Agency and Action
Agent: a person (or creature) with the capacity to act; actions are intentional and purposeful, unlike behaviours which are automatic, unconscious, or non-purposeful.
Distinction example: gesticulating without a reason (behaviour) vs. speaking in class, being kind, or reading a textbook (actions with reasons).
Autonomy: actions involve agency and thus moral responsibility.
Normative moral theories assess the actions of agents, not merely observed behaviours.
Review: Agent-Neutral vs Agent-Relative
Agent-neutral reasons: value what an agent ought to value independently of personal relations to themselves.
Agent-relative reasons: depend on the agent’s particular characteristics or circumstances.
Thomas Nagel example (from Equality and Partiality, 1991): “Each of us has an agent-neutral reason to care about everyone, and in addition an agent-relative reason to care more particularly about himself.”
Cited in The Penguin Dictionary of Philosophy (2000) p. 9.
Decision procedures are disembodied
Normative questions ask “how should I act?”
Questioning how one should act in a given circumstance is not the same as motivating them to act that way.
Decision procedures treat rationality as an abstract, disembodied feature of the mind.
Virtue ethics challenges this by viewing rationality as involved in our desires and embodied experiences.
Virtue Ethics
Western tradition: Aristotle’s Nicomachean Ethics (384-322 BC) is central, but ideas extend to Stoics, Epicureans, Christian and Islamic thinkers, and beyond.
Core claim: the possession of virtues is necessary for living a good life (Arete).
Implication: a good life is inherently a moral life.
Cultivating the good person
Starting point is not merely solving moral dilemmas via decision procedures, but becoming the kind of person who can resolve them.
Aim: eudaimonia – to live a good life.
Aristotelian answer: cultivate arête (virtue) through deliberate actions.
Eudaimonia: understanding the good life
Eudaimonia can be understood as a form of happiness or enlightenment; contemporary theorists frame it as objective well-being.
Living well requires ethical excellence, not just mere hedonic states.
It is a kind of psychological health with objective moral consequences, not a transient emotional state.
Dispositions and Virtues
Virtue ethics emphasizes virtue as a disposition: a tendency to act in certain ways.
Not every disposition is rationally controllable (e.g., shyness is often emotionally based).
Ethics becomes about cultivating and training rational sensitivity and awareness of actions and emotions.
Reason and the Doctrine of the Mean
Aristotle: virtue is the mean between excess and deficiency regarding emotions and actions.
Example: courage is the mean between cowardice and rashness.
Quote: “To have [such feeling as fear, confidence, appetite, anger and in general pleasure and pain] on the right occasions, about the right things, towards the right people, for the right end and in the right way is the mean and the best; this is the business of excellence”
Nicomachean Ethics, Book II, 1106b21-22.
Practical note: action must align with the mean, end, and right manner; it is not trivial to perform correctly.
Courage and the mean
Courage requires balancing fears and risks appropriately, not merely avoiding fear or taking excessive risks.
Quotation: “So too, anyone can get angry or give and spend money – these are easy; but doing them in relation to the right person, in the right amount, on the right occasion, with the right end and in the right way – that is not something anyone can do, nor is it easy”
Nicomachean Ethics, 1109a;20-29.
Phronesis vs. Sophia: Two Types of Rationality
Distinction: Wisdom (Phronesis) vs. Intelligence (Sophia).
Eudaimonia requires phronesis (practical wisdom).
Phronesis is gained through practice and habituation; it is dynamic and adaptable (like a musician improvising).
Sophia is theoretical understanding and can be developed early; it does not necessarily rely on habituation or life experience.
Phronesis
Phronesis is a form of practical discernment: the ability to see the right thing to do in a given situation.
Requires experience and the capacity to discern the mean.
Example: choosing how to comfort someone without mentioning a sensitive topic; balancing emotions and rational guidance.
It links rationality with non-rational sensation to justify action.
Eudaimonia and virtue
To achieve eudaimonia, one must possess virtues (Arete) that require phronesis.
Phronesis makes virtue more than a mere disposition; it steers one toward the mean.
It harmonizes desires with reason.
Can we be too virtuous?
Under the mean-based conception of virtue, there is no room for excess like being overly generous, overly honest, or overly kind; virtue involves discerning correct amounts and timing.
This supports the claim that virtue is more than a simple emotional disposition.
Joseph Collins – Should Doctors Tell the Truth? (1927)
“To tell the whole truth is often to perpetrate a cruelty of which many are incapable” (p. 717).
This raises questions about weak vs. strong paternalism and competing moral principles.
Autonomy and Truth Telling
Relation between knowledge and autonomy; connects to Kant’s categorical imperative:
Categorical Imperative Formulation 1:
ext{Act only according to that maxim whereby you can at the same time will that it should become a universal law.}
Formulation 2:
ext{Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end.}
Why might lying be acceptable for utilitarian systems?
In utilitarian frameworks, actions may be judged by their consequences for overall well-being; lying could be justified if it leads to greater good, though this is contested.
Now You May Tell Me the Truth – Four Responses
Four categories of patients who want or need truth:
Those who honestly and courageously want to know.
Those who do not want to know and would be harmed if told.
Those who are wholly incapable of receiving the truth.
Those whose health is not seriously affected by disclosure.
You Can’t Handle the Truth
“It may seem an exaggeration to say that in forty years of contact with the sick, the patients I have met who are in the first category could be counted on the fingers of one hand”
(Collins, p. 717).
“No one can stand the whole truth about himself; why should we think he can tolerate it about his health, and even though he could, who knows the truth?”
(Collins, p. 722).
Reflection question: Do you agree with these sentiments?
Truth Telling and Trust
Question: Do doctors get a special exemption from being truthful because of their work, and under what circumstances?
Joseph Collins: YES, THEY DO! (p. 726)
Joseph Collins on lying
“The Longer I practice medicine the more I am convinced that every physician should cultivate lying as a fine art. But there are many varieties of lying.”
(p. 719)
Unacceptable Lies
Examples:
Pretending to know the diagnosis.
Claiming success without justification.
“Announcing that one has effected the cure which nature has accomplished” (p. 719).
Declaring a condition incurable without evidence.
Acceptable Lies
Reassuring patients while omitting full truth; preserving hope; partial truths for patient well-being.
Reassuring Patients While Omitting Full Truth
Case: elaborate explanation of surgical intervention without detailing failures; relief of despair by omission (Collins, p. 719).
Case: patient with kidney disease who feels healthy; reassuring the patient to prevent despair; the light of life flickers with the fear of truth; two months later, the patient’s condition would have variants if fully informed (Collins, p. 719).
Preserving Hope
Early detection of malignant disease: It is never justified to tell the patient the real nature of the disease if the pathologist’s report will not yet provide certainty; no good can flow from sharing the knowledge prematurely (Collins, p. 720).
Question: what other statements does Collins make in contradiction with this?
Robert Higgs – Fear of The Unknown and Intentions Matter
Higgs: No special exemption for truth-telling; circumstances matter (p. 726).
Fear of the Unknown: fear is a major barrier; direct information is hard to obtain when lives are on the line (p. 724).
Intentions matter: even if you don’t know the full truth, the intention to mislead is central to judging honesty (p. 726).
Common arguments for lying to patients (1)
Reasons include: difficulty in explaining technical subject to laypeople; questions about possible future symptoms, life expectancy, and cause of death; even for doctors these are informed guesses; lying is immoral if it deprives informed consent (Higgs, pp. 726-727).
Common arguments for lying to patients (2)
Patients often dislike depressing news; other professionals do not suppress information to preserve happiness.
Statistics from studies: about rac15 of patients deny being told after diagnosis; rac23 to rac34 were glad to have been told or would want to know (Higgs, pp. 727).
Common arguments for lying to patients (3)
Truthfulness can cause harm: fear of creating harm may deter discussion of diagnosis, yet often the doctor still performs the surgery; cases of patient suicide are not as common as feared.
The argument shifts toward better telling: determine how much the patient wants to know, explain carefully, and provide after-care and support (Higgs, pp. 728-729).
Beneficence, Utility, and Autonomy
Lying deprives a person of the opportunity to participate in health decisions; questions about why a physician has the right to decide what is best for the patient.
Why we shouldn’t lie to patients
Informed consent requires truthfulness; lying undermines autonomy and erodes trust in the medical system and professionals; enabling lies invites abuses of power.
When to lie: last resort
Lie only when there is NO acceptable alternative; force can be used only as a last resort, e.g., forced confinement for psychiatric reasons.
Decisions should be shared with other healthcare professionals in confidence; discussing options opens up the possibility of alternatives that may not have been initially considered (Higgs, p. 729).
What to do instead?
The cases involving suicide after a diagnosis argue not for no telling, but for better telling: sensitivity in determining how much the patient wants to know, careful explanations, and robust after-care (Higgs, p. 729).