First published in 1985. Routledge is an imprint of Taylor & Francis, an informa company.

I defend the Doctrine of Doing and Allowing: the claim that doing harm is harder to justify than merely allowing harm. A thing does not genuinely belong to a person unless he has special authority over it. The Doctrine of Doing and Allowing protects us against harmful imposition – against the actions or needs of another intruding on what is ours. This protection is necessary for something to genuinely belong to a person. The opponent of the Doctrine must claim that (...) nothing genuinely belongs to a person, even his own body. (shrink)

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely (...) disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation. (shrink)

ABSTRACT Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life – if they are able to swallow and digest them. But despite President Bush's oft‐repeated statements that his philosophy is to ‘trust individuals (...) to make the right decisions’ and his opposition to ‘distant bureaucracies’, his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician‐assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia. (shrink)

Most moral dilemmas in medicine are analysed using the four principles with some consideration of consequentialism but these frameworks have limitations. It is not always clear how to judge which consequences are best. When principles conflict it is not always easy to decide which should dominate. They also do not take account of the importance of the emotional element of human experience. Virtue ethics is a framework that focuses on the character of the moral agent rather than the rightness of (...) an action. In considering the relationships, emotional sensitivities, and motivations that are unique to human society it provides a fuller ethical analysis and encourages more flexible and creative solutions than principlism or consequentialism alone. Two different moral dilemmas are analysed using virtue ethics in order to illustrate how it can enhance our approach to ethics in medicine. (shrink)

Despite tendencies to compete for a prime place in moral theory, neither virtue ethics nor the four principles approach should claim to be superior to, or logically prior to, the other. Together they provide a more adequate account of the moral life than either can offer on its own. The virtues of principlism are clarity, simplicity and (to some extent) universality. These are well illustrated by Ranaan Gillon’s masterly analysis of the cases he has provided. But the vices of this (...) approach are the converse of its virtues: neglect of emotional and personal factors, oversimplification of the issues, and excessive claims to universality. Virtue ethics offers a complementary approach, providing insights into moral character, offering a blend of reason and emotion, and paying attention to the context of decisions. The cases provided can be more adequately understood if we combine the approaches. Both should foster the virtues of humility and magnanimity. (shrink)

The COVID-19 coronavirus pandemic raises a host of challenging ethical questions at every level of society. However, some of the most acute questions relate to decision making in intensive care. The problem is that a small but significant proportion of patients develop severe viral pneumonitis and respiratory failure. It now seems likely that the number of critically ill patients will overwhelm the capacity of intensive care units (ICUs) within many health systems, including the National Health Service in the UK. The (...) experience of Northern Italy—a couple of weeks ahead of the UK, suggests that it will simply not be possible to provide mechanical ventilation to every patient who might need it. When the crunch comes, the unpalatable question facing clinicians is which patient to save. There are some obvious strategies to avoid or reduce the problem—through measures to increase intensive care capacity, and via society-level interventions to reduce the spread of the virus. These are vitally important, but unfortunately they are unlikely to prevent the problem of demand outstripping supply from occurring. What, then, should clinicians do? How should they allocate the scarce resource of intensive care—particularly over the coming weeks as the crisis escalates? There are different values at stake in triage decisions, but at a basic level the key values are those of benefit and …. (shrink)

There is currently an unrecognised conflict between the utilitarian nature of the overall NHS and the basic deontology of the doctor-patient interaction. This conflict leads to mistrust and misunderstanding between managers and clinicians. This misunderstanding is bad for both doctors and managers, and also leads to waste of time and resources, and poorer services to patients. The utilitarian thinkers tend to value finite, short term, evidence based technical interventions, delivered according to specifications and contracts. They appear happy to break care (...) up into smaller pieces, which can then be commissioned from multiple providers. The deontological thinkers tend to think about care delivered through a long term continuous relationship, and regard that relationship as therapeutic and salutogenic in itself. To them breaking care up into smaller fragments is a denial of what caring is really about. Very rarely are either or both sides of this debate fully aware of where their powerfully felt and often well argued positions start from. In this paper we offer an appraisal of the strengths and weaknesses of both moral viewpoints as applied in the UK NHS context and we suggest a way in which they can be reconciled, provided neither is pushed too far or too hard against the other. We believe this reconciliation would be good for patients, doctors, managers and improve the service as a whole. (shrink)