The Bioethical Mandala
A Reflection on the Moral Structure of Health Care (part 5)
Utilitarians have focused upon the "objective" consequences of our actions. They argue that actions should be governed by rational decisions based on impartial assessment of evidence. Emotions and other non-rational states are dismissed as incommensurate with rational aims and so irreconcilable with them; oddly enough, the emotion of pleasure, or at least its pursuit, is promoted by utilitarians as the final goal of action.
This inconsistency arises in the equation of pleasure with happiness; in a problematic opposition of the "sensation of pain" to the "sensation of pleasure", equating pain with evil; and from a failure to recognise that both pain and pleasure are to a large degree psychological states, creating more of an epistemological problem than an ethical one.(10) (That such states may be placed under the control of the will – whether actively, as exemplified in, say, yoga, or passively, as displayed in the behaviour of hypnotised subjects, has hardly been considered.)(11)
Happiness for one may exclude the prospect of happiness for another; utilitarians therefore propose that the good lies in the establishment of the greatest happiness for the greatest number (even if some, perhaps innocent, parties may thereby be forced to endure great suffering and privation). The good may be better defined in terms of satisfaction of the preferences of the greatest number; it seems intuitively better that more people should get to have what they prefer.
Consider, however, the event that a majority of doctors preferred to experiment upon live, unanaesthetised human subjects. Even if (as in the case of the Nazi domination of Germany, when such work was actually performed upon the inmates of concentration camps) the majority of the population agreed, or at least did not disagree with them, it seems even more intuitively sound to propose that there must be something objectively wrong with such behaviour.
Perhaps a committed utilitarian might reply that the satisfaction of the preferences of the greater population for useful consequences of such research should outweigh the immediate suffering of the victims. On the other hand, a more humanitarian utilitarian might give more weight to massive, measurable, present suffering over a hypothetical future benefit.
Nazi Germans, however, considered that the Jews and other oppressed races were not persons, thus metaphysically avoiding both the utilitarian dilemma and the deontological question of the abuse of human rights (though not the matter of the interests of the disadvantaged).
This weighted preference approach is fraught with peril. Should we wish to resolve disputes with some sense of an enduring, objective scale of values, wherein a resolution of conflicting desires can depend upon a standard which is agreed to be greater than the simple preferences of any individual or group,(12) we are left with the problem of exactly whose preferences are to be satisfied. Moreover, we are given no guidance with regard to the selection of two equally attractive preferences should we be unable to determine the required weighting of the balance.
The bioethical utilitarian conceives an overall balance of happiness in terms of the minimisation of suffering for the greatest possible number. Even should happiness be defined as the satisfaction of preferences, however, may we determine with any accuracy the preferences of, say, a comatose accident victim, or of any other person (or morally relevant entity such as a laboratory animal, or a foetus) who may be unable for whatever reason to communicate their preferences?
And even if we may so do, who is to say that such preferences (suicide attempt; desire for euthanasia) would be rational and not subject to the probability of radical change in the very near future should the circumstances of the case be shown to have distinctly altered: as, for example, when the suicide's reason for desiring death (depression from a marriage breakdown) has been repaired (perhaps by the return of the partner, or by falling in love with the nurse!).
The key to bioethical utilitarianism, given our system of financing health care, lies in the allocation of funds. Utilitarians assign weights to those actions which offer alternative routes to the most economical promotion of the supposed balance of happiness over suffering. A balance sheet is drawn up, weighing opposing options: take the value of improving the quality of a single human life by heart transplant at a cost of $100,000 in contrast to the benefits of sacrificing the cardiac patient by allocating those funds to some worthy, but less expensive procedure that may be used to save the lives of more than a dozen other people for the same amount of money. Of course there are normally many other more complex calculations. The "bottom line" emerges, expressing the calculated impact of proposed actions. This method is chosen because it seems objective, located within clearly defined parameters, having the attractive quality of a rational, scientific and/or businesslike approach to a thorny problem.
Disadvantages to this approach present themselves should an attempt be made to ascertain the true weights of each element, in the absence of any standard other than the maximisation of happiness. Happiness is notoriously hard to quantify – especially given an equation weighted in favour of some more Nietzschean, or Machiavellian position, such as that of the Nazi camp experiments. Such quantificatory decisions are theory-laden, usually failing to take relevant interests of such disadvantaged groups as experimental animals, concentration camp Jews, or the victims of violence into account (other than noting their existence as economic factors). Moreover, the balance of happiness is weighted differently among those who think that older women, poor people, or aborigines, for example, deserve less consideration than a favoured group, say, middle-aged men, the medical profession, or native-born white Australians.
The solution is looked for in bioethical utilitarianism in a form of Rule Utilitarianism, whereby a body of rules, or laws are selected to guide our behaviour and which we accept a moral obligation to apply. The practitioner is thus absolved from the difficult task of weighing the issues every time he must act ethically, but has simply passed the decision back along the line to those who have decided on the elements that will comprise the set of rules. This is a sort of cross-fertilisation of consequentialism and the rights-based approach that I shall next examine.
This article goes on to consider the rights-based ethical positions, and the implications of harmony and wellbeing.
Read more about the Bioethical Mandala