an
unintended or indirect consequence. More specifically, four conditions
must be satisfied:
1. The action itself must be morally indifferent or morally good.
2. The bad effect must not be the means by which the good effect is
achieved.
3. The motive must be the achievement of the good effect only.
4. The good effect must be at least equivalent in importance to the bad
effect.

44. Double effect example
The principle might be illustrated by the example of Mary and Jodie:
• The doctors wanted to save the life of Jodie, a morally good action.
• The death of Mary was a bad consequence of saving Jodie but it
was not the means; it was a foreseen but unintended by-product of
saving Jodie.
• The doctors intended to save the life of Jodie, it was not to kill
Mary.
• Saving the life of Jodie is morally as significant as the death of Mary.

45. Principle of totality
• This principle says that an individual has a right to dispose
of his or her organs or to destroy their capacity to function
only to the extent that the general well-being of the whole
body demands it.
• Thus, it is clear that we have a natural obligation to
preserve our lives, but, by the Roman Catholic view, we also
have a duty to preserve the integrity of our bodies.
• This duty is based on the belief that each of our organs was
designed by God to play a role in maintaining the functional
integrity of our bodies— that each has a place in the divine
plan. As we are the custodians of our bodies, not their
owners, it is our duty to care for them as a trust.

46. Principle of totality
• The principle of totality has implications for a great
number of medical procedures.
• Strictly speaking, even cosmetic surgery is morally right
only when it is required to maintain or ensure the
normal functioning of the rest of the body.
• More important, procedures that are typically
employed for contraceptive purposes— vasectomies
and tubal ligations—are ruled out since such
procedures involve “mutilation” and the destruction of
the capacity of the organs of reproduction to function
properly.

47. Virtue ethics
• Virtue ethics is ethics based on character. Its
fundamental idea is that a person who has acquired
the proper set of dispositions will do what is right
when faced with a situation involving a moral choice.
• Thus, virtue ethics doesn’t involve invoking principles
or rules to guide actions.
• The virtuous person is both the basic concept and the
goal of virtue ethics. The virtuous person is one who
acts right, because she is just that sort of person.

48. Virtue ethics
• Right actions flow out of character, and the
virtuous person has a disposition to do the right
thing. Rules need not be consulted, calculations
need not be performed, abstract duties need not
be considered.
• In medical contexts, virtue ethics calls attention
to the central role which such virtues as courage,
loyalty, integrity, compassion, and benevolence,
along with determination and intelligence, should
play in the practices of medical providers.

49. Care ethics
• Care ethics is an outgrowth of feminist ethics or, perhaps more accurately,
is a particular strand of feminist ethics.
• Care ethics is not a unified doctrine that can be captured in a set of
abstract statements. It is perhaps best characterized as a family of beliefs
about the way values should be manifested in character and in behavior.
• It is unified by a set of shared concerns and commitments, as well as by
the rejection of the traditional philosophical view that ethics can be
adequately represented by rules and principles.
• As the name implies, the sentiment of caring is taken as a central
consideration in deciding what to do. In medical ethical contexts this
perspective is perhaps exemplified by how a doctor looks at his or her
patient: is this a problem to fix or is this a person whose health I care
about?

50. General moral principles relevant to
bioethics
• The following are thumbnail sketches of a
number of principles which most, if not all, of
the ethical theories considered endorse in one
form or another. They all have relevance to
bioethical issues.

51. Principle of Non-maleficence
• “Above all, do no harm” is perhaps the most
famous and most quoted of all moral maxims
in medicine. It captures in a succinct way what
is universally considered to be an overriding
duty of anyone who undertakes the care of a
patient.

52. Principle of beneficence
• The principle of beneficence can be stated in
various and different ways. Here is one
formulation: We should act in ways that
promote the welfare of other people. That is,
we should help other people when we are
able to do so.

53. Principle of utility
• The principle of utility can be formulated in this way: We should act
in such a way as to bring about the greatest benefit and the least
harm.
• The principle is the very foundation of the moral theory of
utilitarianism. However, the principle need not be regarded as
unique to utilitarianism.
• It can be thought of as one moral principle among others that
present us with a prima facie duty, and, as such, it need not be
regarded as always taking precedence over others.
• In particular, we would never think it was justified to deprive
someone of a right, even if by doing so we could bring benefit to
many others.

54. Rules of distributive justice
• We expect (and can demand) to be treated justly in our
dealings with other people and with institutions. The
following rules reflect this basic sentiment.
• They are best understood in terms of John Rawls’
position summarized earlier.
• From a bioethical perspective, they have clear
relevance to questions about, for example, access to
health insurance, the distribution of organs, and who
should shoulder the burden of health care costs.

55. Rules of distributive justice
Equality
• According to the principle of equality, all benefits and burdens are to be
distributed equally.
Need
• The principle of need is an extension of the egalitarian principle of equal
distribution.
• If goods are parceled out according to individual need, those who have
greater needs will receive a greater share. However, the outcome will be
one of equality.
• Since the basic needs of everyone will be met, everyone will end up at the
same level. The treatment of individuals will be equal, in this respect, even
though the proportion of goods they receive will not be.

56. Rules of distributive justice
Contribution
• According to the principle of contribution, people
should get back that proportion of social goods
that is the result of their productive labor.
Effort
• According to the principle of effort, the degree of
effort made by the individual should determine
the proportion of goods received by the
individual.

57. Principle of autonomy
• The principle of autonomy can be stated this way:
Rational individuals should be permitted to be self-
determining. According to this formulation, we act
autonomously when our actions are the result of our
own choices and decisions.
• Autonomy is significant not only because it is a
condition for moral responsibility, but because it is
through the exercise of autonomy that individuals
shape their lives. Autonomy is a significant
consideration when thinking about euthanasia and
abortion.