A critical examination of the underpinning ethical philosophies and the ethical issues arising

from a research topic.

H. Green
University of Lincoln
_______________________________________________________________________
Research Topic: The cross-language efficacy of the Improving Access to Psychological
Therapies (IAPT), Low-intensity cognitive behaviour therapy (CBT) service, for depression
and/or anxiety.
Ethical principles are concerned with protecting the rights, dignity and welfare of research
participants (Barker, Pistrang, & Elliot, 2002). Health care researchers have an inherent
responsibility to undertake research that is ethically right, good, correct, competent and
culturally sensitive in the pursuit of understanding human behaviour. This as a philosophy is
grounded in the rules and principles that are societally embraced as ethical normative
guidelines concerning right and wrong human conduct (Green, 2000). In considering the
ethicality of research, it is paramount to not only recognise how values and beliefs influence
both the behaviour of the researcher and research participants, but to consider ethical issues
from differing ethical philosophies. The purpose of this essay is to discuss and critically
evaluate some of the underpinning ethical philosophies pertinent to the research topic, and
critically evaluate how these philosophies affect the ethical issues of the research topic in
health care practice.

Utilitarianism
Consequentialism or teleology (Greek for logic of ends) is associated with goals, ends,
purposiveness and purpose, and arguments centring on consequences and outcomes. What is
ethical is seen in terms of the good produced as a consequence of an action (Tschudin, 2003).
Utilitarianism originates in the work of Bentham ([1781], 1970) and was further developed
by Mill ([1861], 1954). It is one of the best known subgroups of teleology and is classically
associated with producing the greatest happiness for the greatest number of people (Baggini
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& Fosl, 2007). As an ethical philosophy, the problem of defining and measuring happiness
has been extensively criticised (Seedhouse, 2009). Moreover, time has developed distinct
branches of ethical philosophy within the utilitarian calculus.
Act-utilitarianism tenets focus on cost-benefit calculations for making ethical judgements.
Therefore, after assessing every possible outcome of an action, if the intended action on
balance, (regardless of motive) is likely to create a more positive outcome than negative
outcome the action is warranted (Seedhouse, 2009). As a philosophy, it has been criticised as
ignoring human fallibility and sanctioning any action as ethically justifiable if an action
brings about favourable consequences (Hugman, 2005) and criticised as an unrealistic tool
for the urgent world of health care due to the laboriousness of utility calculations (Dickenson
& Fulford, 2000).
Rule-utilitarianism contrasts with act-utilitarianism as each decision is treated separately
(Mepham, 2008). Therefore, the action which if always adhered to will produce the greatest
balance of positive over negative for the longest period (Beauchamp & Childress, 2009)
becomes the general rule of conduct. A difficulty in the implementation of all forms of
utilitarianism within health care is that as an ethical philosophy it would permit possibly
justifiable discrimination, and permit dangerous research experimentation if potential
findings resulted in great benefit to many (Loewy, 1996). Further difficulties arise in that,
ethical decision making (to a degree) is speculative as it is future outcomes that are the focus.
The challenges in who or whats interest is included in ethical analysis, and the vastness of
the information required for utilitarian calculation has prompted philosopher John Mackie
description of utilitarianism as fantasy ethics (Mepham 2008).

Deontology
Deontological (derived from the Greek deon for duty) ethical tenets are
non-consequentialist as they focus on right conduct and duties, or
absolutes of right and wrong (Tschudin, 2003). Duty is based on the
assumption that ethical laws are duties. Deontological principles are
defined abstractly, are generalizable, universal, and are impartial in
applying equally to everyone in the same type of situation. Classically
known as the categorical imperative the consequences themselves are
irrelevant in determining what is right (Kant, [1724] (1978) and may not
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result in an increase of the good. Morality of actions is judged on the

intention of an action rather than on the motivation, people should
therefore act out of a sense of duty- a principle that is right in of itself
(Mepham, 2008 p.33). In essence, the principles of deontology correspond
with the golden rule: Do as you would be done by (Mepham, 2008 p.34).
Like utilitarianism, deontology has developed distinct branches of
deontological tenets. Act-deontology opposes the following of rules.
Ethical judgements are based on moral action only and are unique to each
circumstance. There are no standards other than the individuals central
convictions. Situations are seen as too idiosyncratic, in general, to be
subsumable under general rules. Such ethical tenets highlight that within
health care overt rules and principles of conduct are required as guidance
for the development of standards of professionalism (Seedhouse, 2009).
Act-deontology also highlights how it is ethically inadequate for health
care professionals to unquestionably follow rules and convention, as each
health care or research context requires the fullest possible ethical
attention to develop professional authenticity. However, pure actdeontology is built on a philosophy that advocates arbitrary decisions
rendering its tenets as inordinately impractical within health care
(Tschudin, 2003).
Contrasting with act-deontology, rule-deontology states that ethical
principles must be applied in the form of rules to determine whether
particular acts are ethically right or wrong regardless of likely outcome
(Baggini et al., 2007). Some rule-deontologists assert that the rules in
themselves are good and to not act accordingly with the rules is unethical
(Seedhouse, 2009). Many codes of practice are limited forms of ruledeontology. However, codes in themselves do not necessarily provide the
predictability that deontologists require (Thompson, 2003). A significant
problem with rule deontology particularly within the health care setting is
that there will be times that it will be better to break implemented rules
rather than follow them. Furthermore, if a set of rules is implemented and
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conflict between the rules arises rule-deontology provides no guidance for

conflict management (Tschudin, 2003).
Utilitarian and deontological principles provide useful ways of thinking and have
undoubtedly provided foundational ethical principles for the health care profession. However,
as ethical approaches they cannot be simply imposed onto practical situations as they stand.
As attempts to construct pure utilitarian or deontological premises from which all practical
ethical debates and dilemmas are viewable leads to an over simplification of the complex
circumstances in which health care professionals practice (Hugman, 2005).

Codes of Practice
Traditional liberal ethics are based on formal reasoning; a strength of such principles is that
general statements can be made about professional practice. Further, codes of ethics and
practice are underpinned by deontological principles. It is reasonable to assume that within
the health care profession as a collective entity, professionals will not share the same moral
values and beliefs. Codes provide both general and specific rules of conducts and the
definitions of good practice which health care professionals should observe, during the
exercise of their profession (Roger France, 1998). The development of codes of practice not
only provides a moral framework for thought and the action of health care professionals, they
provide accountability and transparency. Codes are not law, nor do they provide legal base for
ethical decision, in a sense they come before law, they do not declare the obvious, they point
to what should be (Tschudin, 2002). In the development of codes, ethical norms often become
embodied in codes through procedures of democratic pluralism, which as process recognises
nuanced interpretation of ethicality, and that modified ethical norms retain their substantive
meaning (Green, 2000). Therefore, as an instrument, codes provide ethicality based on
reasoning, and serve an accessible instrument to both health care professionals and the public
alike (Hugman, 2005). Due to the research topic examining the Improving Access to
Psychological Therapies (IAPT) Low-intensity cognitive behaviour therapy (CBT)
programme, it is reasoned that the research topic lends itself to adhering to the code of
conduct and ethical principles of the British Psychological Society (BPS, 2000). Its purpose
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is to provide guidelines to all psychologists and psychological researchers at both a country

and international level. The code itself consists of general principles and sections on respect,
competence, responsibility, integrity, obtaining consent, confidentiality and personal conduct,
and is designed to provide clear ethical principles, values and standards to guide and support
decisions in difficult and challenging situations (BPS, 2000). It is important to note that other
codes, statutes and ethical guidelines are relevant in the context of the research topic, which
includes but are not limited to the university ethical principles and procedures and legislation
in addition to the Declaration of Helsinki (World Medical Association, 2008) which is
binding for all research involving human participants. A difficulty of codes in practice is that
the principles of the codes under which individual professionals are practicing are not always
made explicit. For example, within a multidisciplinary team, a counselling therapist could be
practicing under a psychological code, whilst the clinical psychologist is practicing under a
medical code and the forensic psychologist is practicing under a legal code. This could in turn
affect the ethical frameworks of the multidisciplinary nature of the health care service
(Seedhouse, 2009). Codes in themselves are by their very nature both prescriptive and
general, in providing guidance about right conduct and best practice whilst at the same time
serving as categorical rules governing professional action (Hugman, 2005). However,
Pattison (2002) contends that the ontological and epistemological underpinnings of
statements made within health care codes are not declared, and thus the helpfulness of codes
is devalued. Codes of ethics are produced within the profession to which they apply. Thus,
often written by groups or members of a profession that has a responsibility for ethical issues
within that profession. This seemingly provides a reasonable way of delineating ethical issues
within a specific profession. However, due to the nature of the tasks of healthcare
professionals, there is a risk that code developers are removed from the normative moral
values of the society in which they practice (Hussey, 1996) rather than drawing from the
same pool of human understanding as the layperson. Codes of ethics may then risk becoming
a source of determination of what is good or right, in and of itself, based solely on the
formal reasoned statements of a recognised authority in the guise of a professional
association (Hussey, 1996, p.254). Suggesting that the way in which codes are written as
rules could contribute to marginalising ethical thinking.
In taking a critical psychology perspective, further problems with ethical codes are revealed.
Ethical codes define the power relationship between health care professionals and those
whom which they work as essentially benign, as long as the rules of conduct are followed.
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Therefore, highlighting that hierarchy is not only permissible within ethical norms but is
valued and reified (Brown, 1997). Thus, the Hippocratic Oaths relevance in health care
ethics today perpetuates fundamental underpinnings of the ancient world. Where a rigidized
hierarchical power structure afforded only property owning men with rights, and all other
humans were deemed as inferior and a property (Brown, 1997). Within dominant ethical
codes, it appears that, the values or worth of such hierarchy remains unquestioned. Rather it
is accepted that hierarchies will exist and are beneficial when the powerful party (in this case
health care professionals) is careful with the use of power (Brown, 1997).

Four Principle Approach

Theories of ethics tend to be exclusive and consistent only within their own reasoning. To
make them accessible, clear principles are needed which embody and cover the main tenets
of ethical theories. Beauchamp and Childress 1979 (2009) established a set of four universal
principles, which have dominated biomedical ethics for the past 30 years (Bowling, 2005). As
an approach, they provide simplicity and practicality in addressing ethical problems and
avoid the inherent problems of strict adherence to utilitarianism and deontology (Hugman,
2005) to accept that neither consequence or duty can be ignored (Mepham, 2008).
Beauchamp and Childress (2009) describe the principles as:
Autonomy - the obligation to respect the decision-making capacities of autonomous persons.
Beneficence - the obligation to provide benefits and to balance benefits against risks.
Non-maleficence - the obligation to avoid causing harm.
Justice - the obligation of fairness in the distribution of benefits and risks.
As principles, they are prima facie relevant to ethical issues in health care research meaning
each principle is intuitively balanced against one another when rationalising the relative
importance of each principle in each given case. As an approach to ethical dilemma, it has
been constructive in broadening the understanding of the research topic. The principles
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produced increased awareness of the implications of the research topic: firstly, through
forcing thinking to consider all aspects of the research topic. Secondly, through changing
attitudes towards data collection as the principles demonstrated how particular approaches
may be bias, culturally inappropriate or impact the therapy process. Thirdly, the principles
highlighted gaps in topic knowledge, and fourthly improved overall thinking skills by
providing a structure with which to analyse the ethical issues of the research topic. However,
due to a deceptive simplicity, a danger of Beauchamps, et al. (2009) principles (particularly
when used independently) is that when misunderstanding occurs it suggests an ethicality of
solvability rather than one of guidance (Dickenson et al., 2000). Callahan (2003) argues that
as an approach it is narrow, too individualistic to adequately assess the appropriate needs of
communities, and too mechanical to encourage analytical and personal skills. Further
Callahan (2003) proposes the principles reflect the liberal, individualist culture from which
they emerged and are thus culture congenial. The relative simplicity of conceptualisation and
application of the principles make them particularly attractive to clinical decision making.
Callahan (2003) further proposes prima facie principles in effect are analogous to ethical
reductionism and thereby blocking substantive ethical inquiry. Clouser and Gert have
emerged as the most prominent critics of the Beauchamp and Childress four principles
(Beauchamps, et al., 2009). Their criticisms include firstly, that the principles are little more
than value check lists that offer no deep no moral substance and produce no directive
guidelines for moral conduct. Secondly, the principles fail to provide clear directive guidance,
theory of justification or theory that ties the principles together, and thirdly that the prima
facie principles in difficult circumstances often conflict, and Beauchamp and Childresss
account is too indeterminate to adjudicate conflicts. Beauchamp and Childress acknowledge
that these are valid criticisms, but are unable to proffer resolute answers to them due to their
rejection of the existence of a single, clear, coherent and comprehensive decision procedure
for arriving at answers (Beauchamps, et al., 2009 p.372).
Quality Adjusted Life Years (QALYs)
Quality Adjusted Life Years (QALYs) are about the benefits of health care. An illustration of
using utilitarianism in health care ethics can be found in the use of the QALY cost-utility
analyses in resource allocation. To ascertain QALYs, the years of life are weighted with a
preference-based index of health-related quality of life in an attempt to value the health effect
directly in monetary units (Konnopka, Leichsenring, Leibing & Knig, 2009). The
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Department of Health (DoH, 2008) monetise wellbeing as valued at around 40,000 per
QALY with each extra year of good mental health representing around 0.11 QALYs. This is
based on the EuroQol Descriptive system and uses the average of
(i) a change from moderate depression or anxiety for those with good health (rated at
0.152 QALY and (ii) a change from moderate depression or anxiety for those with
moderate other health (rated at 0.071 QALYs) (DoH, 2008, P.20).

The impact of the Improving Access to Psychological Therapies (IAPT) service is estimated
as providing service users with an extra 6.5 months (or 0.54 years) of good health for two
years post Cognitive Behavioural Therapy (CBT) intervention, comparatively to those not
receiving treatment (Layard, Clark, Knapp, & Mayraz, 2007). By valuing each extra year of
good mental health at 0.11 QALYs, the DoH quantifies the average benefits per patient
treated at 0.06 QALYs over 2 years or approximately 0.03 QALYs per year monetized as
1206 per patient, per year for two years post treatment.
The DoH (2008) recognises that the benefits from treatment will depend on the severity of
the condition and that their estimates are representative of an average service user treated,
and allows for the impact of both natural recovery and for the reduced rates of relapse
associated with interventional psychological therapy. These statistics therefore, seemingly
appear as a clear economic evaluation of IAPT CBT outcomes. IAPT CBT follows a specific
model for intervention (see Richards, & Whyte, 2008) thus outcomes for all average service
users should be similar. Ethnic minorities currently comprise of approximately 5.8% of
Lincolnshires population (Lincolnshire Research Observatory, 2009) this number is growing,
indeed Lincolnshire is one of the fastest growing areas of the UK particularly with
Portuguese, Polish and Eastern European migrants (NHS Lincolnshire, 2009). IAPT sites
located in areas with low ratios of ethnic minorities are likely to have low ratios of
multilingual therapists. Professional interpreters are available to services users with a poor
grasp of the English language when native language speaker therapists are unavailable.
However, IAPT CBT is more likely to continue occurring cross-language in regions with a
low ratio of ethnic minorities. Therefore, barriers to treatment efficacy are likely to arise. The
QALY for the IAPT service is likely to fail to recognise ethnic minority service users, as part
of the average. Therefore, should the aims of the research topic conclude that the efficacy of
cross-language IAPT low-intensity CBT is reduced, the QALY could be used for denying
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service users cross-language IAPT CBT. Rather than the research topic outcomes providing
catalyst for IAPT CBT change.
The QALY is a way of assessing differences in the quality of life of different individuals.
Seedhouse (2009) notes seven ways in which the results the QALY produces are intended to
be used:
1.
2.
3.
4.
5.
6.
7.

For clarifying the cost of treatment without generating practical change.

To make priorities explicit.
For comparison of short-term treatment benefit against long-term treatment benefit.
For ensuring the most cost-effective use of heath care service funds.
To ensure the most beneficial distribution of health care.
To aid reflective judgement as a matter of calculation.
To aid selection of those people whos treatment is most likely to produce the most
QALYs.

Points 1-6 are ethically innocuous. The QALY being used to decide which treatment from a
range of treatments will bring about the most favourable quality outcome for the same person
also is not disputed, as heath care professionals are endeavouring to rationalise the optimum
treatment for an individual patient (Quigley, 2007). However, point 7 highlights the
discriminatory possibilities of the QALY. Current research attempting to refine and define the
QALY, highlights, that many practitioners and policymakers remain uncritical and
unapologetic of the discriminatory usage of the QALY for the purposes of health care
assessment (Smith, Drummond, & Brixner, 2009). Supporters of the QALY (Dracopoulou,
1999) purport that there is no escape from the negative consequences of priority setting, as
when more resources devoted to health care become available the highest priority uses to
which they should be put still has to be rationalised. Thus, when viewed from this
perspective, priority setting the consequence of negative effect on some health care service
users is considered as acceptable. The QALY therefore can be used to discriminate between
services users such as the sick, elderly or the non-productive or to rationalise, which
conditions to give priority in the allocation of health care resources (Seedhouse, 2009). For
example in the case of conditions being equal saving the life of a younger person is more
likely to produce more QALYs than saving the life of an older person (Beauchamp et al.,
2009). The use and endorsement of this particular aspect of the QALY highlights that QALYs
are not only an ethically contentious issue but any wider policy in which the QALY is
incorporated also becomes ethically contentious (Quigley, 2007).
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A burgeoning literature spanning more than 30 years (for example, Harris, 1987; Cubbon,
1991; Dowie, 2001; Smith, et al., 2009) critique the QALY as a form of marginalisation for
receiving health care. As it is people receiving health care that largely become the primary
research participants of health care research, it therefore reasonable to examine this critiques
impact on health care research participation. In applying the QALY to this domain it
highlights that the QALY directly affects the research process, not only in context of the
research topic, but it is suggested to the domain of health care research itself. Research aims
to provide purposeful contribution to the development of theory and professional knowledge.
The QALY potentially directly affects the services and treatments researched as well as the
population taking part in the research. Health care research should be generalizable to
populations but the use of the QALY raises ethical issues with research samples,
generalizability and what is researched. Therefore, the QALY further has the potential to
biasing research outcomes toward positive outcomes, due to the nature of the QALY selecting
people for health care interventions who are more likely to have positive health outcomes.
Researchers record attrition rates and details of how many people declined research
participation as a matter of professionality. However, health care research as a matter of
course fails to acknowledge that a proportion of the potential population sample includable in
research have been excluded from research participation through QALY rationalisation of
non-treatment. Therefore, truly reflective sampling of populations experiencing disorder,
disease, treatment etc is not achievable due to a biasing that current research fails to account
for and further (almost inherently) biasing research outcomes. A factor that the research
literature seems to largely ignore. Codes of practice, ethical underpinnings and ethical
committees provide frameworks to eradicate unethical, oppressive or discriminatory health
care research. Yet, the use of the QALY has potentially discriminated, oppressed and
marginalised before any health care research takes place, a factor that requires health care
research to move toward recognising. Whether health care research practice will be able to
achieve

this,

remains

to

be

seen.

Perusal

of

NHS

websites

(for

example

http://www.nhs.uk/Pages/HomePage.aspx) seemly promotes health care to the public as

providing choice for all, in a realm of fairness and equality (Quigly, 2007). However, the
NHS and the National for Clinical Excellence (NICE) propensity for the usage of the QALY
combined with the findings of (Smith et al., 2009) demonstrates society remains divided
along lines of power. For fully ethical health care research practice to occur, it firstly requires
governing bodies to acknowledge that value judgements are being made about which people
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have worthwhile lives and which lives the NHS attempt to save or ameliorate (Quigley, 2007)
and this in turn is directly affecting health care research. Indeed, it appears that health care
research has been subtly institutionalised into accepting the discrimination and oppression of
the QALY making it harder to recognise in operation and to combat its presence.
In closing, this paper has examined some of the most influential ethical philosophies relating
to the research topic, it demonstrates the sea of decision making ethical philosophies is vast
and there is no one theory sufficient for all health care decision making neither are there
objectively right answers. It also demonstrates that a lack of an agreed standard or an inability
to generalise ethical theory does not render ethical reasoning valueless (LaFollettee, 2007).
Examination of the QALY exposes the potential for injustice in health care service decision
making, and how these decisions potentially affect the research process. Ethical theory, codes
and committees help to achieve a balanced view of a course of action. Indeed, researchers are
obliged to explore and seek advice and judgement of the specific ethical issues arising from
their research. At degree level, ethics and validity are taught independently as issues.
However, Seedhouse (2009) notes, the relationship of ethics and validity is one of symbiosis,
because the external validity of research is reduced through unethical practice resulting in
research procedures that cannot be translated into practice, whilst ethicality is reduced by
poorly designed research. There are many conflicting philosophical underpinnings to research
and many conflicting ethical considerations within practice. When practicing within the
realms of judgement, there are often difficult choices to be made and there is no such thing as
an ethical resolute.

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