Again a set of different case studies, but, superficially, they all appear similar. The task for the students is to identify why they are different and in doing so they see the significance of the differences. It also makes it easier to categorize and develop distinctions between different concepts. You may find it easier to see the point of this exercise if you also consider Escalation and Difference.

What is it in a nut-shell?
Different cases studies, but superficially similar – can the students uncover the real differences?


Getting in Wrong

Consider the following types of behavior. They are all, in different senses, wrong. Can you identify in what sense they are wrong and how the judgment about their wrongness differs in each case? (if this sounds weird, read the cases and you may come to see the differences). Note that some cases may involve more than one kinds of wrongful behavior.

If, having read the cases, the students can’t make sense of this question, help them out a bit. Give them a hint that some examples are examples of moral wrongs, some of legal wrongs, mistakes of convention and etiquette, etc.

Alan is invited to a dinner party. While there he uses his knife to scoop up food in his mouth, burps loudly after each course and drinks wine out of the water glass.

Beatrice is on her first holiday abroad. She has taken her car hoping to fill up with cheap alcohol in France and eagerly drives out of the ferry at Calais using the left hand side of the road.

Cyril hates Brussels sprouts. He likes all other kinds of vegetables but not sprouts. In fact he finds them so disgusting he can’t put them in his mouth and the sight of other people eating them makes him queasy. Cyndi loves Brussels sprouts. She is always on the look out for new recipes and will eat them with any meal. Which one of them is wrong?

Dennis thinks that homosexuality is disgusting. The very thought of two men having sex is really off-putting and therefore he thinks homosexuality is immoral. He is not that bothered about lesbianism as it doesn’t seem too disgusting to him.

Eamon believes that the role of women is to stay in the house and look after the children. He hasn’t really thought about this since as it happens it hasn’t been an issue in his life and he has never had to discuss it with anyone. His mother adopted this role, as does his wife, as do most women in his society.

Frederica believes that abortion is wrong. The human embryo is a human life and all human life is sacred. It says so clearly in the Bible, God created man and every human life is a sacred soul. Voluntary euthanasia, i.e. purposefully killing someone, usually someone terminally ill or severely disabled, who has requested to die, is illegal in the UK. Voluntary euthanasia, practiced under certain conditions is legal in the Netherlands. Which one of them is wrong?

Gregory has been married to Harriet for fifteen years. During this time he has had numerous affairs. This involved lying to Harriet about his actions and feelings for her, betraying her trust and letting her down.

Alan: This is a breach of etiquette. It would be useful here to ask your students to think about whether Alan has done anything morally wrong. The answer is no as rules of etiquette are rules of convention and/or taste. Notice how etiquette rules, unproblematically, vary from society to society. We can make perfect sense of the thought that burping in public is considered rude in Britain, but a sign of having enjoyed one’s meal and a compliment to the cook in Crete. You may want to refer to a recent series of TV adverts by a high street bank which make exactly this point: the bank understands its customers and is willing to adapt its behavior accordingly.

Beatrice: This is a breach of the law. Clearly in France the law stipulates that drivers should stay on the right hand side of the carriageway. This in itself is a matter of convention. It could just have easily have been the case that everyone drove on the left, but as it happens some countries have ended up driving on the right and some on the left. So some matters of law are matters of convention and agreement for social ease and functionality.

Cyril: This is a trick question. Of course neither of them is wrong. This is not a matter of right and wrong, it’s just a matter of taste, a matter of preference without moral importance. It is not problematic that one person likes sprouts and the other does not, it’s just a matter of preference and we all prefer different things.

Dennis and Eamon: This one is related to the question above. A dislike for Brussels sprouts is unlikely to be a controversial issue. People have different tastes for food and drink and this is not problematic. However, now a matter of disgust is linked to morality. Is it OK to claim that something is immoral (i.e. the person doing it is vicious and the subject of moral blame) simply on the grounds of one’s disgust? Could I say that anyone who eats Brussels sprouts is immoral just because I find them disgusting? Now matters get a little bit more difficult. What we have here is a matter of convention but with moral implications. Notice that Eamon hasn’t really thought about his beliefs, he isn’t really leading the reflective life (nice link to Session 1 here and Socrates). At the same time his beliefs are about moral issues, e.g. his interpretation of the role of the sexes, equality, duties, etc. The distinction here is between reflective morality and conventional morality. Conventional morality may refer to beliefs one holds without really thinking about them, because they were handed down by one’s elders or family, because these beliefs are generally accepted by one’s society, because of a ‘knee-jerk’ reaction to a moral problem. Moral principles and ideals on the other hand are the result of reflection and independent thought. It seems to be important that our fundamental moral beliefs are the result of the exercise of our free agency, i.e. not imposed from outside or an uncritical acceptance of the status quo.

Frederica: Again this one is a bit more difficult. Here we have a belief on a moral issue, however Frederica’s reasoning is based on religious grounds. Since Frederica believes that the moral value of the embryo is dependent on it having a soul imparted to it by God, then her argument is based on her religious beliefs. The important point to note here is that arguments based on religion are only convincing to those who share the same religion. That is, it would be impossible to use Frederica’s reasoning to convince an atheist of the value of fetuses, as he would reject the existence of God in the first place. Here we have a controversial moral issue, that of the permissibility of killing mentally competent, consenting adults, which is also part of the domain of the law. The two different laws in this particular cases are based on diverging conceptions of the morality of euthanasia. For example, the Netherlands makes a case for the importance of patient autonomy and respect for the ability of competent adults to make choices even about the timing and method of their death. The UK by contrast focuses on the ‘do no harm’ principle in medicine, concerns about slippery slopes and abuse of a possible relaxation of the law and also on the sanctity of human life. The pros and cons of this particular argument as not as relevant as the underlying idea that the law sometimes reflects moral values. In some cases these moral values are widely and unproblematically shared, e.g. ‘it is wrong to kill innocent human beings’ seems to be a moral ideal which forms part of all legal codes. In other cases the law reflects certain moral positions on more controversial issues, e.g. euthanasia, abortion, etc. You could draw a link here with Beatrice. In Beatrice we had an illegal act but what made it illegal was a matter of convention. There is no moral principle behind the idea that one should drive on the right in France, it’s merely a matter of convention and convenience.

Gregory: Arguably Gregory has done something wrong. Perhaps not all cases of adultery are immoral; one could imagine a couple who decide to have extra-marital sex and do so openly and without deceit. However, Gregory’s case is not like that and he is purposefully portrait as a rather nasty person to make the point that this is immoral behavior (i.e. not just because of the sex, but also because of the deceit, betrayal of trust, hurt caused, etc.). Although his behavior is immoral it is not illegal (at least not in the UK). When he is found out, Gregory is likely to loose his wife and mistresses and likely to be shunned by his former friends, however there are no grounds for prosecuting him. So the law does not reflect all our views on immoral behavior, in some cases the law remains neutral (of course the law changes, adultery used to be illegal in the UK but it was then decided that even though it was an immoral act it was one which was not the proper domain of the law to get involved in. Perhaps Harriet will be able to get favorable divorce terms because of the adultery, but the adultery is not penalized as such).


Lying is Wrong

“Lying is always wrong”. Can you think of any cases when lying might not be wrong (perhaps you agree with the statement, but can you think of possible cases when other people would claim that lying is not wrong?)?

Allow your students 5 minutes to think about this on their own, and then split them into small groups and ask them to consider the following cases: For each one of these cases ask: Is the person in this case lying? Is there anything wrong with what he/she is doing? If they are lying, is it wrong to lie in this case?

Annabel is on stage playing the role of Juliet. She utters the famous lines professing her love for Romeo with great conviction. In reality she finds the actor who plays Romeo quite repulsive.

It’s the start of the Christmas holidays and Bobby comes back from nursery looking a bit upset. Apparently one of the other children at nursery claims that Santa Claus does not exist. Bobby’s mother reassures him that the child was wrong, Santa will be here this year like every year.

Claudia has been invited to dinner by her best friend. Her friend is not a very good cook, but has been trying hard to learn ever since he got divorced from his wife (while they were married the wife did all the cooking). Unfortunately the food he has prepared is quite terrible. The friend expectantly asks Claudia what she thinks of it and she says it was delicious.

Delia’s sister loves singing. She only sings on family occasions and for fun. Unfortunately she is almost tone deaf and a terrible singer, however, her family hasn’t let on about this. Delia asks her sister whether she should audition for a TV talent show and her sister tells her to go for it, after all you only live once!

Eddie’s best friend is madly in love with his long term girlfriend. In fact he is considering asking her to marry him. Unfortunately Eddie has just walked in on the girlfriend having sex with her flat mate. Eddie decides not to say anything, after all his friend hasn’t exactly asked ‘Is my girlfriend having an affair with her flat mate?’

Fabian works for the R and D department of a major tobacco company. He has known since the 1970s of a number of medical studies showing a link between smoking and cancer. Fabian has never discussed his information with anyone. Fabian is aware that there have been a number of groups trying to prove that there is a link between smoking and cancer and also that there are some groups claiming that the tobacco companies have this information.

Garry’s advertising agency is mounting a huge campaign to promote an alternative to breast milk for newborns. The campaign never claims that the alternative is better than breast milk as such (and it isn’t!), but encourages mothers to view the alternative as better by offering free samples, implying that mothers of twins and premature babies are unable to breast feed and implying that breast feeding is an outdated and primitive practice. Garry has also been involved in designing labels for a cosmetics company which read “This product was not tested on animals”. The ingredients of the product, however, were tested on animals.

Helen has been out clubbing. She has been drinking orange juice as she intends to drive. Unknown to her someone spikes her drink. While on her way home she is stopped by the police who ask her whether she has been drinking. She confidently replies “I never drink and drive”. In reality she is over the legal limit.

The cases raise a variety of issues including:

Although it would be correct to say that Annabel does not love the actor who plays Romeo, it seems wrong to say she has lied. What drives this intuition is that this is a play and the actors and audience are aware of this. Plays are stories which require actors to take on personas other than their own and require the audience to accept this ‘deception’. If the actor who plays Romeo pursued Annabel in real life based on her utterances as Juliet we would be very surprised at his behavior.

Bobby: This one is a bit more difficult. The idea of Santa Claus is a story (either imaginary or perhaps a religious parable) frequently told to children to entertain them and encourage their imagination. Children do grown up to find out the truth and this can be traumatic for them, but arguably believing the unbelievable seems to be a positive aspect of childhood, which is seen as a time when we are protected from ‘harsh reality’ and are allowed to believe that anything is possible. These claims about imagination and creativity are arguably positive aspects of childhood and should be encouraged. If you agree with this, you may want to say that although strictly speaking this utterance is untrue, it is made for good reasons.

Claudia: This is what we would call a white lie. Strictly speaking the utterance is not true, but it is has little consequences and the lie is said in order to avoid hurting the person. In general it appears as if white lies share two characteristics: they are inconsequential and they told with the aim of avoiding hurting someone. On this grounds one could argue that there is nothing wrong with telling such lies. This case is similar to the one above. We have utterances which are not true, but which are said in order to benefit the other person (or preserve him from harm) on matters which are of little consequence).

Delia: Now this one is a bit more difficult. Obviously singing is something Delia’s sister enjoys and there is no harm in that. Furthermore, arguably Delia has an obligation to preserve her sister’s self-esteem. However, encouraging her to participate in the auditions could go both ways. The sister could have a great time even though she is not selected or she may realize she cannot sing. If the sister has a great time does that mean the original lie is justified? If the sister is devastated does that mean the original lie was wrong? How can that be? How can it be that a future event (enjoyment or failure at the talent show) determines the moral quality of an earlier act (whether the lie was wrong or not)?

Eddie: Here we have two issues. The first is that the consequences of not telling the truth are now more significant. This is a much more serious issue and potentially likely to cause more harm to the friend, Eddie’s friendship and the girlfriend. Furthermore, it is a difficult issue to decide. In such cases is it better to know the truth and suffer or is it better to live in ignorant bliss (avoid discussion on the affair itself and whether the friend will find out anyway and so on. These are important questions, but slightly besides the issue here). The second is whether Eddie has lied at all in the first place. As the friend hasn’t asked this specific question, Eddie has at best lied by omission. Is this lying? Is there anything wrong with not telling the truth when you are not specifically asked about it?

Fabian: Again here we have the same issue with disclosure. Has Fabian lied when he hasn’t actually said anything and he hasn’t even been asked anything? Who has Fabian lied to if he hasn’t actually said anything? Suppose Fabian hasn’t lied, does that mean he hasn’t done anything wrong either? I.e. one could claim that in some cases there is a duty to come forward with information and not doing so is tantamount to lying.

Gary: Now these statements are clearly misleading. Although they do not contain lies as such, they lead people to believe things that are not true. Is this as bad as lying? Is it perhaps worse, or is it acceptable and a case of ‘buyer beware’?

Helen: Again this is a complex case. Although what Helen says is not true, she does not know this nor is she culpable for not knowing it. This may lead us to think that Helen has not done anything wrong in saying she has not drunk and maybe even that she has not lied.

These cases should bring out the point that it is not easy to define what lying might be in the first place or what makes it wrong (the definition brings out reasons why lying is wrong, so the two questions are inter-related). This is often the case with many difficult concepts. At first glance it seems easy to say that lying is always wrong and that we can always clearly identify cases when lies are said, however when we look at different examples things become more difficult. It may be helpful to try to summarize some main points about lying (although some are open to debate):

  • lying involves a distortion of the truth
  • this can involve an outright lie, or a misrepresentation, or an incorrect suggestion, or a misleading statement, etc.
  • one can also lie by omitting to say something as well as making a statement. Whether one has an obligation to say something will depend on the circumstances (after all I am currently not telling you many things about my personal life, but that is not lying as this information is entirely irrelevant to our topic)
  • lying seems to be wrong because it intends to deceive. Deceiving by mistake or non-culpable
  • ignorance seems excusable as there is no intention there.
  • deception is (particularly?) wrong when it seeks to harm the person or involves other morally objectionable elements such as a betrayal of trust. The deception is worse the worse the harm it causes.
  • lying may be justified if it seeks to protect the person from harm, this depends on the severity of the harm and how much we value autonomy and informed self-determination.


Tolerance B

There is also a theme of Escalation in this exercise with the harm caused becoming, arguably, more severe.

Aaron and Barbara live in a quiet, secluded community, made up of heterosexual married couples. They, however, are different from their neighbors in that they engage in sex with multiple partners at the same time. This is known in the village through gossip, as these practices take place entirely in private. The couple’s house is well insulated and isolated so no one has ever heard or seen these things doing on – nevertheless they are going on and the couple would affirm this. Would you tolerate this kind of behavior in your society? Why?

Christopher would like to get officially married to his long time partner David. Up until now the state only sanctioned heterosexual marriages but David and Christopher would like this to change to include legal recognition for same sex couples. Would you tolerate this kind of behavior in your society? Why?

Eve is the director of a major publishing company, publishing a variety of books and journals. Her company has a division specializing in books on works of art. These books have included paintings by famous artists on different topics including nudes and works of art by contemporary artists, which include violent and sexually explicit subjects. Eve is now thinking of expanding her business into a new direction and introducing magazines of a pornographic nature. The content is similar to the books on art in terms of the explicit material but is intended for sexual gratification. Would you tolerate this behavior in your society? Why?

Felicity is the editor of a local newspaper. She has written a series of editorials focusing on recent problems in the town that she identifies as being caused by a religious minority group. She attributes lost jobs, falling living standards, a drop in house prices, a drop in public standards and civil unrest to the arrival of this group who have disrupted the social cohesiveness of the town. She is also offended by the religious practices of this group that involve using private places of worship (these practices do not cause any physical harm as such to either the worshipers or others). Her editorials are becoming more vehement in tone, asking concerned private citizens to ‘stir en masse and directly address the problem before it is too late’ and encouraging the citizens ‘to act now and take matters out of the hands of the apathetic authorities’. Would you tolerate this kind of behavior in your society? Why?

Gerald is a well known author. His latest work of fiction deals with a sensitive topic. He portrays the leader of a major religion not as the son of god but as the son of man. The story narrates a number of incidents which involve sinful behavior and are contrary to the teachings of this religion. Would you tolerate this behavior in your society? Why? The main theme here is offence, whether offence causes any harm (or any harm comparable to other kinds of harm such as physical harm) and whether the harm caused by offence is sufficient to warrant some restriction of liberty (freedom of speech, freedom of movement, freedom of assembly, freedom of action, etc.).

Aaron and Barbara are engaged in promiscuous sexual practices you may well find immoral, disgusting or just unappealing. However, they are doing so in public without offending anyone. Does simply the knowledge that something you do not like (which does not harm anyone) is going on, cause sufficient offence to warrant stopping this practice? Note that restricting Aaron’s and Barbara’s sexual practices would cause them substantial emotional and possibly physical harm. How does offence compare with physical harm? Is it sufficient justification for restricting the behavior of others or should we tolerate this?

Christopher and David now want public recognition for something that some other people find offensive. Is this feeling of offense sufficient reason for restricting Christopher's and David's public rights? Does it extend to everything anyone may find offensive (e.g. the worshiping of another god, nudity, promiscuity, vice?)

Eve's case introduces the difficult difference between art and pornography. Why is one acceptable when the other is not? How does all this affect freedom of expression? Shouldn’t the press be allowed to publish all sorts of different things, expressing all sorts of different views and catering for all sorts of different tastes? If your students tend to think that pornography should be tolerated, put some pressure on them: what about the impact it has on the role of women in society? What about the exploitation of people in the pornography industry?

Felicity’s case ties in nicely with Eve’s. You can really put your students to the test especially if they have argued for the freedom of the press in the previous case. If the freedom of the press is an important value in a liberal society, then Felicity has a right to publish her (erroneous) editorials. Notice that there is a possible escalation here: one can hold racist/sexist/elitist views against others, one can express these views in a private setting, express these views in a public setting, express these views in a manner which incites anger or violence in others, etc. Felicity’s case is purposefully extreme: she is a bigot with a position of public responsibility and she is using her position to incite others to violence.

Gerald’s case is another difficult variation on the theme of freedom of the press. This time is the freedom of an artist to express himself. We protect freedom of the press because the press are after the truth (of course this is not always the case but this is a price we are willing to pay in order to encourage criticism and scrutiny). We also think that artistic freedom of expression is important, as art can reveal significant insights into human nature and should not be restricted by political or social expediency. But how far can art go? When art is offensive to others should this be a problem for the artist or for those who are offended by it?


The Hairdresser and the Surgeon

The Hairdresser

Lizzie has a keen interest in fashion and makes sure she is up to date with all the latest fashion trends. Fashions for hairstyles have changed rapidly in the past year following the whims of a certain well known celebrity sports wife, going from a blond look, to a dark haired look earlier this year. Lizzie, faithful to her style icon, has gone from blond to dark brunette, but at a recent film premiere it was clear that blond is back in fashion again. Lizzie is at the hairdressers asking for her now dark hair to be bleached back to blond, which would mean changing colour three times in less than a year. Lizzie also wants a new hairstyle, one of the fashionable, sleek, short bobs everyone seems to be wanting, but her hair is thick and coarse and unlikely to suit this style. The hairdresser tries to explain that taking the hair back to blond again is very likely to weaken it and may even cause more serious damage as the hair is already quite coarse from being bleached blond then changed to dark brown. He also tries to explain that the ‘sleek bob’ sported by the celebrities is unlikely to suit Lizzie’s hair type. The hairstyle is likely to need a lot of maintenance, e.g. blow-drying, straighteners, etc. that will further damage the hair.

Should the hairdresser go ahead and cut a style he knows is unlikely to suit the client?
Should the hairdresser go ahead and bleach hair he knows is likely to be damaged by the process?
In what ways is Lizzie likely to be harmed by an unsuitable hairstyle?
In what ways is Lizzie likely to be harmed by the colour change?

The hairdresser spends a long time with Lizzie trying to explain his concerns, but Lizzie insists that she knows what she wants and is paying good money to get it!

Who knows best, the hairdresser or Lizzie?
Who should make the final decision about what should be done to Lizzie’s hair?

This case study focuses on unusual client requests. Professionals aim to provide a service, one that they are experts in providing due to their professional skills. Clients who wish to access the service cannot do so on their own, so rely on professionals to help them. In this sense professionals enable others achieve their goals. However, not all client requests are unproblematic. In this particular case the client is making two requests:

  • a change in hairstyle to a style which is unlikely to suit her, therefore she won’t be satisfied with the result
  • a change in hair colour which is likely to seriously damage her hair, therefore causing her harm

Should the professional give in to these requests?

The questions for this activity encourage the students to consider the nature of the two requests and whether the professional should fulfill them. The first request is less problematic, as judgments about the aesthetics of hairstyles are subjective, and, perhaps, what the hairdresser thinks will be unsuitable, might turn out to be satisfactory for the client. The second request is more problematic as it involves a clearer notion of harm; loss of hair is more likely to be considered harmful despite subjective preferences.

Now ask the students to consider these further questions:

Suppose the hairdresser decides to go ahead and both bleaches and cuts the hair. Two weeks later Lizzie is back at his salon complaining that her hair looks frizzy and horrible, nothing like the bob she had in mind, and, worse still, her hair is falling out, now looking sparse and unhealthy:

Should the hairdresser offer a free hair treatment and new cut?

Does Lizzie have grounds for a complaint?

The questions for this activity encourage the students to consider who is responsible for the end result. If the hairdresser gives the client exactly what she asked for, is she responsible if the client realizes, after the fact, that she was mistaken in her request? John Stuart Mill suggests that the individual is the best judge of what is in his own best interests, regardless of whether he is right or wrong, as this is a matter of responsibility for one’s own choices. Mill might suggest here that if the client gets exactly what she asked for and does not like it, then that is entirely the client’s problem. On the other hand, one could argue that professionals have special responsibilities which might include doing no harm (this is especially true in the colour request), and cannot be forced to meet client requests when these are clearly ill-advised. The questions for this activity focus on complaints because if one agrees with Mill there is no ground for complaint, whereas if one thinks that professionals are bound by special obligations then there is ground for complaint.


The Surgeon:

In an episode of the hit TV series Ally McBeal (aired in the US on Fox, the UK on Channel 4 in the late nineties/early naughties), a client asks a plastic surgeon to give him a large, Roman-shaped nose as he is a Barbara Streisand impersonator and would like to look more like his idol.

If you were a plastic surgeon would you give your patient a nose you considered to be beautiful if he asked for it?

Would you give him a nose you considered to be ugly if he asked for it?

On what grounds would you make your decision in each case? Would you give your patients whatever they asked for? Or only what you think suits them and will look good? Or only what you think won’t cause them serious harm?

This case study continues the theme of unusual client requests. We are quite used to people opting for cosmetic surgery to ‘improve’ their looks in accordance with social norms of what is beautiful and pleasing. We might think the individual who goes in for this kind of surgery is a bit vain, but really requests for smaller noses are quite unproblematic – surgeons fulfil them every day without a second thought. However, if the cosmetic surgeon is merely offering a service, then it should be as unproblematic to fulfil a request for a larger, Roman-shaped, ‘uglier’ nose, than for a smaller nose. Whose decision is it whether this nose is desirable or not? One line of thought would be that as this is the patient’s nose, it is the patient’s choice. If he wants something other people think is ugly then that is his choice to make and what other people think is irrelevant. In fact, it doesn’t matter why the patient wants this nose, whether he is a Barbara Streisand impersonator or not, the fact that he wants it is the only relevant consideration. On the other hand, surgeons have an obligation not to expose their clients to unnecessary harm (the risk of the operation and recovery), so perhaps the surgeon’s judgment that this is not an aesthetically pleasing request should carry more weight.

In 1997 and 1999 surgeon Robert Smith amputated the healthy legs of two patients suffering from Body Dysmorphic Disorder at their request. His patients were articulate, well educated, competent and said the, otherwise healthy, limbs “did not belong to them” and they wanted them amputated. The operations were carried out privately in an NHS hospital. Both patients were very satisfied with the results.

If you were a surgeon would you give your patient the healthy limp amputation he requested?

Body Dysmorphic patients are usually articulate, educated and informed about their condition, persuasive in general and show no (other) signs of irrationality or incompetence. Their requests for amputations are deeply held, they often live a trial period as amputees (using wheelchairs, etc.), and if denied they will go to extreme measures to carry out the amputations themselves. We offer people multiple cosmetic procedures to conform to rather arbitrary social standards of beauty, so why not satisfy this desire as well? However, healthy limb amputations seem to clearly violate principles of beneficence and nonmaleficence enshrined in the health care professions and go against health care professionals’ duty to do what is best for their patients. Who decides what is in the patient’s best interests in such cases?

You may want to draw particular attention to the differences between patient refusals and patient requests and how they generate different requirements with respect to negative and positive conceptions of autonomy. The general consensus, both in terms of medical ethics and UK law, is that (competent) patients have the right to refuse any treatment they like on whatever grounds they like, as violating this refusal constitutes an attack on bodily integrity, but can only have requests fulfilled if the professional also concurs that this is a beneficial and warranted intervention (because requests involve another person whose assent to the request is significant).

(Example adapted from materials produced for the Level 3 Perspectives on Science course)


Lifestyle Choices and Access to Treatment

Introduce the students to the problem, explaining how the NHS was set up to help everyone according to need and how doctors are taught that their role is to relieve suffering not to pass judgement. However, because resources are scarse and not everyone can receive the treatment they need when they need it, doctors have to made decisions on priorities. Should such decisions be made purely on clinical need, or should patients take some responsibility for their conditions?

Ask the students to consider the following two cases:

Case 1: Adam practices unsafe sex with other men. He is well educated and knows the risks involved in this practice, but enjoys it and is not willing to be either celibate or take precautions. He thinks his sexual orientation is a matter of personal choice, which has nothing to do with anyone else. Unfortunately Adam contracts HIV and now needs to be on a regime of drugs including AZT. Adam’s treatment costs his NHS Local Health Authority £615 per month. He is also likely to need more intensive care if his disease progresses.

Case 2: Marilyn suffers from a congenital heart defect (an abnormality of the heart present from birth). Every year four out of every 1,000 babies will need treatment for this condition, and the causes of the condition are not known (although there may be a genetic factor). Unfortunately Marilyn suffers from a serious variety of the condition, which means she needs haemo-dilution on a regular basis (some of her blood is removed in hospital and replaced with clear fluid). The cost of her treatment is £800 per week for her Health Authority and in future she may well need a heart/lung transplant.

Unfortunately, both Adam and Marilyn are cared for by the same cash-strapped Health Authority, which can no longer afford to treat both of them.

  • How will you decide who gets the treatment?
  • Who needs it most (where need is understood as medical need)?
  • Who deserves it most?
  • Is Adam responsible for his disease? Does this matter?
  • Could Adam have done something to prevent his disease? Does this matter?
  • Is Mary an ‘innocent victim’? Does this matter?

Debate on the provision of public health care:

Split the students into two groups, ask them to examine the following cases and present an argument on whether these patients have lost the right to publicly funded health care. Ask them to take notes while the other group are putting forward their views and come back with questions and objections:

The cases: Some people engage in dangerous sports or pursuits, e.g. mountain climbers, speeding drivers, etc. which put them at more risk of injury. Some people make life-style choices which put them at more risk of disease, e.g. having unprotected sex, refusing to loose weight, etc. Some people ignore medical advice, e.g. smoke when they have a heart condition, accept a transplant and do not comply with their drug regime, decline a cancer screen and get cancer. These patients then have to compete for limited resources (e.g. ICU beds, drugs, operations, organ transplants, etc.) with other patients who have just been unlucky in becoming ill and follow medical advice.

One group should argue that these patients lose the right to publicly funded health care and consider the following questions:

Group 1, ‘Yes, they lose their right’:

  • Are these people a drain on precious resources?
  • If we treat these people are we being unjust to those who protect their health?
  • Shouldn’t competent adults have to live with the decisions they make? Isn’t that what autonomy is about?
  • Shouldn’t public funds be spent wisely and not thrown away on those who do not take care of themselves?
  • Are doctors wasting their time by treating those who are not willing to take responsibility for their health?

The other group should argue that these patients do not lose the right to publicly funded health care and consider the following questions:

Group 2, ‘No, they do not lose their right’:

  • Doesn’t everyone engage in some kind of dangerous/detrimental activity anyway?
  • These patients are already suffering from their disease, do we want to make them suffer more by not treating them?
  • Why should the patients’ actions mean that they have forfeited their right to treatment? Wasn’t the NHS set up for everyone?
  • Is it the job of doctors to judge their patients?
  • Is health care a form of punishment or reward?