Ethics are moral principles unrelated to the conduct of an individual or a group.

Moral Philosophy: Deontology Vs. Utilitarianism

The field of ethics (moral philosophy) involves systematizing, defending, and recommending concepts of right and wrong behavior. Clinical ethics frameworks have been developed from these various philosophical approaches, including deontology and utilitarianism. Developed by the moral philosopher Immanuel Kant,deontology is also referred to asKantian ethics orduty-based ethics. The morality of an action is based solely on the nature of the action regardless of the consequences or any other factors. Decisions are made on what is in the best interest for the patient. Deontology views actions as either right or wrong without any regard to contextual features. An example sometimes used is that of the Ten Commandments (i.e., “Honor your father and mother,” “Do not kill,” “Do not steal”). We can easily point to deontology's influence in health care in regard to promoting truth telling with patients. What should a clinician do though if the truth might cause harm to the patient or others? A commonly cited criticism in relation to the moral imperative of “truth telling” or “do not lie” is the hypothetical scenario that you are hiding someone from a murderer. The murderer comes to your home and asks if the person, their intended victim, is there. A critique of Kantian ethics is that the moral thing to do would be to tell the truth, regardless of the consequences.

Utilitarianism is a consequentialist moral theory that emphasizes efforts to maximize the overall good. Consequentialism, as an ethical theory, is concerned only with the consequences of an action. Applying a utilitarian framework for decision making entails an analysis with a goal to achieve the greatest benefit for the greatest number of persons. The consequence or outcome of the decision determines the morality of the action. Examples of utilitarian approaches include institutional requirements for vaccinations and reporting communicable disease infections to public health authorities. While many believe such approaches limit expression of personal choice and may pose harm, the benefits are seen as greater and thus morally (ethically) permissible. A counterpoint critique of a utilitarian approach that has been depicted in popular culture is how health care professionals may act in the aftermath of public health disasters by triaging patients based on the amount of limited resources required to ensure the likelihood of survival. Such practices may violate one or more of the four principles that guide our conception of a medical standard of care while creating significant moral distress for the health professionals involved.

Deontology

Deontology is a system of ethical analysis, most closely associated with Immanuel Kant, that bases the correctness of one’s actions on fulfilling the duties of the actor (Alexander and Moore, 2008). Thus individuals have moral obligations to others and, if they fulfill those obligations, they are acting ethically; if they do not, they are acting unethically. Among the major challenges of deontology is to determine the basis of one’s duties and the nature of one’s duties. Religious ethics typically is deontological. For example, the 10 commandments of the Old Testament define both specific duties all persons are expected to fulfill and also the basis for the duties – i.e., the commandments of an almighty deity. Thus, for persons who are committed to a particular religious tradition, their ethical duties are often defined by that tradition. However, for those who do not subscribe to that tradition, those duties may not be perceived as binding. Furthermore, in a pluralistic secular society, no one religious perspective is likely to be endorsed by all individuals. Therefore religiously based deontology cannot provide a common framework for such a society’s ethics.

However, some scholars have argued that duties can be defined on bases other than religion. Most importantly, Immanuel Kant argued that duties could be defined based on reason alone. He argued that, because humans are inherently rational beings, our ethical duties derive directly from rationality. If we are to be rational, we are obligated to act such that our actions could be universalized. This is Kant’s categorical imperative: “I ought never to act except in such a way that I could also will that my maxim should become a universal law.” Thus, anything we are permitted to do, everyone else must be permitted to do.

For example, if we are permitted to lie, according to the categorical imperative, everyone is permitted to lie. Although we might be tempted to argue that some specific circumstances might permit lying, once we argue that there are exceptions to the categorical imperative, we give tacit permission to others to define exceptions for themselves and others and the imperative is no longer categorical (i.e., universal). The advantage of Kant’s approach is that the categorical imperative applies to everyone equally and is not dependent on religion or ideology. However, it is problematic in that it defines universal duties in a form that permits no exceptions.

The other maxim attributed to Kant’s deontology is the statement that morality requires that we "act so as never to treat another rational being merely as a means." Thus we can never knowingly and intentionally sacrifice the good of one person for the good of another. This maxim is widely accepted throughout the western ethical tradition.

The limitations of deontology become apparent when we consider situations in which doing our duty leads to very bad consequences. A classic example is the situation confronted by those who hid and protected Jews in Nazi Germany. If German soldiers came to the door and asked the homeowner if he or she were hiding any Jews, it is hard to argue that ethics would obligate one to tell them the truth. One response to this is that this situation creates a conflict of fundamental duties – the duty to tell the truth and the duty to protect innocents from harm. However, deontology does not resolve this conflict satisfactorily. Indeed, one could argue the duty always to tell the truth is more fundamental than the duty to protect innocents from harm, if only because the latter is entirely under one’s own control, whereas the latter is rarely entirely under one’s own control. Indeed, there is no guarantee that lying to the soldiers will prevent them from discovering and murdering the Jews hidden in the house. It appears that the only satisfactory way to resolve this dilemma is to consider the consequences of one’s actions: Telling the truth will likely lead to the deaths of innocents (a profound evil) whereas telling a lie will more likely prevent that outcome and instead result only in the deception of those who would do great evil (a minor evil at most, and arguably a good).

Deontology

The termdeontology is derived from the rootdeon, meaning “duty,” and deontological theory is based on the importance of duty. Duty is based more on the intentions that lead a person to act than on the outcomes or consequences of the action. Utilitarian thinking is mostly situational and depends on the specific aspects of a given situation; deontological thinking strives to be more universal and to emphasize decisions that would apply in all relevant situations. Thus Kant's categorical imperative states that we should act only in a way that is consistent with a universal law or obligation.14 Using people as means to an end implies that different actions (or reactions) are needed depending on the end or outcome that is desired; therefore, the actions are not universally applicable. For this reason, deontological thinking stipulates that we should treat all people as “ends” and not as means to an end. This could cause problems in thinking about the morality of organ transplantation if the organ donor is thought of only as a means to the end of survival for the recipient. Clearly, deontological thinking imposes a duty to respect the rights and value of the donor as much as those of the recipient because anyone could be either a donor or a recipient.

Deontological thinking emphasizes duties and obligations, but these may conflict. For example, physicians may have different and competing obligations toward patients, families, hospitals, insurance companies, and society. The attempt to describe duties leads to formulation of general or universal rules for moral action, but these rules may also conflict. Rules may be too abstract and impractical to apply to real-life situations. Deontologically based rules do not take into account the messiness of human relationships, a point that it is essential to keep in mind when considering the ethics of care discussed later in this chapter.

Fundamentals of Moral Decision Making

Detailed discussion of the process of moral decision making can be found elsewhere in this encyclopedia. However, it may be helpful to provide a brief overview of the main approaches to moral decision making. Inevitably, this will involve some degree of simplification, and it may also imply a greater degree of separation between different approaches than is the case.

Virtue Ethics, Utilitarianism, and Duty-Driven Ethics

The classic “paternalism” of medical practice was derived fromvirtue-based ethics. In this view, the physician is a genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism, who naturally knows and does what is correct for the patient. The patient, uneducated about medicine, has to trust the physician to decide what is best. Western society and legal systems have changed substantially since paternalism flourished, giving way to practices based in the four “pillars” of medical ethics: respect for patient autonomy, beneficence, nonmaleficence, and justice. Many different ethical frameworks are applied in modern medicine, but two of the most prominent frameworks relevant to western medicine are utilitarian ethics and deontology.2

Inutilitarian ethics, actions are judged right or wrong on the balance of their good and bad consequences. A “right” action produces the most good, based on a perspective that gives equal weight to the interests of all affected parties. Utilitarian theory is compelling but falls short in defining which benefits are most important. Is it the “good” that all reasonable people want or the “good” defined by the individual patient? What if the only way to maximize good is to commit an entirely immoral act? For example, what if the only way to win a war is to systematically torture children? Outcomes of actions continue to accumulate over time—when on that continuum is it appropriate to determine that an action was right or wrong? The “good” act of saving an individual’s life today may be viewed through a completely different lens when, 20 years from now, that same individual is revealed as a mass murderer.

Utilitarian theory may be best when applied to analyzing broad-based policies, in decisions regarding rationing of resources, and when attempting to resolve conflicting ethical obligations between several equally interested parties.

The premise of Kantian-based ethics (also called deontologic—orduty-based—theory) is that features of actions other than their consequences make them right or wrong.Intention is more important than outcome. Furthermore, no person should use another exclusively as a means to an end, because each personis the end for which we should act. No person should be used to further the purposes of another person without that other person’s autonomous consent. Kantian philosophy would forbid killing one innocent person to save another innocent person, for example.

Individualism and autonomy are valued highly in Western society, and people tend to turn to Kantian philosophy when ethical questions arise that balance the authority of the physician against the goals and values of individual patients.

Some of the toughest ethical questions in medical practice occur when the rights and desires of individual patients conflict with social policies. Clashes between deontologic and utilitarian principles are common in the intensive care unit (ICU), in managed care settings, in end-of-life care, in transplant medicine, in triage during civilian mass casualty events, and in the care of poor and older patients whose medical management is funded by the government. In each of these settings, the will of the individual patient may conflict with broader principles of minimizing expense, fairly allocating scarce resources, protecting the broader interests of many patients, and determining where and how society’s healthcare dollars are best spent.

Criticisms of Kant

Kant’s deontology is not without its opponents. Here are some of the criticisms commonly raised.

One criticism of Kant’s ethics is that he ultimately assumed the freedom of the will without proof. Given our observations about the human condition, it is viewed by many as more tenable to postulate determinism over freedom, regardless of what that does to human morality. In Kant’s case, he seems to make a pragmatic decision that moral responsibility is so important that this justifies the assumption of human freedom.

Many reject Kant’s contention that genuine moral worth is grounded in a purely rational activity of the will married to an impersonally calculable logical consistency. Kant does not try to hide this. And yet his view of intentionality, though rigorous, fails to capture much of what we admire as moral motivation, such as the admiration of maternal instinct judiciously applied.

Another criticism of Kant concerns the issue of maxims. When humans act, Kant says that we act according to subjective principles of action called maxims. What he never does is argue for a consistent way to form these maxims prior to assessment via the three tests for categorical imperatives. Once again, honesty serves as a good case in point. Suppose I am unemployed and tempted to steal to feed my family. If I phrase the maxim generally, “It is OK to steal,” I am breaking a categorical moral law by the three tests. But Kant does not really specify that I cannot phrase the maxim anyway I wish, such as “I may steal to feed my starving family when I know I will not get caught, and when I can reasonably assume that others in the same position are not doing the same.” Universalize this maxim, and there is no apparent practical contradiction. Here we seem to have a case where a maxim fails the first test but passes the second and third ones.

Kant insists that moral situations never, if thought out carefully, cash out as genuine dilemmas over conflicting categorical imperatives. Otherwise, the status of absolute moral rules as a class would be in jeopardy. During World War II, Dutch fishermen hid Jewish fugitives in their boats and ferried them to safety over in England. Often, SS patrol boats and submarines would stop these fishing boats. When Nazi captains asked the fishermen if there were Jews on board, what were the fishermen to do? If the maxims “It is wrong to lie” and “Permitting the murder of innocent people is wrong” are both viewed as categorical imperatives, as I think they must be, then we have a genuine categorical dilemma. In these cases, most Dutch captains viewed it as permissible to sacrifice absolute honesty to save innocent lives. Kant has trouble with these types of scenarios.

Deontology

The final dominant paradigm is deontology. Deontology comes from the Greek word for duty, deon. Deontologists primarily define what is “good” or “right” as a function of behavior and the context in which that behavior occurs. Deontologists establish the central components of this paradigm by highlighting weaknesses in virtue and consequentialist theories.

Deontologists argue that virtue theory is wrong because virtue theory claims specific behaviors are always “right” or “wrong.” As a result, virtue theory cannot account for instances where you should not behave virtuously (e.g., lying to your significant other about where you are going to get them to a surprise party organized for them). Deontologists argue that the context in which behavior occurs is also relevant in determining what is “right” and “wrong.” Behavior should not be labeled “right” or “wrong” based only on what the behavior looks like (i.e., the behavior’s formal properties).

Deontologists argue that consequentialism is wrong for three reasons. First, deontologists believe the consequences of our behaviors are often outside of our control. As a result, consequences are ethically insignificant. For example, it seems unfair to say someone behaved unethically by purchasing coffee that is produced through illegal child labor conditions if they do not know about those labor conditions. Second, deontologists believe that consequentialism places impractical demands on people because you would have to consider all potential consequences for all potential behaviors for all potential people before making a choice (Marino, 2010). Not only would this require a tremendous amount of time and effort, but it also is not clear how all the potential consequences could be included and appropriately compared. Third, deontologists argue that consequentialism fails because it can result in extreme permissiveness. In certain circumstances, consequentialism seems to demand that innocent people be killed, beaten, lied to, or deprived of resources as long as it results in greater benefits for others.

To summarize, deontologists argue that the context within which a behavior occurs has to be considered when determining what is “right” and “wrong.” In addition, deontologists argue that the environmental change resulting from a behavior cannot be used to justify a behavior as ethical or unethical. Rather, a behavior is right or wrong based on conformity to a socially derived norm of behavior (Alexander & Moore, 2016).

Deontology can also be critiqued. One critique of deontology relates to who decides the norms of behavior. Often the people who decide these norms are people who have power of some kind (e.g., religious leaders, governmental officials). However, there is no reason to assume those individuals have any greater ability to decide what is right than other members of society. Second, deontology can potentially lead to posthoc justification for many different behaviors. If what is considered the correct behavior depends solely on the context, then one could argue the reason they behaved in a certain way was based on contextual factors that others did not observe or consider.

Deontological Ethics of Human Dignity

The central insight that gives deontology its name is that in moral reflection, the self discovers that an act ought to be done; it owes it to itself to do justice to this obligation. Agency is not only a straightforward drive, a movement of expansion, but also governed by a reflection that links it back to the self as its author. The ability to turn back on itself and to halt an action that is not in keeping with the agent’s view of himself needs to be explained in its possibility. This is what Kant (1724–1804) does in a transcendental analysis that seeks to uncover the condition of the possibility of knowing and acting within the self. In this metatheoretical move, one goes behind what is experienced – for instance, that there are actions that are done out of respect for the moral law – to understand the condition of its possibility. This condition that one has to assume, but cannot prove empirically, is freedom. While Kant admits that it is equally thinkable that human beings are completely determined by nature, he takes the experience of obligation or sensitivity to moral concerns as a reason against a purely naturalistic explanation of human consciousness and action. A deontological account of ethics thus sees the human person as capable of perceiving duties and rights, of understanding that the other person in her equally original freedom is a limit to one’s action if this action means that I instrumentalise her for my own plans. The humanistic formulation of Kant’s ‘Categorical Imperative’ is: ‘Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means but always at the same time as an end.14 ’ How demanding this account of morality is can be seen in the fact that this obligation holds regardless of whether the other person returns the recognition offered. Even if the relationship is not mutual, thus, also in cases of silence or of enmity, morality demands of the self to continue to extend respect even if it remains one-sided. We owe it to our dignity not to act in certain ways. As the capability for morality, dignity is the foundation of autonomy, which means self-government by the moral law. Not to do justice to this dimension is heteronomy.

In distinction from virtue ethics, the autonomy approach puts forward a formal rule of judgment, left to the agent’s conscience to decide, instead of substantive and concrete contents, such as courage or compassion. Intentions or maxims of actions are judged by the principle of universalisability of whether every one could do so. Thus, its measure is not the social expectation of a specific cultural context. On the contrary, it submits these contexts to moral evaluation, transcending their historical values and judging them by principles based on moral self-reflection, discerning whether a maxim or intention respects or violates the other or humanity in oneself. Its horizon is not communitarian but cosmopolitan. With such an extensive scope of ethics, namely all humanity, the question arises where such an encompassing perspective can be anchored. For Kant, it is in the ‘good will’ that is a human disposition.15 Ricoeur sees a parallel in it to Aristotle’s most comprehensive and leading virtue, the capacity for justice.16 Good action is not, however, anchored in the striving for a happy or flourishing life congruent with the typical features of human nature. The quest for meaning or happiness is recognised in Kant’s concept of the highest good that comprises both moral goodness and happiness, but the second has to be proportionate to the first. Morality is an order of its own, the two have to be distinguished, and their conflict leads to the antinomy of practical reason. The harmonious view of human striving as coinciding with what is good is not shared by Kant; the painful experience that good intentions can fail to reach their goal or be counteracted is acknowledged as a problem so serious that it puts into question the foundations of ethics.

The decisive difference to Utilitarianism is that it excludes the sacrificial principle. Deontology insists that individuals may never be instrumentalised and fundamentally disputes that moral choices can be justified by their consequences. The only feature that can make an act good is the intention that guides it, the good will. This is what distinguishes it both from antique ethics and from Utilitarianism: the shift from ends towards which we strive naturally (as in virtue ethics) to an emphasis on the will. One can see the influence of the heritage of biblical monotheism in Kant’s repositioning of the good from the cognitive sphere of insight to which it was linked in Greek philosophy to the quality of the will. Kant’s insistence that acts need to be judged imminently, rather than by their external results, recognises the decisive role of conscience and self-reflection that modern Neo-Hegelian virtue ethics and Utilitarianism downplay for different reasons. What is crucial for an adequate analysis of Kant’s theory of practical reason is that it is not based on rationality as such, as in the Critique of Pure Reason but on the will that realises the human capability to be moral, which is the foundation of human dignity.

Evaluating this approach in terms of its concepts of self, agency and inter-subjectivity, its historical achievement is that it provides a definition of human dignity that is the source of human rights and the uniting foundation of respect for pluralistic self-understandings.17 Several chapters in this book refer to how it operates as a guiding principle in constitutions, United Nations declarations and documents both of the Council of Europe and of the European Union. Its decisive quality is the argument and the scope it gives for the protection of vulnerable subjects. Human freedom and its actualisation in the good will is not of an order that can be demonstrated and proved empirically, as some current definitions of personhood by empirically verifiable features – consciousness, or ability to voice one’s interests – assume. The capability for morality has to be assumed as belonging to every human being, regardless of their actual cognitive or other capacities.

It has, however, in its emphasis on morality as distinct from self-interest and from striving for a flourishing life, reduced the sphere of practical reason to an analysis of its deontological dimension. The rationality in determining priorities of values that Aristotelian ethics excelled in has been outside of its purview. Its major deficits are seen in the failure to provide a link to what motivates agency, such as the hope for a flourishing life in keeping with the virtues, and the gap between justification and application. It needs middle axioms or intermediary principles to specify what dignity means in concrete cases, such as of children’s rights. Kant provides categories for differentiated proposals, such as the distinction between perfect and imperfect duties, and designates decision-making on concrete cases to the faculty of judgment (Urteilskraft) which mediates between principles (e.g. to tell the truth) and concrete situations. However, the uniqueness that is discussed in relation to artists and their standard-setting works in the Critique of Judgment, urgently needs to be extended to persons in their singularity, as Ricoeur has shown convincingly in his critique of the contradiction between the ‘universal law’ and the pluralist (‘persons as ends in themselves’) formulations of the Categorical Imperative.18

The final two schools are Neo-Kantian in that their social and political ethics proposals start out from ‘free and equal’ citizens. They agree to the difference between the ‘right’ and the ‘good’ that has arisen from Kant’s distinction between duties of law and duties of virtue. Much of the debate between and about them is on how they reinterpret their Kantian heritage.19

Conclusions

Auditors’ moral reasoning has been considered from two viewpoints, deontology and consequentialism, assuming that the auditors are acting in an altruistic manner. It has been shown that deontology would imply that an auditor should always tell the truth irrespective of the consequences. However, an altruistic auditor reasoning consequentially could occasionally believe that greater good would result if he or she failed to reveal information that would have serious consequences for the client firm and its employees (e.g., by not revealing that a company might go into bankruptcy in the near future in a ‘going concern’ qualification in the audit report).

The problem faced by the auditing profession is that readers of audited financial statements are skeptical about whether auditors can be trusted (the audit expectations gap). Hence, the assumption that the profession and the interested government agencies have to make is that auditors are egoists interested in their own welfare. Such a view suggests that the best way to ensure honesty is either to make the costs of dishonesty so large that no one will be dishonest or to reduce the benefits that might accrue to auditors from being dishonest. Thus, the auditing professions in advanced countries have developed codes of ethics enforced by fines and expulsion from the professional bodies, which set out to steel the auditors’ resolve to avoid temptation by limiting their involvement with any one client. Although they are described as codes of ethics, they are little more than instructions for behavior in particular circumstances, with penalties for failure to comply. To ensure that auditors act in a technically competent and an independent manner, legislators have allowed large legal penalties to be extracted from negligent auditors.

However, the main difficulty with the previously discussed approaches relates to the notion that trust can be produced by the correct use of economic incentives. The central assumption of most of the measures would appear to be that everyone’s honesty has a price and that the best way to produce honesty is to ensure that nobody is tempted to be dishonest. This notion does have the attraction of being consistent with the need for auditing in the first place because that is based on the assumption that company directors cannot be trusted either. Nevertheless, it does have a rather defeatist view because it implies that as a whole, human beings can be trusted to tell the truth only when it suits them, but that as soon as there are incentives not to tell the truth, then dishonesty can be expected. The reality is probably that only a minority of auditors behave as egoists, but to convince a skeptical world that all auditors follow minimum standards of behavior, the professional rules have to be targeted at this minority.

Deontological concerns

The first approach identified by Vandemeulebroucke and colleagues analyzes carebots with a deontological lens. Deontology (from the Greek Deon, which means “duty” or “obligation”) is an influential moral theory that prohibits certain actions as wrong and is best understood in layperson's terms as claiming that the “ends do not justify the means.” Some ethical objections to carebots raised by the deontological approach include issues of autonomy, dignity, deception, and social isolation. Authors taking this approach argue that the introduction of carebots “into aged-care settings leads to inappropriately viewing older adults as means to ends” (Vandemeulebroucke et al., 2018, p. 19). In other words, caring for the elderly should not be treated just as a burden on society that robots could solve, and should robotic care be implemented, the elderly being cared for must benefit from the arrangement.a Deception is a focus of some deontological analysis of carebots. Some authors of literature on carebots, especially Sharkey and Sharkey (2011) and Sparrow and Sparrow (2006), argue that the use of carebots is a kind of deception—especially when robots are presented with anthropomorphic features that mimic emotions. As is seen in a number of the technologies covered in the previous section, we may be tricking the elderly into feeling that they are getting something they are not: cared for by robots that are, in fact, incapable of caring. Sparrow & Sparrow (2006, p. 155) state that “thinking that an expensive and sophisticated electronic toy is really our friend is sentimentality of a sort we should avoid.” Finally, the deontological approach raises concerns about the social isolation that may arise as a result of the use of carebots—and, conversely, the positive effects carebots may provide in helping the elderly remain connected to their communities. While homebound individuals receiving care from robots may become isolated from society, carebots may also “relieve human caregivers’ workloads, providing them more time to focus on improving older adults’ quality of life” (Vandemeulebroucke et al., 2018, p. 20).

Notably lacking from the deontological approach to analysis of the ethics of carebots is consideration for the wants and needs of the elderly themselves. Though approaching carebots with well-intentioned skepticism, some utilizing the deontological approach (such as Sharkey & Sharkey) seem to take a somewhat paternalistic view toward the elderly. Ironically, while those taking the deontological approach are concerned about the objectification of the elderly, there seems to be little consideration for the ability of those in need of care to themselves make decisions about their own care. Arguments about deception and truth, for instance, seem to stereotypically assume that the elderly can be easily fooled into thinking that carebots are capable of empathizing and providing genuine emotion and care. However, people of all ages may anthropomorphize and grow attached to objects, like anyone who has ever named a car and attributed to it personality quirks that truly represent manufacturing defects. In fact, there is ample evidence for this effect of anthropomorphizing and even ascribing personhood to inanimate objects (see Farah & Helberlein, 2007). Despite this, the (arguably deontological) moral unease some people feel about human-like robots seems to have prompted the development of obviously nonhumanoid robots, such as Pearl (see discussion above).

Arguments from social isolation seem to misrepresent the elderly as individuals incapable of advocating for their own needs and acting in their own best interests—while interacting with a carebot may provide some very basic level of positive psychosocial stimulation, elders not suffering from significant cognitive impairment should be assumed capable of arranging for social activities to provide necessary mental stimulation. Additionally, any carebots or technologies that would allow elders to stay in their own homes and communities rather than relocating to caregiving facilities would mean that those individuals would experience less severing of social connections that would have otherwise resulted from a forced move. The use of carebots could therefore actually result in greater connectedness for those receiving care.