his article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and has now been updated.
Why is it important to understand the basics of utilitarianism? The answer, at least, in part is that democratic government and what we might broadly term current ‘Western’ culture, owes much to the political philosophy that has its roots in some form of utilitarianism. Thus, whether we know it or not, utilitarianism has had a major influence on the culture, which shaped many of us.
Culture and socialisation are not the only influences on us, but they are significant. Ethics in pain management has its roots in utilitarianism and therefore it is important to understand the concepts involved. The (earliest form of utilitarianism is to be found in the writing of Francis Hutcheson in 1725). The best-known advocates of utilitarianism as a moral theory are Jeremy Bentham (1748-1832) and John Stuart Mills (1808-1873).
Jeremy Bentham was one of the leaders of a group known as the philosophical radicals. He advocated an egalitarianism that was in contrast to, for instance, British Imperialism in India. He argued on the grounds of fairness and justice for universal suffrage and campaigned against power being held in the hands of aristocracy and even opposed the monarchy.
He was also an atheist. The reason why Bentham and those who followed him are important is that the philosophical radicals were responsible for far-reaching social and political changes in Britain. Among the radicals was the father of John Stuart Mill. John Stuart Mill’s upbringing and education are described in his autobiography, which shows that his father believed Bentham’s thesis that anyone’s character and even his intelligence could be determined by education.
What was the driving force behind what we would broadly call utilitarianism? The answer to this question is the concept of utility. The concept of utility can be expressed as the greatest happiness for the greatest number. This was seen by the founding fathers of utilitarianism as an objective principle for deciding whether a particular action was right or wrong. Betham, and later Mill, interpreted happiness to mean pleasure and can therefore by said to be hedonistic. However, there are many ways in which utilitarianism has developed without tying the idea of utility only, or even, to pleasure. Utilitarianism is clearly consequentialist in nature. Acts are not right or wrong by virtue of their intent, but as a result of their outcome. Bentham actually went so far as to develop a hedonic calculus because he believed that the balance of pain over pleasure could be an objective scale for moral judgment of an act.
One of the results of utilitarianism is that is makes a clear distinction between the goodness of the person who does any act (the agent) and the goodness of the act itself measured by its consequences. In a moment, we shall look at interpreting this in Act utilitarianism and Rule utilitarianism. Thus, the strict utilitarian position would say that any act that brought about something bad, for example acute pain, remains immoral, despite any good intentions of the agent.
If utilitarianism seeks the greatest good for the greatest number (whether or not we think of good in terms of pleasure) then the rightness of wrongness of an act is determined by the majority who believes it gives them more ‘utility’ (good) than bad.
In terms of health care, utilitarianism has established in our minds a principle and a moral right that everyone should have equal access to care, and prompt us to say that to be free from pain is everyone’s right. More specifically, there should be equal access to care regardless of the cause of the problem with no distinction made between, for instance a woman with smoking related lung cancer and a young man with appendicitis.
No moral theory can remain undeveloped and utilitarianism is no exception, as different thinkers have challenged and, in some cases, modified our understanding of the theory. Within a variety of ways in which utilitarianism has been expressed, here are a few.
Positive and negative utilitarianism
This is the distinction between acts that attempt to maximise the good (utility) and acts that seek to minimise harm. Think about the distinction; it is important, not least in pain management.
The definition of good as utility
Bentham and Mill identified utility with happiness, defined as enjoyment in certain states of feeling. Today we tend to think more in terms of desires and preferences. It sounds convincing that, provided the majority have their desires fulfilled, then any act that brings that about must be morally good. However, two things must be asked. First, is it self-evidently good to satisfy the majority’s wishes without regard to the nature of that wish? For example, if a majority wanted a 24-hour hard pornography channel freely available to everyone, including children, would its provision be morally right? In other words, what is it in a majority which to have a desire satisfied that makes it something which ought to be granted? Second, if a majority desired to improve the standard of living for themselves by enslaving a minority of the population, would that make the majority morally right? How large a minority should be disadvantaged and to what degree before they have to be taken into moral account? Specifically, would it be morally right to disadvantage a minority by providing minimal pain control (for instance to smokers or drug addicts) while providing the majority with first-rate pain management? Utilitarianism has difficulty responding to these kinds of questions.
Utilitarianism as consequentialism and as welfarism
This is simply the distinction between utilitarianism as a moral theory that says that acts must be judged in the light of their consequences in terms of the difference such acts make to society, or even to the history of the world and welfarism which says that utility means the good that results for individuals in relation to the act. On one hand, is the world a better place and on the other hand am I happier, more satisfied? What if you can’t have both?
Act and Rule utilitarianism
The usual distinction within utilitarianism is that between act and rule utilitarianism.
Each individual action should be judged on the results produced by that act. This form of utilitarianism is concerned with personal behaviours in a social context. If I am faced with a choice of making a donation to one of a number of worthy causes, to decide which worthy cause is most worthy, I must decide where my donation would result in the greater good outcome, happiness or utility.
Where the act utilitarianism asks what the outcome would be of his or her individual act, the rule utilitarian asks what would happen if everyone did this? Thus, while an act utilitarian might decide that instead of paying a bill he or she would give the money to a charitable cause, thus maximising the good effect, the rule utilitarian would say, for the good order of society as a whole, the best outcomes would result from everyone agreeing to pay their bills.
Similarly resources spent on pain management may not result in one individual being pain free but not to tackle pain in its many forms would be an act of omission and thus unethical.
Much more can be said about the differences between act and rule utilitarianism and hope this is sufficient for you to grasp not only the power of this moral theory, but also its diversity in application.