Ethics. Bioethics. Health Care. Oh My.

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Being human, we’re accustomed to eating contradictions for breakfast. Even if we eat little else. We intend to behave quite a bit better than we usually do, and we squabble over what it means to be moral, or to live a good, fulfilling, worthy life.

Even if we agree on a moral rule, or make a law, we might observe the rule or obey the law for radically different reasons, or break the law for reasons we believe to be moral. Yes, indeed, dear readers. Dr. Bossypants knows it’s difficult to sort this all out, even though she has tried mightily to blog about morality and ethics in a most intriguing and approachable manner. Now, we have one more lens through which we might view moral decision-making, and then a bit of a summary, so those of you determined to put these ethical thoughts into ethical actions might do so. Right away. Please.

In the late 1970s, bioethics became a recognized specialty as hospitals and healthcare providers grappled with ethical decision-making in the increasingly contentious, conflicted, expensive world of healthcare.

Tom Beauchamp and James Childress identified four  guiding principles in the first edition of their influential book Principles of Biomedical Ethics:

  • Autonomy (Human beings should have authority over decisions affecting their health and well-being.)
  • Beneficence (Decisions should be made on the basis of doing good and being of help to others.)
  • Nonmaleficence (People should strive to do no unjustified harm.)
  • Justice (All people should be treated equally and benefits and burdens should be distributed fairly.)

Principles don’t offer concrete answers, but provide a framework to begin the hard work of ethical decision-making in the face of competing needs and limited resources.

Robert Bellah said “Cultures are dramatic conversations about things that matter to their participants.”

Listen, dear readers. Right now, we are engaged in a monumental conversation in our culture. We’re talking health care. Is it a basic human right? If so, how much health care should we make available in a world of apparently limited resources? Who should profit in the provision of health care, and how much profit is justified? Who should pay, and how should that duty be distributed?

Should we provide abortions to those who do not wish to be pregnant? Should we provide viagra to those who wish to have a pharmaceutically-assisted erection? Should we provide a means by which someone suffering, or near death, could choose to die with medical assistance? Oh, the inflammatory and politically-loaded questions just go on and on. They require deep thought. They require wisdom. These matters are seething with ethical quandaries.

Kant reminds us we should never treat people as a means to an end, nor deny anyone rights we would wish for ourselves.

John Stuart Mill reminds us we should choose paths, practices, and laws that insure the greatest possible good (health) for the greatest number.

Aristotle urges us to find the golden mean, the balancing point between excesses. And to be generous, courageous, and prudent.

Feminists remind us of the huge, destructive problems that arise when power is used to abuse others, to deny basic rights, and to enrich the already-rich.

Those who practice relationship-inclusive ethics remind us that we must always consider the direct impact of our actions–and our goal should be to take the most compassionate action possible.

The bioethicists offer us principles to consider, though admittedly these principles might actually conflict with each other sometimes.

We do not live in a perfect world. It is our job to make it better, not to give up in anger or despair. The ability to reason, converse, and find common ground is a human attribute we should treasure. Courage, dear ones. Be good people.

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Utilitarian Ethics–a Tall Order

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Let’s face it folks. We live in a broken world. Let’s not get into who broke it, but we can all pretty much agree things are far from ideal, or perfect, or even as good as they could be. So how do we make it better? We ask ourselves the question made famous by Jeremy Bentham and his protege (and admirably early feminist) John Stuart Mill, the forefathers of Utilitarian Ethics. The question is this: What action will bring about the greatest good for the most people?  This approach is also known as consequentialist or teleological ethics–the focus is on the outcome of an action. It is a good, or moral, action if it beings about the most good possible for the most people.

Englishman, Jeremy Bentham (1748-1832), believed that pleasure or happiness was the “substance” that should be measured in this equation. To evaluate the moral merits of one action over another action, you assess how many people would be made happy, or be given pleasure by each action. Bentham wrote, “Nature has placed mankind under the governance of two sovereign masters, pain and pleasure.  It is for them alone to point out what we ought to do…”

Bentham’s thinking was heavily influenced by the enormous social upheaval that gripped 18th century England.  He witnessed tremendous affliction all around him and sought a basis for morality that was both practical and social in nature. Bentham’s claim was that all acts and institutions must justify themselves by their utility—hence, the label “utilitarian.”

John Stuart Mill (1806-1873) was Jeremy Bentham’s godson and Bentham was a close friend of the Mill family. Though in basic agreement, as Mill developed his thinking, he came to believe that Bentham was wrong on one important point. Bentham believed that any kind of happiness was of the same value as any other kind of happiness. Mill argued that some forms of human pleasure was of higher quality than others, and therefore worth more in the utilitarian equation. He argued for the betterment of all humankind.

People are social beings. We tend to want to be in harmony with our fellow human beings.  Mill believed that at our core, people want the best for each other and are inclined to promote the common good. Wouldn’t it be nice if he was right about this??

Modern day utilitarians no longer try to quantify or qualify pleasure in a specific equation. They simply assert that morality is based on finding outcomes that will increase the common good, and decrease human suffering.

In contrast to deontological approaches (see the DUTY blog), utilitarians abandon any claim to moral certainty, because as I noted at the beginning, we live in an imperfect and fluid world. How could anyone assume moral certitude in an uncertain world? The best we can hope for is finding the greatest balance of good over evil in a world that has no perfection, no absolute goodness.

Many social reform movements can be seen as expressions of broadly-defined utilitarian thinking.  The welfare of the weak and disenfranchised members of society is counted as having equal weight and import in the overall fabric of society.  For instance, John Stuart Mill along with his wife, Harriet Taylor, was an early and articulate advocate for equal rights for women.

He wrote “…the principle which regulates the existing social relations between the two sexes—the legal subordination of one sex to the other—is wrong in itself, and now one of the chief hindrances to human improvement; and it ought to be replaced by a principle of perfect equality, admitting no power or privilege on the one side, nor disability on the other.”

Democracy, as a form of government, could also be seen as an expression of utilitarian orientation. Robert Bellah and his co-authors have pointed out that the right to vote in a democracy is one in which we ask the individual to assess and support the common good.  If a politician makes decisions based only on personal gain, we consider that politician corrupt (or at least, we used to…). This is equally true of the voter who votes not for the common good, but for their own personal gain. As moral citizens in a democracy, we are charged to evaluate and support what is best for the whole community.

In summary, utilitarian morality requires that we consider the outcome of our actions, and act to bring about the greatest good for the greatest number of people. It is immoral not to do so. This requires us to go beyond our own desires and preferences, and act in ways likely to enhance the lives of everyone around us, close by and far-flung. We are increasingly connected globally as a human community. floating along on our little blue earth. The moral challenge, to consider the common good, has never been more complicated, nor has ever been more crucial.

It’s All About Duty

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Why, oh why is Dr. Bossypants yammering on about morality…?? Three posts already, and more to come. Ugh. It can be SO boring. Yes. True. Boring. And vital. Do you want to survive as a species or not? Well. Then…

Onward in our journey through the land of morality. Someday, maybe soon, you’ll use this blog to scold or defend yourself. It will all be worth it. Today, we’re looking at morality through a lens called Deontological Ethics, a lens provided by Immanuel Kant (1724-1804).

Kant was the original “just do it” moral philosopher.  Regardless of how one feels about it, and regardless of outcome, there are moral duties that are applicable at all times and in all places. Some actions are morally wrong, no matter where or when they are enacted, and some are right. No weasel clauses allowed.

Kant also understood that we are mere mortals, incapable of always doing the right thing. He insisted that we at least be aware of when we are failing. For example, Kant argues that lying always causes some damage, even if that damage is no more than the liar knowing that he is choosing to do something wrong. But Kant also knew that people lie. He did not expect humans to completely stop lying, but he did urge people to consciously admit that they weren’t making a moral choice.  For Kant, lying was never, under any circumstances, morally correct.

Of course, the big question is this:  How do we know which actions qualify as always morally correct?  Kant came up with a guide for judging moral actions. He called it the Categorical Imperative–the ultimate yardstick for checking the morality of the action.  One of his formulations of the categorical imperative is this:

So act that you could will your action to be a universal law for all humankind. This is very similar to Jesus’s instruction: Do unto others as you would have them do unto you. Or remember when your parents said, “Now how would you like it if everybody acted like you’re acting?”

Another take on this imperative is this: So act as to treat humanity, whether yourself or another person, as an end-in-itself, never as a means only

Kant argued that even though there will be compelling practical or emotional factors in a given situation, it is our duty to consider the action through the lens of “always, everywhere, for everyone.”  Regardless of the circumstances, and regardless of the outcome, there are moral actions that are always right or always wrong.

Kant also believed that ethical principles apply to anyone capable of deliberation and reason. He believed there were three ways rational beings could interact with their duty, but only one would yield moral behavior.

  • They could act in ways that are clearly bad: actions such as lying, cheating, stealing, or torturing people.
  • They could act dutifully, but only for the show of it. Not because it is simply the right thing to do.
  • They could act from, or because of their duty–doing the right thing for the right reasons.

Only the third is a genuinely moral action. If you do the right thing for the right motives, then you have acted morally.  In fact, the less benefit you derive from doing your duty, and the less you actually want to do it, the more you can be sure your action is truly moral.

So, to sum up this stern Kantian input: You cannot use other people as a means to your own end. You must always evaluate your actions and act in ways that you would want everyone to act, in all times and in all places. An you simply cannot make yourself an exception to the rule.

The United Nations Declaration of Human Rights

In Dr. Bossypants’s recent efforts to revisit basic ethical thinking, it seems important to take a glance globally. The human community has witnessed and participated in horrific acts of cruelty towards each other that boggle the mind and breaks the heart into pieces.

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Photo from: http://www.latimes.com/world/europe/la-fg-us-refugees-asylum-20150904-story.html

The human community has witnessed and participated in horrific acts of cruelty towards each other that boggles the mind and breaks the heart into pieces. This morning, Amnesty International revealed ongoing practices in Syria that sickened me and ruined my admittedly privileged breakfast. How can we, as a species, keep forgetting? How can we take part in such violence?

After World War II, Eleanor Roosevelt and others took the lead in crafting a document to declare basic rights for all humans. It isn’t perfect, but it is an important marker.

On December 10, 1948 the General Assembly of the United Nations adopted and proclaimed the Universal Declaration of Human Rights. Following this historic act the Assembly called upon all Member countries to publicize the text of the Declaration and “to cause it to be disseminated, displayed, read and expounded principally in schools and other educational institutions, without distinction based on the political status of countries or territories.”  As part of this self-styled ethics series, with hopes and prayers that we move towards our positive potential as humans, I am pasting the whole darn thing right here in my blog, hoping you might use it to impress your friends and neighbors at your next dinner party. Here it is:

PREAMBLE

  • Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world
  • Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,
  • Whereas it is essential, if man is not to be compelled to have recourse, as a last resort, to rebellion against tyranny and oppression, that human rights should be protected by the rule of law,
  • Whereas it is essential to promote the development of friendly relations between nations,
  • Whereas the peoples of the United Nations have in the Charter reaffirmed their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women and have determined to promote social progress and better standards of life in larger freedom,
  • Whereas Member States have pledged themselves to achieve, in co-operation with the United Nations, the promotion of universal respect for and observance of human rights and fundamental freedoms,
  • Whereas a common understanding of these rights and freedoms is of the greatest importance for the full realization of this pledge,

Now, Therefore THE GENERAL ASSEMBLY proclaims THIS UNIVERSAL DECLARATION OF HUMAN RIGHTS as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction.

Article 1.

All human beings are born free and equal in dignity and rights.They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2.

Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3.

Everyone has the right to life, liberty and security of person.

Article 4.

No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms.

Article 5.

No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.

Article 6.

Everyone has the right to recognition everywhere as a person before the law.

Article 7.

All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.

Article 8.

Everyone has the right to an effective remedy by the competent national tribunals for acts violating the fundamental rights granted him by the constitution or by law.

Article 9.

No one shall be subjected to arbitrary arrest, detention or exile.

Article 10.

Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal, in the determination of his rights and obligations and of any criminal charge against him.

Article 11.

(1) Everyone charged with a penal offence has the right to be presumed innocent until proved guilty according to law in a public trial at which he has had all the guarantees necessary for his defence.

(2) No one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offence, under national or international law, at the time when it was committed. Nor shall a heavier penalty be imposed than the one that was applicable at the time the penal offence was committed.

Article 12.

No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honour and reputation. Everyone has the right to the protection of the law against such interference or attacks.

Article 13.

(1) Everyone has the right to freedom of movement and residence within the borders of each state.

(2) Everyone has the right to leave any country, including his own, and to return to his country.

Article 14.

(1) Everyone has the right to seek and to enjoy in other countries asylum from persecution.

(2) This right may not be invoked in the case of prosecutions genuinely arising from non-political crimes or from acts contrary to the purposes and principles of the United Nations.

Article 15.

(1) Everyone has the right to a nationality.

(2) No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.

Article 16.

(1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution.

(2) Marriage shall be entered into only with the free and full consent of the intending spouses.

(3) The family is the natural and fundamental group unit of society and is entitled to protection by society and the State.

Article 17.

(1) Everyone has the right to own property alone as well as in association with others.

(2) No one shall be arbitrarily deprived of his property.

Article 18.

Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance.

Article 19.

Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.

Article 20.

(1) Everyone has the right to freedom of peaceful assembly and association.

(2) No one may be compelled to belong to an association.

Article 21.

(1) Everyone has the right to take part in the government of his country, directly or through freely chosen representatives.

(2) Everyone has the right of equal access to public service in his country.

(3) The will of the people shall be the basis of the authority of government; this will shall be expressed in periodic and genuine elections which shall be by universal and equal suffrage and shall be held by secret vote or by equivalent free voting procedures.

Article 22.

Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality.

Article 23.

(1) Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.

(2) Everyone, without any discrimination, has the right to equal pay for equal work.

(3) Everyone who works has the right to just and favourable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection.

(4) Everyone has the right to form and to join trade unions for the protection of his interests.

Article 24.

Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay.

Article 25.

(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

(2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Article 26.

(1) Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit.

(2) Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace.

(3) Parents have a prior right to choose the kind of education that shall be given to their children.

Article 27.

(1) Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.

(2) Everyone has the right to the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author.

Article 28.

Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized.

Article 29.

(1) Everyone has duties to the community in which alone the free and full development of his personality is possible.

(2) In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society.

(3) These rights and freedoms may in no case be exercised contrary to the purposes and principles of the United Nations.

Article 30.

Nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein.

Dr. Bossypants wishes everyone the wisdom, love, deep peace, and ferocious courage needed to stand against all forms of torture, violence, genocide, and hatred.

Thank you, Mayo Clinic

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Well, hello there. Today I’m re-launching this particular blog, realizing I shouldn’t waste my expensive and difficult graduate education just because I want to write poetry.

The complexities of the human race require many prisms to achieve a decent level of understanding. I’m a clinical psychologist. I respect science. I honor the efforts humans make to solve problems and explain mysteries. I know, I know. It’s become very rewarding to twist scientific inquiry into whatever shape suits our self-interests, but people, listen: We are playing increasingly dangerous games. Self-serving delusions eventually shatter. Repeating something over and over might make you rich in dollars and clicks, but it won’t make it true.

I have friends who are not psychologists. They are cowgirls, artists, bus drivers, carpenters, hot air balloon pilots, dancers, plumbers, and gardeners. These lucky folks may have less occasion to ponder the many ways human personalities become diseased, destructive, entrenched, frozen, or malignant. But ponder, we must.

Dr. Bossy Pants has no need to re-create the wheel in her own words. Because the esteemed folks at Mayo Clinic are excellent writers, I’m going to quote them extensively below. I hope it will be helpful in our quest to understand our species, and seek healing and wholeness, as we the people continue to strive to form a more perfect Union.

From: http://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/basics/symptoms/con-20025568

Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others. But behind this mask of ultraconfidence lies a fragile self-esteem that’s vulnerable to the slightest criticism.

A narcissistic personality disorder causes problems in many areas of life, such as relationships, work, school or financial affairs. You may be generally unhappy and disappointed when you’re not given the special favors or admiration you believe you deserve. Others may not enjoy being around you, and you may find your relationships unfulfilling. …

If you have narcissistic personality disorder, you may come across as conceited, boastful or pretentious. You often monopolize conversations. You may belittle or look down on people you perceive as inferior. You may feel a sense of entitlement — and when you don’t receive special treatment, you may become impatient or angry. You may insist on having “the best” of everything — for instance, the best car, athletic club or medical care.

At the same time, you have trouble handling anything that may be perceived as criticism. You may have secret feelings of insecurity, shame, vulnerability and humiliation. To feel better, you may react with rage or contempt and try to belittle the other person to make yourself appear superior. Or you may feel depressed and moody because you fall short of perfection.

DSM-5 criteria for narcissistic personality disorder include these features:

  • Having an exaggerated sense of self-importance
  • Expecting to be recognized as superior even without achievements that warrant it
  • Exaggerating your achievements and talents
  • Being preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate
  • Believing that you are superior and can only be understood by or associate with equally special people
  • Requiring constant admiration
  • Having a sense of entitlement
  • Expecting special favors and unquestioning compliance with your expectations
  • Taking advantage of others to get what you want
  • Having an inability or unwillingness to recognize the needs and feelings of others
  • Being envious of others and believing others envy you
  • Behaving in an arrogant or haughty manner

Although some features of narcissistic personality disorder may seem like having confidence, it’s not the same. Narcissistic personality disorder crosses the border of healthy confidence into thinking so highly of yourself that you put yourself on a pedestal and value yourself more than you value others.

When to see a doctor

When you have narcissistic personality disorder, you may not want to think that anything could be wrong — doing so wouldn’t fit with your self-image of power and perfection. … (end of Mayo quote).

As a human community, striving to live responsibly and lovingly together on the astonishingly beautiful planet we’ve been given to care for, we need to put aside our narcissistic tendencies, even if they are not full-blown pathologies. That’s my opinion. And even though I’m bragging a bit here, it’s both an educated and prayer-informed opinion.