Dean Emeritus of the Royal Society of Medicine, Course Director of the Diploma of the Philosophy of Medicine of the Society of Apothecaries, and BJGP Senior Ethics Advisor.
ADDRESS FOR CORRESPONDENCE David Misselbrook Faculty of the History and Philosophy of Medicine, Society of Apothecaries, Black Friars Lane, London, EC4V 6EJ, UK. E-mail: ku.ca.msr@koorblessiM.divaD
Copyright © British Journal of General Practice 2013Kant, like Bentham, was an Enlightenment man. Morals must come not from authority or tradition, not from religious commands, but from reason. Kant also thought he had it sorted. The funny thing is that his answers were almost the opposite of Bentham’s.
Kant started not with pain and pleasure but rather with the fact that mankind’s distinguishing feature is our possession of reason. Therefore, it follows that all humans have universal rational duties to one another, centring on their duty to respect the other’s humanity. To Kant, all humans must be seen as inherently worthy of respect and dignity. He argued that all morality must stem from such duties: a duty based on a deontological ethic. Consequences such as pain or pleasure are irrelevant. (Well, he was German).
To Kant some duties are absolute. These are the obligations to do certain types of actions. Kant calls this general type of obligation a categorical imperative, that is, the action is imperative because it falls within a certain category.
Kant has three formulations of his categorical imperative. The most famous is ‘Act only by that maxim by which you can, at the same time, will that it be a universal law’. In other words, when working out what you should do you must ask yourself ‘would it be OK if everyone took this type of action?’ So if one day it would be convenient to tell a lie I should ask myself ‘would it be OK if everyone lied?’ Clearly the answer is no, as if everyone lied then no one could have any meaningful dealings with anyone else. Therefore for Kant I must never lie. The act of lying is morally wrong.
Kant’s second formulation of the categorical imperative is to ‘So act as to treat humanity, whether in your own person or in that of any other, in every case as an end in itself, never as a means only’. Other people should never be seen just as a means to an end. A useful reminder to us on a hard day!
The ethos of medicine is generally Kantian: who would deny that a doctor has duties? The GMC publication Good Medical Practice is a prime example of duty-based guidelines. It spells out my specific duties to behave only in certain sorts of ways to my patients. Kant would approve.
Kant is good at telling me how I should usually behave. But most ethicists would feel he is less useful in difficult circumstances. So, I must never lie. As the patient starts to drift off under the anaesthetic to repair his critically ruptured aneurysm he asks me ‘will I be OK doc?’ or the relative asks me ‘did he suffer much at the end?’ Must I always tell nothing but the truth? And Kant would be useless at triage: he cannot tell me which duties I should prioritise over others, as all my duties are absolute. So I don’t think he would be much good at public health.
In many ways Kant represents the voice of a parent: ‘you must always keep your promises’ or ‘you must never lie’. This is normally good advice. But in a complicated world sometimes it is not enough.