Doing Good and Avoiding Evil
Part I. Principles and Reasoning
by Lisa Newton

II. Decision Procedures for Ethics: ORDER
From Morals to Ethics

A problem of moral concern--like the heirs desire to dispatch their rich father, the boss's desire to make a quick profit, or the starvation of the African children--is not the same as an ethical dilemma. In a moral problem, we know what is right, but we may be puzzled about the right way to say "No" or the best means to obtain the best outcome. (Additionally, we may be tempted to preserve our level of comfort by doing nothing at all!) In an ethical dilemma, we really do not know what is right. Consider the following case:

Peter and Dora Vlasovic, 51 years and 43 years of age respectively, are at a loss as to what to do about Dora's 67-year old mother, who lives with them. She is suffering from Alzheimer's disease, and while her periods of confusion are not yet continual, she is becoming too unreliable to be left alone. Both husband and wife work outside the house, and cannot stay with Mother during the day. They started looking into appropriate Nursing Homes, but Mother, who was a schoolteacher and fiercely independent all her life, has put her foot down: no Homes. "Look, you know how valuable my mind and my dignity have been to me," she finally said to them. "I simply cannot endure the thought of ending my days tied in a chair drooling on my lap. See that pillow on my bed? When I can't function any more, my life is over, as far as I'm concerned, and I want you just to put that pillow over my face and sit on it for about twenty minutes. Just call the doctor in the morning and say I died in my sleep. I won't contradict you. No Homes."

Meanwhile, the couple has found out that the cost of these Homes is well beyond their means, and that Mother will be left on Medicaid after her assets are gone. Their own assets are not large, and they would be totally responsible for the costs if they hired nurses to come to the house to take care of her. They also have teen-age children, approaching college, to think about, who will need money for college and probably financial help as young adults after their education is finished.

"How did people used to handle this type of situation? Before there were Nursing Homes?" Dora had once asked her doctor. "Easy," he had replied, "People didn't used to live this long. And when they did, in this state, with no other choice in the matter, people simply left them home alone, tied down or roaming wherever they wanted to roam." That did sound "easy" to Dora, but on balance, worse than the other alternatives. They have the house to think of, too, and leaving Mother alone all day sounds like playing Russian Roulette with house and Mother both.

But their first concern is for Mother. The life projected for her does not really seem to be worth living, the more they think about it. "Putting a pillow over her face" is a dreadful thought, of course, but it is what Mother wants, and if they can't face the pillow, the Hemlock Society advertises many more humane ways to bring life to an end. Should they go the pillow route? Should they explore the "rational suicide" alternatives with Mother? Or should they insist on the Home (or put her there anyway after she is no longer organized enough to resist)? Or should they devastate their own financial resources with hired nurses? Are there other alternatives?

In our attempts to reach the good or just solution in this case, what approach do we take? Typically, if we are (personally) in the middle of cases like this, we are strongly tempted to grasp at whatever "solution" appeals to us at the moment: that is, whatever solution accords with our previous prejudices and tendencies. But one of the major objectives of the teaching of ethics is to draw us beyond that subjective stance to one where all rational persons could agree that the right course, or a right course, is being pursued. That means that we must reach a course of action that is objectively right, or at least open for public scrutiny.

What would constitute an orderly approach to such problems? First, as participants and decisionmakers, we should organize our options in the situation--what alternatives are really open to us? and note the probable outcomes of each. What, in this situation, is it possible, and reasonable, for us to do? And what will be the likely results of each of those choices? Which of the outcomes on the list are totally unacceptable? They should be eliminated, and the rest left for further consideration at a later stage. In this step, we are reasoning teleologically or consequentially (more on these terms below), looking to the means that will produce the most desirable ends.

The Vlasovics, in this case, have the options of
1. Leaving Mother alone--and risking her and the house. That's not acceptable, save for very short periods of time.
2. Bringing in nurses by the day. That will turn out to be very expensive.
3. One of them quitting whatever else they're doing and just taking care of Mother. That will lower the family income, for all purposes, substantially, and no one wants either the burdensome task or the loss of income.
4. Putting that pillow over her face. The thought makes everyone queasy, and they really don't want to go to jail.
5. Putting Mother in a home. She will complain, but she will be safe, and the rest of the family can continue their own lives. This may also be very expensive, until they can establish Mother's eligibility for Medicaid.

Before they act, however, they must review the rights of the various participants, for legally protected rights, in our system, trump, or override, considerations of right outcome. We must also respect moral (usually legally enforced) rules that are held to be valid regardless of the consequences. That is an important point: in this step we are reasoning deontologically or non-consequentially; that which violates a rule is prohibited by that rule no matter what consequences flow from doing or omitting the act.

Two of the most powerful rights and rules confront us in this situation:

1. First, the right of the individual to refuse the well-meaning administrations, for his or her health and safety, imposed by others without consent. Mother does not want to go into a Home, and that should settle that. Medicaid has nothing to do with it.
2. Second, the option preferred by Mother herself, the pillow placed over her face, violates a stringent rule against voluntary homicide, "thou shalt do no murder." It is not our purpose at this point to enter the emotional debate about the permissibility of assisted suicide or euthanasia, as requested by a competent patient. At the time that the pillow route would have to be followed, Mother would not be competent to request anything of the sort, and placing pillows over faces does not qualify as physician-assisted euthanasia. The act would be homicide, in fact murder in the first degree, and there are very good reasons why our society forbids it. If Pete and Dora take this option, they will have violated that rule.

Meanwhile, there are other rights to be taken into account. The minor children have an absolute right to their parents' support, for maintenance (food and shelter), affection (yes, that's a right), and provision of education. To what extent will care for Mother have an impact on them?

When we have our options clear and our rights and rules factored in, we should

determine our decision, make a disposition of the problem, for the moment. The situation will not wait, after all; an initial decision must be taken immediately. For the moment, Mother is rational, and peaceable, enough to be kept at home with her family; also, during her periods of lucidity, she enjoys being with them and they enjoy her. Perhaps a local daycare program can take her during school hours, and the teenagers can switch off afternoons to be with her before Pete and Dora come home from work. Nurses can be hired in occasionally to give everyone a break. The solution can't last forever; will it work at all? Note that the family must act, with very incomplete information; that is typical of such dilemmas. Pete and Dora decide to try it. And then, in a few days, weeks, or months, they must

evaluate the effects of the decision. The decision and the action do not, as Macbeth pointed out, trammel up the consequences. The world continues. We need to follow up, to find out what results our decisions have had. The Vlasovics, in this situation, will not be able to avoid the results; Mother is still in the house with them. How much are the teenagers losing from their sacrifice of their afternoons? The answer to that will depend very much on the peculiarities of this family's situation. How is Mother responding to the new program? That depends very much on the peculiarities of Mother. The trouble with ethical dilemmas, as opposed to ethics as a discipline, is that the real solution is empirical, day to day, trial and error. Finally, we have to

review the situation, reconsider the decision, with an eye toward revision. Nothing, in human affairs, is ever set in stone. We make our decisions, usually, for today, knowing that the decision will probably produce a new situation, with its own new dilemmas, and we will have to take on the whole problem again. The Vlasovics' decision to keep Mother home without round-the-clock nurses, bringing her to day care as often as they can, has saved them money, but after awhile it will not work any more: most day care programs cut off when the disease renders the patient violent or incontinent, and new arrangements will have to be made. But by then, there will be a new situation, with a different set of options, and possibly, a revised set of rights. The children, for instance, will eventually leave home, and confront their parents with a completely different set of demands. The federal government, for another instance, changes its mind every month about what programs to fund for the elderly; these will have to be taken into account in future deliberations.

This decision procedure, like many others in the field of ethics, covers all necessary bases for rational decisions. I prefer it to the others only because it builds in, as others do not, the recognition that nothing is ever decidedÜnot well, anywayÜonce for all. The temptation to come to resolution, to solve something forever, is enormous. Resist it. Situations change, and the more flexible our decision procedure, the better suited it is to the messy world of human conduct.

Like ADAPT, this decision procedure for ethical dilemmas can be remembered easily by its acronym, ORDER:

• Options and Outcomes
• Rights and Rules
• Determination, Decision
• Evaluation of Effects
• Review, Reconsideration

While we're at getting down procedures that are easy to remember, we may take note of three preliminary steps that have to be taken before we can put things in ORDER:

First, we have to define the dilemma that we are facing. What conflicts make the situation difficult to deal with?

In the Vlasovics' case, the dilemma is painfully evident: how to ensure Mother's and the family's welfare while respecting Mother's choices and the most serious rules of our society, while allocating the family's not-abundant resources justly among the generations that call upon them.

Second, we have to conduct empirical inquiries as appropriate, discover the facts, get as much information as we can.

What day-care programs are available? What about support groups, for patients and caregivers alike, at the local hospital? Can we get the church involved? How fast is Mother's disease progressing? What should we know about advance directives, living wills, therapies? Our options, once the decision procedure is engaged, will depend upon what is available.

Third, we have to sort out the stakeholders. We mentioned above that it is important to know whose interests are to be taken into account in making any decision.

Part of the work of sorting out the stakeholders is to make sure that all whose interests are really affected are taken into account. Another part of the work is to see that non-stakeholders who seek to attach themselves to a decision--the nosy neighbors, for instance, who don't like the cars of the visiting nurses parked (legally) on the street--are excluded from influence on the decision. Of course, that means that we may not take their happiness--the satisfaction they derive from running other peoples' lives--into account. The rights of the family take precedence over the preferences of their neighbors: rights trump likes and dislikes. This is why mere appeals to the "greatest happiness of the greatest number" are not always sufficient to decide ethical dilemmas. On the same principle, more commonly, we do not allow neighborhoods to exclude persons of an ethnic background different from that of the current residents, even though it would make all the neighbors overwhelmingly happy to be able to do that; the right of the minority family to live where they choose trumps the preferences of the neighbors not to let minorities live there. Of course the neighbors are stakeholders to some extent--they certainly have a right to be protected from Mother's wandering, should it come to that. The Anglo-Saxon Common Law, of which we are the inheritors, has spent patient centuries working out the details of the rights that people have vis-a-vis the neighbors, and we must be conscious of the whole corpus of that tradition.

So our first three determinations, in any ethical decision process, are of the definition, the factual information, and the stakeholders. If it makes it any easier to remember, think of these steps as a "DIS" preface to the "ORDER" decision procedure:

• Definition of the Dilemma
• Inquiry to obtain all necessary Information
• Sorting out the Stakeholders

This leaves us with a procedure whose steps are easy to remember, but leaves the field of ethics in DISORDER! Insofar as this DISORDERed formula helps us to remember the essential messiness and anguish of ethical dilemmas, that serves our purposes very well.

Let's revisit cases A and B in the last section, and add some complications:

Case A, but Dad is unconscious, and expected to remain so. He apparently has no sense or feeling, is unable to think or communicate. He may be in some pain sometimes, however, and the children, backed up by the court-appointed conservator, request that he be given quite a bit more morphine "to make sure he doesn't suffer at all."

Case B, but your boss suggests only that you speed up the process from penicillin culture to filling the ampules, raising a 2% probability that the drug dispensed will not be up to strength. That doesn't sound good; but there is no evidence that such a change will hurt anyone at all. Meanwhile, the extra income generated will pay off some serious short term debt and put the company in a better position to carry on its research. The quality control manager, who would prohibit this change on general principles, has just retired, and the company is "searching" for another, so you have a probable three-week window during which you can get the new standard drug on the market.

In these cases, the need for higher level reasoning is evident. Terminally ill patients should certainly be kept comfortable; there is nothing to be gained from prolonging this man's life, but a heavy dose of morphine? A balancing act begins, weighing the legitimate, if distasteful, interests of the heirs against the duties associated with the practice of medicine, especially the duty to protect one's patients, especially against this sort of proposal. Ultimately the principle that prevails will be an intermediate one, grounded in the practice of the profession: drugs are there to heal, not to kill, and the patient, probably unable to feel anything and certainly defenseless, may not be subjected to the needs and desires of others.

In case B, the harm caused by the acceleration of the manufacturing process is not at all certain--even if penicillin was never prescribed unless it was needed, the mix of batches would ensure that no patient actually got perceptibly less than the proper dose. Here an appeal to a middle level principle is necessary. The manager must ask himself, not, what are the consequences of this action? but, what would happen if everyone did this? what would be the general consequences of a rule that permitted or required this action? (That formulation of a middle level principle is found, by the way, in the major works on ethics of Immanuel Kant, John Stuart Mill and John Rawls; see the reference section at the end.) The "Golden Rule," Do Unto Others As You Would Have Them Do Unto You, is a similar principle. Research is important, and debt-retiring is surely good, but for now they may have to wait for alternative sources of funding.

Materials prepared by Lisa H. Newton, Ph.D. 1998

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