An A–Z of medical philosophy

How do we tell the difference between right and wrong? Perhaps most of the time it’s enough to follow the rules of our particular culture. But how do we justify our cultural rules, and how do we cope with new or difficult cases? Is there any ultimate guide to right and wrong, or are we merely arguing about preferences?

There are four main traditions that inform our current Western consensus statements on medical ethics. These are the virtue ethics of ancient Greece, the Judaeo-Christian tradition, deontology, and utilitarianism. We can see the three main secular moral systems as giving guidance at the three different levels of an act. Virtue guides our choice in the goal or motive of an act. Deontology guides our choice regarding the nature of an act itself. Consequentialism guides our choice when we take into account the specific circumstances of an individual instance of an act.

Problems with enlightenment moral theories are becoming ever more pressing, making one question whether Principlism has any theoretical legs to stand on. Both deontological and utilitarian models work excellently with easy cases. Should I normally steal? Should I aim to betray my friends? Should I routinely break my promises? No one after early childhood has any problem knowing the answer to such questions, but who needs deontological or utilitarian theory to work it out?

Virtue ethics all but disappeared under the onslaught of the enlightenment, and was largely replaced by its competing moral theories. But deontology is notoriously inadequate in guiding my actions when my duties conflict. Utilitarianism is notoriously inadequate in obtaining justice for individuals or minorities. Traditionally both of these theories have been either modified or used selectively to utilise their strong points and minimise their down side. But how can one say that either is a proper theory of morality if one has to adjust the conclusion to ensure the right result? Perhaps we have to look to virtue ethics to fix this.

Virtue ethics supports a broad account of moral realism that enables us to argue the case for broadly based ethical judgements in clinical practice. It also puts me, as a human acting as a practitioner, squarely in the frame. Moral reasoning is not a theoretical exercise analogous to engineering. It is a human activity rooted in human givens, human transactions, human relationships and the context of our wider society.

In the real world we have to make judgements about acts and options that are not perfect, and these three moral theories may all help us to do this. In the real world few acts will be perfect, and we must therefore use our human judgement to decide on the best of the possible options: simple rules may not be able to give us a rigorous answer.

If we take this approach it is clear that the three theories are not of equal weight. This is obvious when I consider the issue of why we find problems with any particular moral system in the first place. Reflection suggests that aretaic morality actually has a place at the top of the food chain in all moral reasoning.

• © British Journal of General Practice 2014