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Monday, 29 August 2016 00:00

Ethics Matrices - Part II

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by Pierre Mallia MD MPhil PhD MRCP FRCGP

Bioethics Research Programme

Medical School, University of Malta

The first part of this article has tackled the issue of separating the main moral argument at hand from other moral pragmatic issues. It was seen that when negotiating moral problems it is sometimes clear what the main argument is – such as, ‘Should we have InVitro Fertilization?’ or ‘Should we sell organs?. On the other hand, other moral arguments, called pragmatic, may not be the main argument but can still have weight on the final acceptance of the moral issue at hand.

Pragmatic arguments are those which may be resolved in time, with advancing technology. On the other hand, ethical arguments are other moral issues which may not be resolved but which in themselves present another moral argument for discussion. In the previous argument, autostimulation to produce a sample of sperm for IVF was considered an ethical issue. It is not pragmatic as this cannot be resolved in time. Yet it is legitimately another moral argument. It should be made clear that this was not the main argument being discussed, if what was being deliberated was IVF. It may merit a separate discussion and within that context be put into the category (or box) labelled ‘moral’. But that would then be another argument.

Another example is freezing of embryos. This again is considered immoral by many. However it cannot be the main argument against the use of IVF, as it may be bypassed. Conversely it is another ethical issue and may merit discussion on its own, being then put in the category of ‘moral’. It is not a pragmatic issue however as it is not a technology which can be improved, other than its omission.

Sometimes we can be unclear as to whether an argument is simply pragmatic or ethical and therefore we have the convenient category labelled ‘unknown’. We can come to it later without sidelining the arguments at hand. For example, one argument often brought into the case for IVF is that couples should not be encouraged to go through extreme sacrifices like selling a house; for others, having a baby may be more important than owning a large, nice house.

Principles Matrix

Another ethics matrix convenient for use is that developed by Ben Mepham which considers a principles approach. Mepham uses three principles: well-being, autonomy and Fairness. It is basically an attempt to move away from the four-principled approach developed by Beauchamp and Childress which have been discussed in this column in previous articles, ie autonomy, beneficence, non-maleficence, and justice. He applies this matrix, an example of which is given here, in various parts of his book, dealing with many areas of bioethics.

Respect for:





Satisfactory income

Managerial freedom

Fair trade laws and practices


Food Safety

Informed choice

Affordable food

The Biota




Genetically Modified Crop



Intrinsic value

The above matrix deals with genetically modified crops. In reality fairness is a principle used in justice. Justice has fairness and equality as two principles usually defined within it. However one may separate justice into ‘equality’, and ‘fairness’ or put beneficence and non-maleficence in one category for convenience, according to the topic being discussed. One should keep in mind that the four principles proposed by Beauchamp and Childress do not resolve moral problems. They simply allow a framework for discussion and allow one to formulate a path for arriving to a conclusion. This conclusion however is usually based on separate issues than the four principles alone, such as respect for life, which can be used therefore to arrive at quite opposite conclusions . They nevertheless are the main principles discussed in moral discourse.






Can/cannot make a choice


Side effects

What is in his/her best interest?


Who is to act as proxy?


Giving (bad) news

Any right to knowledge

Medical team

Explaining/taking medical choices

Is treatment futile?

Balance benefits with side effects

Cost/benefit ratio


Does it have a say?

Can others benefit?

Slippery slope arguments

Justice to the community

In the case of Terre Schiavo - the American brain-injured woman who died nearly four years ago, after doctors removed the feeding tube that had sustained her for more than a decade - one may apply the four principles to all parties concerned: the patient, the husband & parents, the religious community at large, and the medical team making the decision. We usually balance between principles and specify them to the situation; but arriving at a moral conclusion is usually an a priori affair. One uses the matrix simply to put one’s arguments in a clear, understandable, and common ethical language. Not all boxes need be ‘filled’.

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