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Responsibilities for Healthcare: Kantian Reflections

  • GARRATH WILLIAMS and RUTH CHADWICK

Extract

Many have complained that Kant’s ethics provides little specific guidance as to how we should act. In contemporary healthcare, professionals act in large-scale organizational contexts, with complex reward structures, and in many cases belong to professional bodies that determine the ethical obligations associated with particular roles.

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1. We say “may.” As Kant’s own notorious essay “On a Supposed Right to Lie. . .” demonstrates, despite itself, the simplicity is misleading. In this article we are concerned with one structural reason for this: institutional structures introduce roles whereby people are authorized to act on behalf of a collective. Although coercion is prohibited to persons as private individuals, Kant’s political philosophy provides a well-developed argument that persons who act on behalf of the state should possess limited authorizations to use coercion. This shows that there is a large and important question about how to characterize the maxims of persons who act on behalf of institutions or, more broadly, that individual maxims sometimes depend on structures of collective action.

2. Łuków P. What is “applied” in a Kantian approach to bioethics? Unpublished paper presented at the One-Day Kant Conference; 2009 May 1; Cambridge, UK.

3. 8:37f.

4. Hence his comments regarding the compatibility of making private use of one’s reason with individual conscience, particularly in relation to the priest’s religious convictions (“What Is Enlightenment?” 8:38), or his well-known examples of sovereigns who demand that a subject commit calumny (Critique of Practical Reason, 5:30, 155f).

5. Compare Hannah Arendt’s discussion of Adolf Eichmann’s invocation of Kant, Eichmann being the Nazi functionary who claimed to be a “cog in a machine” rather than “master of his own deeds”: Eichmann in Jerusalem: A Report on the Banality of Evil. New York: Penguin; 1977:135–7, 289.

6. 6:237.

7. As Rawls seems to suggest in his parallel discussion of “natural duties” and “obligations”: A Theory of Justice. Oxford: Oxford University Press; 1972:§§51f.

8. There is an analogy with property in this much: specific role-holders have duties to punish anyone who takes my property, and perhaps to ensure restitution or compensation so far as may be possible.

9. Notwithstanding Kant’s rejection of the idea of a res nullius, that is, an object that has to belong to no one: Metaphysics of Morals, 6:246.

10. O’Neill, O.Towards Justice and Virtue: A Constructive Account of Practical Reasoning. Cambridge: Cambridge University Press; 1996:chs. 5 and 6. Our overall argument is greatly indebted to O’Neill’s focus on institutions as mediating between imperfect duties and realizable entitlements, thereby creating specific rights to healthcare.

11. Cf. Lectures on Ethics (Collins): “Although scholars as a class contribute collectively to the end of humanity, [none] can apportion himself a particular share in that, for every craftsman contributes something by his work to the purpose of humanity, just as much as any scholar does” (27:461).

12. Groundwork, 4:403. Further: “Acquaintance with what is incumbent upon everyone to do, and hence also to know, [is] the affair of every human being, even the commonest. Here one cannot without admiration observe the great advantage the practical capacity to judge has over the theoretical in common human understanding” (4:404).

13. For sophisticated attempts to show the resources Kantian ethics has to deal with Kant’s own implausible conclusions here, see Schapiro’s, Tamararticles: Compliance, complicity, and the nature of nonideal conditions. Journal of Philosophy 2003;100:329–55; Kantian rigorism and mitigating circumstances. Ethics 2006;117:32–5.

14. “What is Enlightenment?” 8:37.

15. If sometimes problematic: we are much more familiar than Kant was with the difficulties posed by the subjectivity and relativity of conscience.

16. Introduction to the Doctrine of Virtue, Metaphysics of Morals, 6:380f.

17. One might try to save Kant’s point by arguing that these are the only two absolute forms of constraint on the human will. Whatever plausibility this point may have, it is not one that Kant could invoke. As any reader of the second Critique knows, Kant’s ethics is based on the “factum” that coercion, even the threat of capital punishment, is not an absolute constraint on the will: otherwise the will would not be free.

18. Differently put, it would be a conceptual mistake to categorize motives based on inclination alongside the fabled motive of duty, let alone to look for any sort of in-between ground, because Kant’s account of the will does not rest on the Humean search for a motivating desire. This point is well made by Barbara Herman: Bootstrapping. In: Herman, B.Moral Literacy. Cambridge, MA: Harvard University Press; 2007:154–75.

19. Readers of the Doctrine of Right may feel that this is too hasty, because contract and status rights (6:271ff, 276ff) constitute specific enablements. Kant’s discussions, however, do not consider the organizational analogues of these.

20. Groundwork, 4:398.

21. Thus Kant’s remarks on “concupiscence” in the Metaphysics of Morals, which Barbara Herman has recently analyzed so well: The will and its objects. In: Herman, B.Moral Literacy. Cambridge, MA: Harvard University Press; 2007:230–53.

22. Or rather, this should be the case: One familiar source of stress in modern organizations is roles that lack the resources or powers needed to fulfill them properly—consider, for example, how nurses have historically lacked the authority to call attention to bad practice.

23. See Fleming, N.The bonus myth. New Scientist 2011;210(2907):40–3.

24. Here we draw on an argument made by Kyla Ebels-Duggan. Kant on freedom and moral education. Unpublished paper at the UK Kant Society Conference “Kant: Morality and Society”; 2009 Aug 27–9; Lancaster, UK.

25. Cf. Davis, M.Thinking like an engineer. Philosophy and Public Affairs 1991;20:150–67. See also Harris, N. Professional codes and Kantian duties. In: Chadwick, R, ed. Ethics and the Professions. Avebury: Aldershot; 1994:104–15. Against Harris, we are suggesting that Kantian ethics should not criticize professional codes for failing to be “universalizable” in any obvious sense.

26. Cf. Banks, S, Gallagher, A.Ethics in Professional Life: Virtues for Health and Social Care. New York: Palgrave Macmillan; 2009: 214–8.

For their helpful comments on versions of this article, we would like to thank Vilhjálmur Árnason, Peter Herissone-Kelly, and Tatiana Patrone.

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