Bert Gordijn and Henk Ten Have (2015) affirm that our ability to create human-made disasters has increased significantly since the industrial revolution. Modern technology means that colossal intentional and non-intentional anthropogenic disasters are possible.
Examples that are currently being discussed are, amongst others, the possibility of nuclear accidents and/or war, the risk that artificial superhumanly intelligent beings might turn against us, potential mishaps with geoengineering, and the threat of terrorists using biotechnology and cyberattacks to disrupt large parts of modern societies. These are all potential threats that have appeared relatively recently, or have not yet materialized at all, but might very well do so in the near future. The disconcerting aspect of these risks is that they are all human-made. We have been exposed to (the threat of) natural disasters since the beginning of humanity without— obviously—having been erased by them (Gordijn & Ten Have, 2015, p. 1).
According to Pierre Mallia, distinguishing between Kantian and utilitarian approaches or theories allows us to make use of broad Kantian principles in everyday moral life while accepting a utilitarian option in certain situations. He affirms that utilitarian ethics can be used in public health to ensure better distribution of resources. But if we need to quarantine people, make vaccinations obligatory etc., then that is a purely utilitarian choice to maximize good and happiness. Therefore does this mean that using a utilitarian approach in disaster situations is morally correct? According to Mallia, the problem is not whether it ought to be done, since it is done, but how we can change the frame of a practitioner’s mind when a disaster has occurred (Mallia, 2015, p. 9).
He holds that when a disaster has run its course, the situation is still far from over. The subsequent consequences and catastrophe that remain are real and have to be dealt with. At that point a utilitarian state of emergency becomes the normal situation.
It may be easier of course for local government to feel more comfortable invoking restrictions. But the perimeter zone outside has to help governments to return to their normal function and let go of the more utilitarian rules which are not only medical, but social and political. It is here that the dialogue must begin especially for the social workers. Helping people within the scope of their culture can produce challenges. But once the worse is over it is that very culture which has to accept that it has been relieved by a different (albeit more modern, or western) culture. .. .[and] our daily deontology has to return back from the immediate utilitarian management of a disaster situation in which it has served its purpose of maximizing the saving of life and thus of overall happiness (Mallia, 2015, p. 11).
Carlo Petrini states that there is an urgent need to discuss the nature and principles of ‘ethical triage’, especially in cases of large-scale medical emergencies, as there is little agreement on the appropriate ethical basis for resolving problems related to prioritizing patients in the event of a disaster, such as an earthquake, flood, tsunami, volcanic explosion, hurricane, tornado, nuclear disaster, etc. He points out that the utilitarian approach usually dominates. He suggests, however, that opinions may vary regarding its application, for instance in the context of human rights, individual autonomy, care for the health of the community, etc. (Petrini, 2010, p. 138). Fatimah Lateef claims that in a disaster the usual goal is to do the greatest amount of good for the largest number of people, i.e. to save as many people as possible, which is in fact an example of the utilitarian approach. Like Petrini, she also realizes that a conflict may arise between this and other possible approaches based on other bioethical conceptions (Lateef, 2011, p. 289). Similarly, J. E. Jesus and G. E. Michael point out that opinions may vary with regard to applying the utilitarian approach in ‘ethical triage’, whereby, in disasters or similar humanitarian crises, the wounded are prioritized according to the level of urgency for medical treatment and the benefit it might have on their health (Jesus & Michael, 2009, p. 111).
One of the latest solutions to the above questions is Brad Hooker’s rule consequentialism; a solution that he claims provides motivation for avoiding or preventing disasters. In his view, it is more important to prevent disasters than deal with the breaking of moral norms.
The desire to prevent a disaster must be stronger than the desire to keep a promise or avoid a lie (Hooker, 2002, p. 98). However, it is not always possible to break a rule; rule consequentialism, for instance, states that rules must not be broken if that would only bring about a minimum prevalence of positive over negative consequences. According to Hooker, a rule can only be broken if it will result in the significant prevalence of positive consequences over negative ones (Hooker, 2002, p. 99). As an example of when there is a need to break rules, he points to situations in which telling a lie, breaking a promise, causing others harm, even hurting or killing an innocent human being would prevent a nuclear disaster (Hooker, 2002, pp. 127, 135). He claims that a minor disaster may justify breaking a minor promise, a greater disaster may justify, for instance, theft and a large-scale disaster may even justify physical harm to an innocent person. Hooker realizes the difficulty of clearly determining the number of negative results that would justify breaking moral norms (Hooker, 2002, p. 135).
Edmund Wall criticises Hooker’s principle of disaster prevention, which, in extreme cases, enables a person to go against the unconditional prohibition of murder, to punish an innocent person, to disclose a secret, etc. Wall cites the absence of any clear evidence that such actions can prevent disasters; moreover, he considers Hooker’s justification of problematic activities to be weak (Wall, 2009, p. 348). Similarly Robert F. Card accuses Hooker of not having defined his principle of disaster prevention clearly enough. In particular, he is not clear as to what he means by a disaster nor as to when the ideal moral code of society can be broken. He asks whether the limit is eight or nine dead or whether it is less or more than that (Card, 2007, p. 250). Fatimah Lateef indirectly addresses Card’s criticisms of Hooker’s definition and argues that, according to the Brussels’ Centre for Research on the Epidemiology of Disasters (CRED) definition,
disaster is a situation that overwhelms the local population’s capacity to respond, necessitating a request for assistance from outside the affected area. There will be disruption and destruction of the local social, economic, and health networks, systems, and organization, resulting in the inability to cope as usual, day-to-day practice (Lateef, 2011, p. 289).
Ethics of social consequences and disaster bioethics
In relation to the issues discussed above, I would like to suggest that the ethics of social consequences could potentially provide us with an alternative way of approaching the issue of ethical triage and with a methodological basis for investigating disaster bioethics in general. The ethics of social consequences is a means of satisficing non-utilitarian consequentialism and constitutes a methodological basis to be used in disaster ethics and bioethics. The ethics of social consequences is concerned with the primary values of humanity, human dignity and moral rights, and these values are developed and realized in relation to positive social consequences expressing the consequentialist value orientation of this theory (Dubiel-Zielińska, 2013; 2015; Gluchman, 2003, pp. 7-19, 141-166; 2007; Gluchman, M. & Kalajtzidis, 2014; Gluchmanová, 2013; Grzybek, 2013, pp. 16-22; Kalajtzidis, 2013; 2014; Lešková Blahová, 2009; Misseri, 2014). These values are the fundamental ones and there are other values which develop in relation to positive social consequences. The secondary values in the ethics of social consequences include justice, responsibility, moral duty and tolerance. Their role and purpose within this ethical structure stems from their ability to help ensure that moral good is attained and achieved (Gluchman, 2003, pp. 7-19). By applying these primary and secondary values fair treatment can be achieved within bioethics.
The value structure inherent in the ethics of social consequences allows other values, conforming to the criteria defined within moral good and positive social consequences, to be accepted and realized Therefore, disaster issues could also be evaluated by the value structure of an ethics of social consequences; however, these values and principles must form the starting point of moral reasoning and action in accordance with the methodology. These values may be ascribed unique content. Although they may, at first sight, appear to be defined in formalist terms, depending on the situation, sufficient space is provided for them to be concretized, i.e. ascribed specific content. Wrongly ascribing values, i.e. ascribing them with undesirable content, is prevented by the fact that the values are accepted and realized according to whether they can be identified with moral good. Another way in which the values are afforded protection is the requirement that they be mutually correlated, i.e. the content ascribed to the value must also correspond to the requirements or conditions relating to other values. This means that a value cannot be realized if it contradicts other primary or secondary values found in the ethics of social consequences. This is also relevant when dealing with disaster issues. The requirements relating to the other values are formulated within the context of the moral agent acting under ordinary circumstances. Under extraordinary circumstances, not all the requirements inherent in the entire value structure of the ethics of social consequences need be taken into consideration. Under extraordinary circumstances, certain values are prioritized and realized. Primary values are realized prior to secondary ones. Primary values are prioritized if their realization leads to positive social consequences, or, at least minimizes the negative social consequences. In bioethics (including medical ethics, health care ethics and research ethics) in particular, it is often necessary to seek out a way to minimize the negative social consequences; thus, actions where the positive social consequences prevail are preferred.
The value structure of the ethics of social consequences is similar to that found in Amartya Sen’s approach to values. On the one hand, Sen accepts the nature of intrinsic values, but, on the other hand, strives to maintain space for their instrumental use (Sen, 1982; 1983; 1984; 1985; 1990; 1992; 1993). The ethics of social consequences accepts, develops and realizes values which also belong to many other ethical, and often non- consequentialist, theories. Nevertheless, it approaches values from a material rather than a formalist viewpoint. Thus, moral values cannot be determined merely on the basis of formalist criteria in some types of ethical theories. It is the content ascribed to a particular moral value in a specific real-life situation that is decisive. The way in which it correlates with other values and is realized is also essential. It is only on this basis that the nature of a particular value can be expressed. As a result, it is incorrect to claim that some values are utilitarian or consequentialist and others deontological, without accurately determining the nature of the value in question. For instance, throughout the history of human thinking the value of happiness has probably been dealt with in almost all ethical theories. This, however, does not mean that all these theories should be considered utilitarian theories simply because utilitarianism considers happiness to be one of its primary values. Similarly, Kant and Hegel, for instance, considered the value of benefit or consequence; on no account, however, could they be considered utilitarians or consequentialists.
The criteria above indicate that the ethics of social consequences is unambiguously consequentialist and that its value structure is of a consequentialist character. This is demonstrated by the fact that it is the content ascribed to these values rather than their formalist similarity to values that some deontological ethical theories claim to have exclusive right to. The value structure of the ethics of social consequences is pluralistic; however, it defines the hierarchy of values and accepts that they are intrinsic and instrumental in character depending on the situation in which the moral agent realizes the values. When dealing with arguments on the relationship between the moral agent and the values and his/ her own interests, projects and plans, the ethics of social consequences inclines to partiality and an “agent-relative” position. The reason for this is that every moral agent has his/her own specific obligations towards his nearest and dearest, and thus should perform moral good by realizing good for the benefit of the people concerned. This issue is very important in moral reasoning on disaster issues, as women’s and children’s rights can be accepted and realized without this being considered a partial action; unlike the utilitarian principle of universalizability. On the one hand, the justified interests and needs of other affected moral agents (including our wives, husbands, children, etc.) have to be considered as widely as possible. On the other hand, if we are to consider the typology of moral agents, then in the ethics of social consequences it is impossible to identify a certain type of moral agent with either the “agent-neutral” or “agent-relative” position. Both positions are compatible with both types of moral agent. It is, however, important for both positions to contribute to the moral good of an individual, his/her relatives and, by effect, the whole moral community (Gluchman, 2003, pp. 85-91).
Therefore, such an approach is productive in achieving positive social consequences because it helps to produce moral good in a social and moral community. The “agentrelative” position prevails in non-utilitarian consequentialism and highlights, above all, how the aims of these ethical theories contrast with those of utilitarianism. By contrast, in consequentialist ethical theory an effort is made to grant sufficient space to the moral agent, his/her interests, projects and plans (including family, relatives, friends, etc.). In consequentialism, taking into account the needs and interests of the acting moral agent is not considered to be wrong or even immoral. On the contrary, the ethical theories mentioned indicate that the “agent-relative” position and partiality need not mean that this action is directed at promoting the selfishness or egoistic interests of individuals. One way of preventing the danger that this position could escalate into selfishness or egoism is to reject maximization as the only criterion of what can be considered a right action. By accepting the “agent-relative” position, partiality and the maximizing principle, it could be assumed that the action of a moral agent would lead to selfishness, and inevitably egoism would become possible, because his/her aim would be to maximize his/her own goodness related either to his/her person or to other persons close to him/her. This maximum aim would be pursued regardless of the other moral agents affected. However, by rejecting maximization as the only criterion, space is created for the moral agent to consider to a much greater extent the justified interests and needs of other affected moral agents. Thus it is possible for moral relations to exist between individuals or within the social community that are not based on a civic or moral war aimed at ascertaining who is the stronger one, but on creating sufficient possibilities to satisfy the interests and needs of many other affected agents (including women, children, races, ethnic minorities, etc. who are often marginalized when solutions are sought to, for example, disaster issues). This also applies to disaster ethics and bioethics because the same approach can be used in relation to all human beings without distinction. Such an approach could be methodologically based on ethical theory and used not only in relation to disaster bioethics but also in relation to research in medical ethics, health care ethics, research ethics, etc.
Similarly in the ethics of social consequences, the goal is not to formulate the maximum aims the moral agent would have to fulfill for the action to be considered right. The strategy in this ethical theory is to formulate partial goals which, with every next step, would, at least minimally, exceed the previous steps aimed at producing positive social consequences. In certain situations, achieving a smaller number of positive consequences may be considered the right action, provided the prevalence of positive social consequences is maintained. In a sense, accepting maximization is also a criterion for moral action. However, this does not mean that maximization should be seen as the main criterion. For an action to be considered right, one need not strive to maximize the positive social consequences resulting from that action (Gluchman, 2003, pp. 16-18).
Ethical theory does not reject the idea that it is possible in specific situations for the moral agent through his/her actions to help achieve the maximum possible positive social consequences. The evidence for this is that in ethics of social consequences one can also make use of the assessment that the action is moral. This means that this particular action achieved the maximum, or at least the maximum possible, number of prevailing positive social consequences. Therefore, within this theory, it is possible to achieve the maximizing of positive social consequences; however, the notion that maximizing should be a criterion for right action is rejected on principal. This broadens the scale of the criteria for assessing right behaviour to include all actions that bring about a prevalence of positive social consequences over negative ones (Gluchman, 2003, pp. 16-18). This is not to justify moral mediocrity but is rather acceptance of the moral reality. Here, we are concerned to protect against the demotivation of the conscience of the moral agent; the average moral agent might doubt his/ her ability to be moral, since, from this viewpoint, the majority of his/her actions could be considered wrong (Gluchman, 2003, pp. 17-18). It is increasingly obvious that maximization or perfectionist ideals are becoming a historic anachronism in the era of postmodern plurality. These ideals fulfilled their role in the past but their significance and role in relation to the present and, above all, to the future, are decreasing (Gluchman, 2003, p.141).
Is it possible, in the context of the ethics of social consequences and discussions on the appropriateness of the utilitarian approach coupled with the principle of maximising, to speculate whether good enough is an acceptable criterion on which to judge the fairness or morality of an action in a rescue operation? Or is it necessary to apply the utilitarian criterion of benefit maximizing? The answer should take account of the fact that non-utilitarian consequentialism does not a priori reject the idea that the maximum benefit can be obtained. This criterion should not be used to assess the moral nature of actions, as every action that has brought about a prevalence of positive social consequences over negative ones is a right action. The greater the prevalence, the more valuable the action; however, this prevalence need not be maximized for it to be accepted as a right action. If, during a rescue operation, a doctor treats and thus saves ten people, while five other people die of their injuries, is his/her action right or wrong?
There are several possible answers to this since the final evaluation depends on, for instance, whether there were enough medical supplies available, and whether there were sufficient health care staff, with the physical and emotional energy, and time and space to rescue some of those who died. A number of objective as well as subjective factors come into play in the final evaluation, which is why an unambiguous conclusion cannot be drawn merely on the basis of the ratio of rescued to deceased. The nature of the injuries sustained by the casualties who died also plays a role, i.e. was there a chance they would have survived had they received the appropriate health care? I am convinced that every life saved represents a right, or even moral, action performed by a doctor taking part in a rescue operation in a natural disaster.
In addition, Petr Zelnicek’s points inscribed in the bioethical code for doctors taking part in humanitarian rescues should be taken in consideration. The first point is that the rescuer must not place his/her own life in danger, that he or she must protect his/her own life and must not expose him/herself to needless risk (Zelnicek, 2002, p. 28). The aim therefore need not lie in benefit maximizing, as this may be counterproductive.
How can we solve the dilemma facing the medical profession and address such issues as abortion within disaster bioethics in cases where the foetus had been seriously harmed and the life of the pregnant woman was at risk? What viewpoint should one take in such a case? The problem with the methodological pluralism favoured by Richard Hugman may be found here (Hugman, 2014, p. 124). In Hugman’s opinion, if professional ethics (in this case including disaster bioethics) is a combination of several methodological approaches, there will always be opportunity to criticize the inconsistency of conclusions accepted in professional ethics, since they may not be compatible with some of the parts that form the basis of that understanding of professional ethics. If a doctor decides to perform an abortion in such a case, he could be criticized on the basis of deontological ethics; if he decides against it, despite the health or even life of the pregnant woman being at risk, he could be criticized from the viewpoint of consequentialist ethics; moreover, he could be criticized in both cases on the basis of virtue ethics, etc. This is why I favour a methodological monism which enables us to define the requirements for members of the profession to perform correct actions in terms of the values contained within ethical theory and, equally, which enables us to make decisions and consequential evaluations of the behaviour and actions of members of the profession in relation to these values and norms. This creates more homogenous forms of professional ethics and disaster bioethics than is the case with methodological pluralism. In this context one can reason as to what the potential (and the circumstances) special ethical obligations or rights might be for the members of the various professions.
Let us, at this point, consider a doctor of humanitarian medicine. The doctor is qualified to pursue his/her medical profession which aims primarily to treat various illnesses and injuries, i.e. he thus realizes the values of humanity, the moral right to life, and to developing and cultivating it. When performing his/her job, he/she has to act in a way that respects the human dignity of all the moral agents involved, including potential moral agents. All his/her thinking inevitably concerns his/her ability to achieve a prevalence of positive social consequences over negative ones. In the dilemma of whether or not to perform an abortion on the pregnant women as a result of a disaster, the question is to what extent is this in keeping with the above values, and to what extent do the doctor’s actions help ensure that positive social consequences prevail over negative ones.
Are we to conclude that if by performing an abortion the positive social consequences prevail over the negative ones and that other key values are equally respected, then his/her actions are right and justifiable? This prompts the question of whether, if it is right and justifiable for the doctor to perform an abortion and all people are morally equal, it is equally right for any other moral agent in a similar situation to perform an abortion in accordance with ethical universalism. Initially the logical conclusion would seem that this is the case, since if the answer were ‘no’ either the methodological approach would lack logical inconsistency or members of certain professions, in this case doctors, would have special ethical rights (ethical particularism).
Any moral agent could perform an abortion in such a situation so long as the action led to the positive social consequences prevailing over the negative ones. However, the decision making process must involve assessment of whether the person holds the required qualifications and necessary experience, whether the medical and health care is adequate and will subsequently be available, whether the technical infrastructure, medicines, staff, suitable environment are all in place, etc. If all these conditions are fulfilled and the positive social consequences prevail over the negative, then any moral agent can perform an abortion on a pregnant woman suffering life-endangering health complications. This is not because the doctor has the special ethical or moral right but because of the general requirement that the moral agent’s actions are performed so as to realize fundamental moral values and ensure that the positive social consequences prevail over the negative.
David Luban considers a similar problem in professional ethics: the discretion required of doctors, lawyers or priests when acquiring confidential information from their clients (Luban, 2007, p. 587). I hold the opinion that the issue of discretion can be approached in the same way as the situation involving the doctor and abortion above. That means reasoning, making decisions and acting according to key values and considering whether positive social consequences will prevail over the negative. Discretion must always be assessed in relation to the values and the resulting consequences. Should it unambiguously fall on the side of the discretion imperative, regardless of the consequences, it would clearly represent a deontological, or, indeed, a Kantian, solution. Let us imagine a situation in which a doctor treats an HIV patient who, after being informed about his/her condition, continues to lead a promiscuous life and has unprotected sex with the attendant risk that the HIV will spread exponentially and cause an epidemic. The patient, despite the doctor’s warning, is not prepared to change his/her way of life, and intends, in a way, to take revenge for being HIV positive on other people. If this situation is approached in relation to key values, i.e. humanity, human dignity and moral right to life, to developing and cultivating it, and also in relation to whether the positive social consequences will prevail, the conclusion is likely to be that, from all viewpoints, the doctor is obliged to do anything he or she can to prevent the spread of HIV and possible medical disaster, i.e. he/she must prevent this patient from behaving in this way since it represents a threat to others and there is the possibility that others may become infected.
The situation would be completely different if the patient had been infected with HIV by means of a blood transfusion during surgery and now has a responsible, stable sex life with a single partner to whom he or she has disclosed their health status, and has protected sex. The doctor would have no reason to publicize the information about the patient’s condition, particularly when taking into consideration the key values, i.e. humanity, human dignity and moral right to life, to developing and cultivating it, and whether the positive social consequences will prevail.
The ethics of social consequences should be used to find an optimum alternative for an action that will, within the circumstances, ensure that the positive social consequences prevail over the negative or, at least, that the negative consequences are kept to a minimum. This suggests that ethical theory is appropriate for use especially by moral agents who reflect on their decisions (are pro-active), i.e. those with a higher level of cognitive and intellectual abilities. Thus it is particularly applicable in professions of an intellectually demanding nature, like those of medical doctor, humanitarian worker, etc. In extraordinary circumstances, including disasters, when reasoning, making decisions, acting and, possibly appraising, the situation- based approach should be used as the basis for making a decision and performing an action that is in keeping, insofar as is possible, with universal ethical values, principles and norms, or for making one that minimizes the negative consequences of performing an action that is not in keeping with these. In such a situation it is appropriate to reason, make decisions, act, and possibly also appraise, using the ethics of social consequences, as this will provide the space required when taking essential ethical and moral values, or principles, into account. Under regular circumstances, this will, to various extents, result in the positive consequences prevailing over negative ones, or, in extraordinary situations, it will provide the space for minimizing the negative consequences. Therefore, the ethics of social consequences demonstrates that consequentialism (at least in its non-utilitarian form) can productively solve issues and problems in disaster bioethics, despite its practical application being a little more demanding than is the case with other ethical theories.
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