2 pages single spaced! need a tutor - Sociology
Ethics Evaluation #2
Due by Friday, August 13th at 11:59 PM PST
Description: Ethics evaluations are short, 850-1000 word decisions offered on a particular issue
and/or debate in ethics written from the perspective of a professional ethicist (that’s you). In them,
you will consider the situation at hand and offer a reasoned analysis of your decision using specific
criteria and ethical theory to back up your decision. You have a choice between two prompts with a
case study for your evaluation: pick only one. In your evaluation, you are to offer your verdict on
how the case should proceed by considering all of the information provided. This includes
supporting your argument (thesis statement) throughout the paper and responding to all questions
listed in the prompt you have chosen.
Goal: The goal of this assignment is two-fold. First, it is to assess your comprehension of the moral
theories and the course material. Second, it assesses your ability to deliberate about and apply these
ideas in a real-world context.
Guidelines:
● For this assignment, you have the choice between two prompts. You may choose either one
but cannot write about both.
● These are short (less than 2-pages single-spaced). Therefore, it is important to be as clear and
concise as you possibly can. That means no introductions or conclusions (I love them, but
there is no space here). Instead, everything in your paper should be geared towards
supporting your argument.
● “I”, first-personal language is fine. Imagine that your report will assist ethicists,
policy-makers, etc., in making their decision as to how to act.
● Assume I (your reader) knows all the details of this case. You only need to explicitly refer to
the details insofar as they are helpful for building your argument. Do not spend 250 words
re-explaining the case to me.
● You must begin your paper with a thesis statement. Your thesis statement for this paper
is your answer to the primary question of whichever prompt you choose as well as your main
argument/justification. For example, for the prompt: Is it or is it not morally permissible for
Patrick to accompany his friend Carlos to Dignitas, you might answer: “I will argue that it is morally
permissible for Patrick to accompany Carlos to Dignitas because [one key reason that follows
from one of the major theories].” Please underline your thesis statement in your paper.
● You are to draw on one and only one reading in ethical theory we’ve discussed so far:
Aristotle, Kant, Mill, or Held, and any one other assigned class reading. Do not source any
additional readings.
● You must choose a different ethical theory than you used in your first Ethics Evaluation.
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A few notes on citations:
● Please include at least two citations from the primary texts (this means one from each text)
and use them to support your argument.
● A few notes on citations:
○ Citations should never stand alone. In other words, they should always be followed
by two things: 1) an explanation of what’s being said in the citation/the main idea or
ideas being expressed; and 2) an argument for how the idea(s) presented there
support your own overall position.
○ Be purposeful in your choice of citations. They should not only be clearly relevant,
but should not be too long, given that the assignment is so short already (as a general
rule of thumb, choose citations that are no more than ~2 sentences).
○ You may quote from lecture but these quotes will not count as your primary source
citations. If quoting from lecture, please follow the same guidelines above re:
explaining what’s being said and applying the idea(s) to your own argument.
● For the most part, you will be paraphrasing, explaining, and arguing key ideas from the text
in your own words. Remember that a major grading criterion is comprehension of the text.
In other words, I am both: looking that you understand the material, and that you can apply
it to the prompt.
● No bibliography is needed, just cite the text(s) using the author’s last name and page # when
quoting or paraphrasing.
● While I am looking for your opinion and your voice, those must be grounded in the readings
and ideas. The most compelling positions are those which are grounded in reasoned
argument and show a deep understanding of the relevant material.
● Submit your final assignment by Friday, August 13th at 11:59 PM PST in either a doc,
docx, or pdf.
Note: I am aware that these cases permit a lot of ambiguity. We have far less information about the
situations, beliefs of those involved, etc., than would be the case in an actual clinical setting. I am
asking you to work with the information that is provided to you. It is okay to take certain liberties
with the information to fill in any gaps.
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Rubric: The assignment will be evaluated out of 10 points based on the following criteria:
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YOU HAVE THE CHOICE BETWEEN THE FOLLOWING TWO PROMPTS.
SELECT ONLY ONE:
PROMPT #1:
Patrick is a 45-year-old student nurse in his last year of training. His friend Carlos has had human
immunodeficiency virus (HIV) for many years. Carlos is now in the terminal stages of the disease
and is in constant pain and suffering. Carlos and Patrick have been friends for a long time and
Patrick has always said that he would be there to support Carlos. Carlos now asks him to travel with
him to Dignitas in Switzerland so that he can be assisted to end his life. Patrick wants to be there for
his friend. Personally, Patrick does not have any ethical quandaries about whether he should prevent
Carlos from making a decision to seek assistance to end his own life. However, he has taken an oath
at his new workplace which includes not supporting assisted dying, and so he is now worried that his
professional duties to his new place of employment would be compromised by travelling to
Switzerland with Carlos.
Using any one ethical theory (that you did not use in your first assignment) and any one additional
class reading to support and argue your position, respond to the following question: Is it or is it not
morally permissible for Patrick to accompany his friend Carlos to Dignitas? In generating your
argument, please also respond to the following questions as a way of supporting your main argument:
1. To what extent must Patrick’s obligations to his workplace be followed, irrespective of the
consequences?
2. What would you advise Patrick to do?
PROMPT #2:
Mike and Lauren, both in their late 20s, have been happily married for four years. Lauren has
congenital deafness due to a known gene mutation, and Mike is an unaffected carrier. They have a
one-in-two chance of having a deaf child, and theywish to avoid that risk. They are referred to the
Pre-implanation Genetic Diagnosis (PGD) clinic as they are seeking in vitro fertilization with PGD
so that an embryo without the mutation causing deafness can be selected for implantation.
Using any one ethical theory (that you did not use in your first assignment) and any one additional
class reading to support and argue your position, respond to the following question: Is it or is it not
morally permissible for Lauren and Mike to select against an embryo carrying the congenital
deafness mutation? In generating your argument, please also respond to the following questions as a
way of supporting your main argument:
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● Is there a moral difference between selecting against an embryo (i.e., that which has not yet
been implanted in a womb) and aborting a fetus with known congenital deafness? How is this
difference (or non-difference) relevant to your argument/position?
● You are tasked with authorizing their request to either approve or deny the IVF. Which do
you decide, and on what grounds?
The following information is relevant for this case (Prompt #2): The 2008 amendments to the Human
Fertilisation and Embryology Act (1990) provide that embryo testing is acceptable where there is a
significant risk that the child to be born will have or will develop a serious illness or disability. The
HFEA Code of Practice provides that in deciding whether to offer PGD the clinic should consider
factors such as the likely degree of suffering associated with the condition, the availability of
effective treatment, the degree of any intellectual impairment, and the social support available. The
genetic mutation here results in deafness, but this is not a life-shortening condition and there are no
other clinical manifestations of the condition. The World Health Organisation states that a disability
is not just a health problem but reflects the interaction between features of a person’s body and
features of the society in which the person lives. Some members of the deaf community do not
consider deafness to be a disability.
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Feedback for the first Ethic Evaluation
Score (68/100)
you make many interesting points here. However, I felt a disconnect between the position you were arguing and the core tenets of utilitarianism itself. I did not see any argument as to how an ethical theory that supports the greatest good for the greatest number could possibly support Pippas decision. Moving forward, itll also be important to select citations from the primary text which you are tasked both with explaining and then applying to your argument. These are key opportunities to demonstrate knowledge of the material and to apply said knowledge to your argument. Its also important to note that your thesis statement should already anticipate the theory youll be drawing on. Please feel free to reach out to me if youd like to discuss my comments and feedback further, and/or to work together on your next assignment.
Ethical Decision Making and parental autonomy
It is morally acceptable for Pippa to exercise her parental autonomy and not vaccinate her daughter, even though that decision would put others at risk because Pippas decision is about to be informed by past events that have left her highly suspicious of the vaccination. However, I believe that it is her right to seek answers regarding the rubella vaccine, which is not forthcoming at the moment. The decision to seek vaccination does not feel her with joy but continued mental uncertainty, as it is the case of her three-year-old son, with whom she is not even sure whether the seizure that occurs is likely to reappear in the future. Therefore, it is imperative to understand and ensure that she is well informed and be allowed to make an informed decision. Thus, I will embrace the Utilitarianism theory, which fosters happiness and oppose actions that cause unhappiness.
Pippa is reluctant to take her daughter for the vaccine for reasons well known. Forcing her to vaccinate her child is unethical and violates the ethical concepts as defined under utilitarian theory. John Stuart Mill illustrates that three basic concepts need to be fully assessed in moral and ethical decision-making. These include personal happiness, an action that promotes peace, and ensuring that everyones satisfaction equally counts. From the basis of this theory, Pippa is not happy, which means that there is no personal happiness essential in building universal joy and peace. The consequence of an action is fundamental to decision making and thus should inform whether a given decision is morally and ethically sound or not (Mill et al. 68).
As a result, an action must base on the needs of numerous people in a specific situation. The assessment of these elements is based on a critical understanding of better processes, which is necessary for developing a positive sense of essential processes that define vital underlying concepts. Understanding fundamental concepts that define crucial aspects that help establish the validity of particular concerns is provided by evaluating various actions. As a result, it is necessary to comprehend the total impact of the activity expressed in many scenarios. Understanding strategic concepts that provide a strategic emphasis on better measurements that assist define positive transformation underpins the integration of essential processes within a particular context.
Pippa has two options in this case, and each of the decisions she makes has far-reaching consequences, although there is a difference to the extent of the decision and how easy it is to make an informed decision. One of the decisions is to vaccinate her daughter and live a life of unhappiness and many uncertainties. Another option is to reject vaccination until she can fully comprehend the basis of decision-making and understand the potential effects. However, based on the information provided, it is evident that refusing the vaccine is more fulfilling and brings her more joy and fewer uncertainties, which she should prioritize.
The ability to make an educated decision is based on the assessment of a given actions outcomes. The methods used to complete a task are unimportant since they do not serve as a foundation for evaluating and developing critical conclusions. As a result, when a person is considering a decision, they must assess the consequences of the action, mainly whether the action is in many peoples best interests. As a result, a critical assessment of these notions is essential in defining strategic concepts that characterize positive development. The two principles are very much consistent with each other since they operate to create a shared understanding within a given setting. Jeremy Bentham and John Stuart Mill developed the good with pleasure just like Epicurus. They also held that we ought to maximize the good, mainly focusing on the tremendous amount of good for the most significant number.
Thus, the decision made in this context assesses if a specific activity is valid and whether it will have the desired impact on an individuals growth. In both cases, a critical evaluation of the action carries out to ensure that the action can be effectively integrated. It is essential to determining essential aspects that define a greater understanding of crucial concepts that represent a greater understanding of critical measures that restrict positive outcomes. Integration of higher-level thinking in determining a beneficial effect is based on a combination of essential processes that aid in comprehending strategic concepts that define key demands in individuals (Mill et al. 69).
Ethics play a critical role in focusing on the vital factors that characterize a positive connection in a fundamentally different way. Working for an organization where personal ethical values and underlying moral policy are successfully linked is always a good idea. However, there are times when a companys ethical code and personal ethical values are at odds. A persons understanding of the companys ethical policy is critical in building a strong focus on critical factors that define a favorable corporate environment. The underlying positive concepts that define a strong understanding of the fundamental issue that defines positive change are quickly impacted (Mill et al. 70). The ethical policy incorporates fundamental principles that describe how people interact within a specific organizational framework. Within an organizational context, and ethical policy should take precedence, although personal moral ideas are critical in personal space.
Generating the greatest good for a large number means that many individuals tend to agree with a given issue in question, thus reducing the harmful effect on their overall well-being. Therefore, minimizing suffering is equal to generating the greatest good for the most significant number. It is the responsibility of healthcare providers to inform Pippa on the importance of vaccination and how she can overcome her fears and allow vaccination. She needs guidance to make an informed decision and ensure that she makes her happy and does not expose any individual to adverse risks that are likely to occur.
The article also outlines no specific theory that emphasizes assigning pleasures of the intellect, feeling of imagination and moral sentiments. A much higher satisfaction defines a broader perspective that defines individual-level well-being and performance. The utilitarian writers have concentrated on mental well-being superiority over bodily pleasure, safety, and costliness. This means that for Pippa, her mental well-being is better and defines the overall ability to make an informed choice based on the current information. It is also worth noting that some kinds of pleasure are more valuable than others hence build a more interactive context for change and improved performance (Mill et al. 71).
ARISTOTLE
Nicomachean Ethics
translated and edited by
ROGER CRISP
St Annes College, Oxford
Book II
Chapter 1
Virtue, then, is of two kinds: that of the intellect and that of character.
Intellectual virtue owes its origin and development mainly to teaching,
for which reason its attainment requires experience and time; virtue of
character (eÅthos) is a result of habituation (ethos), for which reason it has
acquired its name through a small variation on `ethos. From this it is
clear that none of the virtues of character arises in us by nature. For
nothing natural can be made to behave differently by habituation. For
example, a stone that naturally falls downwards could not be made by
habituation to rise upwards, not even if one tried to habituate it by
throwing it up ten thousand times; nor can ®re be habituated to burn
downwards, nor anything else that naturally behaves in one way be
habituated to behave differently. So virtues arise in us neither by nature
nor contrary to nature, but nature gives us the capacity to acquire them,
and completion comes through habituation.
Again, in all the cases where something arises in us by nature, we ®rst
acquire the capacities and later exhibit the activities. This is clear in the
case of the senses, since we did not acquire them by seeing often or
hearing often; we had them before we used them, and did not acquire
them by using them. Virtues, however, we acquire by ®rst exercising
them. The same is true with skills, since what we need to learn before
doing, we learn by doing; for example, we become builders by building,
and lyre-players by playing the lyre. So too we become just by doing
just actions, temperate by temperate actions, and courageous by coura-
geous actions. What happens in cities bears this out as well, because
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1103b
legislators make the citizens good by habituating them, and this is what
every legislator intends. Those who do not do it well miss their target;
and it is in this respect that a good political system differs from a bad
one.
Again, as in the case of a skill, the origin and means of the develop-
ment of each virtue are the same as those of its corruption: it is from
playing the lyre that people become good and bad lyre-players. And it is
analogous in the case of builders and all the rest, since from building
well, people will be good builders, from building badly, bad builders. If
this were not so, there would have been no need of a person to teach
them, but they would all have been born good or bad at their skill.
It is the same, then, with the virtues. For by acting as we do in our
dealings with other men, some of us become just, others unjust; and by
acting as we do in the face of danger, and by becoming habituated to
feeling fear or con®dence, some of us become courageous, others
cowardly. The same goes for cases of appetites and anger; by conducting
themselves in one way or the other in such circumstances, some become
temperate and even-tempered, others intemperate and bad-tempered.
In a word, then, like states arise from like activities. This is why we
must give a certain character to our activities, since it is on the
differences between them that the resulting states depend. So it is not
unimportant how we are habituated from our early days; indeed it
makes a huge difference ± or rather all the difference.
Chapter 2
The branch of philosophy we are dealing with at present is not purely
theoretical like the others, because it is not in order to acquire knowl-
edge that we are considering what virtue is, but to become good people
± otherwise there would be no point in it. So we must consider the
matter of our actions, and in particular how they should be performed,
since, as we have said, they are responsible for our states developing in
one way or another.
The idea of acting in accordance with right reason is a generally
accepted one. Let us here take it for granted ± we shall discuss it later,
both what right reason is and how it is related to the other virtues. But
this we must agree on before we begin: that the whole account of what is
to be done ought to be given roughly and in outline. As we said at the
Nicomachean Ethics
1104a
24
start, the accounts we demand should be appropriate to their subject-
matter; and the spheres of actions and of what is good for us, like those
of health, have nothing ®xed about them.
Since the general account lacks precision, the account at the level of
particulars is even less precise. For they do not come under any skill or
set of rules: agents must always look at what is appropriate in each case
as it happens, as do doctors and navigators. But, though our present
account is like this, we should still try to offer some help.
First, then, let us consider this ± the fact that states like this are
naturally corrupted by de®ciency and excess, as we see in the cases of
strength and health (we must use clear examples to illustrate the
unclear); for both too much exercise and too little ruin ones strength,
and likewise too much food and drink and too little ruin ones health,
while the right amount produces, increases and preserves it. The same
goes, then, for temperance, courage and the other virtues: the person
who avoids and fears everything, never standing his ground, becomes
cowardly, while he who fears nothing, but confronts every danger,
becomes rash. In the same way, the person who enjoys every pleasure
and never restrains himself becomes intemperate, while he who avoids
all pleasure ± as boors do ± becomes, as it were, insensible. Temperance
and courage, then, are ruined by excess and de®ciency, and preserved by
the mean.
Not only are virtues produced and developed from the same origins
and by the same means as those from which and by which they are
corrupted, but the activities that ¯ow from them will consist in the same
things. For this is also true in other more obvious cases, like that of
strength. It is produced by eating a great deal and going through a great
deal of strenuous exercise, and it is the strong person who will be most
able to do these very things. The same applies to virtues. By abstaining
from pleasures we become temperate, and having become so we are most
able to abstain from them. Similarly with courage: by becoming habitu-
ated to make light of what is fearful and to face up to it, we become
courageous; and when we are, we shall be most able to face up to it.
Chapter 3
We must take as an indication of a persons states the pleasure or pain
consequent on what he does, because the person who abstains from
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1104b
Book II
bodily pleasures and ®nds his enjoyment in doing just this is temperate,
while the person who ®nds doing it oppressive is intemperate; and the
person who enjoys facing up to danger, or at least does not ®nd it
painful to do so, is courageous, while he who does ®nd it painful is a
coward. For virtue of character is concerned with pleasures and pains: it
is because of pleasure that we do bad actions, and pain that we abstain
from noble ones. It is for this reason that we need to have been brought
up in a particular way from our early days, as Plato says,10 so we might
®nd enjoyment or pain in the right things; for the right education is just
this.
Again, if the virtues are to do with actions and situations of being
affected, and pleasure and pain follow from every action and situation of
being affected, then this is another reason why virtue will be concerned
with pleasures and pains.
The fact that punishment is based on pleasure and pain is further
evidence of their relevance; for punishment is a kind of cure, and cures
by their nature are effected by contraries.
Again, as we said recently, every state of the soul is naturally related
to, and concerned with, the kind of things by which it is naturally made
better or worse. It is because of pleasures and pains that people become
bad ± through pursuing or avoiding the wrong ones, or at the wrong
time, or in the wrong manner, or in any other of the various ways
distinguished by reason. This is why some have classi®ed virtues as
forms of insensibility or states of rest; but this is wrong, because they
speak without quali®cation, without saying `in the right way and `in the
wrong way, `at the right time and `at the wrong time, and the other
things one can add.
We assume, then, that virtue will be the sort of state to do the best
actions in connection with pleasures and pains, and vice the contrary.
The following considerations should also make it plain to us that virtue
and vice are concerned with the same things.
There are three objects of choice ± the noble, the useful, and the
pleasant ± and three of avoidance ± their contraries, the shameful, the
harmful, and the painful. In respect of all of these, especially pleasure,
the good person tends to go right, and the bad person to go wrong.
For pleasure is shared with animals, and accompanies all objects of
10 Plato, Republic 401e±402a; Laws 653a±c.
Nicomachean Ethics
26
choice, because what is noble and what is useful appear pleasant as
well.
Again, pleasure has grown up with all of us since infancy and is
consequently a feeling dif®cult to eradicate, ingrained as it is in our
lives. And, to a greater or lesser extent, we regulate our actions by
pleasure and pain. Our whole inquiry, then, must be concerned with
them, because whether we feel enjoyment and pain in a good or bad way
has great in¯uence on our actions.
Again, as Heraclitus says, it is harder to ®ght against pleasure than
against spirit.11 But both skill and virtue are always concerned with
what is harder, because success in what is harder is superior. So this is
another reason why the whole concern of virtue and political science is
pleasures and pains: the person who manages them well will be good,
while he who does so badly will be bad.
Let it be taken as established, then, that virtue is to do with pleasures
and pains; that the actions which produce it also increase it, or, if they
assume a different character, corrupt it; and that the sphere of its
activity is the actions that themselves gave rise to it.
Chapter 4
Someone might, however, wonder what we mean by saying that
becoming just requires doing just actions ®rst, and becoming temperate,
temperate actions. For if we do just and temperate actions, we are
already just and temperate; similarly, if we do what is literate or musical,
we must be literate or musical.
But surely this is not true even of the skills? For one can produce
something literate by chance or under instruction from another.
Someone will be literate, then, only when he produces something
literate and does so in a literate way, that is, in accordance with his own
literacy.
Again, the case of the skills is anyway not the same as that of the
virtues. For the products of the skills have their worth within them-
selves, so it is enough for them to be turned out with a certain quality.
But actions done in accordance with virtues are done in a just or
temperate way not merely by having some quality of their own, but
11 Heraclitus, 22 B 85 DK. ¯. c. 500 BCE. Important Ionian philosopher.
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1105a
Book II
rather if the agent acts in a certain state, namely, ®rst, with knowledge,
secondly, from rational choice, and rational choice of the actions for
their own sake, and, thirdly, from a ®rm and unshakeable character. The
second and third of these are not counted as conditions for the other
skills, only the knowledge. With regard to virtues, knowledge has little
or no weight, while the other two conditions are not just slightly, but
all-important. And these are the ones that result from often doing just
and temperate actions. Actions, then, are called just and temperate
when they are such as the just and the temperate person would do. But
the just and temperate person is not the one who does them merely, but
the one who does them as just and temperate people do. So it is correct
to say that it is by doing just actions that one becomes just, and by doing
temperate actions temperate; without doing them, no one would have
even a chance of becoming good.
But the masses do not do them. They take refuge in argument,
thinking that they are being philosophers and that this is the way to be
good. They are rather like patients who listen carefully to their doctors,
but do not do what they are told. Just as such treatment will not make
the patients healthy in body, so being this kind of philosopher will not
make the masses healthy in soul.
Chapter 5
Next we must consider what virtue is. There are three things to be
found in the soul ± feelings, capacities, and states ± so virtue should be
one of these. By feelings, I mean appetite, anger, fear, con®dence, envy,
joy, love, hate, longing, emulation, pity, and in general things accom-
panied by pleasure or pain. By capacities, I mean the things on the basis
of which we are described as being capable of experiencing these feelings
± on the basis of which, for example, we are described as capable of
feeling anger, fear or pity. And by states I mean those things in respect
of which we are well or badly disposed in relation to feelings. If, for
example, in relation to anger, we feel it too much or too little, we are
badly disposed; but if we are between the two, then well disposed. And
the same goes for the other cases.
Neither the virtues nor the vices are feelings, because we are called
good or bad on the basis not of our feelings, but of our virtues and vices;
and also because we are neither praised nor blamed on the basis of our
Nicomachean Ethics
1105b
28
feelings (the person who is afraid or angry is not praised, and the person
who is angry without quali®cation is not blamed but rather the person
who is angry in a certain way), but we are praised and blamed on the
basis of our virtues and vices. Again, we become angry or afraid without
rational choice, while the virtues are rational choices or at any rate
involve rational choice. Again, in respect of our feelings, we are said to
be moved, while in respect of our virtues and vices we are said not to be
moved but to be in a certain state.
For these reasons they are not capacities either. For we are not called
either good or bad, nor are we praised or blamed, through being capable
of experiencing things, without quali®cation. Again, while we have this
capacity by nature, we do not become good or bad by nature; we spoke
about this earlier.
So if the virtues are neither feelings nor capacities, it remains that
they are states. We have thus described what virtue is generically.
Chapter 6
But we must say not just that virtue is a state, but what kind of state. We
should mention, then, that every virtue causes that of which it is a
virtue to be in a good state, and to perform its characteristic activity
well. The virtue of the eye, for example, makes it and its characteristic
activity good, because it is through the virtue of the eye that we see well.
Likewise, the virtue of the horse makes a horse good ± good at running,
at carrying its rider and at facing the enemy. If this is so in all cases, then
the virtue of a human being too will be the state that makes a human
being good and makes him perform his characteristic activity well.
We have already said how this will happen, and it will be clear also
from what follows, if we consider what the nature of virtue is like.
In everything continuous and divisible, one can take more, less, or an
equal amount, and each either in respect of the thing itself or relative to
us; and the equal is a sort of mean between excess and de®ciency. By the
mean in respect of the thing itself I mean that which is equidistant from
each of the extremes, this being one single thing and the same for
everyone, and by the mean relative to us I mean that which is neither
excessive nor de®cient ± and this is not one single thing, nor is it the
same for all. If, for example, ten are many and two are few, six is the
mean if one takes it in respect of the thing, because it is by the same
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1106a
Book II
amount that it exceeds the one number and is exceeded by the other.
This is the mean according to arithmetic progression. The mean relative
to us, however, is not to be obtained in this way. For if ten pounds of
food is a lot for someone to eat, and two pounds a little, the trainer will
not necessarily prescribe six; for this may be a lot or a little for the
person about to eat it ± for Milo,12 a little, for a beginner at gymnastics,
a lot. The same goes for running and wrestling. In this way every expert
in a science avoids excess and de®ciency, and aims for the mean and
chooses it ± the mean, that is, not in the thing itself but relative to us.
If, then, every science does its job well in this way, with its eye on the
mean and judging its products by this criterion (which explains both
why people are inclined to say of successful products that nothing can
be added or taken away from them, implying that excess and de®ciency
ruin what is good in them, while the mean preserves it, and why those
who are good at the skills have their eye on this, as we say, in turning out
their product), and if virtue, like nature, is more precise and superior to
any skill, it will also be the sort of thing that is able to hit the mean.
I am talking here about virtue of character, since it is this that is
concerned with feelings and actions, and it is in these that we ®nd
excess, de®ciency and the mean. For example, fear, con®dence, appetite,
anger, pity, and in general pleasure and pain can be experienced too
much or too little, and in both ways not well. But to have them at the
right time, about the right things, towards the right people, for the right
end, and in the right way, is the mean and best; and this is the business
of virtue. Similarly, there is an excess, a de®ciency and a mean in
actions. Virtue is concerned with feelings and actions, in which excess
and de®ciency constitute misses of the mark, while the mean is praised
and on target, both of which are characteristics of virtue. Virtue, then, is
a kind of mean, at least in the sense that it is the sort of thing that is able
to hit a mean.
Again, one can miss the mark in many ways (since the bad belongs to
the unlimited, as the Pythagoreans portrayed it, and the good to the
limited), but one can get things right in only one (for which reason one
is easy and the other dif®cult ± missing the target easy, hitting it
dif®cult). For these reasons as well, then, excess and de®ciency are
characteristics of vice, the mean characteristic of virtue:
12 Famous athlete from Croton of the later sixth century.
Nicomachean Ethics
1106b
30
For good people are just good, while bad people are bad in all sorts
of ways.13
Virtue, then, is a state involving rational choice, consisting in a mean
relative to us and determined by reason ± the reason, that is, by
reference to which the practically wise person would determine it. It is a
mean between two vices, one of excess, the other of de®ciency. It is a
mean also in that some vices fall short of what is right in feelings and
actions, and others exceed it, while virtue both attains and chooses the
mean. So, in respect of its essence and the de®nition of its substance,
virtue is a mean, while with regard to what is best and good it is an
extreme.
But not every action or feeling admits of a mean. For some have
names immediately connected with depravity, such as spite, shameless-
ness, envy, and, among actions, adultery, theft, homicide. All these, and
others like them, are so called because they themselves, and not their
excesses or de®ciencies, are bad. In their case, then, one can never hit
the mark, but always misses. Nor is there a good or bad way to go about
such things ± committing adultery, say, with the right woman, at the
right time, or in the right way. Rather, doing one of them, without
quali®cation, is to miss the mark.
It would be equally wrong, therefore, to expect there to be a mean, an
excess and a de®ciency in committing injustice, being a coward, and
being intemperate, since then there would be a mean of excess and a
mean of de®ciency, an excess of excess and a de®ciency of de®ciency.
Rather, just as there is no excess and de®ciency of temperance and
courage, because the mean is, in a sense, an extreme, so too there is no
mean, excess or de®ciency in the cases above. However they are done,
one misses the mark, because, generally speaking, there is neither a
mean of excess or de®ciency, nor an excess or de®ciency of a mean.
Chapter 7
But this general account on its own is not enough. We must also apply it
to particular cases, because though more general discussions of actions
are of wider application, particular ones are more genuine. This is
13 Unknown.
31
1107a
Book II
because actions are to do with particulars, and what we say should
accord with particulars. We may take them from our diagram.
In fear and con®dence, courage is the mean. Of those who exceed it,
the person who exceeds in fearlessness has no name (many cases lack
names), while the one who exceeds in con®dence is rash. He who
exceeds in being afraid and is de®cient in con®dence is a coward.
With respect to pleasures and pains ± not all of them, and less so with
pains ± the mean is temperance, the excess intemperance. People
de®cient with regard to pleasures are not very common, and so do not
even have a name; let us call them insensible.
In giving and taking money, the mean is generosity, while the excess
and de®ciency are wastefulness and stinginess. People with these
qualities are excessive and de®cient in contrary ways to one another.
The wasteful person exceeds in giving away and falls short in taking,
while the stingy person exceeds in taking and falls short in giving
away. (At present, we can be content with giving a rough and
summary account of these things; a more detailed classi®cation will
come later.)
There are other dispositions connected with money. One mean is
magni®cence, for the magni®cent person, in so far as he deals with large
amounts, differs from the generous one, who deals with small. The
excess is tastelessness and vulgarity, the de®ciency niggardliness, and
they differ from the states opposed to generosity; how they differ will be
stated below.
In honour and dishonour, the mean is greatness of soul, while the
excess is referred to as a kind of vanity, the de®ciency smallness of soul.
And just as we said generosity is related to magni®cence, differing from
it by being concerned with small amounts, so there is a virtue having to
do with small honours that corresponds in the same way to greatness of
soul, which is to do with great ones. For one can desire small honours in
the right way, and in excessive and de®cient ways as well. The person
who exceeds in his desires is described as a lover of honour, the person
who is de®cient as not caring about it, while the one in between has no
name. Their dispositions are nameless as well, except that of the lover of
honour, which is called love of honour. This is why those at the
extremes lay claim to the middle ground. We ourselves sometimes refer
to the person in the middle as a lover of honour, sometimes as one who
does not care about it; and sometimes we praise the person who loves
Nicomachean Ethics
1107b
1108a
32
honour, sometimes the one who does not care about it. The reason for
our doing this will be stated below. For now, let us discuss the remaining
virtues and vices in the way laid down.
In anger too there is an excess, a de®ciency, and a mean. They are
virtually nameless, but since we call the person in between the extremes
even-tempered, let us call the mean even temper. Of those at the
extremes, let the one who is excessive be quick-tempered, and the vice
quick temper, while he who is de®cient is, as it were, slow-tempered,
and his de®ciency slow temper.
There are three other means, having something in common, but also
different. For they are all to do with our association with one another in
words and actions, but differ in that one is concerned with the truth to
be found in them, while the other two are respectively concerned with
what is pleasant in amusement and in life as a whole. We should talk
about these things as well, then, so that we can better see that in all
things the mean is praiseworthy, while the extremes are neither praise-
worthy nor correct, but blameworthy. Most of them again have no
names, but, for the sake of clarity and intelligibility, we must try, as in
the other cases, to produce names ourselves.
With respect to truth, then, let us call the intermediate person
truthful and the mean truthfulness; pretence that exaggerates is boast-
fulness and the person who has this characteristic is a boaster, while that
which understates is self-depreciation and the person who has this is
self-deprecating. In connection with what is pleasant in amusement, let
us call the intermediate person witty, and the disposition wit; the excess
clownishness, and the person with that characteristic a clown; and the
person who falls short a sort of boor and his state boorishness. With
respect to the remaining kind of pleasantness, that found in life in
general, let us call the person who is pleasant in the right way friendly
and the mean friendliness, while he who goes to excess will be
obsequious if there is no reason for it, and a ¯atterer if he is out for his
own ends; someone who falls short and is unpleasant all the time will be
a quarrelsome and peevish sort of person.
There are also means in the feelings and in connection with the
feelings. Shame, for example, is not a virtue, but praise is also bestowed
on the person inclined to feel it. Even in these cases one person is said
to be intermediate, and another ± the shy person who feels shame at
everything ± excessive; he who is de®cient or is ashamed of nothing at
33
Book II
all is called shameless, while the person in the middle is properly
disposed to feel shame.
Appropriate indignation is a mean between envy and spite; these
three are concerned with pain and pleasure felt at the fortunes of those
around us. The sort of person to experience appropriate indignation is
pained by those who do well undeservedly; the envious person goes
beyond him and is pained by anybodys doing well; while the spiteful
person, far from being pained at the misfortunes of others, actually feels
enjoyment.
There will also be an opportunity elsewhere to discuss means like
these.
As for justice, since it is a term used in more than one way, we shall
distinguish its two varieties after discussing the other virtues, and say
how each variety is a mean.
Chapter 8
Of these three dispositions, then, two are vices ± one of excess, the other
of de®ciency ± and the third, the mean, is virtue. Each is in a way
opposed to each of the others, because the extremes are contrary to the
mean and to one another, and the mean to the extremes. For as the equal
is greater in relation to the less, but less in relation to the greater, so the
mean states are excessive in relation to the de®ciencies, but de®cient in
relation to the excesses; this is so in both feelings and actions. For the
courageous person seems rash in relation to the coward, and a coward in
relation to the rash person. Similarly, the temperate seems intemperate
in relation to the insensible, but insensible in relation to the intemperate,
and the generous person wasteful in relation to the stingy person, but
stingy in relation to the wasteful. This is why those at one extreme push
away the intermediate person to the other, the coward calling the
courageous person rash, the rash person calling him a coward, and
analogously in other cases.
Since they are set against one another in this way, the greatest
opposition is that of the extremes to one another, rather than to the
mean. For they are further from each other than from the mean, as the
great is further from the small and the small further from the great than
either is from the equal. Again, some of the extremes seem rather like
the mean, as rashness seems like courage, and wastefulness like gener-
Nicomachean Ethics
1108b
34
osity. The greatest dissimilarity is that between extremes; and the things
that are furthest from each other are de®ned as contraries, so that the
further things are apart, the more contrary they will be. In some cases,
the de®ciency is more opposed to the mean than is the excess, in others
the excess is more opposed than the de®ciency; for example, it is not
rashness, the excess, which is more opposed to courage, but cowardice,
the de®ciency; while it is not insensibility, the de®ciency, but intemper-
ance, the excess, which is more opposed to temperance. There are two
reasons for this.
One derives from the nature of the thing itself. Because one extreme
is nearer and more like the mean, we set in opposition to the mean not
this but rather its contrary; for example, since rashness is thought to be
more like courage and nearer to it, and cowardice less like it, it is
cowardice rather than rashness that we set in opposition, because things
that are …
IMMANUEL KANT
Groundwork of the Metaphysics of Morals
TRANSLATED AND EDITED BY
MARY GREGOR
WITH AN INTRODUCTION BY
CHRISTINE M. KORSGAARD
Harvard University
CAMBRIDGE
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First published 1998
Eleventh printing 2006
Printed in the United Kingdom at the University Press, Cambridge
Typeset in 10/12 Ehrhardt
A catalogue record for this book is available from the British Library
Library of Congress Cataloguing in Publication data
Kant, Immanuel, 1724-1804.
[Grundlegung zur Metaphysik der Sitten. English]
Groundwork of the metaphysics of morals/Immanuel Kant;
translated and edited by Mary Gregor; with an introduction by
Christine M. Korsgaard.
p. cm. - (Cambridge texts in the history of philosophy)
Includes bibliographical references and index.
ISBN 0 521 62235 2 (hardback). - ISBN 0 521 62695 l (paperback)
1. Ethics. - Early works to 1800. I. Gregor, Mary J. II. Title. III. Series.
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4:393
Section I
Transition from common rational to
philosophic moral cognition
It is impossible to think of anything at all in the world, or indeed even
beyond it, that could be considered good without limitation except a good
will. Understanding, wit, judgment3 and the like, whatever such talents of
mind5 may be called, or courage, resolution, and perseverance in ones
plans, as qualities of temperament, are undoubtedly good and desirable for
many purposes/ but they can also be extremely evil and harmful if the will
which is to make use of these gifts of nature, and whose distinctive
constitution is therefore called character, is not good. It is the same with
gifts of fortune. Power, riches, honor, even health and that complete well-
being and satisfaction1 with ones condition called happiness, produce bold-
ness and thereby often arrogance as well unless a good will is present
which corrects the influence of these on the mind and, in so doing, also
corrects the whole principle of action and brings it into conformity with
universal ends* - not to mention that an impartial rational spectator can
take no delight in seeing the uninterrupted prosperity of a being graced
with no feature of a pure and good will, so that a good will seems to
constitute the indispensable condition even of worthiness to be happy.
Some qualities are even conducive^ to this good will itself and can
s Geistes. Compare Kants use of Geist in Anthropology from a Pragmatic Point of View (7:225)
and of Geisteskrdfte in The Metaphysics of Morals (6:445).
* in mancher Absicht, perhaps in many respects
u Beschaffenheit, occasionally translated as character. Constitution is also used to translate
Einrichtung and sometimes Anlage, which is used rather loosely in the Groundwork.
v Kant uses a great variety of words for what could be called pleasure {Lust) in the most
general sense. Although he later draws broad distinctions among pleasures in terms of their
origins (e.g., between the pleasure of taste and that of sensation, and between both of these and
moral pleasure), these distinctions still leave a number of words problematic. Within the
Groundwork (4:396) he suggests a distinction between Zufriedenheit or satisfaction in general
and reasons own kind of Zufriedenheit, which in that context I have translated as content-
ment. However, his vocabulary is not consistent, and I have not attempted to make it so.
Mut. . . Ubermut
x allgemein-zweckmdfiig mache
y beforderlich. Compare The Metaphysics of Morals (6:407-9). Befordern is usually translated as
to further or to promote.
GROUNDWORK OF THE METAPHYSICS OF MORALS
make its work much easier; despite this, however, they have no inner
4:394 unconditional worth but always presuppose a good will, which limits the
esteem one otherwise rightly has for them and does not permit their being
taken as absolutely good. Moderation in affects and passions, self-control,
and calm reflection are not only good for all sorts of purposes but even
seem to constitute a part of the inner worth of a person; but they lack
much that would be required to declare them good without limitation
(however unconditionally they were praised by the ancients); for, without
the basic principles of a good will they can become extremely evil, and the
coolness of a scoundrel makes him not only far more dangerous but also
immediately more abominable in our eyes than we would have taken him
to be without it.
A good will is not good because of what it effects or accomplishes,
because of its fitness to attain some proposed end, but only because of its
volition, that is, it is good in itself and, regarded for itself, is to be valued
incomparably higher than all that could merely be brought about by it in
favor of some inclination and indeed, if you will, of the sum of all inclina-
tions. Even if, by a special disfavor of fortune or by the niggardly provision
of a stepmotherly nature, this will should wholly lack the capacity to carry
out its purpose - if with its greatest efforts it should yet achieve nothing
and only the good will were left (not, of course, as a mere wish but as the
summoning of all means insofar as they are in our control) - then, like a
jewel, it would still shine by itself, as something that has its full worth in
itself. Usefulness or fruitlessness can neither add anything to this worth
nor take anything away from it. Its usefulness would be, as it were, only
the setting to enable us to handle it more conveniently in ordinary com-
merce or to attract to it the attention of those who are not yet expert
enough, but not to recommend it to experts or to determine its worth.
There is, however, something so strange in this idea of the absolute
worth of a mere will, in the estimation of which no allowance is made for
any usefulness, that, despite all the agreement even of common under-
standing with this idea, a suspicion must yet arise that its covert basis is
perhaps mere high-flown fantasy and that we may have misunderstood the
4:395 purpose of nature in assigning reason to our will as its governor. Hence we
shall put this idea to the test from this point of view.
In the natural constitution of an organized being, that is, one consti-
tuted purposively for life,2 we assume as a principle that there will be
found in it no instrument for some end other than what is also most
appropriate to that end and best adapted to it. Now in a being that has
reason and a will, if the proper end of nature were its preservation, its
welfare, in a word its happiness, then nature would have hit upon a very bad
z zweckmdfiig zum Leben eingerichteten. Zweck is translated as end except when it occurs as
part of zweckmdfiig, Zweckmdfiigkeit, and zwecklos.
FROM COMMON RATIONAL COGNITION TO PHILOSOPHY
arrangement in selecting the reason of the creature to carry out this
purpose. For all the actions that the creature has to perform for this
purpose, and the whole rule of its conduct, would be marked out for it far
more accurately by instinct, and that end would have thereby been at-
tained much more surely than it ever can be by reason; and if reason
should have been given, over and above, to this favored creature, it must
have served it only to contemplate the fortunate constitution of its nature,
to admire this, to delight in it, and to be grateful for it to the beneficent
cause, but not to submit its faculty of desire* to that weak and deceptive
guidance and meddle with natures purpose. In a word, nature would have
taken care that reason should not break forth into practical use and have
the presumption, with its weak insight, to think out for itself a plan for
happiness and for the means of attaining it. Nature would have taken
upon itself the choice not only of ends but also of means and, with wise
foresight, would have entrusted them both simply to instinct.
And, in fact, we find that the more a cultivated reason purposely
occupies itself with the enjoyment of life and with happiness, so much the
further does one get away from true satisfaction; and from this there arises
in many, and indeed in those who have experimented most with this use of
reason, if only they are candid enough to admit it, a certain degree of
misology, that is, hatred of reason; for, after calculating all the advantages
they draw - 1 do not say from the invention of all the arts of common
luxury, but even from the sciences (which seem to them to be, at bottom,
only a luxury of the understanding) - they find that they have in fact only
brought more trouble upon themselves instead of gaining in happiness; 4:396
and because of this they finally envy rather than despise the more com-
mon run of people, who are closer to the guidance of mere natural instinct
and do not allow their reason much influence on their behavior. And to
this extent we must admit that the judgment of those who greatly moder-
ate, and even reduce below zero, eulogies extolling the advantages that
reason is supposed to procure for us with regard to the happiness and
satisfaction of life is by no means surly or ungrateful to the goodness of
the government of the world; we must admit, instead, that these judg-
ments have as their covert basis the idea of another and far worthier
purpose of ones existence, to which therefore, and not to happiness,
reason is properly destined/ and to which, as supreme condition, the
private purpose of the human being must for the most part defer.
Since reason is not sufficiently competent to guide the will surely with
a Begehrungsvermogen. For Kants definition of this term see Critique of Practical Reason (5:8 n)
and The Metaphysics of Morals (6:211). Vermogen by itself is sometimes translated as capacity
or ability.
* bestimmt. Except when it has this sense of vocation, Bestimmung and its cognates are
translated in terms of determination.
GROUNDWORK OF THE METAPHYSICS OF MORALS
regard to its objects and the satisfaction of all our needs (which it to some
extent even multiplies) - an end to which an implanted natural instinct
would have led much more certainly; and since reason is nevertheless
given to us as a practical faculty, that is, as one that is to influence the mill;
then, where nature has everywhere else gone to work purposively in dis-
tributing its capacities/ the true vocation of reason must be to produce a
will that is good, not perhaps as a means to other purposes, but good in
itself for which reason was absolutely necessary. This will need not, be-
cause of this, be the sole and complete good, but it must still be the
highest good and the condition of every other, even of all demands for
happiness. In this case it is entirely consistent with the wisdom of nature if
we perceive that the cultivation of reason, which is requisite to the first
and unconditional purpose, limits in many ways - at least in this life - the
attainment of the second, namely happiness, which is always conditional;
indeed it may reduce it below zero without nature proceeding unpur-
posively in the matter, because reason, which cognizes its highest practical
vocation in the establishment of a good will, in attaining this purpose is
capable only of its own kind of satisfaction, namely from fulfilling an end
which in turn only reason determines, even if this should be combined
with many infringements upon the ends of inclination.
4:397 We have, then, to explicate** the concept of a will that is to be esteemed
in itself and that is good apart from any further purpose, as it already
dwells in natural sound understanding and needs not so much to be
taught as only to be clarified - this concept that always takes first place in
estimating the total worth of our actions and constitutes the condition of
all the rest. In order to do so, we shall set before ourselves the concept of
duty, which contains that of a good will though under certain subjective
limitations and hindrances, which, however, far from concealing it and
making it unrecognizable, rather bring it out by contrast and make it shine
forth all the more brightly.
I here pass over all actions that are already recognized as contrary to duty,
even though they may be useful for this or that purpose; for in their case the
question whether they might have been done from duty never arises, since
they even conflict with it. I also set aside actions that are really in conformity
with duty but to which human beings have no inclination immediately* and
c Anlagen
d entwickeln. In the context of organisms generally, and more specifically with reference to
mans talents and capacities, this is translated as to develop. However, in the context of
analytic and synthetic propositions, see the Jasche Logik (9:111, Anmerkung 1), where it is
said that in an implicitly identical proposition (as distinguished from a tautology), a predicate
that lies unentwickelt (implicite) in the concept of the subject is made clear by means of
Entwicklung (explicatio).
e unmittelbar. Kant occasionally uses direkt as a synonym; no temporal reference is intended.
10
FROM COMMON RATIONAL COGNITION TO PHILOSOPHY
which they still perform because they are impelled^to do so through an-
other inclination. For in this case it is easy to distinguish whether an action
in conformity with duty is done from duty or from a self-seeking purpose. It
is much more difficult to note this distinction when an action conforms with
duty and the subject has, besides, an immediate inclination to it. For exam-
ple, it certainly conforms with duty that a shopkeeper not overcharge an
inexperienced customer, and where there is a good deal of trade a prudent
merchant does not overcharge but keeps a fixed general price for everyone,
so that a child can buy from him as well as everyone else. People are thus
served honestly; but this is not nearly enough for us to believe that the
merchant acted in this way from duty and basic principles of honesty; his
advantage required it; it cannot be assumed here that he had, besides, an
immediate inclination toward his customers, so as from love, as it were, to
give no one preference over another in the matter of price. Thus the action
was done neither from duty nor from immediate inclination but merely for
purposes of self-interest.
On the other hand, to preserve ones life is a duty, and besides every-
one has an immediate inclination to do so. But on this account the often
anxious care that most people take of it still has no inner worth and their
maxim has no moral content. They look after their lives in conformity with 4:398
duty but not from duty. On the other hand, if adversity and hopeless grief
have quite taken away the taste for life; if an unfortunate man, strong of
soul and more indignant about his fate than despondent or dejected,
wishes for death and yet preserves his life without loving it, not from
inclination or fear but from duty, then his maxim has moral content.
To be beneficent^ where one can is a duty, and besides there are many
souls so sympathetically attuned that, without any other motive of vanity or
self-interest they find an inner satisfaction in spreading joy around them
and can take delight in the satisfaction of others so far as it is their own
work. But I assert that in such a case an action of this kind, however it may
conform with duty and however amiable it may be, has nevertheless no
true moral worth but is on the same footing with other inclinations, for
example, the inclination to honor, which, if it fortunately lights upon what
is in fact in the common interest and in conformity with duty and hence
honorable, deserves praise and encouragement but not esteem; for the
maxim lacks moral content, namely that of doing such actions not from
inclination but from duty. Suppose, then, that the mind of this philanthro-
pist were overclouded by his own grief, which extinguished all sympathy
with the fate of others, and that while he still had the means to benefit
f getrieben. Antrieb is translated as impulse.
g Wohltdtig sein. In view of Kants distinction between Wohltun and Wohlwollen (6:393, 450
ff.), Wohltun and its cognates are translated in terms of beneficence and Wohlwollen in
terms of benevolence.
11
GROUNDWORK OF THE METAPHYSICS OF MORALS
others in distress their troubles did not move him because he had enough
to do with his own; and suppose that now, when no longer incited to it by
any inclination, he nevertheless tears himself out of this deadly insensibil-
ity and does the action without any inclination, simply from duty; then the
action first has its genuine moral worth. Still further: if nature had put
little sympathy in the heart of this or that man; if (in other respects an
honestA man) he is by temperament cold and indifferent to the sufferings
of others, perhaps because he himself is provided with the special gift of
patience and endurance toward his own sufferings and presupposes the
same in every other or even requires it; if nature had not properly fash-
ioned such a man (who would in truth not be its worst product) for a
philanthropist, would he not still find within himself a source from which
to give himself a far higher worth than what a mere good-natured tempera-
ment might have? By all means! It is just then that the worth of character
4:399 comes out, which is moral and incomparably the highest, namely that he is
beneficent not from inclination but from duty.
To assure ones own happiness is a duty (at least indirectly); for, want
of satisfaction with ones condition, under pressure from many anxieties
and amid unsatisfied needs, could easily become a great temptation to
transgression of duty. But in addition, without looking to duty here, all
people have already, of themselves, the strongest and deepest inclination
to happiness because it is just in this idea that all inclinations unite in one
sum. However, the precept of happiness is often so constituted that it
greatly infringes upon some inclinations, and yet one can form no determi-
nate and sure concept of the sum of satisfaction of all inclinations under
the name of happiness. Hence it is not to be wondered at that a single
inclination, determinate both as to what it promises and as to the time
within which it can be satisfied, can often outweigh a fluctuating idea, and
that a man - for example, one suffering from gout - can choose to enjoy
what he likes and put up with what he can since, according to his calcula-
tions, on this occasion at least he has not sacrificed the enjoyment of the
present moment to the perhaps groundless expectation of a happiness that
is supposed to lie in health. But even in this case, when the general
inclination to happiness did not determine his will; when health, at least
for him, did not enter as so necessary into this calculation, there is still left
over here, as in all other cases, a law, namely to promote his happiness not
from inclination but from duty; and it is then that his conduct first has
properly moral worth.
It is undoubtedly in this way, again, that we are to understand the
* ehrlicher. I have translated this as honest because Kant gives the Latin honestas as a
parenthetical equivalent of such derivatives oiEhre as Ehrbarkeit. However, the context often
makes it clear that he is not thinking of honesty in the narrow sense.
allgemeine
12
FROM COMMON RATIONAL COGNITION TO PHILOSOPHY
passages from scripture in which we are commanded to love our neighbor,
even our enemy. For, love as an inclination cannot be commanded, but
beneficence from duty - even though no inclination impels us to it and,
indeed, natural and unconquerable aversion opposes it - is practical and
not pathologicaP love, which lies in the will and not in the propensity of
feeling/ in principles of action and not in melting sympathy; and it alone
can be commanded.
The second proposition is this: an action from duty has its moral worth
not in the purpose to be attained by it but in the maxim in accordance with
which it is decided upon, and therefore does not depend upon the realiza-
tion of the object of the action but merely upon the principle of volition in 4:400
accordance with which the action is done without regard for any object of
the faculty of desire. That the purposes we may have for our actions, and
their effects as ends and incentives of the will, can give actions no uncondi-
tional and moral worth is clear from what has gone before. In what, then,
can this worth lie, if it is not to be in the will in relation to the hoped for
effect of the action? It can lie nowhere else than in the principle of the will
without regard for the ends that can be brought about by such an action.
For, the will stands between its a priori principle, which is formal, and its a
posteriori incentive, which is material, as at a crossroads; and since it must
still be determined by something, it must be determined by the formal
principle of volition as such when an action is done from duty, where every
material principle has been withdrawn from it.
The third proposition, which is a consequence of the two preceding, I
would express as follows: duty is the necessity of an action from respect for lam.
For an object as the effect of my proposed action I can indeed have
inclination but never respect, just because it is merely an effect and not an
activity of a will. In the same way I cannot have respect for inclination as
such, whether it is mine or that of another; I can at most in the first case
approve it and in the second sometimes even love it, that is, regard it as
favorable to my own advantage. Only what is connected with my will
merely as ground and never as effect, what does not serve my inclination
but outweighs it or at least excludes it altogether from calculations in
making a choice-hence the mere law for itself-can be an object of
respect and so a command. Now, an action from duty is to put aside
entirely the influence of inclination and with it every object of the will;
hence there is left for the will nothing that could determine it except
J pathologische, i.e., dependent upon sensibility
k Empfindung. In the Critique of Judgment (5:206) Kant distinguishes an objective sensation
(e.g., green) from a subjective sensation (e.g., pleasure) and suggests that misunderstand-
ing could be avoided if feeling (Gefiiht) were used for the latter. I have followed his
suggestion, while indicating the German word in a note.
lbeiderWahl
13
GROUNDWORK OF THE METAPHYSICS OF MORALS
objectively the law and subjectively pure respect for this practical law, and so
4:401 the maxim* of complying with such a law even if it infringes upon all my
inclinations.
Thus the moral worth of an action does not lie in the effect expected
from it and so too does not lie in any principle of action that needs to
borrow its motive from this expected effect. For, all these effects (agree-
ableness of ones condition, indeed even promotion of others happiness)
could have been also brought about by other causes, so that there would
have been no need, for this, of the will of a rational being, in which,
however, the highest and unconditional good alone can be found. Hence
nothing other than the representation of the law in itself, which can of course
occur only in a rational being, insofar as it and not the hoped-for effect is the
determining ground of the will, can constitute the preeminent good we
call moral, which is already present in the person himself who acts in
accordance with this representation and need not wait upon the effect of
his action. +
4:402 But what kind of law can that be, the representation of which must
determine the will, even without regard for the effect expected from it, in
order for the will to be called good absolutely and without limitation?
Since I have deprived the will of every impulse that could arise for it from
obeying some law, nothing is left but the conformity of actions as such
with universal law,w which alone is to serve the will as its principle, that is,
#A maxim is the subjective principle of volition; the objective principle (i.e., that which would
also serve subjectively as the practical principle for all rational beings if reason had complete
control over the faculty of desire) is the practical law.
tit could be objected that I only seek refuge, behind the word respect, in an obscure feeling,
instead of distinctly resolving the question by means of a concept of reason. But though
respect is a feeling, it is not one received by means of influence; it is, instead, a feeling self-
wrought by means of a rational concept and therefore specifically different from all feelings of
the first kind, which can be reduced to inclination or fear. What I cognize immediately as a
law for me I cognize with respect, which signifies merely consciousness of the subordination
of my will to a law without the mediation of other influences on my sense. Immediate
determination of the will by means of the law and consciousness of this is called respect, so
that this is regarded as the effect of the law on the subject, and not as the cause of the law.
Respect is properly the representation of a worth that infringes upon my self-love. Hence
there is something that is regarded as an object neither of inclination nor of fear, though it
has something analogous to both. The object of respect is therefore simply the law, and
indeed the law that we impose upon ourselves and yet as necessary in itself. As a law we are
subject to it without consulting self-love; as imposed upon us by ourselves it is nevertheless a
result of our will; and in the first respect it has an analogy with fear, in the second with
inclination. Any respect for a person is properly only respect for the law (of integrity and so
forth) of which he gives us an example. Because we also regard enlarging our talents as a
duty, we represent a person of talents also as, so to speak, an example of the law (to become
like him in this by practice), and this is what constitutes our respect. All so-called moral
interest consists simply in respect for the law.
m die allgemeine Gesetzmdfiigkeit der Handlungen uberhaupt
14
FROM COMMON RATIONAL COGNITION TO PHILOSOPHY
/ ought never to act except in such a way that I could also will that my maxim
should become a universal law. Here mere conformity to law as such, with-
out having as its basis some law determined for certain actions, is what
serves the will as its principle, and must so serve it, if duty is not to be
everywhere an empty delusion and a chimerical concept. Common human
reason also agrees completely with this in its practical appraisals and
always has this principle before its eyes. Let the question be, for example:
may I, when hard pressed, make a promise with the intention not to keep
it? Here I easily distinguish two significations the question can have:
whether it is prudent or whether it is in conformity with duty to make a
false promise. The first can undoubtedly often be the case. I see very well
that it is not enough to get out of a present difficulty by means of this
subterfuge but that I must reflect carefully whether this lie may later give
rise to much greater inconvenience for me than that from which I now
extricate myself; and since, with all my supposed cunning, the results
cannot be so easily foreseen but that once confidence in me is lost this
could be far more prejudicial to me than all the troubles I now think to
avoid, I must reflect whether the matter might be handled more prudently
by proceeding on a general maxim and making it a habit to promise
nothing except with the intention of keeping it. But it is soon clear to me
that such a maxim will still be based only on results feared. To be truthful
from duty, however, is something entirely different from being truthful
from anxiety about detrimental results, since in the first case the concept
of the action in itself already contains a law for me while in the second I
must first look about elsewhere to see what effects on me might be
combined with it. For, if I deviate from the principle of duty this is quite
certainly evil; but if I am unfaithful to my maxim of prudence this can 4:403
sometimes be very advantageous to me, although it is certainly safer to
abide by it. However, to inform myself in the shortest and yet infallible
way about the answer to this problem, whether a lying promise is in
conformity with duty, I ask myself: would I indeed be content that my
maxim (to get myself out of difficulties by a false promise) should hold as a
universal law (for myself as well as for others)? and could I indeed say to
myself that every one may make a false promise when he finds himself in a
difficulty he can get out of in no other way? Then I soon become aware
that I could indeed will the lie, but by no means a universal law to lie; …
The Ethics of Care:
Personal, Political, and
Global
Virginia Held
OXFORD UNIVERSITY PRESS
1
The Ethics of Care as Moral Theory
The ethics of care is only a few decades old.1 Some theorists do not like the term
‘care’ to designate this approach to moral issues and have tried substituting ‘the
ethic of love,’ or ‘relational ethics,’ but the discourse keeps returning to ‘care’
as the so far more satisfactory of the terms considered, though dissatisfactions
with it remain. The concept of care has the advantage of not losing sight of the
work involved in caring for people and of not lending itself to the interpretation
of morality as ideal but impractical to which advocates of the ethics of care often
object. Care is both value and practice.
By now, the ethics of care has moved far beyond its original formulations, and
any attempt to evaluate it should consider much more than the one or two early
works so frequently cited. It has been developed as a moral theory relevant not only
to the so-called private realms of family and friendship but to medical practice,
law, political life, the organization of society, war, and international relations.
The ethics of care is sometimes seen as a potential moral theory to be sub-
stituted for such dominant moral theories as Kantian ethics, utilitarianism, or
Aristotelian virtue ethics. It is sometimes seen as a form of virtue ethics. It is
almost always developed as emphasizing neglected moral considerations of at
least as much importance as the considerations central to moralities of justice and
rights or of utility and preference satisfaction. And many who contribute to the
understanding of the ethics of care seek to integrate the moral considerations,
such as justice, which other moral theories have clarified, satisfactorily with those
of care, though they often see the need to reconceptualize these considerations.
Features of the Ethics of Care
Some advocates of the ethics of care resist generalizing this approach into
something that can be fitted into the form of a moral theory. They see it as
9
a mosaic of insights and value the way it is sensitive to contextual nuance and
particular narratives rather than making the abstract and universal claims of
more familiar moral theories.2 Still, I think one can discern among various
versions of the ethics of care a number of major features.
First, the central focus of the ethics of care is on the compelling moral
salience of attending to and meeting the needs of the particular others for
whom we take responsibility. Caring for one’s child, for instance, may well and
defensibly be at the forefront of a person’s moral concerns. The ethics of care
recognizes that human beings are dependent for many years of their lives, that
the moral claim of those dependent on us for the care they need is pressing, and
that there are highly important moral aspects in developing the relations of
caring that enable human beings to live and progress. All persons need care for
at least their early years. Prospects for human progress and flourishing hinge
fundamentally on the care that those needing it receive, and the ethics of care
stresses the moral force of the responsibility to respond to the needs of the de-
pendent. Many persons will become ill and dependent for some periods of their
later lives, including in frail old age, and some who are permanently disabled
will need care the whole of their lives. Moralities built on the image of the
independent, autonomous, rational individual largely overlook the reality of
human dependence and the morality for which it calls. The ethics of care
attends to this central concern of human life and delineates the moral values
involved. It refuses to relegate care to a realm ‘‘outside morality.’’ How caring
for particular others should be reconciled with the claims of, for instance,
universal justice is an issue that needs to be addressed. But the ethics of care
starts with the moral claims of particular others, for instance, of one’s child,
whose claims can be compelling regardless of universal principles.
Second, in the epistemological process of trying to understand what mo-
rality would recommend and what it would be morally best for us to do and to
be, the ethics of care values emotion rather than rejects it. Not all emotion is
valued, of course, but in contrast with the dominant rationalist approaches,
such emotions as sympathy, empathy, sensitivity, and responsiveness are seen
as the kind of moral emotions that need to be cultivated not only to help in the
implementation of the dictates of reason but to better ascertain what morality
recommends.3 Even anger may be a component of the moral indignation that
should be felt when people are treated unjustly or inhumanely, and it may
contribute to (rather than interfere with) an appropriate interpretation of the
moral wrong. This is not to say that raw emotion can be a guide to morality;
feelings need to be reflected on and educated. But from the care perspective,
moral inquiries that rely entirely on reason and rationalistic deductions or
calculations are seen as deficient.
The emotions that are typically considered and rejected in rationalistic
moral theories are the egoistic feelings that undermine universal moral norms,
the favoritism that interferes with impartiality, and the aggressive and
vengeful impulses for which morality is to provide restraints. The ethics of
care, in contrast, typically appreciates the emotions and relational capabilities
that enable morally concerned persons in actual interpersonal contexts to
10 CARE AND MORAL THEORY
understand what would be best. Since even the helpful emotions can often
become misguided or worse—as when excessive empathy with others leads to
a wrongful degree of self-denial or when benevolent concern crosses over into
controlling domination—we need an ethics of care, not just care itself. The
various aspects and expressions of care and caring relations need to be sub-
jected to moral scrutiny and evaluated, not just observed and described.
Third, the ethics of care rejects the view of the dominant moral theories that
the more abstract the reasoning about a moral problem the better because the
more likely to avoid bias and arbitrariness, the more nearly to achieve im-
partiality. The ethics of care respects rather than removes itself from the claims
of particular others with whom we share actual relationships.4 It calls into
question the universalistic and abstract rules of the dominant theories. When
the latter consider such actual relations as between a parent and child, if they
say anything about them at all, they may see them as permitted and cultivating
them a preference that a person may have. Or they may recognize a universal
obligation for all parents to care for their children. But they do not permit
actual relations ever to take priority over the requirements of impartiality. As
Brian Barry expresses this view, there can be universal rules permitting people
to favor their friends in certain contexts, such as deciding to whom to give
holiday gifts, but the latter partiality is morally acceptable only because uni-
versal rules have already so judged it.5 The ethics of care, in contrast, is skeptical
of such abstraction and reliance on universal rules and questions the priority
given to them. To most advocates of the ethics of care, the compelling moral
claim of the particular other may be valid even when it conflicts with the
requirement usually made by moral theories that moral judgments be uni-
versalizeable, and this is of fundamental moral importance.6 Hence the po-
tential conflict between care and justice, friendship and impartiality, loyalty
and universality. To others, however, there need be no conflict if universal
judgments come to incorporate appropriately the norms of care previously
disregarded.
Annette Baier considers how a feminist approach to morality differs from a
Kantian one and Kant’s claim that women are incapable of being fully moral
because of their reliance on emotion rather than reason. She writes, ‘‘Where Kant
concludes ‘so much the worse for women,’ we can conclude ‘so much the worse
for the male fixation on the special skill of drafting legislation, for the bureau-
cratic mentality of rule worship, and for the male exaggeration of the importance
of independence over mutual interdependence.’ ’’7
Margaret Walker contrasts what she sees as feminist ‘‘moral understanding’’
with what has traditionally been thought of as moral ‘‘knowledge.’’ She sees the
moral understanding she advocates as involving ‘‘attention, contextual and
narrative appreciation, and communication in the event of moral deliberation.’’
This alternative moral epistemology holds that ‘‘the adequacy of moral un-
derstanding decreases as its form approaches generality through abstraction.’’8
The ethics of care may seek to limit the applicability of universal rules to
certain domains where they are more appropriate, like the domain of law, and
resist their extension to other domains. Such rules may simply be inappropriate
THE ETHICS OF CARE AS MORAL THEORY 11
in, for instance, the contexts of family and friendship, yet relations in these
domains should certainly be evaluated, not merely described, hence morality
should not be limited to abstract rules. We should be able to give moral
guidance concerning actual relations that are trusting, considerate, and caring
and concerning those that are not.
Dominant moral theories tend to interpret moral problems as if they were
conflicts between egoistic individual interests on the one hand, and universal
moral principles on the other. The extremes of ‘‘selfish individual’’ and ‘‘hu-
manity’’ are recognized, but what lies between these is often overlooked. The
ethics of care, in contrast, focuses especially on the area between these extremes.
Those who conscientiously care for others are not seeking primarily to further
theirown individual interests; their interestsare intertwined withthe persons they
care for. Neither are they acting for the sake of all others or humanity in general;
they seek instead to preserve or promote an actual human relation between
themselves and particular others. Persons in caring relations are acting for self-
and-other together. Their characteristic stance is neither egoistic nor altruistic;
these are the options in a conflictual situation, but the well-being of a caring
relation involves the cooperative well-being of those in the relation and the well-
being of the relation itself.
In trying to overcome the attitudes and problems of tribalism and religious
intolerance, dominant moralities have tended to assimilate the domains of
family and friendship to the tribal, or to a source of the unfair favoring of one’s
own. Or they have seen the attachments people have in these areas as among the
nonmoral private preferences people are permitted to pursue if restrained by
impartial moral norms. The ethics of care recognizes the moral value and
importance of relations of family and friendship and the need for moral
guidance in these domains to understand how existing relations should often be
changed and new ones developed. Having grasped the value of caring relations
in such contexts as these more personal ones, the ethics of care then often
examines social and political arrangements in the light of these values. In its
more developed forms, the ethics of care as a feminist ethic offers suggestions
for the radical transformation of society. It demands not just equality for
women in existing structures of society but equal consideration for the expe-
rience that reveals the values, importance, and moral significance, of caring.
A fourth characteristic of the ethics of care is that like much feminist thought
in many areas, it reconceptualizes traditional notions about the public and the
private. The traditional view, built into the dominant moral theories, is that the
household is a private sphere beyond politics into which government, based on
consent, should not intrude. Feminists have shown how the greater social,
political, economic, and cultural power of men has structured this ‘‘private’’
sphere to the disadvantage of women and children, rendering them vulnerable
to domestic violence without outside interference, often leaving women eco-
nomically dependent on men and subject to a highly inequitable division of
labor in the family. The law has not hesitated to intervene into women’s private
decisions concerning reproduction but has been highly reluctant to intrude on
men’s exercise of coercive power within the ‘‘castles’’ of their homes.
12 CARE AND MORAL THEORY
Dominant moral theories have seen ‘‘public’’ life as relevant to morality
while missing the moral significance of the ‘‘private’’ domains of family and
friendship. Thus the dominant theories have assumed that morality should be
sought for unrelated, independent, and mutually indifferent individuals as-
sumed to be equal. They have posited an abstract, fully rational ‘‘agent as such’’
from which to construct morality,9 while missing the moral issues that arise
between interconnected persons in the contexts of family, friendship, and
social groups. In the context of the family, it is typical for relations to be
between persons with highly unequal power who did not choose the ties and
obligations in which they find themselves enmeshed. For instance, no child can
choose her parents yet she may well have obligations to care for them. Relations
of this kind are standardly noncontractual, and conceptualizing them as con-
tractual would often undermine or at least obscure the trust on which their
worth depends. The ethics of care addresses rather than neglects moral issues
arising in relations among the unequal and dependent, relations that are often
laden with emotion and involuntary, and then notices how often these attri-
butes apply not only in the household but in the wider society as well. For
instance, persons do not choose which gender, racial, class, ethnic, religious,
national, or cultural groups to be brought up in, yet these sorts of ties may be
important aspects of who they are and how their experience can contribute to
moral understanding.
A fifth characteristic of the ethics of care is the conception of persons with
which it begins. This will be dealt with in the next section.
The Critique of Liberal Individualism
The ethics of care usually works with a conception of persons as relational,
rather than as the self-sufficient independent individuals of the dominant
moral theories. The dominant theories can be interpreted as importing into
moral theory a concept of the person developed primarily for liberal political
and economic theory, seeing the person as a rational, autonomous agent, or a
self-interested individual. On this view, society is made up of ‘‘independent,
autonomous units who cooperate only when the terms of cooperation are such
as to make it further the ends of each of the parties,’’ in Brian Barry’s words.10
Or, if they are Kantians, they refrain from actions that they could not will to be
universal laws to which all fully rational and autonomous individual agents
could agree. What such views hold, in Michael Sandel’s critique of them, is that
‘‘what separates us is in some important sense prior to what connects us—
epistemologically prior as well as morally prior. We are distinct individuals first
and then we form relationships.’’11 In Martha Nussbaum’s liberal feminist
morality, ‘‘the flourishing of human beings taken one by one is both analyti-
cally and normatively prior to the flourishing’’ of any group.12
The ethics of care, in contrast, characteristically sees persons as relational
and interdependent, morally and epistemologically. Every person starts out as
a child dependent on those providing us care, and we remain interdependent
THE ETHICS OF CARE AS MORAL THEORY 13
with others in thoroughly fundamental ways throughout our lives. That we can
think and act as if we were independent depends on a network of social
relations making it possible for us to do so. And our relations are part of what
constitute our identity. This is not to say that we cannot become autonomous;
feminists have done much interesting work developing an alternative con-
ception of autonomy in place of the liberal individualist one.13 Feminists have
much experience rejecting or reconstituting relational ties that are oppressive.
But it means that from the perspective of an ethics of care, to construct morality
as if we were Robinson Crusoes, or, to use Hobbes’s image, mushrooms sprung
from nowhere, is misleading.14 As Eva Kittay writes, this conception fosters the
illusion that society is composed of free, equal, and independent individuals
who can choose to associate with one another or not. It obscures the very real
facts of dependency for everyone when they are young, for most people at
various periods in their lives when they are ill or old and infirm, for some who
are disabled, and for all those engaged in unpaid ‘‘dependency work.’’15 And it
obscures the innumerable ways persons and groups are interdependent in the
modern world.
Not only does the liberal individualist conception of the person foster a false
picture of society and the persons in it, it is, from the perspective of the ethics of
care, impoverished also as an ideal. The ethics of care values the ties we have
with particular other persons and the actual relationships that partly constitute
our identity. Although persons often may and should reshape their relations
with others—distancing themselves from some persons and groups and de-
veloping or strengthening ties with others—the autonomy sought within the
ethics of care is a capacity to reshape and cultivate new relations, not to ever
more closely resemble the unencumbered abstract rational self of liberal po-
litical and moral theories. Those motivated by the ethics of care would seek to
become more admirable relational persons in better caring relations.
Even if the liberal ideal is meant only to instruct us on what would be
rational in the terms of its ideal model, thinking of persons as the model
presents them has effects that should not be welcomed. As Annette Baier writes,
‘‘Liberal morality, if unsupplemented, may unfit people to be anything other
than what its justifying theories suppose them to be, ones who have no interest
in each others’ interests.’’16 There is strong empirical evidence of how adopting
a theoretical model can lead to behavior that mirrors it. Various studies show
that studying economics, with its ‘‘repeated and intensive exposure to a model
whose unequivocal prediction’’ is that people will decide what to do on the
basis of self-interest, leads economics students to be less cooperative and more
inclined to free ride than other students.17
The conception of the person adopted by the dominant moral theories
provides moralities at best suitable for legal, political, and economic interac-
tions between relative strangers, once adequate trust exists for them to form a
political entity.18 The ethics of care is, instead, hospitable to the relatedness
of persons. It sees many of our responsibilities as not freely entered into but
presented to us by the accidents of our embeddedness in familial and social and
historical contexts. It often calls on us to take responsibility, while liberal
14 CARE AND MORAL THEORY
individualist morality focuses on how we should leave each other alone. The
view of persons as embedded and encumbered seems fundamental to much
feminist thinking about morality and especially to the ethics of care (see chapter
3 for further discussion).
Justice and Care
Some conceptions of the ethics of care see it as contrasting with an ethic of
justice in ways that suggest one must choose between them. Carol Gilligan’s
suggestion of alternative perspectives in interpreting and organizing the ele-
ments of a moral problem lent itself to this implication; she herself used the
metaphor of the ambiguous figure of the vase and the faces, from psychological
research on perception, to illustrate how one could see a problem as either a
problem of justice or a problem of care, but not as both simultaneously.19
An ethic of justice focuses on questions of fairness, equality, individual
rights, abstract principles, and the consistent application of them. An ethic of
care focuses on attentiveness, trust, responsiveness to need, narrative nuance,
and cultivating caring relations. Whereas an ethic of justice seeks a fair solution
between competing individual interests and rights, an ethic of care sees the
interests of carers and cared-for as importantly intertwined rather than as
simply competing. Whereas justice protects equality and freedom, care fosters
social bonds and cooperation.
These are very different emphases in what morality should consider. Yet both
deal with what seems of great moral importance. This has led many to explore
how they might be combined in a satisfactory morality. One can persuasively
argue, for instance, that justice is needed in such contexts of care as the family, to
protect against violence and the unfair division of labor or treatment of children.
One can also persuasively argue that care is needed in such contexts of justice as
the streets and the courts, where persons should be treated humanely, and in the
way education and health and welfare should be dealt with as social responsi-
bilities. The implication may be that justice and care should not be separated into
different ‘‘ethics,’’ that, in Sara Ruddick’s proposed approach, ‘‘justice is always
seen in tandem with care.’’20
Few would hold that considerations of justice have no place at all in care.
One would not be caring well for two children, for instance, if one showed a
persistent favoritism toward one of them that could not be justified on the basis
of some such factor as greater need. The issues are rather what constellation of
values have priority and which predominate in the practices of the ethics of care
and the ethics of justice. It is quite possible to delineate significant differences
between them. In the dominant moral theories of the ethics of justice, the
values of equality, impartiality, fair distribution, and noninterference have
priority; in practices of justice, individual rights are protected, impartial
judgments are arrived at, punishments are deserved, and equal treatment is
sought. In contrast, in the ethics of care, the values of trust, solidarity, mutual
concern, and empathetic responsiveness have priority; in practices of care,
THE ETHICS OF CARE AS MORAL THEORY 15
relationships are cultivated, needs are responded to, and sensitivity is dem-
onstrated.
An extended effort to integrate care and justice is offered by Diemut Bu-
beck. She makes clear that she ‘‘endorse[s] the ethic of care as a system of
concepts, values, and ideas, arising from the practice of care as an organic part
of this practice and responding to its material requirements, notably the
meeting of needs.’’21 Yet her primary interest is in understanding the exploi-
tation of women, which she sees as tied to the way women do most of the
unpaid work of caring. She argues that such principles as equality in care and
the minimization of harm are tacitly, if not explicitly, embedded in the practice
of care, as carers whose capacities and time for engaging in caring labor are
limited must decide how to respond to various others in need of being cared
for. She writes that ‘‘far from being extraneous impositions . . . considerations
of justice arise from within the practice of care itself and therefore are an
important part of the ethic of care, properly understood.’’22 The ethics of care
must thus also concern itself with the justice (or lack of it) of the ways the tasks
of caring are distributed in society. Traditionally, women have been expected
to do most of the caring work that needs to be done; the sexual division of labor
exploits women by extracting unpaid care labor from them, making women
less able than men to engage in paid work. ‘‘Femininity’’ constructs women as
carers, contributing to the constraints by which women are pressed into ac-
cepting the sexual division of labor. An ethic of care that extols caring but that
fails to be concerned with how the burdens of caring are distributed contributes
to the exploitation of women, and of the minority groups whose members
perform much of the paid but ill-paid work of caring in affluent households, in
day care centers, hospitals, nursing homes, and the like.
The question remains, however, whether justice should be thought to be
incorporated into any ethic of care that will be adequate or whether we should
keep the notions of justice and care and their associated ethics conceptually
distinct. There is much to be said for recognizing how the ethics of care values
interrelatedness and responsiveness to the needs of particular others, how the
ethics of justice values fairness and rights, and how these are different em-
phases.23 Too much integration will lose sight of these valid differences. I am
more inclined to say that an adequate, comprehensive moral theory will have
to include the insights of both the ethics of care and the ethics of justice,
among other insights, rather than that either of these can be incorporated into
the other in the sense of supposing that it can provide the grounds for the
judgments characteristically found in the other. Equitable caring is not nec-
essarily better caring, it is fairer caring. And humane justice is not necessarily
better justice, it is more caring justice.
Almost no advocates of the ethics of care are willing to see it as a moral
outlook less valuable than the dominant ethics of justice.24 To imagine that
the concerns of care can merely be added on to the dominant theories, as, for
instance, Stephen Darwall suggests, is seen as unsatisfactory.25 Confining the
ethics of care to the private sphere while holding it unsuitable for public life,
as Nel Noddings did at first and as many accounts of it suggest,26 is also to be
16 CARE AND MORAL THEORY
rejected. But how care and justice are to be meshed without losing sight of
their differing priorities is a task still being worked on.
My own suggestions for integrating care and justice are to keep these
concepts conceptually distinct and to delineate the domains in which they
should have priority.27 In the realm of law, for instance, justice and the as-
surance of rights should have priority, although the humane considerations of
care should not be absent. In the realm of the family and among friends,
priority should be given to expansive care, though the basic requirements of
justice surely should also be met. But these are the clearest cases; others will
combine moral urgencies. Universal human rights (including the social and
economic ones as well as the political and civil) should certainly be respected,
but promoting care across continents may be a more promising way to achieve
this than mere rational recognition. When needs are desperate, justice may be a
lessened requirement on shared responsibility for meeting needs, although this
rarely excuses violations of rights. At the level of what constitutes a society in
the first place, a domain within which rights are to be assured and care pro-
vided, appeal must be made to something like the often weak but not negligible
caring relations among persons that enable them to recognize each other as
members of the same society. Such recognition must eventually be global; in
the meantime, the civil society without which the liberal institutions of justice
cannot function presume a background of some degree of caring relations
rather than of merely competing individuals (see chapter 8). Furthermore,
considerations of care provide a more fruitful basis than considerations of
justice for deciding much about how society should be structured, for instance,
how extensive or how restricted markets should be (see chapter 7). And in the
course of protecting the rights that ought to be recognized, such as those to
basic necessities, policies that express the caring of the community for all its
members will be better policies than those that grudgingly, though fairly, issue
an allotment to those deemed unfit.
Care is probably the most deeply fundamental value. There can be care
without justice: There has historically been little justice in the family, but care
and life have gone on without it. There can be no justice without care, however,
for without care no child would survive and there would be no persons to
respect.
Care may thus provide the wider and deeper ethics within which justice
should be sought, as when persons in caring relations may sometimes compete
and in doing so should treat each other fairly, or, at the level of society, within
caring relations of the thinner kind we can agree to treat each other for limited
purposes as if we were the abstract …
Chapter 5: Informed Consent 213
it is possible to have a morally acceptable set of re-
quirements for informed consent in sense2 that devi-
ates considerably from the conditions of informed
consent in sense1. However, the burden of moral proof
rests with those who defend such deviations since the
primary moral justification of the obligation to obtain
informed consent is respect for autonomous action.
notes
1. President’s Commission, Making Health Care
Decisions, Vol. 1, 15 and Jay Katz, The Silent World of
Doctor and Patient (New York: The Free Press, 1984),
87 and “The Regulation of Human Research—
Reflections and Proposals,” Clinical Research 21
(1973): 758– 91. Katz does not provide a sustained
analysis of joint or shared decisionmaking, and it is
unclear precisely how he would relate this notion to
informed consent.
2. Jay Katz, “Disclosure and Consent,” in A. Milunsky
and G. Annas, eds., Genetics and the Law II (New York:
Plenum Press, 1980), 122, 128.
3. We have already noted that Katz’s “idea” of informed
consent— as the active involvement of patients in the
medical decisionmaking process— is different from our
sense
1.
Informed Consent— Must It Remain a Fairy Tale?
JAY KATZ
The ideal of informed consent with its presumptions of autonomy and joint
decision-making is yet to be fully realized in practice, says Katz. The concept has
been legally recognized, but genuine patient self-determination is still not the norm.
Physicians acknowledge it but are likely to see it as a perfunctory fulfillment of legal
requirements or as an enumeration of risks. The goal of joint decision-making be-
tween physicians and patients is still unfulfilled. Physicians must come to see that
they have a “duty to respect patients as persons so that care will encompass allow-
ing patients to live their lives in their own self-willed ways.”
I. The Pre-History of Informed
Consent in Medicine
The idea that, prior to any medical intervention,
physicians must seek their patients’ informed con-
sent was introduced into American law in a brief
paragraph in a 1957 state court decision,1 and then
elaborated on in a lengthier opinion in 1960.2 The
emerging legal idea that physicians were from now
on obligated to share decisionmaking authority
with their patients shocked the medical commu-
nity, for it constituted a radical break with the si-
lence that had been the hallmark of physician-patient
interactions throughout the ages. Thirty-five years
are perhaps not long enough for either law or medi-
cine to resolve the tension between legal theory and
medical practice, particularly since judges were re-
luctant to face up to implications of their novel
doctrine, preferring instead to remain quite defer-
ential to the practices of the medical profession.
Viewed from the perspective of medical history,
the doctrine of informed consent, if taken seriously,
constitutes a revolutionary break with customary
practice. Thus, I must review, albeit all too briefly,
the history of doctor-patient communication. Only
then can one appreciate how unprepared the medi-
cal profession was to heed these new legal com-
mands. But there is more: Physicians could not
easily reject what law had begun to impose on them,
because they recognized intuitively that the radical
transformation of medicine since the age of medi-
cal science made it possible, indeed imperative, for
a doctrine of informed consent to emerge. Yet,
bowing to the doctrine did not mean accepting it.
Indeed, physicians could not accept it because, for
reasons I shall soon explore, the nature of informed
consent has remained in the words of Churchill,
“an enigma wrapped in a mystery.”
Originally published in the Journal of Contemporary Health
Law and Policy, vol. 10, Spring 1994. Used with permission.
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214 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
and specific judgments and measures cannot be
competently judged by the layman and that the
latter must take doctors’ judgments and measures
on ‘authority.’ 7 The necessity for such authority was
supported by three claims:
First, physicians’ esoteric knowledge, acquired in
the course of arduous training and practical experi-
ence, cannot be comprehended by patients. While it is
true that this knowledge, in its totality, is difficult to
learn, understand and master, it does not necessarily
follow that physicians cannot translate their esoteric
knowledge into language that comports with pa-
tients’ experiences and life goals (i.e., into language
that speaks to quality of future life, expressed in
words of risks, benefits, alternatives and uncertain-
ties). Perhaps patients can understand this, but phy-
sicians have had too little training and experience
with, or even more importantly, a commitment to,
communicating their “esoteric knowledge” to pa-
tients in plain language to permit a conclusive answer
as to what patients may comprehend.
Second, patients, because of their anxieties over
being ill and consequent regression to childlike think-
ing, are incapable of making decisions on their own
behalf. We do not know whether the childlike be-
havior often displayed by patients is triggered by
pain, fear, and illness, or by physicians’ authoritar-
ian insistence that good patients comply with doc-
tors’ orders, or by doctors’ unwillingness to share
information with patients. Without providing such
information, patients are groping in the dark and
their stumbling attempts to ask questions, if made
at all, makes them appear more incapable of under-
standing than they truly are.
We know all too little about the relative contri-
butions which being ill, being kept ignorant, or
being considered incompetent make to these re-
gressive manifestations. Thus, physicians’ unexam-
ined convictions easily become self-fulfilling
prophesies. For example, Eric Cassell has consis-
tently argued that illness robs patients of autonomy
and that only subsequent to the act of healing is au-
tonomy restored.8 While there is some truth to
these contentions, they overlook the extent to which
doctors can restore autonomy prior to the act of
healing by not treating patients as children but as
adults whose capacity for remaining authors of
Throughout the ages physicians believed that they
should make treatment decisions for their patients.
This conviction inheres in the Hippocratic Oath: “I
swear by Apollo and Aesculepius [that] I will follow
that system of regimen which according to my ability
and judgment I consider for the benefit of my pa-
tients . . . .”3 The patient is not mentioned as a person
whose ability and judgment deserve consideration.
Indeed, in one of the few references to disclosure in
the Hippocratic Corpus, physicians are admonished
“to [conceal] most things from the patient while at-
tending to him; [to] give necessary orders with
cheerfulness and serenity, . . . revealing nothing of
the patient’s future or present condition.” 4 When
twenty-five centuries later, in 1847, the American
Medical Association promulgated its first Code of
Ethics, it equally admonished patients that their
“obedience . . . to the prescriptions of [their] physi-
cian should be prompt and implicit. [They] should
never permit [their] own crude opinions . . . to influ-
ence [their] attention to [their physicians].” 5
The gulf separating doctors from patients seemed
unbridgeable both medically and socially. Thus,
whenever the Code did not refer to physicians and pa-
tients as such, the former were addressed as “gentle-
men” and the latter as “fellow creatures.” To be sure,
caring for patients’ medical needs and “abstain[ing]
from whatever is deleterious and mischievous” 6 was
deeply imbedded in the ethos of Hippocratic medi-
cine. The idea that patients were also “autonomous”
human beings, entitled to being partners in decision-
making, was, until recently, rarely given recognition
in the lexicon of medical ethics. The notion that
human beings possess individual human rights, de-
serving of respect, of course, is of recent origin. Yet it
antedates the twentieth century and therefore could
have had an impact on the nature and quality of the
physician-patient relationship.
It did not. Instead, the conviction that physi-
cians should decide what is best for their patients,
and, therefore, that the authority and power to do
so should remain vested in them, continued to have
a deep hold on the practices of the medical profes-
sion. For example, in the early 1950s the influential
Harvard sociologist Talcott Parsons, who echoed
physicians’ views, stated that the physician is a
technically competent person whose competence
05-Vaughn-Chap05.indd 214 26/05/16 4:29 PM
Chapter 5: Informed Consent 215
II. The Age of Medical Science
and Informed Consent
During the millennia of medical history, and until
the beginning of the twentieth century, physicians
could not explain to their patients, or— from the
perspective of hindsight— to themselves, which of
their treatment recommendations were curative
and which were not. To be sure, doctors, by careful
bedside observation, tried their level best “to ab-
stain from what is deleterious and mischievous,” to
help if they could, and to be available for comfort
during the hours, days or months of suffering.
Doing more curatively, however, only became pos-
sible with the advent of the age of medical science.
The introduction of scientific reasoning into medi-
cine, aided by the results of carefully conducted re-
search, permitted doctors for the first time to
discriminate more aptly between knowledge, igno-
rance and conjecture in their recommendations for
or against treatment. Moreover, the spectacular
technological advances in the diagnosis and treat-
ment of disease, spawned by medical science, pro-
vided patients and doctors with ever-increasing
therapeutic options, each having its own particular
benefits and risks.
Thus, for the first time in medical history it is
possible, even medically and morally imperative,
to give patients a voice in medical decisionmak-
ing. It is possible because knowledge and igno-
rance can be better specified; it is medically
imperative because a variety of treatments are
available, each of which can bestow great benefits
or inflict grievous harm; it is morally imperative
because patients, depending on the lifestyle they
wish to lead during and after treatment, must be
given a choice.
All this seems self-evident. Yet, the physician-
patient relationship— the conversations between
the two parties— was not altered with the transfor-
mation of medical practice during the twentieth
century. Indeed, the silence only deepened once
laboratory data were inscribed in charts and not in
patients’ minds, once machines allowed physicians’
eyes to gaze not at patients’ faces but at the numbers
they displayed, once x-rays and electrocardiograms
began to speak for patients’ suffering rather than
their suffering voices.
their own fate can be sustained and nourished. Cas-
sell’s views are reminiscent of Dostoyevsky’s Grand
Inquisitor who proclaimed that “at the most fearful
moments of life,” mankind is in need of “miracle,
mystery and authority.”9 While, in this modern age,
a person’s capacity and right to take responsibility
for his or her conduct has been given greater recog-
nition than the Grand Inquisitor was inclined to
grant, it still does not extend to patients. In the con-
text of illness, physicians are apt to join the Grand
Inquisitor at least to the extent of asserting that,
while patients, they can only be comforted through
subjugation to miracle, mystery and authority.
Third, physicians’ commitment to altruism is a
sufficient safeguard for preventing abuses of their
professional authority. While altruism, as a gen-
eral professional commitment, has served pa-
tients well in their encounters with physicians,
the kind of protection it does and does not pro-
vide has not been examined in any depth. I shall
have more to say about this later on. For now, let
me only mention one problem: Altruism can only
promise that doctors will try to place their pa-
tients’ medical needs over their own personal
needs. Altruism cannot promise that physicians
will know, without inquiry, patients’ needs. Put
another way, patients and doctors do not neces-
sarily have an identity of interest about matters of
health and illness. Of course, both seek restora-
tion of health and cure, and whenever such ends
are readily attainable by only one route, their in-
terests indeed may coincide.
In many physician-patient encounters, however,
cure has many faces and the means selected affect
the nature of cure in decisive ways. Thus, since
quality of life is shaped decisively by available treat-
ment options (including no treatment), the objec-
tives of health and cure can be pursued in a variety
of ways. Consider, for example, differences in value
preferences between doctors and patients about
longevity versus quality of remaining life. Without
inquiry, one cannot presume identity of interest. As
the surgeon Nuland cogently observed: “A doctor’s
altruism notwithstanding, his agenda and value
system are not the same as those of the patient. That
is the fallacy in the concept of beneficence so cher-
ished by many physicians.”10
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216 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
patients should know, particularly in light of the
harm that the spectacular advances in medical
technology could inflict. Thus, the doctrine was
limited in scope, designed to specify those minimal
disclosure obligations that physicians must fulfill to
escape legal liability for alleged non-disclosures.
Moreover, it was shaped and confined by legal as-
sumptions about the objectives of the laws of evi-
dence and negligence, and by economic philosophies
as to who should assume the financial burdens for
medical injuries sustained by patients.
Even though the judges based the doctrine on
“Anglo-American law[̓ s] . . . premise of thorough-
going self-determination,”14 the Kansas court put it,
or on “the root premise . . . fundamental in Ameri-
can jurisprudence that ‘every human being of adult
years and sound mind has a right to determine what
shall be done with his own body,’”15 as the Circuit
Court for the District of Columbia put it in a subse-
quent opinion, the doctrine was grounded not in
battery law (trespass); but in negligence law. The
reasons are many. I shall only mention a compelling
one: Battery law, based on unauthorized trespass,
gives doctors only one defense— that they have
made adequate disclosure. Negligence law, on the
other hand, permits doctors to invoke many de-
fenses, including “the therapeutic privilege” not to
disclose when in their judgment, disclosure may
prove harmful to patients’ welfare.
Two recent opinions illustrate the problems iden-
tified here. First, in a rare opinion, the Supreme Court
of Pennsylvania reconfirmed its adherence to the mi-
nority view among American jurisdictions that bat-
tery, not negligence, is the appropriate cause of action
whenever lack of informed consent is alleged. The
court held that whenever “the patient . . . demon-
strated, and the jury found, that he was not advised
of . . . material facts, risks, complications and alterna-
tives to surgery which a reasonable man would have
considered significant in deciding whether to have
the operation . . . the causation inquiry ends. The sole
issue remaining [is] a determination of damages.”16
Earlier in its opinion, the court quoted, with approval,
a prior Pennsylvania decision:
[W]here a patient is mentally and physically able to
consult about his condition, in the absence of an
What captured the medical imagination and
found expression in the education of future physi-
cians, was the promise that before too long the diag-
nosis of patients’ diseases would yield objective,
scientific data to the point of becoming algorithms.
Treatment, however, required subjective data from
patients and would be influenced by doctors’ subjec-
tive judgments. This fact was overlooked in the quest
for objectivity. Also overlooked was the possibility
that greater scientific understanding of the nature of
disease and its treatment facilitated better commu-
nication with patients. In that respect contemporary
Hippocratic practices remained rooted in the past.
III. The Impact of Law
The impetus for change in traditional patterns of
communication between doctors and patients came
not from medicine but from law. In a 1957 California
case,11 and a 1960 Kansas case,12 judges were as-
tounded and troubled by these undisputed facts:
That without any disclosure of risks, new technolo-
gies had been employed which promised great ben-
efits but also exposed patients to formidable and
uncontrollable harm. In the California case, a pa-
tient suffered a permanent paralysis of his lower ex-
tremities subsequent to the injection of a dye,
sodium urokan, to locate a block in the abdominal
aorta. In the Kansas case, a patient suffered severe
injuries from cobalt radiation, administered, in-
stead of conventional x-ray treatment, subsequent to
a mastectomy for breast cancer. In the latter case,
Justice Schroeder attempted to give greater specifi-
cations to the informed consent doctrine, first pro-
mulgated in the California decision: “To disclose
and explain to the patient, in language as simple as
necessary, the nature of the ailment, the nature of
the proposed treatment, the probability of success or
of alternatives, and perhaps the risks of unfortunate
results and unforeseen conditions within the body.”13
From the perspective of improved doctor- patient
communication, or better, shared decisionmaking,
the fault lines inherent in this American legal doc-
trine are many:
One: The common law judges who promulgated
the doctrine restricted their task to articulating
new and more stringent standards of liability when-
ever physicians withheld material information that
05-Vaughn-Chap05.indd 216 26/05/16 4:29 PM
Chapter 5: Informed Consent 217
to the realities of medical practices in an age of sci-
ence and to the commands of law. As I said years ago,
[T]ranslating the ingredients of [the informed con-
sent] process into legal and useful medical prescrip-
tions that respect patients’ wishes to maintain and
surrender autonomy, as well as physicians’ unend-
ing struggles with omnipotence and impotence in
the light of medical uncertainty, is a difficult task
[which the medical profession] has not pur-
sued . . . in any depth.21
Thus, disclosure practices only changed to the
extent of physicians disclosing more about the risks
of a proposed intervention in order to escape legal
liability.
Three: Underlying the legal doctrine there lurks a
broader assumption which has neither been given
full recognition by judges nor embraced by physi-
cians. The underlying idea is this: That from now on
patients and physicians must make decisions jointly,
with patients ultimately deciding whether to accede
to doctors’ recommendations. In The Cancer Ward,
Solzhenitsyn captured, as only a novelist can, the
fears that such an idea engenders. When doctor
Ludmilla Afanasyevna was challenged by her pa-
tient, Oleg Kostoglotov, about physicians’ rights to
make unilateral decisions on behalf of patients, Afa-
nasyevna gave a troubled, though unequivocal,
answer: “But doctors are entitled to the right— doc-
tors above all. Without that right, there’d be no such
thing as medicine.”22
If Afanasyevna is correct, then patients must
continue to trust doctors silently. Conversation, to
comport with the idea of informed consent, ulti-
mately requires that both parties make decisions
jointly and that their views and preferences be
treated with respect. Trust, based on blind faith—
on passive surrender to oneself or to another—
must be distinguished from trust that is earned
after having first acknowledged to oneself and
then shared with the other what one knows and
does not know about the decision to be made. If all
of that had been considered by physicians, they
would have appreciated that a new model of doc-
tor-patient communication, that takes informed
consent seriously required a radical break with
current medical disclosure practice.
emergency, the consent of the patient is “a prerequi-
site to a surgical operation by his physician, and an
operation without the patient’s consent is a techni-
cal assault.”17
Second, the Court of Appeals of California, in a
ground-breaking opinion, significantly reduced the
scope of the therapeutic privilege by requiring that
in instances of hopeless prognosis (the most
common situation in which the privilege has gener-
ally been invoked) the patient be provided with
such information by asking, “If not the physician’s
duty to disclose a terminal illness, then whose?”18
The duty to disclose prognosis had never before
been identified specifically as one of the disclosure
obligations in an informed consent opinion.
Thus, the appellate court’s ruling constituted an
important advance. It established that patients have
a right to make decisions not only about the fate of
their bodies but about the fate of their lives as well.
The California Supreme Court, however, reversed.
In doing so, the court made too much of an issue
raised by the plaintiffs that led the appellate court
to hold that doctors must disclose “statistical life
expectancy information.”19 To be sure, disclosure of
statistical information is a complex problem, but in
focusing on that issue, the supreme court’s atten-
tion was diverted from a more important new dis-
closure obligation promulgated by the appellate
court: the duty to inform patients of their dire prog-
nosis. The supreme court did not comment on that
obligation. Indeed, it seemed to reverse the appel-
late court on this crucial issue by reinforcing the
considerable leeway granted physicians to invoke
the therapeutic privilege exception to full disclo-
sure: “We decline to intrude further, either on the
subtleties of the physician-patient relationship or in
the resolution of claims that the physician’s duty of
disclosure was breached, by requiring the disclo-
sure of information that may or may not be indi-
cated in a given treatment context.”20
Two: The doctrine of informed consent was not
designed to serve as a medical blueprint for interac-
tions between physicians and patients. The medical
profession still faces the task of fashioning a “doc-
trine” that comports with its own vision of doctor-
patient communication and that is responsive both
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218 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
fractured hip, a peptic ulcer, a stroke, a myocardial
infarction. . . . At a time of potent drugs and formi-
dable surgery, the exact effects of many therapeutic
procedures are dubious or shrouded in dissension.”25
Medical uncertainty constitutes a formidable
obstacle to joint decisionmaking for a number of
reasons: Sharing uncertainties requires physicians
to be more aware of them than they commonly
are. They must learn how to communicate them to
patients and they must shed their embarrassment
over acknowledging the true state of their own
and of medicine’s art and science. Thus, sharing
uncertainties requires a willingness to admit igno-
rance about benefits and risks; to acknowledge the
existence of alternatives, each with its own known
and unknown consequences; to eschew one single
authoritative recommendation; to consider care-
fully how to pre sent uncertainty so that patients
will not be overwhelmed by the information they
will receive; and to explore the crucial question of
how much uncertainty physicians themselves can
tolerate without compromising their effectiveness
as healers.
To so conduct oneself is most difficult. For,
once doctors, on the basis of their clinical experi-
ence and knowledge, conclude which treatment is
best, they tend to disregard, if not reject, the view
of other colleagues who treat the same condition
differently. Consider the current controversy over
the management of localized prostate cancer: sur-
gery, radiation or watchful waiting.26 Some of the
physicians involved in the debate are not even
willing to accept that uncertainty exists, or at least
they minimize its relevance to choice of treatment.
Most who advocate treatment strongly prefer one
type over another based on professional special-
ization (radiologists tend to recommend radiation;
surgeons surgery).
Moreover, acknowledgment of uncertainty is
undermined by the threat that it will undermine
doctors’ authority and sense of superiority. As
Nuland put it, to feel superior to those dependent
persons who are the sick, is after all a motivating
factor that often influences their choice of medicine
as a profession.27 All of this suggests that implemen-
tation of the idea of informed consent is, to begin
with, not a patient problem but a physician problem.
Four: The idea of joint decisionmaking is one
thing, and its application in practice another. To
translate theory into practice cannot be accom-
plished, as the Judicial Council of the American
Medical Association attempted to do in one short
paragraph. The Judicial Council stated that “[t]he
patient should make his own determination on
treatment. Informed consent is a basic social
policy . . . .”23 To translate social policy into medical
policy is an inordinately difficult task. It requires a
reassessment of the limits of medical knowledge in
the light of medical uncertainty, a reassessment of
professional authority to make decisions for pa-
tients in light of the consequences of such conduct
for the well-being of patients, and a reassessment of
the limits of patients’ capacities to assume responsi-
bility for choice in the light of their ignorance about
medical matters and their anxieties when ill. Turn-
ing now to these problems, I wish to highlight that,
in the absence of such reassessments, informed
consent will remain a charade, and joint decision-
making will elude us.
IV. Barriers to Joint Decisionmaking
A . Medical Uncer tainty
The longer I reflect about doctor-patient decision-
making, the more convinced I am that in this
modern age of medical science, which for the first
time permits sharing with patients the uncertainties
of diagnosis, treatment, and prognosis, the problem
of uncertainty poses the most formidable obstacle to
disclosure and consent. By medical uncertainty I
mean to convey what the physician Lewis Thomas
observed so eloquently, albeit disturbingly:
The only valid piece of scientific truth about which
I feel totally confident is that we are profoundly
ignorant about nature. . . . It is this sudden confron-
tation with the depth and scope of ignorance that
represents the most significant contribution of
twentieth-century science to the human intellect.
We are, at last facing up to it. In earlier times, we
either pretended to understand . . . or ignored the
problem, or simply made up stories to fill the gap.24
Alvan Feinstein put this in more concrete language:
“Clinicians are still uncertain about the best means
of treatment for even such routine problems as . . . a
05-Vaughn-Chap05.indd 218 26/05/16 4:29 PM
Chapter 5: Informed Consent 219
but also that we contribute to their welfare includ-
ing their health. [Thus the principle asserts] the
duty to help others further their important and
legitimate interests . . . to confer benefits and ac-
tively to prevent and remove harms . . . [and] to
balance possible goods against the possible harms
of an action.31
Beauchamp and Childress’ unequivocal and
strong postulate on autonomy contrasts with the am-
biguities contained in their postulate on beneficence.
What do they mean by “benefits” and “harms” that
allow invocation of beneficence? Do they mean only
benefits and harms to patients’ physical integrity, or
to their dignitary integrity as choice-making indi-
viduals as well? Furthermore, what degree of discre-
tion and license is permissible in the duty “to
balance?” I have problems with balancing unless it is
resorted to only as a rare exception to respect for au-
tonomy. While human life is, and human interac-
tions are, too complex to make any principle rule
absolute, any exceptions must be rigorously justified.
I appreciate that mine is a radical proposal and
constitutes a sharp break with Hippocratic prac-
tices. If informed consent, however, is ever to be
based on the postulate of joint decisionmaking,
the obligation “to respect the autonomous choices
and actions of …
136 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
the personal and professional qualifications, to
assume it. Perhaps the current crop of nursing
school graduates do not desire it, but there is ample
room in the health care system for the sort of
“autonomous professional” they wish to be, apart
from the hospital nursing role. Wherever we must
go to fill this role, it is worth going there, for the
traditional nurse is the major force remaining for
humanity in a system that will turn into a mechan-
ical monster without her.
Advocacy or Subservience for the Sake of Patients?
HELGA KUHSE
Kuhse asks whether nurses should be patient advocates ready when necessary to
question physician authority, or be skilled and caring professionals who must always
defer to physicians on important medical decisions. Contrary to Lisa Newton’s
view, she favors the former, arguing that the nurse’s subservience to physicians is
not necessary for managing serious medical problems and issues and that requiring
nurses to be subservient would probably harm patients.
The view that doctors were gods whose commands
must always be obeyed was beginning to be seri-
ously questioned in the 1960s and 1970s. There had
always been courageous nurses who had occasion-
ally challenged orders, but it is almost as if nurses
needed a new metaphor to capture their new under-
standing of their role before they could finally at-
tempt to free themselves from the shackles of the
past. This new focus was provided by the metaphor
of the nurse as patient advocate. Whereas the old
metaphors had focused attention on such virtues as
submissiveness and unquestioning obedience and
loyalty to those in command, the new metaphor of
patient advocate highlighted the virtues of asser-
tiveness and courage, and marked a revolutionary
shift in the self- perception of nurses and their role.
The nurse’s first loyalty, the metaphor suggested, is
owed not to the doctor but to the patient. In thus
focusing on the nurse’s responsibilities to patients,
that is, on the recipients rather than the providers of
medical care, the metaphor of the nurse as patient
advocate made it possible for nurses to see them-
selves as professionals. No longer were they, as the old
From Caring: Nurses, Women and Ethics, Helga Kuhse
(New York: Wiley-Blackwell, 1997), 35–36, 41–53, 58–60.
metaphors had suggested, the loyal handmaidens of
medical men: they were professionals whose primary
responsibility—like that of all professionals—was
to their clients or patients. . . .
Nursing—a Naturally Subservient
Profession?
. . . Our first question must be this: should nurses
reject their traditional largely subservient role and
act as patient advocates? . . .
. . . I shall, without argument, assume that a pro-
fession such as medicine or nursing does not exist
for the sole or even primary purpose of benefiting
its members. This view is widely shared and is im-
plicit in most if not all professional codes; it is also
regarded as one of the necessary conditions for an
organization to claim professional status. For the
purposes of our discussion, then, I shall assume
that both nursing and medicine are professions
which are, or ought to be, aiming at the welfare of
others, where those others are patients or clients.
This raises the question of the relationship be-
tween medicine and nursing, and between doctors
and nurses. Might it not be the case that the subordi-
nate role of nurses has its basis not in objectionable
sexism but rather in a natural hierarchy between the
professions, a hierarchy that serves patients best?
03-Vaughn-Chap03.indd 136 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 137
Robert Baker is among those who have pointed
out that we cannot simply assume that the nurse’s
subservient role has a sexist basis. He does not deny
that sexism exists or that the subservient nursing
role has traditionally been seen as a feminine one;
but, he writes,
it is not at all clear whether the role of the nurse is
seen as dependent because it is filled by females,
who are held to be incapable of independent action
by a male-dominated, sexist society . . . or whether
females have been channelled into nursing because
the profession, by its very nature, requires its
members to play a dependent and subservient role
(i.e., the traditional female role in a sexist society).
In other words, the facts that almost all nurses are
women, that the traditional nurse’s role has been a
subservient one and that most societies were and
are male-dominated and sexist, cannot lead us to
the conclusion that the nurse’s role necessarily rests
on objectionable sexism. The nurse’s role may, ‘by
its very nature’, be a subservient one. But is nursing
‘by its very nature’ subservient to medicine—is it a
naturally subservient profession?
There is clearly something odd about speaking
of the ‘natural subservience’ of nursing to medicine,
or for that matter of ‘the natural subservience’ of
any profession in relation to another. To speak of
‘natural subservience’ suggests that the subservient
or dominant character of the relevant profession is
somehow naturally given and in that sense fixed and
largely unchangeable. But is this view correct? As we
have seen above, nursing has developed in a very
particular social and historical context, in response
to the then prevailing goals and purposes of medi-
cine on the one hand and the social roles of women
and men on the other. Would this not make it more
appropriate to view the character of the two health-
care professions, and the tasks and privileges that
attach to them, as a historically contingent accident
or social construct, rather than as a compelling nat-
ural necessity?
It seems to me the answer must be ‘yes’. There are
no natural professional hierarchies that exist inde-
pendently of human societies, and we should reject
the idea that professions have fixed natures and in-
stead view them as changing and changeable social
institutions. When looking at professions in this
way we may, of course, still want to think of them
as having particular characteristics by which they
can be defined (‘social natures’, if you like), but we
would now view these characteristics as socially
constructed, in much the same way as the institu-
tion itself is a social and historical construct.
How, then, might one go about capturing the
‘social nature’ or characteristics of a profession?. One
might do this in one of two ways: either by focusing
on the functions or roles performed by members of
the profession or by focusing on the profession’s
philosophical presuppositions or goals.
Function or Role
What is the function or role of a nurse? What is a
nurse? The clear and neat boundaries and distinc-
tions presupposed by our everyday language and by
the terms we use rarely accord with the real world.
We often speak of ‘the role’ or ‘the function’ of the
nurse, or of the ‘the role’ or ‘the function’ of the
doctor. These terms are problematical because nurses
and doctors working in different areas of health care
perform very different functions and act in many
different roles, and there is a considerable degree of
overlap between the changeable and changing func-
tions performed by members of the two professions.
The expansion of knowledge, of nursing educa-
tion, and of medical science and technology has
resulted in the redefinition and scope of nursing
practice. Nurses now carry out a range of proce-
dures that were formerly exclusively performed
by doctors. Some nurses give injections, take blood
samples, administer medication, perform diagnostic
procedures, do physical examinations, respond to
medical emergencies and so on.
Take diagnosis and medical treatment. The diag-
nosis and treatment of medical problems had always
been regarded as the realm solely of doctors. But,
as Tristram H. Engelhardt notes, if one looks closely
at the diagnostic activities performed by nurses,
it is difficult to see them as essentially different from
medical diagnoses. Nursing diagnoses such as
‘ “Airway clearance, ineffective”; “Bowel elimination,
alteration in: Diarrhoea”; “Cardiac output, alteration
in, decrease”; “Fluid volume deficit”,’ Engelhardt
points out, all have their medical equivalents; and
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138 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
the diagnosis of psychological or psychiatric distur-
bances, such as ‘ “Coping, ineffective individual”, or
“Thought processes, alteration in” can be given ana-
logues in the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric
Association.’
Nurses are not permitted by law to perform
any ‘medical acts’, but in practice the line be-
tween medical and nursing acts has become rather
blurred and is, in any case, the result of social and
historical choice. Moreover, as nurses have become
more assertive and conscious of their own knowl-
edge and expertise, there has been a broadening
of the definitions of nursing practice. In 1981 the
American Nursing Association thus produced a
model definition of nursing practice, which included
‘diagnosis . . . in the promotion and maintenance of
health’. By 1984, 23 US states had included [nursing]
diagnoses, or similar terms, in their nursing prac-
tice acts.
To conclude, then, the fact that nurses work in
very different areas of health care, where they per-
form very different functions, and the fact that
there are considerable overlaps between contem-
porary nursing functions and the functions tradi-
tionally performed by doctors makes it difficult to
see how it would be possible to define nursing in
terms of a particular function or role performed
by nurses. If we thus think of ‘the nature’ of nurs-
ing in terms of some specific function or role per-
formed by all nurses, this suggests not only that
nursing lacks a particular nature, but also makes it
difficult to claim that nursing is ‘naturally subser-
vient’ to medicine.
It is true, of course, that nurses frequently work
under the direction of doctors, and that control
over many of the functions performed by them is
retained by the medical profession. It is also true
that only doctors may, by law, perform operations,
prescribe medical treatments and authorize access
to certain drugs. This might lead one to the conclu-
sion that nursing and medicine can be distin-
guished by the range of socially and legally
sanctioned tasks and privileges that members of
one but not of the other profession may lawfully
engage in. Such a distinction would, of course, be
possible. But it is not a distinction that allows one to
infer anything about the subservient or dominant
‘nature’ of either one of the two professions. The
distribution of socially and legally sanctioned priv-
ileges and powers between medicine and nursing is
itself a historically contingent fact, and there is
nothing to suggest that the current distribution of
powers and privileges is either natural or that it is
the one that we should, upon reflection, adopt.
For example, why should it be the doctor who
decides whether a patient should be resuscitated or
not? Should it not be the patient? And if not the pa-
tient, why not the nurse?
Philosophical Commitment
Is it possible to distinguish the two professions by
their philosophical commitment, that is, by the
philosophical presuppositions that guide their re-
spective health-care endeavours? It is, again, not
easy to see how this might be done. Someone intent
on rejecting the view that nursing is naturally sub-
servient to medicine might point out that there is
no essential difference between the philosophical
commitment of the two professions that would
allow one to speak of one of them as being subservi-
ent to the other. Both nursing and medicine are
other-directed and committed to the welfare of cli-
ents or patients; members of both professions have
a similar understanding of pain and of suffering, of
well-being and of health, and both accept the same
scientific presuppositions. If there are differences
between individual doctors and nurses, these are
no more pronounced than those found between in-
dividuals from the same professions. Hence, one
might conclude, nursing does not have a nature
which is different from that of medicine and can
therefore not be said to be naturally subservient to
medicine.
Another, diametrically opposed avenue is some-
times chosen by those writing in the field to prove
wrong the claim that the nurse’s role is a naturally
subservient one. Rather than trying to show that the
nurse’s role is—either functionally or in terms of its
philosophical commitment—indistinguishable from
that of doctors, this second group of nurses claims
that the nursing commitment is fundamentally dif-
ferent from that of medicine. In other words, those
who take this approach start with the premise that
03-Vaughn-Chap03.indd 138 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 139
medicine and nursing have different philosophical
commitments or ‘natures’, and then go on to deny
that this will necessarily lead to the conclusion that
nursing ought to be playing a subservient role to
medicine.
This is generally done in one of two ways. The first
involves drawing a distinction in terms of a com-
mitment to ‘care’ and to ‘cure’. Whereas medicine
is said to be directed at ‘cure’, the therapeutic com-
mitment or moral end of nursing is identified as
‘care’. Medicine and doctors, it is said, often focus
on treating or curing the patient’s medical condi-
tion; nursing, on the other hand, is based on holistic
care, where patients are treated as complex wholes.
As a number of Australian nurses put it in their
submission to a 1987 inquiry into professional issues
in nursing:
Medical science and technology is concerned with
disease diagnosis and cure. This reductionist
model of care inevitably dissects, fragments and
depersonalises human beings in the process of
caring. The nurse’s caring role demands the preser-
vation and integrity of the wholeness of human
beings.
The second way of attempting to draw a distinc-
tion between nursing and medicine involves an
appeal to two different ethics. Whereas medicine is
said to be based on principles and rules (a so-called
[male] ethics of justice), nursing is said to be based on
relational caring (a so-called [female] ethics of care).
This means, very roughly, that doctors will put ethi-
cal principles or rules before the needs or wants of
individual patients, whereas nurses regard the needs
or wants of individual patients as more important
than adherence to abstract principles or rules.
These two views do not deny that nursing is
context-dependent or that nurses perform very dif-
ferent functions in different health-care settings; they
also acknowledge that nurses and doctors some-
times perform very similar or identical functions
and act in very similar roles. None the less, those
who take this view assume that nursing is different
from medicine because it has a different philosoph-
ical commitment or end—that of care. ‘Care’—the
nurture, the physical care, and the emotional sup-
port provided by nurses to preserve the ‘human
face’ of medicine and the dignity of the patient—
cannot, the suggestion is, ‘be absent if nursing is
present’.
There are a number of reasons why I am pessi-
mistic about the endeavour of distinguishing nurs-
ing from medicine and nurses from doctors in this
way. We will discuss some of these at length in later
chapters of this book. Here the following will suf-
fice: it seems very difficult, in a straightforward
and practical sense, to make philosophical com-
mitments, such as the commitment to care, the
defining characteristic of a profession. Such a defi-
nition would presumably include all nurses who
have this commitment, but would exclude all those
who do not. A registered nurse, who has all the rel-
evant professional knowledge and expertise, who
performs her nursing functions well, but—let us
assume—subscribes to ‘the scientific medical model’
or to an ‘ethics of justice’ would now, presumably,
no longer be a nurse. Would her philosophical com-
mitment make her a doctor? And would a doctor,
who subscribes to ‘care’ now more appropriately be
described as a nurse?
The problem is raised particularly poignantly in
settings, such as intensive care units (ICUs), where
the emphasis is on survival and ‘cure’. After Robert
Zussman, a sociologist, had observed doctors and
nurses in two American ICUs for some time, he
reached the conclusion that ICU nurses were not
‘gentle carers’ but technicians. Zussman does not
deny that other nurses may well be differently moti-
vated, but in the ICU, he says, they are ‘mini-interns’.
‘They are not patient advocates. They are not “angels
of mercy”. Like physicians, they have become
technicians.’
For all practical purposes, attempts to define a
profession in terms of its philosophical commit-
ment simply would not work. How would one test a
potential nursing candidate for it? How could one
ensure continued commitment—especially in a
high-technology environment such as intensive
care? And why should we assume that ‘care’ should
always have priority over either principle or cure?
Are there not times when proper care demands that
we attempt to ‘cure’ or when ethical principle ought
to trump care? If the answer is ‘yes’, as I think it
should be, then we should abandon the attempt to
03-Vaughn-Chap03.indd 139 26/05/16 4:29 PM
140 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
draw a distinction between nursing and medicine
in these ways.
There is, of course, another reason as well: Even
if a sound distinction in the philosophical or ethical
commitments of nursing and medicine could be
drawn, this would not settle the question of whether
nursing is or is not a naturally subservient profes-
sion. The fact (if it is a fact) that medicine has one
philosophical commitment or nature and nursing
another is quite independent of the further question
of whether one of the professions is, or ought to be,
subservient to the other. Further argument would be
needed to show that, for nothing of substance fol-
lows from establishing that one thing, or one pro-
fession, is different from another.
Subservience for the Sake of Life or Limb?
What arguments could be provided to show that
nurses and nursing ought to adopt a subservient
role to doctors and medicine? In accordance with
our assumption that nursing is an other-directed
profession, a profession that primarily aims at the
good of patients, such arguments would have to show
that nurses’ subservience would benefit patients
more than nurses’ autonomy. . . .
[O]ur main focus will be hospital-based nurses.
Most nurses work in hospitals, and it is part of their
role to carry out the treatment plans of doctors. Here
a powerful argument is sometimes put that, regard-
less of what is true for other nurses, it is essential
that nurses who work in acute-care settings adopt a
subservient role. Those who take this view do not
necessarily deny that it may be quite appropriate for
some nurses, in some contexts, to play an autonomous
role; but, they insist, when we are talking about hos-
pitals matters are different.
Hospitals are bureaucratic institutions and bu-
reaucratic institutions, so a typical argument goes,
rely for efficient functioning on vertical structures
of command, on strict adherence to procedure and
on avoidance of initiative by those who have been
charged with certain tasks. While this is true of all
bureaucratic institutions, strict adherence to rules
and to chains of command becomes critically im-
portant when we are focusing on hospitals. In such a
setting much is at stake. A patient’s health, and even
her life, will often depend on quick and reliable
responses by members of the health-care team to
the directions of the person in charge.
Let us accept that efficiency will often depend
on some of the central criteria identified above. This
does not, however, answer questions regarding the
proper relationship between nurses and doctors.
Take the notion of a bureaucratic hierarchy. A
simple appeal to that notion does not tell us how the
bureaucratic hierarchy should be arranged. Here it
is generally assumed that it is appropriate for doctors
to be in charge and appropriate for nurses to follow
the doctors’ orders. But why should this be so? Why
is it so widely assumed that doctors should perform
the role of ‘captain of the ship’ and nurses those of
members of the crew?
The Argument from Exper tise
The reason most commonly given for this type of
arrangement is that doctors, but not nurses, have
the relevant medical knowledge and expertise to
deal with the varied and often unique medical con-
ditions that afflict patients, and the different emer-
gencies that might arise. Just as it would not do to
put crew-members with only a limited knowledge of
navigation in charge of a ship traversing unpredict-
able and potentially dangerous waters, so it would
not do to put nurses with only a limited knowledge
of medicine in charge of the treatment plans of
patients. Many a ship and many a patient would be
lost as a result of such an arrangement. Hence, if we
want ships and patients to be in good hands, it follows
that those with expertise—doctors and captains—
must be in charge.
Such an argument is put by Lisa H. Newton, a
vocal critic of nursing’s quest for autonomy. If the
purpose of saving life and health is to be accom-
plished in an atmosphere which is often tense and
urgent, then, Newton argues,
all participating activities and agents must be
completely subordinated to the medical judgments
of the physician. . . . [T]hose other than physicians,
involved in medical procedures in a hospital
context, have no right to insert their own needs,
judgments, or personalities into the situation. The
last thing we need at that point is another autono-
mous professional on the job, whether a nurse or
anyone else.
03-Vaughn-Chap03.indd 140 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 141
is appropriate for doctors to exercise and for nurses
to recognize medical authority. . . .
There is a connection, then, between the posses-
sion of particular expertise and authority. Expertise
can be crucial to the achievement of goals and,
provided the goals are shared, it will frequently be
appropriate for people who are authorities in a par-
ticular field to also be in authority.
If we accept this argument, it follows that doc-
tors ought, other things being equal, to be in charge
in medical emergencies and in other specialized
contexts that are characterized by an element of
urgency. They ought to be in charge because this
arrangement best ensures that the therapeutic goal
will be reached.
Acceptance of this view has, however, less far-
reaching consequences than might be assumed. First,
even if particular therapeutic treatment goals are
most likely to be achieved if a single medically
trained person is in charge during, for example, op-
erations or resuscitation procedures, this does not
entail that the doctor should have overall authority
as far as the patient’s treatment is concerned. The
authority to decide on an operation or on the desir-
ability of implementing resuscitation procedures
might, for example, rest with the patient or her rela-
tives, and the nurse could conceivably be in charge
of the overall treatment plan of the patient.
Second, it does not follow that nurses must, even
during emergency procedures, blindly follow a doctor’s
order. Doctors, like the rest of us, are fallible human
beings and sometimes make mistakes. This means
that the nurse’s obligation to follow a doctor’s order,
even in these specialized contexts, cannot be absolute
and may at times be overridden by other consider-
ations, such as the avoidance of harm to patients.
A study conducted in 1966, when nurses were
probably more likely unquestioningly to follow a
doctor’s order than they are now, demonstrates that
unquestioning obedience to doctors is likely to have
some rather undesirable consequences for patients.
In the 1966 study, nurses were asked by a doctor, by
telephone, to prepare medication which was obvi-
ously excessive and to give it to a patient. Twenty-one
out of 22 nurses followed the doctors’ orders and
were ready to give the medication to the patient when
the researchers intervened. . . .
There is something right and something wrong
about the above kind of argument. To see this, the
argument needs untangling.
Shared Goals, Urgency and Medical
Authority
In her argument Newton implicitly assumes that the
therapeutic goals of doctors are morally worthy ones,
and that the ethical question of whether a doctor
should, for example, prolong a patient’s life or allow
her to die is not in dispute. This assumption is inher-
ent in her observation that the tasks at hand are, or
ought to be ‘protective of life itself ’. While we know
that this very question is frequently in dispute, let us,
for the purpose of our initial discussion, accept and
work with that assumption. We shall question it later.
There is no doubt that doctors have special med-
ical expertise that is relevant to the achievement of
various therapeutic goals, including the goal of saving
or prolonging life. Extensive medical studies and
registration or licensing procedures ensure that doc-
tors are experts in medical diagnosis and medical
therapy. Their education equips them well to act
quickly and decisively in complicated and unfore-
seen medical circumstances. As a general rule (but
only as a general rule—there could be exceptions to
this rule) doctors would thus be better equipped than
nurses to respond to a range of medical emergencies.
In emergency situations, then, where urgent action
is required, it is likely that the best outcome for pa-
tients as a whole will be achieved if doctors are in
charge. Moreover, since the outcome of medical
measures in such contexts often depends crucially
on the practical assistance of nurses, it is important
that nurses will, as a general rule, quickly and un-
questioningly respond to the doctor’s orders.
It seems that we should accept this type of ar-
gument. During emergency procedures it is more
likely that the desired outcome will be achieved if
there is not only a single decision-maker, but if this
single decision-maker is also the most expert medi-
cal professional in the field. This will typically be the
doctor.
In addition to those cases where urgent action by
a medical expert is required to achieve the desired
therapeutic goal, there are also some other special-
ized contexts, such as the operating room, where it
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142 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
Given, then, that doctors will occasionally make
mistakes and that nurses frequently have the pro-
fessional knowledge to detect them, it will be best
if nurses do not understand their duty to follow a
doctor’s order as an absolute and exceptionless
one. If the doctor’s order is, in the nurse’s profes-
sional judgment, clearly wrong, then the nurse
must bring her ‘professional intelligence’ into play
and question it. . . .
Does a nurse who subscribes to the general prop-
osition or rule that there are times when it will best
serve the interests of patients that she accept the au-
thority of doctors thereby necessarily adopt a subser-
vient or non-autonomous role? Does she abrogate
her autonomy? I think not. As long as a nurse does
not surrender her autonomy or judgment, that is,
does not blindly follow every order she is given, but
rather decides, after reflection, to adopt a general rule
that it will be best to accept and act on the doctor’s
authority under certain circumstances, then she is
not a subservient tool in the doctor’s hands. She is
not, as was once proposed, simply ‘an intelligent ma-
chine’. She is a moral agent who, in distinction from
a mere machine, chooses to act in one way rather
than another.
To sum up, then: the argument that nurses
should—for the sake of achieving certain worthy
therapeutic goals such as the saving of life—adopt
a subservient role to doctors typically rests on at
least two rather dubious assumptions. The first
assumption is that all …
128 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
providers treating the patient. The physician
may not discontinue treatment of a patient as
long as further treatment is medically indi-
cated, without giving the patient reasonable
assistance and sufficient opportunity to make
alternative arrangements for care.
6. The patient has a basic right to have available
adequate health care. Physicians, along with
the rest of society, should continue to work
toward this goal. Fulfillment of this right is
dependent on society providing resources so
that no patient is deprived of necessary care
because of an inability to pay for the care.
Physicians should continue their traditional
assumption of a part of the responsibility for
the medical care of those who cannot afford
essential health care. Physicians should advo-
cate for patients in dealing with third parties
when appropriate.
2. The patient has the right to make decisions
regarding the health care that is recom-
mended by his or her physician. Accordingly,
patients may accept or refuse any recom-
mended medical treatment.
3. The patient has the right to courtesy, respect,
dignity, responsiveness, and timely attention
to his or her needs.
4. The patient has the right to confidentiality.
The physician should not reveal confidential
communications or information without
the consent of the patient, unless provided
for by law or by the need to protect the
welfare of the individual or the public
interest.
5. The patient has the right to continuity of
health care. The physician has an obligation
to cooperate in the coordination of medically
indicated care with other health care
In Defense of the Traditional Nurse
LISA H. NEWTON
In this essay Newton rejects the contemporary model of a nurse as an “autonomous
professional” who can challenge physicians’ authority and be a strong advocate for
patients. She argues instead for the traditional notion of nurse as a caregiver cum
surrogate mother who is subordinate to physicians. She insists that unambiguous
lines of authority and clearly specified roles are essential to a well-run hospital and
that in this setting physicians alone must be in charge when serious medical problems
come up.
From Lisa H. Newton, “In Defense of the Traditional
Nurse,” Nursing Outlook, vol. 29 (June 1981). Reprinted
with permission.
When a truth is accepted by everyone as so obvious
that it blots out all its alternatives and leaves no re-
spectable perspectives from which to examine it, it
becomes the natural prey of philosophers, whose
essential activity is to question accepted opinion. A
case in point may be the ideal of the “autonomous
professional” for nursing. The consensus that this
ideal and image are appropriate for the profession is
becoming monolithic and may profit from the
presence of a full-blooded alternative ideal to re-
place the cardboard stereotypes it routinely con-
demns. That alternative, I suggest, is the traditional
ideal of the skilled and gentle caregiver, whose role
in health care requires submission to authority as
an essential component. We can see the faults of
this traditional ideal very clearly now, but we may
perhaps also be able to see virtues that went unno-
ticed in the battle to displace it. It is my contention
that the image and ideal of the traditional nurse
contain virtues that can be found nowhere else in
the health care professions, that perhaps make an
irreplaceable contribution to the care of patients,
03-Vaughn-Chap03.indd 128 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 129
and that should not be lost in the transition to a new
definition of the profession of nursing.
A word should be said about what this article is,
and what it is not. It is an essay in philosophical
analysis, starting from familiar ideas, beliefs, and
concepts, examining their relationships and impli-
cations and reaching tentative conclusions about
the logical defensibility of the structures discovered.
It is not the product of research in the traditional
sense. Its factual premises—for example, that the
“traditional” nursing role has been criticized by those
who prefer an “autonomous professional” role—are
modest by any standard, and in any event may
be taken as hypothetical by all who may be disposed
to disagree with them. It is not a polemic against
any writer or writers in particular, but a critique
of lines of reasoning that are turning up with in-
creasing frequency in diverse contexts. Its argu-
ments derive no force whatsoever from any writings
in which they may be found elsewhere.
Role Components
The first task of any philosophical inquiry is to de-
termine its terminology and establish the meanings
of its key terms for its own purposes. To take the
first term: a role is a norm-governed pattern of action
undertaken in accordance with social expectations.
The term is originally derived from the drama, where
it signifies a part played by an actor in a play. In cur-
rent usage, any ordinary job or profession (physi-
cian, housewife, teacher, postal worker) will do as an
example of a social role; the term’s dramatic origin
is nonetheless worth remembering, as a key to the
limits of the concept.
Image and ideal are simply the descriptive and
prescriptive aspects of a social role. The image of
a social role is that role as it is understood to be in fact,
both by the occupants of the role and by those with
whom the occupant interacts. It describes the charac-
ter the occupant plays, the acts, attitudes, and expec-
tations normally associated with the role. The ideal of
a role is a conception of what that role could or should
be—that is, a conception of the norms that should
govern its work. It is necessary to distinguish between
the private and public aspects of image and ideal.
Since role occupants and general public need
not agree either on the description of the present
operations of the role or on the prescription for its
future development, the private image, or self-image
of the role occupant, is therefore distinct from the
public image or general impression of the role main-
tained in the popular media and mind. The private
ideal, or aspiration of the role occupant, is distinct
from the public ideal or normative direction set for the
role by the larger society. Thus, four role-components
emerge, from the public and private, descriptive and
prescriptive, aspects of a social role. They may be dif-
ficult to disentangle in some cases, but they are surely
distinct in theory, and potentially in conflict in fact.
Transitional Roles
In these terms alone we have the materials for the
problematic tensions within transitional social roles.
Stable social roles should exhibit no significant dis-
parities among images and ideals: what the public
generally gets is about what it thinks it should get;
what the job turns out to require is generally in
accord with the role-occupant’s aspirations; and
public and role-occupant, beyond a certain base level
of “they-don’t-know-how-hard-we-work” grumbling,
are in general agreement on what the role is all
about. On the other hand, transitional roles tend to
exhibit strong discrepancies among the four ele-
ments of the role during the transition; at least the
components will make the transition at different
times, and there may also be profound disagreement
on the direction that the transition should take.
The move from a general discussion of roles in
society to a specific discussion of the nursing pro-
fession is made difficult by the fact that correct
English demands the use of a personal pronoun. How
shall we refer to the nurse? It is claimed that consis-
tent reference to a professional as “he” reinforces the
stereotype of male monopoly in the professions, save
for the profession of nursing, where consistent ref-
erence to the professional as “she” reinforces the
stereotype of subservience. Though we ought never
to reinforce sex and dominance stereotypes, the effort
to write in gender-neutral terms involves the use of
circumlocutions and “he/she” usages that quickly
becomes wearisome to reader and writer alike. Re-
ferring to most other professions, I would simply use
the universal pronouns “he” and “him”, and ignore
the ridiculous accusations of sexism. But against a
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130 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
background of a virtually all-female profession,
whose literature until the last decade universally
referred to its professionals as “she”, the consistent
use of “he” to refer to a nurse calls attention to itself
and distracts attention from the argument.
A further problem with gender-neutral termi-
nology in the discussion of this issue in particular is
that it appears to render the issue irrelevant. The
whole question of autonomy for the nurse in profes-
sional work arises because nurses have been, and
are, by and large, women, and the place of the pro-
fession in the health care system is strongly influ-
enced by the place of women in society. To talk
about nurses as if they were, or might as well be,
men, is to make the very existence of a problem a
mystery. There are, therefore good reasons beyond
custom to continue using the pronoun “she” to refer
to the nurse. I doubt that such use will suggest to
anyone who might read this essay that it is not ap-
propriate for men to become nurses; presumably we
are beyond making that at this time.
Barriers to Autonomy
The first contention of my argument is that the issue
of autonomy in the nursing profession lends itself to
misformulation. A common formulation of the issue,
for example, locates it in a discrepancy between
public image and private image. On this account,
the public is asserted to believe that nurses are
ill-educated, unintelligent, incapable of assuming
responsibility, and hence properly excluded from
professional status and responsibility. In fact they
are now prepared to be truly autonomous profes-
sionals through an excellent education, including
a thorough theoretical grounding in all aspects of
their profession. Granted, the public image of the
nurse has many favorable aspects—the nurse is
credited with great manual skill, often saintly dedi-
cation to service to others, and, at least below the
supervisory level, a warm heart and gentle manners.
But the educational and intellectual deficiencies that
the public mistakenly perceives outweigh the “posi-
tive” qualities when it comes to deciding how the
nurse shall be treated, and are called upon to justify
not only her traditionally inferior status and low wages,
but also the refusal to allow nursing to fill genuine
needs in the health care system by assuming tasks
that nurses are uniquely qualified to handle. For the
sake of the quality of health care as well as for the
sake of the interests of the nurse, the public must be
educated through a massive educational campaign
to the full capabilities of the contemporary nurse;
the image must be brought into line with the facts.
On this account, then, the issue of nurse autonomy
is diagnosed as a public relations problem: the private
ideal of nursing is asserted to be that of the autono-
mous professional and the private image is asserted
to have undergone a transition from an older sub-
servient role to a new professional one but the public
image of the nurse ideal is significantly not men-
tioned in this analysis.
An alternative account of the issue of professional
autonomy in nursing locates it in a discrepancy be-
tween private ideal and private image. Again, the
private ideal is that of the autonomous professional.
But the actual performance of the role is entirely
slavish, because of the way the system works—with
its tight budgets, insane schedules, workloads bor-
dering on reckless endangerment for the seriously
ill, bureaucratic red tape, confusion, and arrogance.
Under these conditions, the nurse is permanently
barred from fulfilling her professional ideal, from
bringing the reality of the nurse’s condition into
line with the self-concept she brought to the job. On
this account, then, the nurse really is not an autono-
mous professional, and total reform of the power
structure of the health care industry will be neces-
sary in order to allow her to become one.
A third formulation locates the issue of auton-
omy in a struggle between the private ideal and an
altogether undesirable public ideal: on this account,
the public does not want the nurse to be an autono-
mous professional, because her present subservient
status serves the power needs of the physicians; be-
cause her unprofessional remuneration serves the
monetary needs of the entrepreneurs and callous
municipalities that run the hospitals; and because
the low value accorded her opinions on patient care
protects both physicians and bureaucrats from
being forced to account to the patient for the treat-
ment he receives. On this account, the nurse needs
primarily to gather allies to defeat the powerful
interest groups that impose the traditional ideal for
their own unworthy purposes, and to replace that
03-Vaughn-Chap03.indd 130 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 131
degrading and dangerous prescription with one
more appropriate to the contemporary nurse.
These three accounts, logically independent, have
crucial elements of content in common. Above all,
they agree on the objectives to be pursued: full pro-
fessional independence, responsibility, recognition,
and remuneration for the professional nurse. And
as corollary to these objectives, they agree on the
necessity of banishing forever from the hospitals
and from the public mind that inaccurate and de-
meaning stereotype of the nurse as the Lady with
the Bedpan: an image of submissive service, com-
forting to have around and skillful enough at her
little tasks, but too scatterbrained and emotional
for responsibility.
In none of the interpretations above is any real
weight given to a public ideal of nursing, to the
nursing role as the public thinks it ought to be
played. Where public prescription shows up at all,
it is seen as a vicious and false demand imposed by
power alone, thoroughly illegitimate and to be de-
stroyed as quickly as possible. The possibility that
there may be real value in the traditional role of the
nurse, and that the public may have good reasons to
want to retain it, simply does not receive any serious
consideration on any account. It is precisely that
possibility that I take up in the next section.
Defending the “Traditional Nurse”
As Aristotle taught us, the way to discover the pe-
culiar virtues of any thing is to look to the work that
it accomplishes in the larger context of its environ-
ment. The first task, then, is to isolate those factors
of need or demand in the nursing environment that
require the nurse’s work if they are to be met. I shall
concentrate, as above, on the hospital environment,
since most nurses are employed in hospitals.
The work context of the hospital nurse actually
spans two societal practices or institutions: the
hospital as a bureaucracy and medicine as a field
of scientific endeavor and service. Although there
is enormous room for variation in both hospital
bureaucracies and medicine, and they may there-
fore interact with an infinite number of possible
results, the most general facts about both institu-
tions allow us to sketch the major demands they
make on those whose function lies within them.
To take the hospital bureaucracy first: its very
nature demands that workers perform the tasks
assigned to them, report properly to the proper
superior, avoid initiative, and adhere to set proce-
dures. These requirements are common to all bu-
reaucracies, but dramatically increase in urgency
when the tasks are supposed to be protective of life
itself and where the subject matter is inherently
unpredictable and emergency prone. Since there is
often no time to re-examine the usefulness of a pro-
cedure in a particular case, and since the stakes are
too high to permit a gamble, the institution’s ef-
fectiveness, not to mention its legal position, may
depend on unquestioning adherence to procedure.
Assuming that the sort of hospital under discus-
sion is one in which the practice of medicine by quali-
fied physicians is the focal activity, rather than, say,
a convalescent hospital, further contextual require-
ments emerge. Among the prominent features of the
practice of medicine are the following: it depends
on esoteric knowledge which takes time to acquire
and which is rapidly advancing; and, because each
patient’s illness is unique, it is uncertain. Thus, when a
serious medical situation arises without warning, only
physicians will know how to deal with it (if their licen-
sure has any point), and they will not always be able to
explain or justify their actions to nonphysicians, even
those who are required to assist them in patient care.
If the two contexts of medicine and the hospital
are superimposed, three common points can be seen.
Both are devoted to the saving of life and health; the
atmosphere in which that purpose is carried out is
inevitably tense and urgent; and, if the purpose is to
be accomplished in that atmosphere, all participat-
ing activities and agents must be completely subordi-
nated to the medical judgments of the physicians. In
short, those other than physicians, involved in medi-
cal procedures in a hospital context, have no right to
insert their own needs, judgments, or personalities
into the situation. The last thing we need at that
point is another autonomous professional on the job,
whether a nurse or anyone else.
Patient Needs: The Prime Concern
From the general characteristics of hospitals and
medicine, that negative conclusion for nursing fol-
lows. But the institutions are not, after all, the focus
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132 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
of the endeavor. If there is any conflict between the
needs of the patient and the needs of the institutions
established to serve him, his needs take precedence
and constitute the most important requirements of
the nursing environment. What are these needs?
First, because the patient is sick and disabled, he
needs specialized care that only qualified personnel
can administer, beyond the time that the physician
is with him. Second, and perhaps most obviously
to the patient, he is likely to be unable to perform
simple tasks such as walking unaided, dressing him-
self, and attending to his bodily functions. He will
need assistance in these tasks, and is likely to find
this need humiliating; his entire self-concept as an
independent human being may be threatened. Thus,
the patient has serious emotional needs brought on
by the hospital situation itself, regardless of his dis-
ability. He is scared, depressed, disappointed, and
possibly, in reaction to all of these, very angry. He
needs reassurance, comfort, someone to talk to. The
person he really needs, who would be capable of
taking care of all these problems, is obviously his
mother, and the first job of the nurse is to be a
mother surrogate.
That conclusion, it should be noted, is inherent
in the word “nurse” itself: it is derived ultimately
from the Latin nutrire, “to nourish or suckle”; the
first meaning of “nurse” as a noun is still, according
to Webster’s New Twentieth Century Unabridged
Dictionary “one who suckles a child not her own.”
From the outset, then, the function of this nurse is
identical with that of the mother, to be exercised
when the mother is unavailable. And the meanings
proceed in logical order from there: the second defi-
nitions given for both noun and verb involve caring
for children, especially young children, and the
third, caring for those who are childlike in their
dependence—the sick, the injured, the very old, and
the handicapped. For all those groups—infants,
children, and helpless adults—it is appropriate to
bring children’s caretakers, surrogate mothers, nurses,
into the situation to minister to them. It is especially
appropriate to do so, for the sake of the psychological
economies realized by the patient: the sense of self,
at least for the Western adult, hangs on the self-
perception of independence. Since disability requires
the relinquishing of this self-perception, the patient
must either discover conditions excusing his de-
pendence somewhere in his self-concept, or invent
new ones, and the latter task is extremely difficult.
Hence the usefulness of the maternal image associ-
ation: it was, within the patient’s understanding of
himself “all right” to be tended by mother; if the
nurse is (at some level) mother, it is “all right” to
reassume that familiar role and to be tended by her.
Limits on the “Mother” Role
The nurse’s assumption of the role of mother is there-
fore justified etymologically and historically but
most importantly by reference to the psychological
demands of and on the patient. Yet the maternal role
cannot be imported into the hospital care situation
without significant modification—specifically, with
respect to the power and authority inherent in the
role of mother. Such maternal authority, includes the
right and duty to assume control over children’s lives
and make all decisions for them; but the hospital pa-
tient most definitely does not lose adult status even
if he is sick enough to want to. The ethical legitimacy
as well as the therapeutic success of his treatment
depend on his voluntary and active cooperation in
it and on his deferring to some forms of power and
authority—the hospital rules and the physician’s
sapiential authority, for example. But these very par-
tial, conditional, restraints are nowhere near the
threat to patient autonomy that the real presence of
mother would be; maternal authority, total, diffuse,
and unlimited, would be incompatible with the re-
tention of moral freedom. And it is just this sort of
total authority that the patient is most tempted to
attribute to the nurse, who already embodies the
nurturant component of the maternal role. To prevent
serious threats to patient autonomy, then, the role of
nurse must be from the outset, as essentially as it is
nurturant, unavailable for such attribution of au-
thority. Not only must the role of nurse not include
authority; it must be incompatible with authority:
essentially, a subservient role.
The nurse role, as required by the patient’s situa-
tion, is the nurturant component of the maternal
role and excludes elements of power and authority.
A further advantage of this combination of mater-
nal nurturance and subordinate status is that, just
as it permits the patient to be cared for like a baby
03-Vaughn-Chap03.indd 132 26/05/16 4:29 PM
Chapter 3: Paternalism and Patient Autonomy 133
handle the human needs of the human beings in-
volved in the process.
The general public entering the hospital as pa-
tient or visitor encounters and reacts to that health
care system as an indivisible whole, as if under a
single heading of “what the hospital is like.” It is at
this level that we can make sense of the traditional
claim that the nurse represents the “human” as op-
posed to “mechanical” or “coldly professional”
aspect of health care, for there is clearly some-
thing terribly missing in the combined medical
and bureaucratic approach to the “case”: they fail
to address the patient’s fear for himself and the
family’s fear for him, their grief over the separa-
tion, even if temporary, their concern for the fi-
nancial burden, and a host of other emotional
components of hospitalization.
The same failing appears throughout the hospi-
tal experience, most poignantly obvious, perhaps,
when the medical procedures are unavailing and
the patient dies. When this occurs, the physician
must determine the cause and time of death and the
advisability of an autopsy, while the bureaucracy
must record the death and remove the body; but
surely this is not enough. The death of a human being
is a rending of the fabric of human community, a
sad and fearful time; it is appropriately a time of
bitter regret, anger, and weeping. The patient’s family,
caught up in the institutional context of the hospi-
tal, cannot assume alone the burden of discovering
and expressing the emotions appropriate to the oc-
casion; such expression, essential for their own regen-
eration after their loss must originate somehow within
the hospital context itself. The hospital system must,
somehow, be able to share pain and grief as well as
it makes medical judgments and keeps records.
The traditional nurse’s role addresses itself di-
rectly to these human needs. Its derivation from the
maternal role classifies it as feminine and permits
ready assumption of all attributes culturally typed
as “feminine”: tenderness, warmth, sympathy, and a
tendency to engage much more readily in the expres-
sion of feeling than in the rendering of judgment.
Through the nurse, the hospital can be concerned,
welcoming, caring, and grief-stricken; it can break
through the cold barriers of efficiency essential to
its other functions and share human feeling.
without threatening his autonomy, it also permits
him to unburden himself to a sympathetic listener
of his doubts and resentments, about physicians and
hospitals in general, and his in particular, without
threatening the course of his treatment. His resent-
ments are natural, but they lead to a situation of
conflict, between the desire to rebel against treat-
ment and bring it to a halt (to reassert control over
his life), and the desire that the treatment should
continue (to obtain its benefits). The nurse’s func-
tion speaks well to this condition: like her maternal
model, the nurse is available for the patient to talk to
(the physician is too busy to talk), sympathetic, un-
derstanding, and supportive; but in her subordinate
position, the nurse can do absolutely nothing to
change his course of treatment. Since she has no more
control over the environment than he has, he can let
off steam in perfect safety, knowing that he cannot
do himself any damage.
The norms for the nurse’s role so far derived from
the patient’s perspective also tally, it might be noted,
with the restrictions on the role that arise from the
needs of hospitals and medicine. The patient does
not need another autonomous professional at his
bedside, any more than the physician can use one or
the hospital bureaucracy contain one. The conclusion
so far, then is that in the hospital environment, the
traditional (nurturant and subordinate) role of the
nurse seems more adapted to the nurse function
than the new autonomous role.
Provider of Humanistic Care
So far, we have defined the hospital nurse’s func-
tion in terms of the specific needs of the hospital,
the physician, and the patient. Yet there is another
level of function that needs to be addressed. If we
consider the multifaceted demands that the pa-
tient’s family, friends, and community make on
the hospital once the patient is admitted, it be-
comes clear that this concerned group cannot be
served exclusively by attending to the medical
aspect of care, necessary though that is. Nor is it
sufficient for the hospital-as-institution to keep
accurate and careful records, maintain absolute
cleanliness, and establish procedures that protect
the patient’s safety, even though this is important.
Neither bureaucracy nor medical professional can
03-Vaughn-Chap03.indd 133 26/05/16 4:29 PM
134 PA R T 2 : M E D I C A L P R O F E S S I O N A L A N D PAT I E N T
The nurse therefore provides the in-hospital
health care system with human capabilities that
would otherwise be unavailable to it and hence
unavailable to the community in dealing with it.
Such a conclusion is unattractive to the supporters
of the autonomous role for the nurse, because the
tasks of making objective judgments and of ex-
pressing emotion are inherently incompatible; and
since the nurse shows grief and sympathy on behalf
of the system, she is excluded from decision-making
and defined as subordinate.
However unappealing such a conclusion may be,
it is clear that without the nurse role in this function,
the hospital becomes a moral monstrosity, coolly and
mechanically dispensing and disposing of human
life and death, with no acknowledgement at all of
the individual life, value, projects, and relationships
of the persons with whom it deals. Only the nurse
makes the system morally tolerable. People in pain
deserve sympathy, as the dead deserve to be grieved;
it is unthinkable that the very societal institution to
which we generally consign the suffering and the
dying should be incapable of sustaining sympathy
and …
682 PA R T 3 : L I F E A N D D E AT H
Let us begin with two observations about chronic
illness and death:
1. Death does not always come at the right time.
We are all aware of the tragedies involved
when death comes too soon. We are afraid
that it might come too soon for us. By con-
trast, we may sometimes be tempted to
deny that death can come too late—wouldn’t
everyone want to live longer? But in our more
sober moments, most of us know perfectly
well that death can come too late.
2. Discussions of death and dying usually
proceed as if death came only to hermits—or
others who are all alone. But most of the
time, death is a death in the family. We are
connected to family and loved ones. We are
sustained by these connections. They are a
major part of what makes life worth living
for most of us.
Because of these connections, when death comes
too soon, the tragedy is often two-fold: a tragedy
both for the person who is now dead and for those
of us to whom she was connected. We grieve both
for our loved one who is gone and for ourselves who
have lost her. On one hand, there is the unrealized
good that life would have been for the dead person
herself—what she could have become, what she could
have experienced, what she wanted for herself.
On the other, there is the contribution she would
have made to others and the ways their lives would
have been enriched by her.
We are less familiar with the idea that death can
come too late. But here, too, the tragedy can be two-
fold. Death can come too late because of what living
on means to the person herself. There are times
when someone does not (or would not) want to live
like this, times when she believes she would be
better off dead. At times like these, suicide or as-
sisted suicide becomes a perfectly rational choice,
perhaps even the best available option for her. We
are then forced to ask, “Does someone have a right
to die?” Assisted suicide may then be an act of com-
passion, no more than relieving her misery.
There are also, sadly, times when death comes
too late because others—family and loved ones—
would be better off if someone were dead. (Better off
overall, despite the loss of a loved one.) Since lives
are deeply intertwined, the lives of the rest of the
family can be dragged down, impoverished, com-
promised, perhaps even ruined because of what they
must go through if she lives on. When death comes
too late because of the effect of someone’s life on
her loved ones, we are, I think, forced to ask, “Can
someone have a duty to die?” Suicide may then be
an attempt to do what is right; it may be the only
loving thing to do. Assisted suicide would then be
helping someone do the right thing.
Most professional ethicists—philosophers, theo-
logians, and bioethicists—react with horror at the
Dying at the Right Time: Reflections on (Un)Assisted
Suicide
JOHN HARDWIG
John Hardwig is a professor emeritus of the Department of Philosophy at the
University of Tennessee. In this essay he argues that when “death comes too late,”
we may have a duty to die or a duty to help someone else die. Severe, unrelieved
pain is just one of several problems that could justify ending a life. Sometimes
preserving a life can devastate the lives of those who care about the person.
In parti cularly dire situations, there may be moral justification for unassisted suicide,
family-assisted suicide, or physician-assisted suicide.
John Hardwig, “Dying at the Right Time: Reflections on
(Un)Assisted Suicide,” in Ethics in Practice, ed. Hugh
LoFollette (Oxford: Blackwell, 2007), 91–102.
10-Vaughn-Chap10.indd 682 26/05/16 4:28 PM
Chapter 10: Euthanasia and Physician-Assisted Suicide 683
very idea of a duty to die. Many of them even argue
that euthanasia and physician-assisted suicide should
not be legalized because then some people might
somehow get the idea that they have a duty to die.
To this way of thinking, someone who got that idea
could only be the victim of vicious social pressure
or perverse moral reasoning. But when I ask my
classes for examples of times when death would
come too late, one of the first conditions students
always mention is: “when I become a burden to my
family.” I think there is more moral wisdom here
than in the dismay of these ethicists.
Death does not always come at the right time.
I believe there are conditions under which I would
prefer not to live, situations in which I would be
better off dead. But I am also absolutely convinced
that I may one day face a duty or responsibility to
die. In fact, as I will explain later, I think many of us
will one day have this duty.
To my way of thinking, the really serious ques-
tions relating to euthanasia and assisted suicide
are: Who would be better off dead? Who has a duty
to die? When is the right time to die? And if my
life should be over, who should kill me? 1 However,
I know that others find much of what I have said
here surprising, shocking, even morally offensive.
So before turning to these questions that I want us
to think about, I need to explain why I think some-
one can be better off dead and why someone can
have a duty to die. (The explanation of the latter will
have to be longer, since it is by far the less familiar
and more controversial idea.)
When Someone Would Be Better
Off Dead
Others have discussed euthanasia or physician-
assisted suicide when the patient would be better off
dead. 2 Here I wish to emphasize two points often
omitted from discussion: (1) Unrelieved pain is not
the only reason someone would be better off dead.
(2) Someone can be better off dead even if she has
no terminal illness.
(1) If we think about it for even a little while, most
of us can come up with a list of conditions under
which we believe we would rather be dead than
continue to live. Severe and unrelieved pain is one
item on that list. Permanent unconsciousness may
be another. Dementia so severe that we no longer
recognize ourselves or our loved ones is yet another.
There are some people who prefer not to live with
quadriplegia. A future shaped by severe deterioration
(such as that which accompanies MS, ALS, AIDS,
or Huntington’s chorea) is a future that some people
prefer not to live out.
(Our lists would be different because our lives
and values are different. The fact that some people
would not or do not want to live with quadriplegia
or AIDS, for example, does not mean that others
should not want to live like that, much less that their
lives are not worth living. That is very important.
The point here is that almost all of us can make a list
of conditions under which we would rather not live,
and that uncontrolled pain is not the only item on
most of our lists.)
Focusing the discussion of euthanasia and as-
sisted suicide on pain ignores the many other vari-
eties of suffering that often accompany chronic
illness and dying: dehumanization, loss of indepen-
dence, loss of control, a sense of meaninglessness
or purposelessness, loss of mental capabilities, loss
of mobility, disorientation and confusion, sorrow
over the impact of one’s illness and death on one’s
family, loss of ability even to recognize loved ones,
and more. Often, these causes of suffering are
compounded by the awareness that the future will
be even bleaker. Unrelieved pain is simply not the
only condition under which death is preferable to
life, nor the, only legitimate reason for a desire to
end one’s life.
(2) In cases of terminal illness, death eventually
offers the dying person, relief from all her suffering.
Consequently, things can be even worse when there
is NO terminal illness, for then there is no end in
sight. Both pain and suffering are often much worse
when they are not accompanied by a terminal ill-
ness. People with progressive dementia, for example,
often suffer much more if they are otherwise quite
healthy. I personally know several old people who
would be delighted to learn that they have a termi-
nal illness. They feel they have lived long enough—
long enough to have outlived all their loved ones
and all sense of a purpose for living. For them, even
daily existence is much worse because there is no
end in sight.
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684 PA R T 3 : L I F E A N D D E AT H
Discussions of euthanasia and physician-assisted
suicide cannot, then, be restricted to those with
unrelieved pain and terminal illness. We must also
consider requests made by those who have no un-
treatable pain and no terminal illness. Often, their
case for relief is even more compelling.
Sometimes, a refusal of medical treatment will
be enough to bring relief. Competent adults who are
suffering from an illness have a well-established
moral and legal right to decline any form of medical
treatment, including life-prolonging medical treat-
ment. Family members who must make medical
decisions for incompetent people also have the right
to refuse any form of medical treatment on their
behalf, so long as they are acting in accordance with
the known wishes or best interests of their loved
one. No form of medical treatment is compulsory
when someone would be better off dead. 3
But those who would be better off dead do not
always have terminal illnesses; they will not always
need any form of medical treatment, not even medi-
cally supplied food and water. The right to refuse med-
ical treatment will not help these people. Moreover,
death due to untreated illness can be agonizingly
slow, dehumanizing, painful, and very costly, both in
financial and emotional terms. It is often very hard.
Refusing medical treatment simply will not always
ensure a dignified, peaceful, timely death. We would
not be having a national debate about physician-
assisted suicide and euthanasia if refusal of medical
treatment were always enough to lead to a reasonably
good death. When death comes too late, we may need
to do more than refuse medical treatment.
Religion and Ending a Life
Some people can easily see that there are people
who would be better off dead. But they still cannot
accept suicide or physician-assisted suicide because
they believe we have a duty to God not to take our
own lives. For them, human life is a gift from God
and it remains a gift no matter how much pain and
suffering it may bring. It is a sin or an offense against
God, the giver of life, to take your own life or to help
someone else end theirs. Such believers may also feel
that no one should be allowed to end their lives—
every life is a gift from God, even the lives of those
who do not believe that this is so.
I do not understand this position for two rea-
sons. First, it involves the assumption that it is
possible to take a human life (our own or someone
else’s) before God wants it ended, but we cannot
possibly preserve it after God wants it ended. For
if we do not make that assumption, we face two
dangers—the danger that we are prolonging human
life beyond its divine purpose, as well as the danger
that we are ending it too soon. If we can extend life
longer than God intends, suicide and physician-
assisted suicide may be more in accord with God’s
wishes than attempts to preserve that life.
I can understand the view that everyone dies at
precisely the right time, the moment God intends.
If that is so, people who commit suicide or who are
intentionally killed by physicians also die at precisely
the moment God wants them to die. I can also un-
derstand the view that we can take life before God
wants it ended but we can also extend life longer
than God wants it prolonged. But I cannot make
sense of the view that we can end a human life too
soon but not preserve it too long. Surely, God has
given us both abilities or neither one.
I also have a second difficulty with this religious
objection to suicide, assisted suicide and euthanasia.
Suppose there is a right time to die, a divinely or-
dained moment when God wants each life to end.
Even so, we have no right to assume that God will
“take my life” when it’s the right time for me to die.
In fact, we cannot even assume that God will send a
terminal illness that will kill me at the right time.
There could be a religious test—God may want me
to take my own life and the question is whether I will
meet this final challenge. Or a God who loves me
might see that I would benefit spiritually from the
process of coming to the conclusion that I should
end my own life and then preparing to take it. That
might be a fitting ending for me, the culminating
step in my spiritual growth or development.
In short, a God not totally obsessed with the
sheer quantity of our lives may well have purposes
for us that are incompatible with longer life—even
if we want to live longer. So, I think we should not
believe that we always have a duty to God not to take
our lives or to assist others in ending theirs. God
may want me to step up and assume the responsi-
bility for ending my own life or for seeing that
10-Vaughn-Chap10.indd 684 26/05/16 4:28 PM
Chapter 10: Euthanasia and Physician-Assisted Suicide 685
someone else’s suffering is ended. This observation
leads to our next question: Can there be a responsi-
bility or duty to die?
The Duty to Die
I may well one day have a duty to die, a duty most
likely to arise out of my connections with my family
and loved ones. 4 Sometimes preserving my life can
only devastate the lives of those who care about me.
I do not believe I am idiosyncratic, morbid or morally
perverse in believing this. I am trying to take steps
to prepare myself mentally and spiritually to make
sure that I will be able to take my life if I should one
day have such a duty. I need to prepare myself; it
might be a very difficult thing for me to do.
Our individualistic fantasy about ourselves some-
times leads us to imagine that lives are separate and
unconnected, or that they could be so if we chose.
If lives were unconnected, then things that happen
in my life would not or need not affect others.
And if others were not (much) affected by my life,
I would have no duty to consider the impact of
my life on others. I would then be morally free to
choose whatever life and death I prefer for myself.
I certainly would have no duty to die when I would
prefer to live.
Most discussions of assisted suicide and eutha-
nasia implicitly share this individualistic fantasy:
they just ignore the fact that people are connected
and lives intertwined. As a result, they approach
issues of life or death as if the only person affected
is the one who lives or dies. They mistakenly assume
the pivotal issue is simply whether the person her-
self prefers not to live like this and whether she her-
self would be better off dead. 5
But this is morally obtuse. The fact is we are not
a race of hermits—most of us are connected to
family and loved ones. We prefer it that way. We
would not want to be all alone, especially when we
are seriously ill, as we age, and when we are dying.
But being with others is not all benefits and plea-
sures; it brings responsibilities, as well. For then what
happens to us and the choices we make can dramat-
ically affect the lives of our loved ones. It is these
connections that can, tragically, generate obliga-
tions to die, as continuing to live takes too much
of a toll on the lives of those connected to us. 6
The lives of our loved ones can, we know, be seri-
ously compromised by caring for us. The burdens
of providing care or even just supervision 24 hours
a day, 7 days a week, are often overwhelming. 7 But
it can also be emotionally devastating simply to be
married to a spouse who is increasingly distant,
uncommunicative, unresponsive, foreign and un-
reachable. A local newspaper tells the story of a
woman with Alzheimer’s who came running into
her den screaming: “That man’s trying to have sex
with me! He’s trying to have sex with me! Who IS
that man?!” That man was her loving husband of more
than 40 years who had devoted the past 10 years of
his life to caring for her (Smith, 1995). How terrible
that experience must have been for her. But how
terrible those years must be for him, too.
We must also acknowledge that the lives of our
loved ones can also be devastated just by having
to pay for health care for us. A recent study docu-
mented the financial aspects of caring for a dying
member of a family. Only those who had illnesses
severe enough to give them less than a 50 percent
chance to live six more months were included in
this study. When these patients survived their ini-
tial hospitalization and were discharged, about one-
third required considerable caregiving from their
families; in 20 percent of cases a family member
had to quit work or make some other major lifestyle
change; almost one-third of these families lost all of
their savings, and just under 30 percent lost a major
source of income (Covinsky et al., 1994).
A chronic illness or debilitating injury in a
family is a misfortune. It is, most often, nobody’s
fault; no one is responsible for this illness or injury.
But then we face choices about how we will respond
to this misfortune. That is where the responsibility
comes in and fault can arise. Those of us with fami-
lies and loved ones always have a responsibility not
to make selfish or self-centered decisions about our
lives. We should not do just what we want or just
what is best for us. Often, we should choose in light
of what is best for all concerned.
Our families and loved ones have obligations to
stand by us and to support us through debilitating
illness and death. They must be prepared to make
sacrifices to respond to an illness in the family.
We are well aware of this responsibility and most
10-Vaughn-Chap10.indd 685 26/05/16 4:28 PM
686 PA R T 3 : L I F E A N D D E AT H
families meet it rather well. In fact, families deliver
more than 80 percent of the long-term care in the
US, almost always at great personal cost.
But responsibility in a family is not a one-way
street. When we become seriously ill or debilitated,
we too may have to make sacrifices. There are limits
to what we can ask our loved ones to do to support
us, even in sickness. There are limits to what they
should be prepared to do for us—only rarely and
for a limited period of time should they do all they
can for us.
Somehow we forget that sick, infirm, and dying
adults also have obligations to their families and
loved ones: a responsibility, for example, to try to
protect the lives of loved ones from serious threats
or greatly impoverished quality, or an obligation to
avoid making choices that will jeopardize or seri-
ously compromise their futures. Our obligations to
our loved ones must be taken into consideration in
making decisions about the end of life. It is out of
these responsibilities that a duty to die can develop.
Tragically, sometimes the best thing you can do
for your loved ones is to remove yourself from their
lives. And the only way you can do that may be to
remove yourself from existence. This is not a happy
thought. Yet we must recognize that suicides and re-
quests for assisted suicide may be motivated by love.
Sometimes, it’s simply the only loving thing to do.
Who Has a Duty to Die?
Sometimes it is clear when someone has a duty to
die. But more often, not. WHO has a duty to die? And
WHEN—under what conditions? To my mind, these
are the right questions, the questions we should be
asking. Many of us may one day badly need answers
to just these questions.
But I cannot supply answers here, for two rea-
sons. In the first place, answers will have to be very
particular and individualized . . . to the person, to
the situation of her family, to the relationships
within the family, etc. There will not be simple an-
swers that apply to everyone.
Secondly and perhaps even more importantly,
those of us with family and loved ones should not
define our duties unilaterally. Especially not a deci-
sion about a duty to die. It would be isolating and
distance-creating for me to decide without consulting
them what is too much of a burden for my loved
ones to bear. That way of deciding about my moral
duties is not only atomistic, it also treats my family
and loved ones paternalistically—THEY must be
allowed to speak for themselves about the burdens
my life imposes on them and how they feel about
bearing those burdens.
I believe in family decision making. Important
decisions for those whose lives are interwoven should
be made together, in a family discussion. Granted, a
conversation about whether I have a duty to die
would often be a tremendously difficult conversation.
The temptations to be dishonest in such conversa-
tions could be enormous. Nevertheless, if we can, we
should have just such an agonizing discussion—
partly because it will act as a check on the informa-
tion, perceptions and reasoning of all of us; but
perhaps even more importantly, because it affirms
our connectedness at a critical juncture in our lives.
Honest talk about difficult matters almost always
strengthens relationships.
But many families seem to be unable to talk
about death at all, much less a duty to die. Certainly
most families could not have this discussion all at
once, in one sitting. It might well take a number of
discussions to be able to approach this topic. But
even if talking about death is impossible, there
are always behavioral clues—about your caregiver’s
tiredness, physical condition, health, prevailing
mood, anxiety, outlook, overall well-being, etc. And
families unable to talk about death can often talk
about those clues. There can be conversations about
how the caregiver is feeling, about finances, about
tensions within the family resulting from the illness,
about concerns for the future. Deciding whether
you have a duty to die based on these behavioral clues
and conversation about them is more relational
than deciding on your own about how burdensome
this relationship and care must be. 8
For these two reasons, I cannot say when some-
one has a duty to die. But I can suggest a few ideas
for discussion of this question. I present them here
without much elaboration or explanation.
1. There is more duty to die when prolonging
your life will impose greater burdens—
emotional burdens, caregiving, disruption
10-Vaughn-Chap10.indd 686 26/05/16 4:28 PM
Chapter 10: Euthanasia and Physician-Assisted Suicide 687
of life plans, and, yes, financial hardship—
on your family and loved ones. This is the
fundamental insight underlying a duty to die.
2. There is greater duty to die if your loved ones’
lives have already been difficult or impover-
ished (not just financially)—if they have had
only a small share of the good things that life
has to offer.
3. There is more duty to die to the extent that
your loved ones have already made great
contributions—perhaps even sacrifices—to
make your life a good one. Especially if you
have not made similar sacrifices for their
well-being.
4. There is more duty to die to the extent that
you have already lived a full and rich life.
You have already had a full share of the good
things life offers.
5. Even if you have not lived a full and rich life,
there is more duty to die as you grow older.
As we become older, there is a diminishing
chance that we will be able to make the
changes that would now be required to turn
our lives around. As we age, we will also be
giving up less by giving up our lives, if only
because we will sacrifice fewer years of life.
6. There is less duty to die to the extent that
you can make a good adjustment to your ill-
ness or handicapping condition, for a good
adjustment means that smaller sacrifice will
be required of loved ones and there is more
compensating interaction for them. (However,
we must also recognize that some diseases—
Alzheimer’s or Huntington’s chorea—will
eventually take their toll on your loved ones
no matter how courageously, resolutely, even
cheerfully you manage to face that illness.)
7. There is more duty to die to the extent that
the part of you that is loved will soon be gone
or seriously compromised. There is also more
duty to die when you are no longer capable of
giving love. Part of the horror of Alzheimer’s
or Huntington’s, again, is that it destroys
the person we loved, leaving a stranger and
eventually only a shell behind. By contrast,
someone can be seriously debilitated and
yet clearly still the person we love.
In an old person, “I am not ready to die yet” does
not excuse one from a duty to die. To have reached
the age of, say, 80 years without being ready to die is
itself a moral failing, the sign of a life out of touch
with life’s basic realities.
A duty to die seems very harsh, and sometimes it
is. But if I really do care for my family, a duty to
protect their lives will often be accompanied by a
deep desire to do so. I will normally want to protect
those I love. This is not only my duty, it is also my
desire. In fact, I can easily imagine wanting to spare
my loved ones the burden of my existence more
than I want anything else.
If I Should Be Dead, Who Should Kill Me?
We need to reframe our discussions of euthanasia
and physician-assisted suicide. For we must recog-
nize that pleas for assisted suicide are sometimes
requests for relief from pain and suffering, some-
times requests for help in fulfilling one’s obligations,
and sometimes both. If I should be dead for either
of these reasons, who should kill me?
Like a responsible life, a responsible death requires
that we think about our choices in the context of the
web of relationships of love and care that surround
us. We must be sensitive to the suffering as well as the
joys we cause others, to the hardships as well as the
benefits we create for them. So, when we ask, “Who
should kill me?” we must remember that we are
asking for a death that will reduce the suffering of
both me and my family as much as possible. We are
searching for the best ending, not only for me, but for
everyone concerned—in the preparation for death, the
moment of death, and afterwards, in the memory and
on-going lives of loved ones and family.
Although we could perhaps define a new profes-
sion to assist in suicides—euthanasians??—there are
now really only three answers to the question, “Who
should kill me?” (1) I should kill myself. (2) A loved
one or family member should kill me. (3) A physician
should kill me. I will consider these three possibili-
ties. I will call these unassisted suicide, family-assisted
suicide, and physician-assisted suicide.
1 Unassisted Suicide: I Should Kill Myself
The basic intuition here is that each of us should
take responsibility for herself. I am primarily the
10-Vaughn-Chap10.indd 687 26/05/16 4:28 PM
688 PA R T 3 : L I F E A N D D E AT H
one who wants relief from my pain and suffering, or
it is fundamentally my own duty to die and I should
be the one to do my duty. Moreover, intentionally
ending a life is a very messy business—a heav y,
difficult thing for anyone to have to do. If possible,
I should not drag others into it. Often, I think, this
is the right idea—I should be the one to kill myself.
But not always. We must remember that some
people are physically unable to do so—they are too
weak or incapacitated to commit suicide without
assistance. Less persuasive perhaps are those who
just can’t bring themselves to do it. Without the
assistance of someone, many lack the know-how or
means to end their lives in a peaceful, dignified
fashion. Finally, many attempted suicides—even
serious attempts at suicide—fail or result in terrible
deaths. Those who have worked in hospitals are
familiar with suicide attempts that leave people
with permanent brain damage or their faces shot
off. There are also fairly common stories of people
eating their own vomit after throwing up the medi-
cine they hoped would end their lives.
Even more importantly, if I must be the one to
kill myself, that may force me to take my life earlier
than would otherwise be necessary. I cannot wait
until I become physically debilitated or mentally
incompetent, for then it will be too late for me to
kill myself. I might be able to live quite comfortably
for a couple more years, if I could count on someone
else to take my life later. But if I cannot count on
help from anyone, I will feel pressure to kill myself
when unavoidable suffering for myself or my loved
ones appears on the horizon, instead of waiting
until it actually arrives.
Finally, many suicides are isolating—I can’t die
with my loved ones around me if I am planning to
use carbon monoxide from automobile exhaust to
end my life. For most of us, a meaningful end of life
requires an affirmation of our connection with
loved ones and so we do not want to die alone.
The social taboo against ending your own life
promotes another type of isolation. The secrecy pre-
ceding many …
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