1. Moral Reasoning and Decision Making

2. Moral Reasoning and Decision Making
The aim in this session is to develop an understanding of how ethical decisions are made in practice, rather than in terms of abstract ethical theories.
At the end of this session, you should understand how theory and practice are connected, how empirical ethics is used and gain an understanding of ethical decision making models.

3. Introduction
What are we to make of the numerous ethical theories that have developed over the last two or three millennia?
When we say that someone is thinking ethically or resolving an ethical problem using reasoning, should this involve appeals to the theories of moral philosophers?

4. UTILITARIANISM DEONTOLOGY 4 PRINCIPLES OF BIOMEDICAL ETHICS
RIGHTS
COMMUNITARIAN
ETHICS
DEONTOLOGY
UTILITARIANISM
PRIMA FACIE
ETHICS
NATURAL LAW
NARRATIVES
VIRTUE ETHICS
4 PRINCIPLES OF
BIOMEDICAL ETHICS
CASUISTRY

5. Other Approaches
A number of different ways of considering how to make ethical decisions in practice have been suggested:
Consider individual’s intuitions and ‘considered judgements’ in relation to existing theory,
Use empirical methods to reflect upon how individuals actually act,
Offer pragmatic and practical models of ethical decision making.

6. Linking Theory and Practice
It has been increasingly argued that traditional, normative ethical theories fail to be of relevance in actual situations.
Hegel’s famous criticism of Kant’s deontological approach as ‘empty formalism’ may reflect a difficulty in applying/conforming to some theories.
Society has also become increasingly secular and has largely rejected a monistic or religious approach to ethical justification.
Post-modernism rejects the Enlightenment’s rational aims in the light of linguistic and social uncertainty.

7. Up and Down
The traditional way of thinking about ethical theory was deductively – ‘top down’ - proceeding from accepted general ethical concepts and applying them to particular situations. E.g.
Kant’s Categorical Imperative
Specific formulation ‘treat others as ends in themselves’
Applied to volunteers in drug trial
Leads to decision never to exploit them

8. Up and Down
Increasingly, however, inductive or ‘bottom up’ approaches have been championed. These appeal to our considered judgements and also settled cases and from which generalisations can be made and applied to other situations. (e.g. Casuistry)
But perhaps the most generally accepted form of decision making used is a coherentist one – where one belief can only be justified in relation to another. Rawls’ reflective equilibrium is often used and he describes a process where our considered judgements are tested with reference to more generalised theories that explain these intuitions.

9. Linking theory and practice
Coherentist approaches appeal because they do not require either a search for definitive, paradigm cases on which to decide in an analogous situation or rely upon an abstracted, formal (and perhaps difficult, uncompromising) general ethical theory.
Reflect on considered judgements (intuitions)
Consider how these relate to generalised theories
Are these judgements and theories/rules consistent
Revise theory or intuitions NO
YES
Apply to ethical situation and make decision

10. Criticisms
One initial problem with coherentist approaches is that the process of formulating general rules or theories that accommodate intuitions could have justified Nazism, for example.
Inductivists would also argue that intuitions lack ethical credibility.
Perhaps try to combine the two by arguing that one should balance intuitions with existing ethical theories but how can one weigh-up such concerns?

11. Linking theory and practice
So far, an approach to understanding practical decision making has been offered that is still grounded in philosophy, albeit one that is sensitive to an individual’s ‘gut feelings’ and intuitions.
Obvious points to remember are that ethical reasoning should be free from contradictions and follow logical conclusions (e.g. syllogisms):
The taking of any life is ethically wrong.
Abortion involves the taking of a life.
Therefore, abortion is ethically wrong.

12. Exercise 1
How would you deal with the following situation and what are your intuitions about the situation:
“Mrs. Singh calls at your pharmacy to ask if you could check her son’s computer record and tell her what her son received last month from a locum doctor. The medicine is working but her GP has no record. Her son is not with her today as her has missed two day’s of the effective treatment.”
Now thinking about ethical theories, consider how utilitarianism, a rights-based approach, Kant’s Categorical Imperative and the ‘4 principles’ might be used.
Are your views consistent with theory?

13. Cognitive Moral Development
As psychology developed as a discipline, connections were made between cognitive processes and moral reasoning. Developing Piaget’s work with infant development, Lawrence Kohlberg developed a theory of CMD that has become extremely influential.
Based upon the experimental methods of psychology, Kohlberg’s theory was empirically based but also contained normative aspects.

14. Cognitive Moral Development
Basing his theory on a longitudinal study of adolescent American boys, Kohlberg argued that individuals develop moral reasoning ability in a number of discrete stages.
The theory was significant because it claimed that moral development occurs in much the same way as other psychological attributes like language, social skills, abstract reasoning and cognitive processes.
Individuals develop only a stage at a time and the theory applies to everyone.

15. Exercise 2 Consider the famous Heinz dilemma used in CMD:
“A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: "No, I discovered the drug and I'm going to make money from it." So Heinz got desperate and broke into the man's store to steal the drug for his wife.” (Kohlberg, 1963, p. 19)
Should Heinz break into the laboratory to steal the drug for his wife? Why or why not? Explain

16. Stage one (obedience): Heinz should not steal the medicine, because he will consequently be put in prison.
Stage two (self-interest): Heinz should steal the medicine, because he will be much happier if he saves his wife, even if he will have to serve a prison sentence.
Stage three (conformity): Heinz should steal the medicine, because his wife expects it.
Stage four (law-and-order): Heinz should not steal the medicine, because the law prohibits stealing.
Stage five (human rights): Heinz should steal the medicine, because everyone has a right to live, regardless of the law. Or: Heinz should not steal the medicine, because the scientist has a right to fair compensation.
Stage six (universal human ethics): Heinz should steal the medicine, because saving a human life is a more fundamental value than the property rights of another person. Or: Heinz should not steal the medicine, because that violates the golden rule of honesty and respect.

17. Cognitive Moral Development
Level 1
Stage 1
reasoning related to external punishment
Pre-conventional
Stage 2
egoistic self-interest
Level 2
Stage 3
reasoning that considers ones immediate peers
Conventional
Stage 4
broader social implications and laws
Level 3
Stage 5
principled reasoning that recognises the social contract
Post-conventional
Stage 6
universal ethical principles of Justice

18. Relevance of CMD
In short, its popularity! Especially in its latter development as a psychometric questionnaire test, CMD has been viewed as an ‘easy’ tool that operationalizes ethics and appears to have validity and reliability. Frequently used in health care.
CMD offers insights into how individuals actually make ethical decisions and could be used to identify more basic forms of reasoning.
However, despite empirical origins, it is inherently normative and assumes that higher reasoning is JUSTICE based. The choice of boys in original study and justice dilemmas may be contributory.

19. Criticisms
Despite its empirical origins, Kohlberg’s CMD is inherently normative and assumes that higher reasoning is JUSTICE based.
However, Gilligan has famously argued that Kohlberg’s male sample and selection of scenarios were inherently biased towards justice-based reasoning. Using a sample of women, initially, Gilligan proposed a possible alternative ethic of care.
In later forms, a psychometric‘defining issues test’ was developed (Rest) that pre-coded responses and produced statistical scores. Can you score ethics?

20. Ethical Decision Making Models
These are not the same as those in the psychological or statistical fields, which are grounded in issues such as probability, decision trees and outcome values.
Ethical decision making models are usually derived from two distinct concerns:
A research interest in explaining and also predicting how individuals make ethical decisions in practice.
A practical and pragmatic desire to offer help and assistance to individuals in making ethical decisions.

21. Ethical Decision Making Models
Are they useful?

22. Ethical Decision Making Models
Are they useful?

23. Ethical Decision Making Models
Should we be suspicious of attempts to reduce complex human activities and any attendant reasoning and decision making into convenient models?
It may be argued that some models are underpinned by empirical study and although this applies to models that attempt to predict or explain ethical behaviour, Kohlberg’s normativity might make us suspicious!
The prescriptive models often claim modesty in not attaching any specific ethical theory to their stages.

24. Ethical Decision Making Models
Model Stages in each model
(* denotes explanatory models, all other practical/prescriptive)

25. Ethical Decision Making Models
Despite the plethora of prescriptive and empirical models that exist in relation to ethics problem solving, there appear to be several common features and also some ‘front runners’:
For example, the model by Rest and Jones has been cited in many research papers and has been applied to business ethics and also healthcare (Holm). However, it remains an empirical rather than prescriptive model and provides insights into what individuals are understood to do in practice.

26. Ethical Decision Making Models
The Rest/Jones model contains 4 stages:
Identify ethical problem. An obvious point but concept of ethical attention or perception is often over-looked in literature.
Apply ethical reasoning. Rest (and Jones but not Holm) used CMD but other theories possible.
Establish moral intent (not egoistic self-interest).
Engage in ethical action (again obvious?) Related to moral motivation.
Influential but remains an explanatory model.

27. Ethical Decision Making Models
The prescriptive models often have similarities. In part, this is because they appear to have been influenced by proceeding models (Parker/Pellegrino, Wingfield/Weinstein).
There are several common features that may help guide the ethically conflicted:
Identify the problem and gather all the facts
Consider how law, rules, past experience and advice of others might be of use.
Use some form of ethical reasoning
Justify decision and act.

28. Exercise 3
“Sally calls into a pharmacy late on a Saturday afternoon and asks if she could be supplied with emergency hormonal contraception. The pharmacist, David, believes that EHC is a form of abortion and will not supply it or even recommend where else to obtain it. David does not want to offend Sally and simply says he doesn’t have any. Sally appears to be up-set and asks where else she can obtain EHC.”
Use one of the models described or a combination of them to consider whether David’s actions were ethically justified and what could be done in this situation.

29. Summary
This session has attempted to identify three approaches to how ethical decisions are made in practice and have considered:
Coherentist approaches that try to balance existing ethical theory with one’s intuitions.
CMD that uses empirical data to suggest that individuals progress through different stages but that justice is the most ethical form of reasoning.
Various models that try to either offer assistance or explanations as to how decisions could be made in practice.

30. Summary
Many of the criticisms identified in this session appear to be internecine. Realists clash with idealists, foundationalists with coherentists, psychologists with philosophers with social scientists.
What of the poor pharmacist?
Perhaps simply gaining a basic understanding of the diversity of ethical decision-making, recognising the role of intuitions,having an awareness of existing theory and applying simple rules of consistency and logic could be a helpful start.