The cases in this book deal with ethics. So before looking directly at the problems they pose, we need to have some basic understanding of the meaning of morality and ethics. It will also be helpful to know how moral claims are justified and what some of the major positions are in ethics. This chapter and the next will outline some answers to these questions. In chapter 5 we will explore ways to solve ethical problems as posed in clinical cases.
The Meaning of Ethics and Morals
Distinguishing the Factual from the Evaluative
Many questions faced in dentistry can be viewed as questions of fact. A dentist may want to know whether an amalgam or a composite resin restoration is likely to last longer or whether a pulp is infected. These are questions that we can assume, at least for now, can be answered by good dental science.
There are other kinds of factual questions relevant to dentistry as well. Dental patients may want to know the cost of different kinds of restorations, whether a procedure will be painful, or whether a crown will be cosmetically noticeable. Dentists may want to know whether the law permits a waiver of liability when a patient asks for a procedure the dentist cannot endorse. These are not exactly questions of dental science, but nonetheless they are what we can consider matters of fact.
One can know all of the relevant scientific facts about dentistry and still not know how to proceed with clinical dentistry. It is impossible to know whether a dental procedure is good or bad, right or wrong, without turning to the realm of evaluation. It is only with the combination of knowledge of the relevant facts and some framework of evaluation that one can know what is clinically appropriate. In short, to know what to do, the decision-maker has to know what a desirable outcome is.
Recognizing that an evaluation is taking place is not as easy as it may seem. Deciding that one approach is better than another will in itself require an evaluation. Deciding that a treatment has side effects does so as well. By saying that a treatment has a side effect, we are acknowledging it is undesirable. Even the claim that a dental procedure is “indicated” is a claim with some evaluative component; it is a claim that, all things considered, the procedure offers a better mix of risks and benefits than does any alternative. Evaluations are ubiquitous in dentistry as in all clinical professions.
One way to recognize an evaluation is to look for evaluative terms: “good” or “bad,“ “right” or “wrong,” “desired” or “undesired.” Sometimes the evaluations are slightly disguised, as when a treatment is “recommended” or “ordered.” In addition, the phrases “risk,” “harm,” “side effect,” “treatment of choice,” and “medically indicated” all signal an evaluative judgment. Sometimes evaluations take the form of declarative sentences that are really value judgments in disguise, for example, “You don’t want to chew on that side for an hour” or “the dentist is dedicated to the welfare of the patient.” These statements imply the value judgments that it would be bad to chew too soon or that a “good” dentist is dedicated to the welfare of the patient. One of the keys to dental ethics is learning to recognize the evaluative judgments that occur in all clinical decisions.
Moral and Nonmoral Evaluations
Of course, not all evaluations are moral or ethical; they might simply be matters of personal taste or preference. One person may find a gold crown attractive; another may find it garish. Although both have made evaluations, we do not consider either to have made a moral evaluation. Some evaluations are merely matters of societal preference. Others are esthetic evaluations. Still others may be cultural or religious without being moral or ethical.
A moral or ethical evaluation must meet certain characteristics. First, it must be an evaluation of a person’s actions or character. Even among evaluations of actions or character, not all evaluations are moral. A dancer may be graceful, a dentist may show great manual dexterity. Any value judgment made about an inanimate object—a painting or a partial restoration—will not be a moral judgment (although one may certainly make a moral judgment about the person who did the painting or made the restoration).
The distinction between moral and nonmoral evaluations is not always a sharp one, but most people tend to think of an evaluation as moral or ethical when it meets most, if not all, of the following five characteristics.
Ultimacy Perhaps the most critical characteristic of moral or ethical evaluations is that the standard by which the judgment is made is deemed ultimate, ie, there seems to be no higher standard by which one might judge. The judgment has what the philosopher John Rawls calls ‘‘finality.’’1,2 If we say that lying to a patient to cover up a bungled restoration is immoral, we mean that it is wrong by the highest, most definitive standard that we can imagine. That standard might be “the eyes of God” or some secular equivalent based in reason or on the moral law of nature. By contrast, if when asked why you believe a behavior is right you claim that your favorite textbook said so, or that your friend or community said so, we would be justified in asking why you consider these to be the ultimate standard of reference. When we say something is morally good or bad, right or wrong, we are saying it is so by the most ultimate standard of reference we can imagine.
Universality Moral or ethical evaluations are often also said to be universal.1 By this we mean that if other people are considering exactly the same action or character trait in exactly the same situation, they ought to come to the same evaluative conclusion. If we say that Dr Jones’s lying to cover up a mechanical exposure in a particular patient is morally wrong, we mean that everyone should consider this lie by Dr Jones to be immoral. Used in this way, the term universality does not imply rigidity or legalism. It is not the view that all lying, no matter what the circumstances, is always wrong. It is conceivable that Dr Jones might be thought to be right in lying in some extreme circumstance—to save his life or the life of someone else. The claim made here is that when we say an evaluation is a moral evaluation, we believe that anyone considering an act (like a particular lie) ought to come to the same evaluation that we do.
In this sense moral evaluations are different from matters of personal taste or even societal judgment. We do not consider it a contradiction if one person likes gold and another does not. These preferences we treat as a matter of taste about which people may disagree without contradicting one another. If, however, we say that someone was morally wrong to extract a sound tooth on a particular occasion, we imply that anyone considering that act on that occasion ought to come to the same conclusion.
From this standpoint, moral judgments are like scientific judgments. Any two people considering exactly the same event at the same time ought to agree on their account of it. Of course, this does not mean that people actually do always agree on moral judgments any more than they agree on scientific judgments. It is only that, for matters believed to be universal, there cannot be contradictory accounts that are true simultaneously. If two people give contradictory accounts of the same event at the same time, at most only one can be right.
Altruism or neutralism Another characteristic of moral evaluations is that they are neutral or “general.” Judgments cannot be tailored to the advantage of the person making the judgment. The dentist should not recommend a fixed partial denture only because the amount of profit is greater than that for a partial denture. A rule that permitted dentists to recommend a course solely because it was the most profitable would not satisfy the criterion of neutrality unless one were willing to accept a rule saying that all trusted advisors could recommend action based solely on personal profit. Principles and rules of morality cannot be crafted to promote the advantage of the person stating them.
Publicity Another criterion that tends to make evaluations moral is that one must be willing to publicly state the evaluation and the basis on which it is made. This rules out judgments that rely on secretiveness to produce the desired effect. For example, a pediatric dentist contemplates telling a young child that drilling probably will not hurt when he knows that it almost certainly will. He considers that a white lie in this case will avoid anxiety for the child and is therefore justified. However, if it were publicly known to patients that this dentist followed a policy of lying to make patients feel better, his goal would be defeated. According to the criterion of publicity, a policy such as this is a moral policy only if it can be made known publicly.
Ordering Finally, any set of principles, rules, or character assessments should provide a basis for ranking conflicting claims. Ethical problems often arise in professional practice when one is caught between two competing obligations. For example, the dentist wants to do as much good as possible by restoring a certain tooth, whereas the patient, appealing to autonomy, wants to have it extracted. A systematic ethical account should be able to tell which claim has moral priority and why.
These five criteria—ultimacy, universality, altruism or neutralism, publicity, and ordering—constitute criteria of an ethical system and provide a way to distinguish moral from nonmoral judgments. If an evaluative claim that is made about human conduct or character meets these five criteria, it will be a moral or ethical claim.
Distinguishing the Moral and the Ethical
So far we have distinguished factual claims from evaluative judgments and distinguished those judgments that are not moral or ethical from those that are. We should also clearly understand the two terms that are used to apply to judgments that meet the criteria we have just outlined. We have variously called these evaluative judgments moral or ethical. But what is the difference?
Some people, considering that the term moral has the same root as mores or customs, use moral to apply to social customs or habits. In English, however, mores are distinguished from morals. Mores, in fact, are not considered to be in the realm of the moral. Customs or societal practices, after all, can be well established without necessarily being moral. Mores refer to the well-established practices of a society; they are not necessarily grounded in some ultimate source of judgment beyond which there can be no appeal. For example, a particular culture may consider a woman who wears a short skirt to be immoral, even though we, as outside observers, recognize that this judgment merely reflects current social consensus.
Another attempt to define moral equates the moral with deeply held, even religious, convictions. While moral positions may be deeply held and may be grounded in religious traditions, they need not be either deeply held or religiously grounded. Moreover, ethical positions also may be deeply held and religiously grounded. Thus, whether the conviction is deeply held or religious does not seem to be a basis for separating the terms moral and ethical.
There is another sense in which people have tried to distinguish the moral and the ethical. Our unreflective, ad hoc judgments can be called moral judgments, while more systematic, reasoned accounts of these judgments are sometimes referred to as an ethic. If this distinction correctly distinguishes the two terms, then morality refers to specific judgments while ethics refers to the disciplined, systematic, reasoned theory that might support the specific moral judgments. In this sense, all people make moral judgments, but only some can provide an ethical account that supports the moral judgments. Ethics is the systematic reflection on morals.
In this book we use the term moral to refer to specific judgments and the term ethical to refer to systematic reflection. There is no hard-and-fast separation between the two, but when referring to an ad hoc judgment by a dentist, patient, or society, we will call it a moral judgment. When we are examining a more systematic theory of moral rightness or wrongness, as in the code of ethics of the American Dental Association, a religious group, or a philosophical school, we shall speak of ethics.
If moral judgments and the ethical systems that stand behind them have their grounding in an ultimate standard beyond which there is no appeal, just what might that ultimate grounding be? Much of the history of ethical theory has been devoted to answering that question. Several foundations of ethics have been proposed.
When people first begin to reflect on their moral judgments, it is not uncommon for them to suspect that what we call ethics is really nothing more than the judgments of our culture. For something to be considered moral, according to a position often called cultural relativism, it must simply meet with the approval of one’s culture.
Undoubtedly, the judgments of different cultures differ widely over matters believed to be moral. We are talking not only about skirt length and sexual practices but also about basic beliefs regarding the rightness of lying, killing, breaking promises, and injuring others. One possible explanation is that when people live in different cultures, they express the judgments of their cultures.
Upon examination, this position of cultural relativism poses serious problems. First we must distinguish between descriptive relativism and normative relativism. Descriptive relativism is a factual claim that people in different cultures have differing views about matters believed to be moral. Almost no one who has witnessed more than one culture denies that such differences do, in fact, exist.