Submit a short 250-300 word "Written Assignment." Use these questions as prompts with an introductory opinion or thesis that explains to your readers why people can or cannot always practice some cert

A’s medical condition , and the potential implications of telling her the bad news, i.e. how likely is it that being told the bad new s would threaten her life or complicate the recovery process? These could be discussed with Dr. B, Ms. C, and other medical experts, if available, and we could do general research on traumatic injury cases, to understand the kinds of injuries involved and the kinds of threats such injuries make to continued survival. We could then look for any studies about the implications of psychological or emotional stress on the relevant physiological conditions involved in traumatic injuries, such as blood pressure and heart rate. Perhaps there is good evidence in the medical or psychological literature that emotional stress or grief has a dramatic effect on such physiological conditions, and thus evidence that there is a substantial risk to Ms. C if she is told the bad news. Or perhaps there is evidence that there are no such dramatic effects, e.g. a study indicating that there are no known cases where emotional trauma was causally important to a patient’s death. We might also investigate the history of the person s involved here and their relationships: does Ms. A have a good and trusting relationship with Dr. B and/or Nurse C? Do Dr. B and Nurse C have high regard amongst other HCPs and patients, or do they have a history of questionable decisionmaking? Was Ms. A promised by medical staff that she would be kept informed about her children, e.g. if she protested their absence at some point? These historical factors affect how to apply the principles of rights, virtue, and equality (fairness), and could substantia lly shape a decision about what to do. 26 As for the law and policy issues, these are probably (as always) quite complex, since the contemplated lie (normally against law and policy) is in defense of a life, which law and policy often explicitly or implicitl y allow as an exception. But there might be relevant case law worth exploring, or a history of cases at the specific institution -- and these might concern not only the general question of informing at -risk patients, but also the question of the role of n urses in withholding such information on physician’s orders. It is unlikely that economic considerations are crucial here, though it might be worth looking into a risk assessment regarding a potential suit by Ms. A or her survivors should we make one cho ice or another. But it would clearly be important to know more about Ms. A’s cultural and psychological situation, if possible: is she someone prone to extreme emotional reactions, or more even -keeled? Is she from a cultural or religious tradition that m ight affect her way of seeing the loss of a child, or the event of having been lied to about her child? Step 2: Creative Problem Solving The information gathered in Step 1 might resolve the case – perhaps there is clearly no risk to Ms. A’s health, and the physician is simply misinformed. But more likely, the information has only enriched our understanding without clearly resolving the issue. So the next strategy is to find a way out of the dilemma of whether to tell such a terrible lie, or risk killing M s. A with the truth. A natural thought is for Ms. C to try to avoid doing either, for instance trying to redirect Ms. A’s concern by saying “we need to worry about you right now”. This would not be a lie, and it might avoid causing Ms. A emotional distres s. Alternatively, Ms. C could simply pretend ignorance of the children’s condition, which would involve a lie, 27 but arguably a less troublesome one than saying that all the children are fine. Notice, however, that these techniques could actually cause Ms. A to become more irritated and anxious about not receiving the answers she is seeking, which may still risk causing her condition to worsen. So the strategies might be worth trying, but if they do lead to psychological frustration and physiological decli ne, the nurse would still be faced with the question of whether to ease the anxiety by telling the lie. Another creative strategy would be to find other family or close friends to support Ms. A before telling her the truth. One could even make sure her hu sband is on the phone, having been informed of the situation – and perhaps he could help assess whether Ms. A would be able to handle the news, with his knowledge of how she deals with emotional difficulties. But notice that these sorts of strategies stil l involve acting against the physician’s orders, a moral concern involving virtue and rights, so they do not completely avoid the dilemma. Another possibility would be to medicate Ms. A so that she is unable to ask or worry about her children. Of course, this may be an unreasonable option, given Ms. A’s condition, but it may be that induced sleep would be medically advantageous, in which case it is a solution that would avoid the dilemma. Step 3: Listing the Pros and Cons Let us suppose these creative str ategies all fail, or face serious moral objections, so Ms. C faces just two primary options: telling Ms. A about the death of her daughter, or lying and saying her daughter is still alive. Of course, there are lots of different ways of telling the truth -- bluntly and insensitively, or with care and compassion. And there are different ways of lying -- saying her daughter is perfectly OK, saying you are unsure how 28 she is doing, or saying she is in surgery. The differences are important to consider, but for simplicity, we can speak of two options, telling the truth and lying, keeping in mind that there are various ways of exercising each of the options. The question then is which of the two options is the better one, and to make progress in answering it we can list the pros and cons, putting down the obvious ones first. In favor of telling the truth is that the mother has a right to know about the condition of her own child, which involves the CARVE principle of rights. But in favor of lying to her, despite h er apparent right to know, is the consideration that the physician has instructed the nurse to do so, and ordinarily nurses should follow physician’s orders. This involves the CARVE principle of virtue, since it is appealing to a general trait of characte r that nurses should have – a tendency to respect and follow the instructions of the physicians in charge of their patient’s care. Against that idea is of course the thought that lying is wrong, a violation of the autonomy and rights of patients; but agai nst telling the truth is the thought that doing so could seriously harm the mother, given her vulnerable medical condition. This leaves us with the following chart of basic moral pros and cons, with the related CARVE principles in parentheses: OPTIONS PRO S CONS Tell the truth 1. Ms. A has a right to know about her child (Rights) 3. It could cause her condition to worsen (Nonmaleficence) Lie 2. Dr. B has instructed Ms. C not to tell Ms. A about the daughter’s death (Virtue) 4. Lying is wrong (Autonomy, Rights) To be systematic, let us go on to consider each of the CARVE principles in more detail, 29 to see if we have missed anything. Nonmaleficence is represented by reason #3, the concern not to harm the mother with the news. Beneficence might lead one to try to comfort Ms. A with the lie, but that concern, while morally relevant in most contexts, is trivial in this one, and so it need not be included. Utility requires looking to all those persons affected by one’s choices, and that means con sidering others besides the mother, something not yet incorporated in the pro/con list. Who else might be affected? The other children, of course, if the mother is harmed by hearing the news. There is also a larger concern about the effects of lying on the reputation of health care professionals. If the lie is told, the mother may come to distrust and resent those who lied to her, and that sentiment is one she may share with others. This could harm the reputation of the profession – however important a nd well -intentioned the lie may have been – leading to future patients not trusting medical professionals, which could mean withholding information or even refraining from seeking medical assistance (at least until it is urgent, and perhaps too late). The se are significant concerns overlooked in the first list, and worth adding as a separate reason against lying (see below). As for the principle of respect for autonomy, it also goes against lying to Ms. A, since in misinforming one would be interfering wit h Ms. A’s view of the world for one’s own purposes. 10 This is already reflected in the chart for reason #4. Autonomy might also tell in favor of Ms. C making her own moral decision, rather than just following the physician’s directions, which would underc ut the importance of reason #2. That is worth noting, but it is something that can be considered later since it concerns an evaluation of the strength of a reason rather than a new reason altogether. Rights are represented – the right to know the truth a bout your children, and the right not to be lied to. Virtue 30 appears, as the idea that a good nurse should follow a physician’s orders. But notice that virtue can cut the other way: it is not obvious that the virtue of obedience should override virtues o f honesty and integrity in the nursing profession. So it would be worth inserting this idea into the chart, especially since Ms. C’s own concern, as reflected in the case description, seems to have to do with the matter of her own personal integrity in pa rticipating in the lie (see below). Finally, equality (and the related concept of fairness) do not seem directly relevant, unless one speaks of the unfairness of lying to the mother, something better captured by the idea of her rights. The revised pro/co n list then reads: OPTIONS PROS CONS Tell the truth 1. Ms. A has a right to know about her child (Rights) 3. It could cause her condition to worsen (Nonmaleficence) Lie 2. Dr. B has instructed Ms. C not to tell Ms. A about the daughter’s death (Virtue) 4. Lying is wrong (Autonomy, Rights) 5. May contribute to loss of trust in the medical profession (Utility) 6. Violates the nurse’s honesty and integrity (Virtue) Step 4: Analysis All the reasons listed in the chart are morally relevant, and have some moral force. What assumptions must be made to consider any one reason substantially stronger than another? The most obvious place to start is with 1) factual assumptions about how likely the truth is to cause the mother serious harm. One might a ssume that there is a significant 31 risk, on the grounds that this must be why the doctor wanted to wait until the morning, or based on general knowledge of the effects of emotional stress on the physiology of those under critical care. But is this sufficie nt evidence? Alternatively, one could argue that it is just as likely the doctor simply wanted to wait so the husband could deal with the mother and her emotional reaction, rather than having to deal with it himself. If we are forced to admit uncertainty about the likelihood of harm, it raises the question of what the ‘default’ position should be when one is uncertain about causing harm, which can involve 2) value assumptions worth exploring. For instance, one might be assuming that even a slight chance o f causing death is a powerful, overwhelming moral consideration, based on the idea that the most significant moral principle for health care is to avoid harm (nonmaleficence). Note that this is an assumption about values, not an assumption about the facts -- people who agree about the chance of causing death could disagree about its moral importance. For why think non -maleficence should override prohibitions on lying, or considerations of rights and autonomy? In recent years more emphasis has been put on respecting the rights and autonomy of patients, even when doing so means that patients may be harmed by hearing bad news, or be allowed to make poor choices. Why not extend this argument to cases where risk of death is involved? Here it might be useful to consider what led to the increased importance of autonomy and rights in health care, and whether the reasons extend to the current kind of case. Alternatively, one might assume patient’s rights and autonomy are so important that they can only be overrid den if there is clear and convincing evidence of its necessity to avoid serious harm. What could justify putting the burden of proof on the side of the 32 paternalist here? Is this based on a suspicion of the motives of physicians, or on a prioritization of principles of autonomy and rights? If the former, what is the evidence; if the latter, what considerations (or examples) might be used to show that the patient’s welfare should not be the sole or main focus of health care ethics? One way to think about this is to notice that there is a chance the mother will die even if lied to, and then she would die under the false belief that her daughter was fine. Is that a terrible thing, suggesting that there is something important about knowing (and telling) the truth regardless of the consequences? Or is it a mercy that the mother did not have to spend her last hours agonizing over the loss of her child, and perhaps her own responsibility for the death? Similar factual and value assumptions lie behind assessment s of the other reasons in the chart. Why think a nurse should follow a physician’s orders (reason # 2), even when those conflict with the nurse’s own moral judgment? Is that based on a factual assumptions about the role of nurses in medical practice, and the worry that if nurses were to second -guess physicians’ orders it would undermine that role and thereby cause patient harm? What is the evidence for that? If one assumes nurses should follow their own moral compass, valuing integrity and professional autonomy over obedience to physicians, what justifies that assumption? Again, is it based on assumptions about what would work better for the health care profession, for example that nurses are needed in certain cases to advocate for or protect patients a gainst mistaken or unethical conduct by physicians? What justifies that assumption? Or perhaps there are value assumptions at the root of this question of virtue: perhaps anyone, in any job, should always consider his or her own moral compass, at least w hen asked by superiors to do things which would be 33 a serious violation of his or her moral conscience. Perhaps that is a view based simply on the dignity of human beings, their ultimate autonomy to live by their own values. Another reason worth examinin g is #4, that lying is wrong. Some people assume all lies are serious moral violations, while others take beneficent and ‘white’ lies to be morally legitimate. 11 What is behind these differing assumptions? In the case at hand, all would agree the lie is one of great magnitude or import, so it isn’t a trivial or ‘white’ lie, but arguably it is a beneficent lie – designed to save a life. What assumption must be made to think this beneficence sufficient to justify the lie? Is the assumption that the reason lying is wrong is that it typically is harmful to persons to lie? Is that the essence of the wrongness of lying? Or is lying an interference with rights not so easily overridden by considerations of utility? What assumption must one make to think lying is wrong independent of such utility considerations? If no one is harmed by a lie – indeed, if people are helped -- what is left to make the lie wrong? Step 5: Justification At this point, having worked through the analysis, one should be better prepared to determine which option is morally preferable. There may be room for reasonable people to disagree about the current case, but let us consider the position that the nurse should lie to the mother, waiting until the morning and the arrival of her husband to tell her of her loss. A simple justification, fitting the recommended format, and with minimal information gathering involved, could be offered as follows: I. Introduction : “Faced with Ms. A’s continual request for information about her children, Ms. C should follow the physician’s orders and tell Ms. A her children are fine, 34 seeking to calm the mother and help her make it through the night, when she will be in a more stable and safer condition to receive the news about her loss.” II. Support : “The mo st significant reason for this course of action is the need to protect Ms. A from harm (reason #3). Telling Ms. A of the death of her child could cause her condition to worsen, and increase the risk that she will die. These are reasonably likely conseque nces, given that she is likely to feel substantial grief and anguish about her involvement, and those emotions are well known to cause physiological stresses that threaten those under critical care. The likelihood is further supported by the physician’s o rder, written in the chart, which indicates the seriousness of the threat in the eyes of the physician. It is not for a nurse to second -guess such a medical judgment. Moreover, it is extremely important that a nurse not cause such harms, or take substant ial risk of doing so. That is the primary ethical command in health care, since its purpose is defined by the goal of tending to the well -being of patients.” “Another reason for telling this difficult lie is that the nurse is on orders from the doctor to do so (reason #2). This is not a trivial reason, since physicians are in a clear line of command over nurses. It is an important virtue of nurses that they respect and obey the directives of physicians, since that is their nursing role and generally refl ects the differences in levels of education, training, and expertise. Nevertheless, it must be admitted that there is also an important role for nursing autonomy, even on medical questions about which the nurse is especially experienced, and certainly on e thical questions, since a physician’s medical 35 training is no guarantee of superior ethical instincts. In addition, respect for moral integrity requires that nurses be considered free to consult their own moral conscience. So if a nurse believes following a physician’s orders would involve a serious violation of ethics, it should be open to the nurse to not do so. As a result, this reason is not a strong one in this case – the nurse has serious reservations, and the existence of a physician’s orders does not alone settle what to do.” [Notice: each supporting reason listed in the chart above has been considered, although the author says one of the reasons is not a very important one. The goal is to represent one's own genuine views, not to simply use any reason that one can.) III. Defense : “A significant reason against lying is the simple idea that lying is wrong, a violation of patients’ rights and their autonomy (reason #4). For this reason to prevail, in the face of the risk to Ms. A’s life, we would ne ed to assume that considerations of rights and autonomy are of equal or greater import than ones of welfare in health care contexts. But what could justify such an assumption? The central mission of medicine is by any lights to serve patient well -being, and any rights or other moral rules are themselves best understood in the service of that mission. It is true that in recent years medical paternalism and its prioritization of patient welfare over autonomy has become less accepted, cut back by various rules and laws about informed consent and the rights of patients. But the history of these changes shows that the new rules and laws were developed precisely because they were seen as necessary to protect patients. Thus informed consent 36 rules have their bi rth in the discovery of the abuse of patients in medical research (most importantly in the case of the Tuskegee Syphilis Study). And many of the other rules are due to the decline of the family doctor and the rise of bureaucratic, specialized medicine, wh ere the familiarity and trust crucial to a paternalist model are far more rare. So while there are some good utility reasons for taking rights and autonomy seriously, they do not extend to situations where a person’s unwanted and preventable death might b e the result. In such a context, one should always look to the ultimate mission of medicine and err on the side of life. Another argument against lying is that the mother has a right to know information about her own daughter (reason #1). This is true, but there is the question of timing. The mother has the right to know at some point, but not necessarily right away, in a situation where knowing could endanger her health (or that of others). The right to know is like the right to free speech: it generall y holds, but not when someone wants to yell "fire" in a crowded theatre. Telling the mother the truth immediately would be like yelling "fire”, possibly leading to serious harm or death, and so we need not do so.” “There are also concerns about whether lyi ng in this case, or in cases like this one, could lead to a decrease in trust and respect for the medical profession (reason #5). Again, this is an important consideration, but not a crucial one. The mother will learn the truth in the morning, and it can be explained that the delay was to protect her own life given her unstable condition. Some mothers would focus on the loss of their child, and forget, forgive, or even be grateful for the beneficent lie. Others may be indignant and severely upset, but i t is doubtful that 37 would last very long. The chance that Ms. A will reject the paternalist justification, leading to a long -term distrust of the medical profession that leads to her not seeking necessary care, is fairly small, and worth risking in face of the alternative of definitely risking her health and survival this very night.” “Finally, the point can be raised that for the nurse to tell a lie goes against the virtues of honesty and integrity, virtues which we would want nurses to cultivate (reason # 6). Here the key is to recognize that those virtues, like all virtues, need to be evaluated in context. Honesty is important, as a basic disposition to tell the truth, but there are exceptions where telling the truth can be a vice. That is obvious when it comes to truths which are confidential or inappropriate, but it also means that there are some cases where lying is consistent with virtue, as in the trivial cases of white lies to put people at ease in social situations (“fine, how are you?”). As for integrity, if the nurse thinks through the arguments put forward here, she would recognize the moral legitimacy of the lie, and thus it would not violate her integrity to do so. So the virtues of honesty and integrity are insufficient to undermine the ben eficent lie in this case, as important as they are in other contexts.” IV. Summary : “As difficult as it may be for Ms. C, she should tell Ms. A that her children are doing well, to help increase Ms. C’s chances of getting through the night. The sole reas on is to avoid worsening Ms. A’s condition with the terrible news of her child’s death. Though telling the lie flies in the face of many ordinary moral norms, it is justified by the motive behind it – protecting the well - 38 being of the patient – and the pri macy of that motive in the mission of health care.” Further Steps: Moral Theory and Moral Philosophy This use of the above framework – the CARVE principles, and the five -step AJ Method -- may lead different people to different conclusions about the morally best way to handle ethical issues, in health care contexts and elsewhere. The advantage of using the framework is that it helps make each person’s reasoning more complete, subtle, and complex, but it does not ensure that all reasonable people will end up agreeing with one another. Perhaps nothing can do that, but some have tried, and in closing let us briefly consider two additional stages in the process of moral reflection. The first is the realm of moral theory , in which we step beyond our judgments ab out specific ethical issues and develop a more general moral outlook. 12 This is a natural and common theoretical step, as we seek to organize our moral ideas and make them more coherent, usually by basing them on a set of more fundamental moral principles or values. The theoretically simplest way of doing this is to find a single moral principle on which all our moral judgments can be based. One example of such an approach is a moral theory called “utilitarianism”. Someone who has committed to a utilita rian moral theory takes the CARVE principle of utility to be the most fundamental principle for moral thinking. This means that a utilitarian takes concern for the welfare of all to be the deepest, most general and most important moral consideration, lyin g at the base of all other thoughts about right and wrong, goodness and evil, virtue and vice. For instance, why should we respect individual rights, or the choices and autonomy of individuals? The answer, according to a utilitarian, is that doing so gen erally involves 39 more benefit than it involves harm – people do not like being interfered with, and generally fare better if left to their own devices. Yet in some cases, such as when the rich want to keep all their income despite the health care needs of the poor, or when a sick person is fearful of life -saving surgery, the utilitarian would set aside claims of rights and autonomy to do what would be best for all concerned. So a utilitarian offers a general answer to the question of what is morally right or wrong in any given situation: it is the choice, of the alternatives, that would promote the most general welfare for all who might be affected by one’s choice. 13 Sometimes the benefits and harms are difficult to calculate, so there can be moral controve rsies based on different factual assumptions; but if utilitarianism is right, there is no basis for a dispute over fundamental values – we should all share a fundamental concern for promoting the general welfare, and that value will decide any questions ab out whether to follow a certain moral rule or value in a given case. John Stuart Mill is the most well -known historical proponent of this moral theory, a theory which has had tremendous influence on moral and political thinking in the Western world. 14 Of course, there are other influential moral theories, which prioritize different moral principles, and that’s the rub: to enter into moral theory is to enter the realm of controversy all over again, though at a more general level. For instance, there are Ka ntians who prioritize a version of respect for autonomy over utility. 15 On a Kantian view, the most fundamental moral idea is that we should recognize other moral agents as rational beings -- as able to think and evaluate and reason for themselves – and we should respect the dignity of all such rational beings. This means putting far less emphasis on how people feel , and more on how they reason ; less emphasis on promoting health or 40 well -being, and more on respecting individuals; less emphasis on good outco mes , more on duties . Kantians thus embrace the idea of absolute restrictions on how we can treat other persons. As a result, they reject the utilitarian idea that we should treat persons in ways that promote the general welfare, for that may involve an i nsult to the dignity of an individual we may be using as a means to greater good. Instead, Kantians seek to base all moral reflection on some idea of respect for the autonomy and dignity of rational beings. There are different versions of Kantianism, bas ed on different ways of fleshing out this basic idea of respect for autonomy, and there is controversy over which of the different approaches is best. But like utilitarianism, Kantianism has been quite influential in Western ethical thought, helping creat e the recent emphasis in health care ethics on informed consent procedures, as well as having an influence on moral and political thought more generally. There are also moral theories that reject the attempt to base all ethical thought on a single princip le, while still seeking to provide a coherent story about what it is to take a moral point of view. One approach, called pluralism, insists that none of the major moral principles is fundamental -- different principles have more or less importance in diff erent contexts, with only our moral intuition to judge which principle should prevail in a given case. 16 Other theories stress the importance of virtue, and the development of a virtuous character, rather than the application of principles or rules. 17 Trad itional virtue theorists have sought to further develop Aristotle’s ancient theory of virtue, while some feminists have argued that the virtue of caring for others should be understood as the organizing idea for moral theory. 18 41 To enter moral theory is to i nvestigate these various alternative moral theories, and the kinds of arguments that have been offered for thinking one or another provides a better sense of how to organize and improve ethical reflection. The advantage of engaging in moral theory is that the focus can be on the general value disagreements, which may lead to progress on the larger questions of how to understand and prioritize basic moral principles and values. But a disadvantage is that one may lose a sense of why the value disagreements matter – one may only see what is truly at stake in taking on a general moral outlook if one considers individual decisions about cases and specific moral judgments. Those who study and write about moral theory usually handle this quandary by seeking what John Rawls has defined as “reflective equilibrium”: adjusting their moral theory in light of considered judgments about individual cases, and vice versa, until there is an overall coherence between the moral theory and what the theorist thinks, on reflect ion, is the morally best approach to individual cases. 19 This reflective equilibrium may not fit perfectly with some intuitions or gut instincts about cases, due to considerations at the more general level introduced by the moral theory; but one is searchi ng for the most coherent fit one can find between theory and specific moral beliefs. Once again, however, even if you do find a moral theory that is in reflective equilibrium with your various considered judgments about cases, other people may find that a different and competing moral theory is in reflective equilibrium with their own considered judgments. So how can the difference over moral theory be resolved, once the same level of reflective equilibrium has been reached by each party to the dispute? M oral philosophy is the field of study that seeks to make further progress through the most abstract kinds of questions about the nature of moral thought and discourse. 20 42 What is the relationship between our different moral concepts of the right, the good, and the virtuous? What would it mean to have a good argument for one moral theory or judgment over another? Is it matter of finding absolute certainty, or is some kind of intuitive probability sufficient? What would be the ultimate grounds of such a jud gment? Indeed, what are we even doing when we make an ethical claim? As G.E. Moore put it, how can we know what is good if we do not first figure out we mean when we talk about the good? 21 What kind of judgment is it that something is good, or that an ac t is morally wrong? Is ethical judgment the ascription of an objective property, like the property of being red or of weighing two pounds? 22 Or are ethical judgments subjective, matters of personal taste or emotion that make no claims to objectivity, as w hen we judge a fashion or a musical style to be good or desirable? 23 Yet could a mere difference in subjective tastes be the essence of disagreements about whether patients have a right to refuse treatments, or whether the rich and famous should be given p riority in organ transplants? This level of moral reflection, while quite abstract and seemingly detached, can sometimes enter into practical ethical thinking. A common example is when someone argues against interfering in the affairs of another person or culture, on the grounds that we and they have different ethical judgments, and it is not for us to impose our ethical judgments on them, since ethical judgments are merely relative. This line of reasoning argues from a relativist position in moral philos ophy to the conclusion that we should respect the moral views of others. Note though the paradox: the ethical conclusion about respecting others is not taken to be a relative one, so there must be at least some ethical norms that are not relative. This p rovides an example of how reflections at the most 43 general level of moral philosophy sometimes enter into everyday ethical life, for better or for worse. The upshot is that there is no end to the process of reflecting on moral questions. Which kinds of ref lection are most important is itself a matter of controversy, as is even the question of whether reflection is itself a good thing. This essay has offered a fairly uncontroversial approach, emphasizing principles and basic reasoning steps useful in evalua ting moral issues and justifying one’s position. The CARVE principles and the AJ Method procedure are more than enough for most of us, busy as we are to make our moral choices and get on with our lives. But for those who seek to go further, moral theory and moral philosophy are ways to deepen and enrich one’s understanding of the moral domain. 1 Kurt Baier, The Moral Point of View: A Rational Basis of Ethics (Ithaca: Cornell University Press, 1958). 2 Some writers ha ve made distinctions between ‘the moral’ and ‘the ethical’, with the moral being more closely tied to everyday notions of guilt, punishment, and explicit social rules. We will follow the more common usage and take ‘moral’ and ‘ethical’ to be roughly synon ymous. 3 The judgment that moral considerations should prevail is an overall normative assessment, not a narrowly moral one, a sense of what would be best “all things considered.” 4 See Tom L. Beauchamp and James F. Childress, Principles of Biomedical Et hics , 4 th Ed. (New York: Oxford University Press, 1994), pp. 28 -40. 44 5 This version of the list of principles, and the acronym, is from Becky Cox White and Eric H. Gampel, “Resolving Moral Dilemmas: A Case -Based Method,” HEC Forum , vol. 8:2 (1996), pp. 89 -90. 6 The Principle of Equality does allow unequal treatment if people are different in a way that is morally relevant. As an obvious example, emergency room personnel may treat a person with a jammed finger ‘differently’ than one in cardiac arrest, treati ng the latter more quickly and more intensively than the former, without being in violation of the Principle of Equality. 7 The use of a similar method in teaching is discussed in Eric Gampel, “A Method for Teaching Ethics”, Teaching Philosophy , vol. 19:4 (1996), pp. 371 -383. 8 The “facts” in this sense are not known or provable, but we might find that our own views presuppose that the facts are a certain way. 9 This case is adapted from B. Tate, The Nurse’s Dilemma (Geneva, Switzerland: International Co uncil of Nurses, 1977). The discussion is based on White and Gampel. 10 The principle of autonomy is usually understood to prohibit misinforming while requiring the provision of accurate information. Both involve shaping a person’s choices, but misinforma tion does so in a way that serves one’s own purposes – even if one’s purpose is beneficence -- and thus counts as a kind of interference, whereas informing a person as to the facts simply allows the person to make a decision in light of all the relevant in formation. 11 Sisela Bok, Lying: Moral Choice in Public and Personal Life (New York: Vintage Books, 1989). 45 12 For an accessible overview of moral theory, see James Rachels, The Elements of Moral Philosophy , 2 nd Ed. (New York: McGraw -Hill Publishing Company, 1993). 13 This is a version of utilitarianism called “act utilitarianism”, since we are applying the principle of utility to the individual act to see if it is morally best. A different suggestion is that we should follow the rules that would, if generall y followed, promote the greatest overall welfare. See Richard B. Brandt, A Theory of the Right and the Good (Oxford: Oxford University Press, 1979), pp. 271 -305. 14 John Stuart Mill, Utilitarianism (New York: Bobbs -Merrill, 1957). 15 This approach stems fro m the work of the 18 th Century German philosopher Immanuel Kant. For a good historical survey of Kantian and other moral theories, see T.C. Denise, S.P. Peterfreund, and N.P. White, eds., Great Traditions in Ethics , 9 th Ed. (Belmont, CA: Wadsworth Publish ing Company, 1999). 16 William Ross, The Right and the Good (Oxford: Oxford University Press, 1932). 17 For an overview of virtue ethics, see Elements of Moral Philosophy , pp. 159 - 179). 18 Nel Noddings, Caring: A Feminine Approach to Ethics and Moral Educatio n (Berkeley: University of California Press, 1984). 19 John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), pp. 20 -21, and 46 -50). 20 For an overview that emphasizes these more abstract questions, see Gilbert Harman, The Nature o f Morality (NY: Oxford University Press, 1977). 46 21 G.E. Moore, Principia Ethica (Cambridge: Cambridge University Press, 1903). 22 Moore defended this sort of objectivity of ethical properties in Principia Ethica . For a defense of ethical objectivity in the tradition of virtue ethics and natural law, see John Finnis, Natural Law and Natural Rights (Oxford: Clarendon Press, 1980). In the Kantian tradition, see Christine Korsgaard, Sources of Normativity (Cambridge: Cambridge University Press, 1996). 23 For an account that emphasizes ethical attitudes and emotions, see Allan Gibbard, Wise Choices, Apt Feelings (Cambridge: Harvard University Press, 1990). Another kind of subjectivism has been developed by Simon Blackburn, who draws an analogy between subjective color judgments and ethical judgments; see “How To Be an Ethical Anti -Realist” in Essays in Quasi -Realism (Oxford: Oxford University Press, 1993).