The urgency with which the issues of morality and their associated values are being discussed places greater demands on ethics. Science, technologies and society are undergoing dynamic change and producing many previously unencountered problems. The current need to resolve these issues presents a challenge for ethics, a theoretical discipline that has dealt with practical problems related to human morality since its origins. The most crucial issues facing us are those related to the future of the human race and civilization, particularly the moral aspects of these issues which are global in nature. One of the challenges currently facing moral theory is to consider these issues from an ethical perspective and using a plurality of approaches and concepts. The current plurality of conditions is partly reflected in the value diversity of forms of life. The question, therefore, is whether today’s modern society needs a moral theory, and if so, what kind of moral theory? How can we understand a contemporary culture in which the norms of prosperity and subjective right are often elevated to the position of determining the quality of the autonomous person and are placed above obligation of any kind? At the same time, ethical debates increasingly focus on the ethics of obligation, on traditional ethical values, and their relativity and pluralism in all spheres of life.
The growing social pressures of globalisation also raise questions about scientific responsibility for the future and the further development of humanistic values. Restoring ethical judgement and its centrality mean that the concepts of moral theory must also stand up to higher demands. Although theories tend to make use of general methods they cannot remain abstract from real contexts. Thus practice cannot be understood simply as the application of the theory. The theory itself must be understood as an element or form of practice, not as something “emanating from the exterior” that has to be “enforced” or “implemented” in practice (Višňovský, 2009, p. 186). In seeking new theoretical approaches complementary aspects of existing ethical concepts can be narrowed down by qualifying certain that have proved to be vital and with future potential. Given the plurality of research approaches, hybrid theories can be seen to present a fruitful solution.
Methodologically, the hybrid theory of ethics aims to provide a consistent moral theory, enriched by new ideas and by a validation of interrelatedness that generally enables us to overcome the limits of the original theoretical exploration. This process is assessed by analysing values in the situational context of practical contexts and practical relationships. Furthermore, these enable us to understand the “human condition”, interpreting what it means, particularly in specific contexts such as disasters and catastrophes1. Hybrid ethical theory which consists of deontological approach enriched by the anthropological dimension of a person would provide a suitable, productive model2 that can be used in cases where human life is threatened in an epidemic or pandemic. Given this existential situation confronting the person, it is important to consider and reflect on the human aspects of the situation which are unquestionably tied up with protecting life and dignity. The deontological approach can be bolstered by an anthropological dimension where the focus is on man as a person as found in the philosophy of personalism. In a situational disaster-related context, this integrative step to personalizing deontological moral theory can then be seen as impetus for deepening and updating the human dimension of the deontological tradition in medical theory and practice. The concept proposed should be viewed as a working hypothesis aimed at triggering ethical debate and potentially producing practical solutions.
Importance of ethical theory
Since the time of Aristotle, ethics has been created in keeping with the Ancient view of knowledge as practice: “Science is not an anonymous collection of truths but a particular human attitude. Theory does not stand in opposition to practice but is itself the highest form of practice, the highest form of human existence” (Gadamer, 1999, p. 53). Ethics has the privilege, not only of being able to discuss and define the contexts of life, but also of being able to apply them when a person finds themselves in a particular situation. It emerged generally as a means of practical wisdom (phronesis) in moral action. This notion of the practical foundations of knowledge gradually evolved into a search for the normative basis of human action3. The strength of the principles and rules related to responsibility thus became one of the pillars of deontological ethics, which acquired a prominent place in medical practice.
Traditional ethical concepts have emphasised the need and importance of theoretically reflecting on moral issues. Contemporary moral theory stresses that rules and norms must be reformulated in relation to the differing nature and point of actions performed in diverse spheres and situations. Selecting the appropriate choice in that situation generally involves establishing how one relates to the whole and one’s relationships to others. It is in this way that theoretical ethics enters into the morality of everyday life and helps us to “focus” our value orientation. A person’s ability to ethically appraise and assess a situation correctly is also part of that person’s cognitive activity. No ethical theory can offer a model or ideal of how one should proceed, but despite everything, when resolving moral issues, one cannot avoid being confronted with attitudes shaped by different moral concepts. If we accept Tugendhat’s thesis that “people wish to be capable of making moral judgements” (2004, p. 24), then ethical theory seeks to engage proactively in these processes of critical reflection and help people find their way in the world and assist them in solving their moral dilemmas.
General, the idea prevails that 21st century humankind is “mature” enough to accept the notion of good as the basic referential framework of their desires, including their autonomy and sufficient moral motivation. Prerequisite to this is the recognition that there is no ultimate or absolute justification. Nor is it possible to adopt a methodologically “quasi-deductive manner” (Tugendhat, 1998, p. 45) when appraising moral events in a specific situation. We have to respect the fact that moral assessments can be altered and that normative principles are not deductive in nature. It is this only this kind of approach that can provide us with a flexible space in which to apply the principle of adequacy, enabling us to point out more than just the meaning of the situation by taking account of its specific aspects.
Moral theory and disaster
Disasters come in various forms and are life threatening. One example is an infectious disease spreading and developing into an epidemic or pandemic with all the attendant moral issues. In these situations detecting symptoms and justifying decision making place higher demands not only on medicine itself (science, research and practice) but on medical ethics as well. This existential situation4 is characterised by the fact that the direct threat to life affects our personal existence. This is manifest in the clash between human values and the ethical principles held by all those involved—casualties and aid providers. The complexity of the situation is often intensified by the nature and progression of the threat, demanding in terms of time (progression occurs in phases) and space (spreading beyond the initial site).
Psychologists suggest that in the initial phase of a disaster everyone is responsible for their own life, since in critical situations there is usually insufficient time and thus if the individual makes the right decision at the beginning it could save his/her life. Statistics suggest that up to 75% of people become confused and react passively when thinking and acting. Around 10% of those affected will panic or become hysteric, often endangering themselves and others. Only 15% of casualties keep calm and try to save lives. In a disaster setting, the weakest element is the passive reactions group. As Milan Ač points out, it is not panic that kills (10%) but the fact that people often underestimate or undervalue the extremeness of the situation, how it changes and ultimately the emotions “turn their brains off” (Ač, 2015, p. 10).
From the moral theory viewpoint, considering emotions therefore seems to be an important situational factor.5 They should be seen as the product of a coherent system of rational reasons for acting. Knowledge about value feelings should be considered part of a person’s value rationality, complementing the cognitive dimension. This knowledge has validity and moral theory should devote sufficient attention to it. In practical terms, the appraisal of situational factors always relies on a combination of cognitive and emotional elements. The causes of behaviour are to be found in the reasons and motivations of the actors. They can reasonably be reconstructed and therefore considered as part of cognitive rationality, and not just as an immediate emotional response. “Value rational” feelings or statements are often made on the basis of convincing arguments and need not necessarily be of a consequentially instrumental type (Boudon, 2011, p. 139). The systems of reasons for behaving in a certain way are embedded in the minds of individuals and are perceived to be convincing. They rely on a “cognitive model” (p. 157) formed in that situation and within the contextual dimension of moral feelings. It does not only affect attitudes towards casualties such as (pain, suffering and the process of dying) as well as the way in which help is provided and organized for the casualties of epidemics. The scale of the threat tends to increase and professionals are under the strong pressures of their professional responsibility. At the same time, they face the moral conflict of whether to save one individual or to prevent the risk of a mass threat and help others.
The methodology used in theoretically considerations of the moral aspects of disaster settings deserves a more thorough up-to-date analysis. The need is primarily to further develop a deontological moral theory to account for this set of issues affecting the moral elements of borderline human situations. Ethical reflexivity should be bolstered by including new aspects and facts which deserve new, pluralist approaches. Instrumental and value rationality should form the basis of the methodology. Cognitive rationality cannot be reduced to instrumental rationality and, by creating the concept of value rationality, Weber sought to emphasize that in certain circumstances people have strong reasons to believe that something is good or just (Boudon, 2011, p. 138). The specific relationship one has with another person in a difficult life-threatening situation is rooted deep within the individual, intimate level in each person. This also affects professional attitudes to victims whose existence should primarily be seen in vulnerable and supportive terms.
A “principle based”6 deontological tradition has prevailed in medical ethics. Many authors now agree that the deontological tradition should be updated and its weak points have attracted criticism. The most serious of these is that it overestimates the various principles in ethical explorations and this often leads to ethical reductionism (Callahan, 2003, p. 289). Others have pointed to inadequacies in the anthropological framework of ethical considerations and the associated risk of relativism (Furlan, 2011). There are also reservations that the principles themselves are insuffic ntly flexible and take the form of commands or prohibitions rather than being consensual (Cigman, 2013, p. 15). Nevertheless, other authors consider thinking based on moral principles to be a kind of “logical priority” and acknowledge the importance of this theory in the global context of ethics (Gillon, 2001, p. 311).
It has been demonstrated that principles or rules cannot be applied to particular situations as the only basis for moral decision-making and acting. Although the authors of the theory of principles (T. Beauchamp & J. Childress, 2009) engaged in the ethics debate, and consider the criticism of “principlism” to be fundamentally compatible. In medical practice, the principles are not controversial and all those involved (doctors and patients) generally understand them. The problem arises when the principles7 come into conflict. However, in practice one normative theory cannot compete against another; instead we must discover how they interrelate and constitute a normative strength based on fairness, humanity and responsibility for one another (Beauchamp, 2004, p. 493). All those involved in the ethics debate seek out the most appropriate methods for using ethical approaches. The main assumption underlying these discussions is the reinforcement of a humane position and the importance of medical practice.
Personalization of medicine in ethical reflection
In situations caused by the spread of a dangerous disease there are many factors requiring specific solutions and policies. Disaster medicine8 is mainly concerned with diagnosing and inhibiting disease, reducing the risk of it spreading and dealing with the potential consequences (treatment and therapy). This often involves patients becoming anonymous, threatening their dignity and is often seen as de-humanizing and de-personalizing the individual. Controlling the risk of threats to life especially in the first phase of a disaster also means resolving ethical issues consistent with the interests of the public and the individual. In an epidemic, the duty to protect life and health is often not consistent with the expectations of the casualties. The nature of disease and the growth in moral conflicts requires specific theoretical analysis and we agree that there is a need for an Infectious Disease Ethics9 (Jacobson, 2008, p. 81). The controllability of the risks of disease depends on a series of relationships between patient consent and prevention methods relating to new—ethical— health protection standards for epidemic situations.
In today’s over-technologized (dehumanized) world, the prescriptive value of a deontological approach (Kantian universal respect for the person) has thus far proved to be an important moral stimulus, mainly in terms of the authenticity of a person. In functional terms, it translates into the principle-based theory used in medicine. However, the ethical implications of disaster situations often require collective intervention and this affects the degree to which general principles can be applied and may ultimately highlight the contradictory nature of the situation. The deontological responsibility of showing respect for the individual as a person is bound up with our understanding of human existence as the relationship one has with oneself and with others and this now requires a more proactive approach. An approach that primarily involves identifying the ways in which this can be achieved within a disaster-related context. Respect for human dignity is not in itself sufficient. According to Kauffman, it is more important to develop “properties...that bestow dignity on the bearer of these properties” (2011, p. 59). These properties may be reason to act and so the bearer acquires a different status. Thus, the person is now placed in a relationship based on cooperation and this mutual interaction enables a human perspective to be adopted in cases where a person is being used (Kaufmann, 2011, p. 60). This kind of proactive approach is founded on the belief that a mutual goal is being fulfilled with the consent and support of the other person.
Respecting the value of the individual as a person not only means protecting his/her autonomy but above all his/her life which is under threat, and this requires a specific approach and the removal of many obstacles. This moral duty to oneself and others as persons becomes marked in a disaster-related context. The “person” aspect becomes the basis of a rational strategy of respecting personal uniqueness, independence and human dignity as potential that is seen as “wanted”. In borderline situations, normative reason is not sufficient reason for acting; the motivation for acting this way is also needed. Human dignity is not written on our foreheads, it has to be fought for and promoted, in relation to ourselves and to others (Liessmann, 2010, p. 54). It would seem that proffering a clear definition of the value of an individual as a person is a fundamental methodological problem and challenge, especially for medical ethics in a disaster-related context.
Interesting and potentially rewarding fertile ground for ethical decision-making in medical practice can be found in personalist ethical ideas based on a relational understanding of human dignity. Such an approach to the individual may help further humanize medicine and act as a defence against depersonalization10. The inspiration provided by personalist ethics comes in various forms and interpretations11. It has a consistent set of values and alternative principles that may prove relevant in a disaster-related context. Its values enable us to transcend our immediate interest. Personalist ethics places the person at the centre as a key ethical concept and its uniqueness is found in the identity of the individual (Kirchhoffer, 2013, p. 213). It emphasises the principle of reciprocity and the relatedness of human existence, which allows it to define the person in dynamic terms through dignity. It includes caring for the self and also operating in ceaseless interaction with others. Human dignity is considered to be a constitutive mark of human existence; it is inalienable and its realization is conditioned by our relationships to others. Having regard for others is an inherent part of human identity. This humanistic interpretation may prove to be both appropriate and fruitful. It bolsters the explanation method by providing the answer to a particular state by appealing to its meaning (an aim or end). Thus the world of values becomes part of theoretically highlighted circumstances and procedures for action and so an “empathetic understanding” (cognitive empathy) then has a place in research and in professional approaches, which is especially important in the context of disaster situations.
Global health now includes issues relating to health prevention and the risk of dangerous diseases and must be adequately considered from an ethical perspective. This presents a challenge for global ethics faced with determining which moral values in today’s society will enable us to better understand controversial practices (in a disaster-related context). This dialogue with ethics is required if the anthropological basis of medicine is to be strengthened since borderline situations bring with them new moral questions and problems. These concern violating a person’s identity and results in new challenges and forms of interpersonal relationships, including a new type of responsibility and solidarity. Disasters are existential situations that require a specific ethical approach.
Moral theory is called upon to reflect these new questions and to help institute a mental shift in the moral direction of people today. The theory of ethics can help strengthen humanity by encouraging it to focus more on the future. The longer-term vision is to make use of the opportunities provided by the hybrid creation of ethical theory, thus helping develop the ethical principles, norms and values that have prevailed thus far. In relation to current bioethical problems, the concepts of utility and duty must be extended to include the motivation and value of a person. In borderline situations, the status of the person (his/her rationality and value feelings) plays an important role in moral action. The shift away from individuality and towards the person thus provides a more flexible ethical space in which values and value expectations can be coordinated.
The methodological potential of a personalized deontology in medical ethics appears to lie in further humanizing medical practice. It also appears to be a suitable ethical “model” for assessing borderline situations and the choices and acts of all those involved. Interdisciplinarity and pluralism are considered to be an appropriate basis on which to reform thinking (Morin), create responsibility (Weber) and the horizons of expectation, bringing new forms of solidarity. We can only agree with the recommendation for a “broader perspective for the analysis of cognitive enhancement facilitating more across-the-board reflection. With these recommendations, they aim to advance methodological rigor in order to improve both the practical significance and the scholarly excellence of anticipatory bioethics” (Gordijn & Ten Have, 2014, p. 324).
Funding for the workshop on moral theories and disasters at the University of Prešov, Slovakia (13-15 May 2015) and open-access publication was provided by COST Action IS1201 (http://DisasterBioethics.eu).
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Disasters come in different forms and usually involve a combination of natural and social factors. This paper focuses on situations caused by epidemics or pandemics. They are associated with serious moral issues and problems to which medical ethics seeks to find the answers and solutions
Hybrid ethical (moral) theory originated in the second half of the 20th century. It developed in response to the limitations of classical ethical theories. Hybrid ethical theory combines aspects of various ethicaltheories to achieve a desired outcome. A common example of the approach combines deontological principles with consequentialism (e.g. Samuel Scheffler) (Kalajtzidis, 2014, pp. 24-26).
Since both ethical traditions (teleological and deontological) interrelate and interconnect theoretically and in practice, in some way they have anticipated the further development of ethical theory. Together they represent a relevant resource that can be used to shape ethics in the here and now. They reveal their traditional limits and thus there is a methodological risk of bias. While virtue ethics emphasizes moral motivations as the internal source for decision-making and action, deontology relies on the strength of principles and rules that define a duty-bound human attitude (responsibility).
The term existential situation has its origins in the philosophy of existentialism. It refers to an extreme situation which places the individual under great stress. The complexity and often helplessness of the situation is exacerbated by the person’s inability to influence or change it. Associated events are often conflicting, limit our attitudes and force us to face complicated moral decisions.
In situations where help is being provided, Beata Balogová also considers the interplay between emotional factors and the way this is understood to be an important element in interpersonal or group dynamics. This concerns not only knowledge of the emotional reactions of the affected but also of the medical personnel and nursing (Balogová, 2012, p. 172)
The authors of principlism, T. Beauchamp and J. Childress (2009), do not see their theory as being unambiguously deontological and acknowledge it is linked to utilitarianism. They consider their approach to represent the general principles of medical practice (autonomy, beneficence, nonmaleficence and justice). Other theories are also worth mentioning. Katarína Komenská points to R. Veatch’s theory of seven or nine principles, B. Brody’s five appeals for action and B. Gert’s decalogue as evidence of the dynamic ongoing discussions on the strengths and limits of principlism in medical ethics (Komenská, 2012, p. 83).
Principle as a premise of moral thinking arises out of moral theory and general experience. Thinking based on principlism, a top-down model involves the risk of subjectivism when applied in a real context where usually one of the principles has to be favoured over the others, often coming into conflict with them.
Epidemiology has a role to play here. It investigates the causes and natural history of disease prevention and health promotion. It has its own specific ethical problems associated with empirical research and patient protection and the provision of patient informed consent during research. In addition, data collection often occurs without any direct contact with patients, clinical data are wastedm and the social impact of research is lost. Seeking a balance between empirical research and social principles would require clinical management to reach an ethical consensus on the effectiveness and efficiency of health care provision (Ashcroft, 2008, p. 211).
Infections have become major causes of disease, death and disability and are associated with many ethical issues: “Ethical disease problems arise from the conflicts between values, principles and interests. Infectious disease ethics examines how features of infection shape these problems, especially the tension between honouring patients’ preferences and preventing harm to others” (Jacobson, 2008, p. 481).
The term personalized medicine usually refers to an approach that has been tailored to a particular patient promoting more consistent care for that patient’s health. In clinical practice, the term “personalized medicine” emphasizes the ethical dimension of the way the patient is treated as a person in a unique situation with all the attendant decision-making and consequences that arise out of that situation. In medical practice impersonality is considered to be inappropriate and rooted in a tendency to reduce the patient to the bearer of disease. The patient must be viewed as a person in line with a comprehensive and responsible cure and care approach.
From the personal moral theory point of view, it may be inspiring to conceive of a concept of the person that can exceed its own theological limits. The HPAC concept of a person—the human person adequately considered in relation to itself and others—can be seen to revitalize principlism and opens up a space in which medical norms can be developed. In terms of the eight dimensions of a person (Selling, 1998, pp. 4-11), integrity (the person as a totality), responsibility (including relatedness) and solidarity (including originality and uniqueness) can be seen to enrich principlism and in this approach personalization manifests itself as in the adoption of a more humane approach to the patient.
About the article
Published Online: 2016-02-03
Published in Print: 2016-01-01
Citation Information: Human Affairs, Volume 26, Issue 1, Pages 43–51, ISSN (Online) 1337-401X, DOI: https://doi.org/10.1515/humaff-2016-0006.
© Institute for Research in Social Communication, Slovak Academy of Sciences. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License. BY-NC-ND 3.0