Kantian deontology vs. Mills utilitarianism in medical science
It’s a seemingly simple concept: evaluate an act to decide whether it is a moral act or an immoral act. Without difficulty we accept that the answer is one of degrees - some acts are deeply immoral, others are inspirationally moral. But what does it mean to be moral? When we judge an act, which specific element are we judging? Should we attend to the motive of the act? To its outcome? To the deftness with which it is executed? These are the questions that John Stuart Mill and Immanuel Kant grappled with in defining theories of morality. Kant, writing earlier, proposed the theory that the motive of an act is the only basis upon which its morality can be judged, and further that morality can only be achieved when the motive is duty. A moral act is one executed in dutiful adherence to a personal moral law, and motivated only by duty and not by desire or inclination. The moral law must not be particular or specific to the circumstances of the act; Kant’s formulations of his theory, known as the categorical imperative, demand that the law or maxim must be one that the actor is willing to universalize. Lastly, Kant requires that moral will must always treat humanity as an ends, and never as merely a means to an end.
Mill explicitly rejected Kant’s categorical imperative and proposed an apparently opposite system for moral evaluation, one in which it became not only blessed but necessary to treat individual people as a means to an end. His theory of utilitarianism judges the morality of an act not by its motives or the virtues of the actor but purely by the outcome. Mill argues that the state of the world after an action should be the sole criteria for moral assessment: if there is greater happiness and less pain in the world after than before, then the act was moral no matter the means or motive.
It’s clear that whether people are a means, an end or both is deeply relevant to medical science and the practice of medicine, and how we evaluate the morality of an act directly bears on the development of ethical norms in research and clinical encounters between medical professionals and patients. Research in a clinical setting is an illustrative example: modern norms restrict the ability of surgeons to innovate in surgical practice on living patients, because each patient is entitled to the treatment most likely to be effective in restoring their health. Deontological ethics requires that the surgeon perform the procedure in the best interests of the patient, regardless of any desire to experiment or practice with alternate methods. Utilitarianism permits practice and experimentation if they lead to discoveries or innovation that later benefits many patients, even of the subjects of the research suffer or die during the process.
Utilitarianists would be similarly confounded by clinical research trials for new drugs, where ethics panels will demand that research be halted if patients suffer serious negative effects that researchers suspect are related to the drug being studied. Drugs that may give great benefit to some patients, or to many with further testing and development, are abandoned because they present a risk to the small number of patients participating in the trial. Researchers obey a categorical imperative to refrain from harming any patients, regardless of the ultimate benefit to future patients. This maxim - do no harm - is Kantian in nature and the basis for moral assessment in medicine. It discourages doctors from performing medically unnecessary procedures or prescribing medically unnecessary medications, even if such actions could plausibly lead to greater happiness on the part of their patients. These ethical norms are in clear opposition to utilitarian ethics and its inattention to the motives behind actions.
Immanuel Kant demands that no human being be seen as a means to an end, and argues that the will underlying an action is the only criteria for judging morality. No matter the benefit to the greater good, a decision that treats an individual as means or violates our duty to universalize the laws of treatment that we would apply to ourselves is immoral. Despite Mill’s rejection of deontological ethics and his exhortation to think only of the ultimate outcomes, medical ethics hews closely to Kant’s categorical imperative and his sense of duty to others and ourselves.
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