the health or safety of others. If someone has a highly infectious and serious
condition ,or is seriously mentally disturbed ,under what circumstances should
they be able to determine their own lifestyle in the community?
One way of thinking about these dilemmas is to see them as about considering
the expected costs and benefits of alternative courses of action in order to see
which produces the best overall outcome. This way of thinking is called utilitarian,
and there is a tradition of moral philosophy called utilitarianism in which it is
defended as the basis of ethics. There are many debates about utilitarianism ,and
within utilitarianism ,which cannot be summarised here. But it is possible to
indicate both the plausibility ,and some of the difficulties ,of the central idea.
Its plausibility arises because it seems odd to see ethics as simply about fol-
lowing rules for their own sake. Surely what we are interested in is bringing about
better ,rather than worse ,states of affairs. A nurse who is asked to adopt ethical standards' will expect to see how they are connected to protecting or promoting welfare ,how they make the worlda better place'. Yet a rule or guideline which
seems to work well most of the time may ,on occasions ,seem to do more harm
than good. For example ,it seems important to have rules to protect the con-
fidentiality of clients ,but it also seems that there are circumstances where the risks
or costs of silence may be so grave that confidentiality could justifiably be broken.
It appears that in this kind of example a more fundamental ,and utilitarian ,ethic is
being appealed to.
However ,there are some problems with this way of thinking. There is no exact
ethical accountancy by which the different sorts of costs and benefits can be
optimised ,and different individuals are likely to disagree about when a guideline
is unhelpful and can be broken. At the extreme this could lead not only to a climate
of uncertainty about policy ,but to a nurse's idiosyncratic conception of what
counts as a cost or benefit having undue influence.
More generally a concern about utilitarian thinking is that it can involve sacri-
ficing some people's interests for the sake of others ,and that this could amount to
treating people merely as objects or resources. There is ,on the face of it ,a tension
between certain examples of utilitarian thinking and the idea of respect for
persons.
For example ,consider resource allocation as an ethical issue which ,on the face
of things ,lends itself to utilitarian thinking. A nurse manager might have to decide
how to divide a budget between a number of patients and the professionals who
work with them. It is plausible to suppose that she should use her experience ,and
research evidence ,to determine which pattern of distribution would do the most good' 6although note the complexity and uncertainty inherent in this) ,and opt for this. This sounds fine in the abstract ,but in the real world it would probably involve overriding the views and wishes of the patients and professionals involved. Certainly any decision which entailed not treating certain sick individuals at all because moneywasted' on them might be better spent elsewhere would appear to
treat the former with less than respect. For this reason many people react against
utilitarian thinking ,seeing it as amoral or even `immoral'. Yet health professionals ,
including nurses ,have some responsibility to the general welfare or the public
interest ,as well as to the individuals in front of them ,and need to explore ways of
balancing these responsibilities. This is merely one illustration of the ways in
24 NursingLawandEthics