Keerut Oberai considers the benefits and drawbacks of the main ethical theories - this month, focusing on consequentialist ethics.

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Introduction

As discussed in the first part of this series (https://www.nature.com/articles/s41407-023-1860-z), dental ethics provides us with a way to distinguish between right and wrong action. Furthermore, there are two desirable features of ethical theories. Firstly, they ought to provide a justification or well considered reasons as to why certain moral actions are advocated. Secondly, they ought to be universal and impartial.

In ethics and moral philosophy, there is yet to be agreement on which ethical theory should be universally adopted and considered to be objectively 'correct'. In the remainder of this series, the main ethical theories will be considered along with their benefits and drawbacks, as well as their uses in dentistry. In this part of the series, we will begin by looking at consequentialist ethics in more detail.

Consequentialist ethics

Consequentialism claims that we can distinguish whether an action is right or wrong by looking at the consequences that the action brings about. The right action is the one which brings about the most desirable consequences. Any consequentialist ethical theory must identify what counts as a desirable outcome and provide a justification as to why this is the case.

The most notorious consequentialist theory is utilitarianism which was put forward by John Stuart Mill.1 This ethical theory claims that we as human beings desire happiness and that the right action is the one that promotes the greatest amount of happiness (sometimes referred to as utility) or conversely, the least amount of pain. This is known as the 'Greatest Happiness Principle'. Let us now look at a straightforward example of utilitarianism in action. Imagine we are confronted with an ethical dilemma which presents us with two possible actions.

  1. 1.

    Moral Action A produces 10 units of happiness and 5 units of pain (5 units of happiness overall)

  2. 2.

    Moral Action B produces 20 units of happiness and 10 units of pain (10 units of happiness overall).

Utilitarianism would claim that the right action in this case is Moral Action B as it produces the greatest amount of overall happiness. Importantly, we are considering which action produces the greatest amount of net happiness.

In addition, utilitarianism is objective and impartial which, as we have discussed, are desirable features of an ethical theory. It claims that our aim should not simply be to generate our own maximum happiness but the maximum overall happiness regardless of whose it is. Crisp highlights this by distinguishing between 'egoistic hedonism' and 'universalistic hedonism'.2 In the former, each individual tries to maximise their own happiness. In the latter, which Mill advocates, the individual aims to maximise overall happiness, regardless of whose happiness it is.

Mill's utilitarianism is therefore impartial meaning the moral agent cannot put their own desires above those of others when maximising happiness. He summarises this in Chapter 5 of Utilitarianism by claiming 'that principle is a mere form of words without rational signification, unless one person's happiness, supposed equal in degree… is counted for exactly as much as another's'.1

In dentistry, especially in public health scenarios, utilitarianism can be a useful tool.

To summarise, utilitarianism claims that the right action to take when presented with an ethical dilemma is the one which produces the greatest amount of happiness or conversely, the least amount of pain. In addition, it is impartial and objective. In the next section, we will consider how utilitarianism relates to healthcare and specifically dentistry.

Utilitarianism in dentistry

During the COVID-19 pandemic there were many discussions about how resources should be allocated. In most cases a utilitarian justification was given when making decisions with analysis being based on what would produce the greatest overall utility for the population. However, such justifications are not novel and have been used a great deal in the past. For example, in the use of Quality Adjusted Life Years which measure the utility, in terms of the benefit to the patient's quality of life, that an intervention would produce over a period of time. It is essentially, the 'measure of the value of health outcomes'.3

In dentistry, especially in public health scenarios, utilitarianism can be a useful tool. Utilitarianism allows us to compare two interventions or ways of allocating resources and provide an objective way of justifying our decision of which one to choose. However, comparing two interventions is not always straightforward. For example, let us consider two interventions:

  1. 1.

    Intervention A will produce 5 units of utility for 1,000,000 people thus providing 5,000,000 units of utility overall

  2. 2.

    Intervention B will produce 500 units of utility for 10,000 people thus providing 5,000,000 units of utility overall.

In this example, the same amount of utility is produced in both actions. This creates a tension in knowing which action to take and leaves us having to appeal to other factors to justify our decision.

Let us now imagine that Intervention A and Intervention B are considering two ways in which we can allocate NHS dental resources. As we are aware, access to NHS dentistry has become increasingly difficult with the number of NHS dentists decreasing over the last few years. So, in this case, imagine that Intervention A claims that we should take the remaining funding and resources available and provide dentistry to as many people as possible providing a basic level of dentistry. In contrast, Intervention B would argue that we should take the limited resources available and provide a smaller number of patients with an increased level of care. Again, we see that the same amount of utility would be produced meaning it is difficult to justify which action we should take on purely utilitarian grounds. In this case, we may appeal to other ethical factors such as considering who would be treated in Intervention B - would it be the case that this includes more vulnerable or in need groups such as the elderly and children?

Whilst utilitarianism is a useful tool in straightforward cases, the example above shows that it can be difficult to calculate which intervention to take when the amount of utility or happiness produced appears equal between the range of options. Furthermore, these calculations are based on predictions of the benefit that will be gained from outcomes; however, there will always be variables that we cannot account for. This is a common criticism of utilitarianism with critics arguing that it commits us to a form of 'utilitarian calculus' in which we are left reducing ethical decisions to mathematical ones. In the next section, further criticisms of utilitarianism will be considered.

Criticisms of utilitarianism

In this section, I will present two criticisms which are commonly lodged against utilitarianism. The first criticism claims that basing ethical decisions on what would produce the greatest amount of happiness or utility can result in utilitarianism demanding that we carry out actions which appear morally repugnant.

An example of this was put forward by Thomson who asks us to imagine there is a ward of five patients who all require an organ transplant.4 On the next ward is a healthy patient who has attended for a routine medical check-up. This patient also happens to be a matching donor to the other patients who require organ transplants. Critics argue that utilitarianism would condone killing this healthy patient in order to use their organs for the transplant patients on the basis that it would provide the greatest amount of happiness overall. Whilst it is of course contentious that this would be the case, these critics claim that this example shows that utilitarianism can force us to accept outcomes which appear to conflict with our intuition of what is right and wrong.

Critics argue that utilitarianism would condone killing this healthy patient in order to use their organs for the transplant patients on the basis that it would provide the greatest amount of happiness overall.

Another criticism of utilitarianism is its claim that we only value happiness. Nozick disagrees with this central claim and uses the 'Experience Machine' thought experiment to demonstrate this.5 He asks us to imagine that there is a machine that we could connect to which would transport us to a virtual world. Whilst connected to this machine we would only experience happiness and never experience any pain or upset. Our bodies would be maintained in the real world, but we would forever be connected to the virtual one. Nozick claims that despite the promise of eternal happiness most of us would choose to stay in the real world. He uses this as a justification that we do not only desire happiness. Instead, we want to have authentic experiences in the real world, be certain sorts of people and not be limited to a virtual man-made reality.5

Both criticisms are not silver bullets to discredit utilitarianism, but they do highlight tensions and difficulties that those who support this ethical theory must refute.

Conclusion

Utilitarianism, a form of consequentialism, appears an initially appealing way to help us navigate complex ethical issues and to provide an objective way of distinguishing between a range of options. As we saw in the pandemic it can be used when making public health decisions such as resource allocation. However, it is not without fault as demonstrated in the 'Survival Lottery' and 'Experience Machine' thought experiments. In the next part of this series, we will look at non-consequentialist ethics and virtue ethics whilst considering their role in professionalism in dentistry.