Based on the work of Immanuel Kant (1724-1804), a German philosopher, deontology is an ethical approach centered on rules and professional duties. Deontology derives from the Greek deont, which refers to that which is binding. Kant’s deontological philosophy stemmed from his belief that humans possess the ability to reason and understand universal moral laws that they can apply in all situations. Unlike many other ethical theories, deontology does not focus on the consequences of individual actions. Personal emotions behind actions also do not matter within Kantian deontology because Kant believed humans do not always have rational control over their feelings. Instead, the intent behind chosen actions holds far more importance. Therefore, deontology proponents judge actions based on what most people consider to be morally correct, regardless of actual consequences.
Issues of Concern
Kant divided his deontological beliefs between hypothetical and categorical imperatives. Much of his writing and the focus of deontology centers on categorical imperatives, which Kant defined as moral and unconditional absolutes. When applied to health care, one of Kant’s most famous categorical imperatives would have the health provider consider whether it would be acceptable for everyone to take the same action he or she was about to take. In other words, healthcare providers should act in such a way that any other provider making the same decision would be justified and considered acting morally. If considering whether to withhold full prognosis information from a client, Kant would have the provider think whether it would be acceptable for all other providers to withhold information from their clients. Because situational context and consequences do not matter to Kant, Kant would lead providers never to lie or withhold information from clients because those actions are morally wrong.
Another example of a categorical imperative, or moral law, according to Kant, is the requirement never to treat people solely as a means to an end. According to Kant, each human has his or her own predetermined goals and needs. If healthcare providers use people only to move their agendas forward, they have violated Kant’s moral law. Maintaining this categorical imperative respects the unique worth and dignity of the individual. Kant’s ideas regarding this categorical imperative stand in direct contrast to the ideals of another ethical theory, utilitarianism.
Utilitarianism directly focuses on the consequences of actions while considering the risks and benefits of taking appropriate steps. The basic premise of utilitarianism is that efforts should provide the most benefit for the most people; however, utilitarianism does not consider the overall distribution of burdens and benefits to others. Some unethical research conducted in the past drew on utilitarian principles to suggest that unethical research served the greater good of society by advancing scientific knowledge for generations to come. According to Kantian deontology, these beliefs of the “greatest good” do not place value on individual dignity and worth, which results in a violation of Kant’s categorical imperative.
How can healthcare providers apply the deontological ethical therapy to practice situations, and is deontology the best fit in a complex healthcare environment? There are many applications of deontology for research purposes. For example, consider a research study involving children who have not met the legal age of consent. A typical ethical research practice involves obtaining parent or guardian consent and the child’s assent if the child is cognitively able to understand details about the research study. An ethical dilemma arises when a parent or guardian grants consent for the child’s participation while the child denies assent. Should the researcher include the child in the study without his or her assent? If Kant’s deontological ethical theory were applied to this situation, the answer would be no. Including a non-assenting child in research to advance the “greater good” of science may fit in a utilitarian ethical framework, but it does not mirror Kant’s categorical imperative to never use an individual solely as a means to an end. Based on Kant’s deontological perspective, the only time children below the age of consent should ethically participate in research studies is when they give explicit assent and the parent or guardian gives consent. The same principles hold true for other vulnerable groups who may not be able to provide personal consent.
A clinical-based application of Kant’s ethical theory to client care involves disclosing medical errors to clients. Many barriers surround disclosing errors to clients, including fear of litigation, shame about the error, and lack of training on how to discuss errors with clients. These barriers and organizational culture influences may lead providers to believe that bringing the error to light does more harm than good. However, applying Kant’s deontological theory to this type of decision clearly favors truth telling and full disclosure of errors. According to Gallagher, patients want their providers to show respect for them by being honest about errors. Part of the disclosure process involves issuing an apology for the error, which is an important move in the direction of soothing distress, maintaining a trusting client-provider relationship, and restoring client dignity.
While healthcare providers do have certain duties inherent in their practice, there are situations when Kant’s deontological ethical theory may not provide answers to guide practice. Misselbrook offers the example of relatives asking a provider if a recently deceased loved one suffered much at the end of his life. Supposing the death experience was traumatic and not peaceful, should the provider tell the truth? If providers use Kant’s philosophies to guide this decision, they would be morally bound to tell the full truth of the suffering and trauma surrounding the end of life. However, is that the best course of action in this situation? This is but one example of some of the shortcomings of Kant’s work. In difficult circumstances like this example, deontology may not provide acceptable solutions. In that regard, healthcare providers should be knowledgeable of other common ethical philosophies.
One final example of deontological shortcomings exists in the realm of triage or public health. In a disaster situation, Kant’s principles lead us to believe that providers have absolute moral duties to provide care to every patient. However, in an emergency situation, providers must make decisions that place some needs ahead of others. Because providers must consider consequences of action versus inaction in a triage situation, a different, consequentialist ethical theory would be more fitting to help providers make this type of ethical decision.