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Consequentialism

THIS chapter starts by explaining the theory in moral philosophy called consequentialism. Then a specific version of consequentialism, i.e., utilitarianism, is clarified. Given this, the naïve utilitarian view of public health can be presented. The naïve view is that policies and programmes that maximize public health gain are morally permissible, even morally obligatory. The rest of the chapter queries this naïve view by presenting constraints on the pursuit of maximal public health gain from within the consequentialist tradition to which it belongs. In other words, more sophisticated versions of utilitarianism rule out some public health activities, despite the health gains they can be expected to produce. Let’s start with some definitions of basic terms.

Defining consequentialism and utilitarianism

Consequentialism is a major moral theory that states that the moral value of an action is determined solely by consequences (Rachels and Rachels 2007: 89–116). ‘Action’ is here used as an umbrella term for whatever it is the morality of which is in question, which can include single acts, motives, policies, regulations, laws and public health interventions. Examples of the ‘moral value’ of an act include being right, wrong, permissible, obligatory and supererogatory. This all sounds rather technical, but a virtue of consequentialism – an odd word, but actually quite a helpful piece of academic jargon – is that it captures a very natural and familiar line of thought. All of us have been faced with a moral situation in which we are puzzled as to the right thing to do; consequentialism says, in such circumstances, look only to the consequences of the available actions. The right thing to do is that which will bring about the best consequences. The wrong thing to do is that which will fail to bring about the best consequences.

Left at this, consequentialism is not much use because, unless we explain what makes a set of consequences good, or better than others, the idea that one ought to bring about the best one is unhelpful. This is where utilitarianism comes in. Utilitarianism is the example, or version, of consequentialism that states that what makes a set of consequences good is that it maximizes ‘utility’. ‘Utility’ – a rather old-fashioned word – is often translated in terms of pleasure, happiness and, conversely, freedom from pain. But, since such terms make the theory sound hedonistic in a somewhat shallow sense, better phrases are well-being, welfare and benefit. So, utilitarianism is the version of consequentialism that says that the right action is that which brings about the best consequences, and the best consequences are those that maximize well-being, welfare or benefit.

Further clarifications

Before applying utilitarianism to public health, some further clarificatory remarks are called for in order to avoid misunderstandings. Firstly, utilitarianism is an impartial (or impersonal) theory. To explain, suppose someone were to ask whose welfare we are supposed to bother about, or whose well-being counts for most, when making a moral decision. The answer, according to utilitarianism, is that the well-being of everyone affected by the action in question counts and, moreover, counts equally. This is one of the most appealing aspects of utilitarianism: it is impartial (or impersonal) in the sense of denying that the welfare of some individual(s) or type(s) of people is more important than that of others. So, utilitarianism does not say that the right action is that which maximizes well-being for myself, or white people, or straight people or the able-bodied, or whomever; rather, it says that we should impartially maximize well-being.

To counter another possible misunderstanding, consider an imaginary scenario. A moral agent is walking quickly towards a class that is about to start. They see a frail, elderly person having difficulty crossing a busy road. The agent decides to stop, risking missing the start of their class in order to help. Halfway across, and without any warning, a drunken driver comes careering down the road, heading straight for them. The agent manages to dive out of the way but the elderly person is hit and injured. Did the agent do the morally right thing, according to utilitarianism? Referring to what might be called classical utilitarianism, the answer is, no, because utilitarianism says that the right action is that which maximizes benefit and, in this case, benefit was not maximized. But this might seem counter-intuitive. Here, it is useful to distinguish acting so as to maximize actual benefit and acting so as to maximize expected benefit, in order to suggest that we ought to act so as to maximize expected, not actual, utility. In helping the elderly person across the road the agent had every reason to expect to provide benefit (a safe passage) at a small cost (being late for class). So, according to this, arguably more intuitive, utilitarian account, the agent did the morally right thing, despite the actual, unfortunate outcome of their action.

Another point can cause confusion. Many people associate utilitarianism with the phrase, ‘the greatest good for the greatest number’. To explain the misunderstanding that can arise here, consider another, rather more fanciful scenario. Imagine that a moral agent possesses the last 5 ml of a drug. What makes the drug unusual is that if 1 ml of it is given to each of five people, it has the effect of curing their common colds quite quickly, but if all 5 ml of the drug is given to one person who has a certain life-threatening condition, it has the effect of saving their life. Which should the agent do according to utilitarianism: give 1 ml to each of the five people, or all 5 ml to the one person? A natural line of thought is that, to do the greatest good for the greatest number, the agent should give 1 ml to each of the five people, because that way they help more people. But this is not correct. The utilitarian is interested in maximizing benefit per se, rather than maximizing the number of people who get some benefit from one’s actions: i.e., it is about the greatest good, not the greatest number. So, because saving a person’s life is of immeasurably greater benefit than getting over a cold a bit quicker, the utilitarian would conclude that the right action is to give all 5 ml to the one person.

The idea that the right thing to do is to maximize well-being is known as the principle of utility, and the weighing up of the expected utility of actions is called the utilitarian calculation. One might well complain that it is unrealistic of the utilitarian to expect us to do a utilitarian calculation every time we have to do something. Often, we simply do not have the time, energy or information to do so; and this might seem to imply that most of us are, for the most part, acting immorally. This is part of a general ‘over-demandingness’ objection to utilitarianism that we revisit in chapter 9, in the context of a discussion about whether there is a general duty not to infect others. But, in the present context, suffice to say that the utilitarian can recognize the role of what are called ‘rules of thumb’ in moral deliberations. Take the example of turning up to work on time. Do we really need, every day, to calculate that being punctual maximizes expected utility? It is easy to notice that, generally speaking, being late for work causes problems to patients, colleagues and even ourselves that can be avoided simply by being on time. Given this, we should act according to the rule of thumb, I ought to get to work on time, rather than having to recalculate the same moral equation and getting the same result over and over again. The point to note is that this is still utilitarianism because what makes it right to act according to such a rule of thumb is that, in our experience, doing so tends to maximize well-being.

There are numerous objections to utilitarianism, debate about which is a massive industry in moral philosophy (Rachels and Rachels 2007). There is not space to go deeply into this, which is not central to our concerns. But, to give a flavour of the discussion, recall the point made above about impartiality: utilitarianism aims at benefit, so it does not endorse preference for, or prejudice against, individuals or even types of people. This is said to be a virtue of the theory, but it is also a source of criticism. In one respect, this is another example of the general over-demandingness objection to utilitarianism just mentioned. But the more pertinent objection here is that utilitarianism must be a false theory because it is at odds with some of our strongest moral intuitions. For example, people value their children’s welfare much more highly than that of strangers, and it is not clear that to do so is to be immoral (this phenomenon is known as ‘agent-relativity’). Utilitarians devise ways around the problem. One involves the notion of ‘satisficing utilitarianism’, which replaces the idea that the right action is that which maximizes benefit with the idea that an action is (all) right provided that it produces a satisfactory amount of benefit (Slote and Pettit 1984; Bradley 2006). This leaves open the possibility of being a utilitarian whilst preferring to benefit one’s nearest and dearest: so long as the agent has acted so as to produce enough benefit given the circumstances, they can prioritize their loved ones even if they could have produced more overall utility by being wholly...