Keywords

Introduction and Case Study

Resource Allocation for Rare Diseases

Cystic Fibrosis (CF) is a chronic and progressive genetic disease that affects lung function and the digestive system. It is a rare disease with around 70,000 sufferers globally. Due to its genetic basis some geographic areas, such as Ireland, have a particularly high incidence. A range of specific genetic defects are responsible for the creation of sticky mucus which obstructs the lungs of CF sufferers and lead to shortness of breath, frequent lung infections and digestive problems. Over time, the lung function deteriorates and ultimately leads to premature death, with a median age of death of CF sufferers in Western countries in their late 30s. Treatment for CF has improved significantly and quality of life and survival times of CF sufferers have extended continuously over the last few decades; however, no cure has yet been developed. Given the level of impairment and the expectation of premature death of CF sufferers, the development of a drug that promised to target specifically the underlying defects of the disease, rather than merely the symptoms of the disease, in a small subgroup of CF sufferers was welcomed enthusiastically. The company Vertex brought ivacaftor (Kalydeco) to market in 2012, a drug that promised to provide such a sustainable treatment. The drug is suitable for those CF sufferers who have a specific genetic mutation in the cystic fibrosis transmembrane conductance regulator (CFTR), around 5% of all CF sufferers. Its initial cost in the US was 300,000 USD per patient per year. This means a significant cost for the healthcare system, albeit for a very small number of patients. Should this drug be covered by the public healthcare system?

There are different possible responses to this question. Many health care professionals would state that a medication that has a chance to significantly improve the management of a life threatening condition should be provided to patients suffering from that condition, no matter what its price is. In contrast, the theory of Utilitarianism proposes to engage with this question primarily on the basis of assessing and comparing consequences of different alternative options. Utilitarianism considers the overall costs and benefits of the use of the medication and compares it to the overall costs and benefits of other possible options. From a Utilitarian perspective, what needs to be considered is the question whether the benefit to CF sufferers, from this drug, is sufficiently high to justify the expense, and whether other ways of spending the money, for other patients or on other aspects of care, might have potentially better consequences overall.

In the following, the Utilitarian approach will be introduced in more detail and important characteristics of the approach will be explored, drawing on examples for its application to issues arising in the health care setting.

History and Core Characteristics of Utiliarianism

Utilitarianism is one of the “big three” traditional moral theories, together with Deontology and Virtue Ethics. Like any of these theories, Utilitarianism has received enthusiastic endorsement as well as trenchant criticism. In assessing the value of Utilitarianism as an ethical theory for health care, it is important to consider carefully what it entails.

Utilitarianism is a theory that was originally developed in the Enlightenment period when many theorists were expecting scientific insight to change human life for the better. Utilitarianism exemplifies this optimism about the role of science for morality. Jeremy Bentham (1748–1832), one of the founders of Utilitarianism, believed that Utilitarianism could provide a science of morality that could be used for the betterment of human life. He addressed a large number of social issues from a Utilitarian perspective, from law-making to prison reform. His writing was characterised by a strong belief in precision and differentiation – for example in his discussion of pleasures and pains in his Introduction to the Principles of Morals and Legislation (1789) he distinguishes between 14 types of pleasures, 12 types of pain, and over 30 types of influences on the experience of pleasure. Incidentally, Bentham’s belief in the importance of science extended to the treatment of his body after his death: he donated his body to science to University College London, where it was kept embalmed in a show cabinet.

A student of Bentham, John Stuart Mill (1806–1873), wrote the most well-known introduction to Utilitarianism, a small book simply entitled Utilitarianism (1861) in which he explained the core assumptions of Utilitarianism. When Utilitarianism was first proposed it encountered similar criticisms as today and was criticised as a theory that misunderstands the nature and depth of our moral obligations. Critics of utilitarianism in the health care field sometimes argue in a similar vein that the duties and obligations of healthcare professionals to help their patients are absolute, and that a theory that weighs up costs and benefits of different options rather than endorsing absolute requirements does not do justice to the moral duties of health care professionals. In response to similar criticisms at the time, Mill wrote his book as a defence of Utilitarianism as a theory that is indeed capable of doing justice to our deepest intuitions about morality.

Utilitarianism defines the morally good as the achievement of “the greatest good for the greatest number”. Its core ethical principle is the “principle of utility”:

By the principle of utility is meant that principle which approves or disapproves of every action whatsoever, according to the tendency which it appears to have to augment or diminish the happiness of the party whose interest is in question: or, what is the same thing in other words, to promote or to oppose that happiness. (Bentham 1789/2010, I.2., pp. 6–7)

Utilitarianism in the tradition of John Stuart Mill has a number of core ethical characteristics:

  1. 1.

    Positive or negative consequences are the most important features for assessing the moral quality of a situation (consequentialism)

  2. 2.

    Effects on an individual’s experiences, interests and well-being are the kinds of consequences that count, especially the avoidance of pain and suffering and the increase in pleasure and happiness (welfarism)

  3. 3.

    Every individual who is able to have certain types of positive and negative experiences or interests should count equally (equality of moral status and impartiality)

  4. 4.

    There is a moral obligation to maximise overall benefit, by counting up the overall consequences and choosing the option with the highest overall benefit (maximisation)

  5. 5.

    Moral quality is determined by aggregating consequences across all affected individuals who can experience positive and negative experiences; Utilitarianism aims for the achievement of the best overall aggregate result across individuals (aggregation)

These core characteristics will be discussed, one by one, in the sections which follow. The main aim of this discussion is to identify and explain criticisms that have been levelled against Utilitarianism and explore whether Utilitarianism can address these criticisms. While the implications for the health care context will be considered throughout, this discussion may nevertheless seem quite theoretical, but it will help define more clearly what exactly Utilitarianism stands for.

Consequentialism

The focus on consequences in Utilitarianism distinguishes Utilitarianism fundamentally from the other big theories of ethics. In Utilitarianism, it is the good or bad consequences that determine whether something is right or wrong. In the short case study on CF and the drug Kalydeco above, relevant consequences are the money spent due to the costs of the medication (which will not be available to other patients once spent) in relation to the benefits of the drugs for the CF patients. In contrast to Utilitarianism, deontological theories identify commands and prohibitions that are determined as binding without regard to consequences.Footnote 1 Similarly, Virtue Ethics is concerned with the practical realisation of good character traits for which consequences are at most indirectly relevant, for example if the assessment of consequences happens to be an important feature of the situationally relevant character trait.Footnote 2

An important distinction in Utilitarianism is whether it should be concerned with the consequences of individual actions (a position that is called Act Utilitarianism) or with the overall consequences of having particular rules (a position that is called Rule Utilitarianism). When considering the example of the CF drug, Act Utilitarianism would ask the individual health professional to consider, for each patient, whether the likely health benefits for this patient are sufficiently positive to merit the cost of the drug. In contrast, Rule Utilitarianism would focus on developing general rules to apply in such cases, regardless of the very specific features of every individual case. In the case of Act Utilitarianism, the individual is responsible for assessing and comparing the likely consequences of their potential actions. In the case of Rule Utilitarianism, the focus is on decisions about the most advantageous rules to follow for society. Decision-making about the best utilitarian rules is left to experts who have the authority and power to implement rules in society, for example by means of laws, education or incentives. In the case of nursing, the implementation of Utilitarian values would thus lie mostly in the hands of the Nursing Bodies who determine the values and rules of the Nursing Codes of Conduct and who determine how nurses are educated. Individual nurses would primarily be expected to apply those rules rather than make Utilitarian calculations about likely consequences themselves.

In general, Utilitarianism highlights that the consequences of our actions are important for how we understand the morality of our actions. The same action might be right in one context, but wrong in another context. So killing a person might be considered wrong by Utilitarianism when it ends a life that would have been characterised by more pleasure than pain whereas it might be considered right under some circumstances if it ends a life that would otherwise have been characterised by terrible pain. That the vast majority of persons takes consequences to be at least somewhat important for morality can be seen in our rejection of at least some absolute demands of moral duties, even in the face of catastrophic consequences. Famously, the deontologist Kant was of the opinion that a person should never lie, even if telling the truth will lead to a friend’s death, whereas lying would have save his life. For a Utilitarian, consequences would have a significant impact on whether a lie would be ethically justified or not.

Whether Utilitarian consequentialism is a convincing moral position depends on how significant we consider consequences to be, and in particular whether we assume that it is ultimately possible to explain all moral obligations on the basis of consequences. With regard to the practice of nursing, Utilitarianism would assume that the core values of nursing can all be explained by the effects that decisions have on patients, families, health professionals, or other stakeholders. In assessing the value of Utilitarianism for nursing, one needs to reflect on whether that appears to be an accurate depiction of the values of nursing.

Welfarism

Classic or traditional Utilitarianism assumes that the consequences that matter ethically are the impacts on an individual’s experiences and well-being, especially the avoidance of pain and suffering and the increase in pleasure and happiness. This focus on pleasure and pain as core moral characteristics in traditional Utilitarianism was met with scepticism from the outset. Many philosophers have understood morality as a function of the “higher” aspects of human nature, for example rationality or religious faith, while considering bodily or emotional characteristics of human beings to be a “lower” aspect that does not represent what is essential about human beings. In contrast, Utilitarianism appears to focus on the sensory or bodily characteristics of pleasure and pain as core moral features, and thereby on exactly those “lower” features. Accordingly, critics said that Utilitarianism was a theory not adequate for rational and spiritual human beings.

In response to these criticisms, Mill himself introduced a distinction between higher and lower pleasures. He stated that we experience pleasures and pains also with regard to other realms of our experience, such as intellectual or cultural pleasures which he identified as “higher” types of pleasure. Mill argued that the higher pleasures were actually considerably more valuable than the bodily pleasures, and famously stated that:

It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, are of a different opinion, it is because they only know their own side of the question. The other party to the comparison knows both sides. (Mill 1861/2008, Ch.2, p. 7)

It can certainly be questioned whether this lower ranking of bodily pleasures and pains is convincing, especially from a nursing perspective that is so closely familiar with how intertwined bodily, mental and social aspects of human life are.

However, the more general core point for Utilitarian ethics is the focus on human welfare which takes the experience of human pleasures and pains to be essential for our ethical decision-making. It could be argued that such a focus encapsulates core values of nursing with its holistic approach to human health and human experience. Unlike more abstract and rationality focused theories like Kantian Deontology, Utilitarian theory allows the appreciation of the variety of human experiences, from bodily pain, pain relief or the pleasure of bodily comforts, to psychological suffering and discomfort or the enjoyment of activities, to the pains of loneliness or the pleasures of company and social integration.

Equality of Moral Status and Impartiality

Utilitarianism is a theory that, despite some of the problems that will be discussed in the following sections, takes impartiality seriously. Jeremy Bentham famously characterised Utilitarianism as demanding “[e]veryone to count for one and nobody for more than one”. He assumes that pleasures and pains should count the same no matter who experienced them. While this might sound obvious at first sight, especially from today’s point of view, at the time strict social hierarchies meant that it was unusual that persons from different walks of life should be considered equally. For example, John Stuart Mill was considered revolutionary in his claims in On the Subjection of Women (Mill 1869) that women should be assumed to be as rational and cognitively able as men, and should be treated equally to men with regard to important rights, like having the vote or having access to the same educational opportunities as men. He also drew on Utilitarian thinking in his condemnation of slavery. Even more recently, Utilitarianism has been notable in drawing attention to the neglect of global inequalities in ethics and the importance of avoiding suffering in the developing world, no matter how distant the problem might appear. Similarly, among the strongest proponents of animal rights have been Utilitarians like Peter Singer who have argued that animals that can experience pleasure and pain have moral significance, and our social practices around animals need to be changed to take account of this.

However, this focus on the equality of consideration of those who can experience pleasure and pain also has a flip side which is particularly important for the healthcare context. What about those human beings who are not able to have such experiences? Famously, Peter Singer argued that there should be the option of euthanasia for some newborns with significant cognitive disabilities that impair their ability to have certain kinds of experiences and interests. This position is based on the assumption that they are not equal to human beings with full experiential capacities, due to their significant impairments and therefore did not meet the criteria for moral significance. Singer has been strongly criticised for his position. Especially in a nursing context, such a position is potentially troublesome, given that many nurses regularly care for patients who are in conditions, such as profound cognitive disability, severe dementia or persistent vegetative state. A position that does not consider these patients as deserving of an equal level of care appears to be highly problematic and goes against the fundamental values of nursing.

Maximisation

Utilitarianism is a theory which is focused on the maximisation of positive consequences and the minimisation of negative consequences. To follow the demand to maximise overall benefit has at the very least intuitive appeal. If we have a choice of several options, it appears obvious that the option with the most positive consequences is preferable to options with less positive consequences. But does that mean that it is appropriate not to buy the expensive CF drug and rather spend the money on other cheaper interventions that will have cumulatively better consequences? A Utilitarian would answer yes to this question.

There are a number of problems related to Utilitarian maximisation. First of all, if you want to maximise positive consequences, how exactly do you do this? How can you judge different types of consequences on a single scale of goodness? This is sometimes called the problem of “commensurability”. A traditional Utilitarian needs to assume that ultimately all experiences of pleasure and pain can be quantified on a single scale, and that different potential consequences can be assessed with regard to how much benefit they bring about. With regard to the healthcare context that would mean, for example, that you can compare the experience of pain from an operation with the impairment in life quality arising from asthmatic shortness of breath, or the experience of alleviation of symptoms of depression, the relief of receiving a negative test for a serious condition, the recovery from a debilitating illness, or the pleasure of a friendly conversation, all by assigning a certain positive or negative value to each that makes them comparable across each other in a quantifiable way.

This is the theory. But even if we assume that this works in principle, how exactly can we make such judgments in practice? The Utilitarian position demands that we decide to maximise overall benefit by comparing different options. In the case of Act Utilitarianism such assessment requires consideration of all possible consequences in a particular situation where a decision needs to be made. This raises a number of practical problems: How do we know what the likely consequences are, given that we are notoriously bad at predicting the future? How far into the future are we supposed to go? How widely do we need to consider likely effects on different stakeholders? How do we not just capture, but also accurately assess the overall benefits of each of the different identified options? For example, imagine making a decision on how to engage with a patient who refuses to cooperate with treatment while their family pressures the patient to conform with the suggested treatment. Utilitarian decision-making would have to take into account the likely health and emotional consequences of the patient cooperating vs refusing to cooperate; the likely interpersonal and health consequences of the nurse actively intervening in either direction; the likely consequences of family being ignored or brought in; the potential consequences within the team of the nurse taking a particular course of action; the longer term consequences for trust of the patient in the healthcare system etc. And this is only a small subset of considerations that proper Utilitarian reasoning would need to take into account. As human beings we are significantly cognitively limited; Act Utilitarianism in particular appears to be an incredibly demanding approach. This is one of the reasons why Rule Utilitarianism has been proposed, assuming that it is more feasible for an individual to follow a limited number of rules, and also that it is more feasible to identify rules that are likely to be beneficial overall.

The Utilitarian demand for maximisation however goes even further, in that it can be used to compare the ethical desirability of certain “types of life”, associated with the ethical obligation to choose those lives that are characterised by the most positive consequences overall. To illustrate the issue, Crisp (1997) provides the example of “Haydn vs. Oyster” :

You are a soul in heaven waiting to be allocated a life on Earth. It is late Friday afternoon, and you watch anxiously as the supply of available lives dwindles. When your turn comes, the angel in charge offers you a choice between two lives, that of the composer Joseph Haydn and that of an oyster. Besides composing some wonderful music and influencing the evolution of the symphony, Haydn will meet with success and honour in his own lifetime, be cheerful and popular, travel and gain much enjoyment from field sports. The oyster's life is far less exciting. Though this is rather a sophisticated oyster, its life will consist only of mild sensual pleasure, rather like that experienced by humans when floating very drunk in a warm bath. When you request the life of Haydn, the angel sighs, ‘I'll never get rid of this oyster life. It's been hanging around for ages. Look, I'll offer you a special deal. Haydn will die at the age of seventy-seven. But I'll make the oyster’s life as long as you like... (Crisp 1997, p. 24)

According to traditional Utilitarianism, the oyster with its infinite life will ultimately accumulate more pleasure overall than Haydn with his full human life. Accordingly, it can be argued that a Utilitarian would have to choose the oyster over Haydn, a choice that few people would probably make when choosing between both options. What this example indicates is that if a single quantitative measure is applied, maximisation can end up with strange results that do not appear particularly desirable.

However, this idea of assessing the overall quality of a life is perceived as a positive feature by many Utilitarians, as it might help make treatment and intervention decisions, especially when there are resource constraints. However, non-Utilitarians would highlight that such an attitude of assessing the quality and worthiness of whole lives could be considered to be profoundly paternalistic, arrogant, and demeaning. Especially in a nursing context, to make judgments with regard to patients on whose lives are more worthy of intervention than others would appear to go against the fundamental demand of treating every patient with equal care and respect.Footnote 3

Aggregation

The Utilitarian demand for maximisation is a demand for maximisation of benefits across all affected individuals; that means it understands moral decision-making as by its very nature addressing and affecting a wider group of people. With this focus, it differs to some extent from deontological and virtue ethics approaches which in the healthcare ethics context tend to be focused on the relationship of the healthcare professional and patient rather than considering a wider range of stakeholders.

Bentham (1789) understands community to be “the sum of the interests of the several members who compose it” (I.4, p. 7); the impact of moral actions needs to be considered with regard to all those who are going to be affected by those actions. This highlights what could be seen as both a particular strength and particular problem of the Utilitarian approach. On the one hand it shows its sensitivity to the importance of considering a wide range of stakeholders when thinking about the morality of actions. This is linked to the Utilitarian goal of improving society for the better through Utilitarian interventions. Both Bentham and Mill were actively engaged during their lifetime in trying to achieve social and legal reform to improve lives in society on the basis of Utilitarian principles. On the other hand, this reform enthusiasm also comes with the potential problem of promoting changes that might be contrary to popular concerns, and perhaps being overly quick in endorsing change, without due regard to the more complex and unpredictable longer term consequences that might arise from social changes in the name of increasing overall utility.

One particular challenge that Utilitarianism encounters with regard to aggregation across persons is related to the issue of justice. On the one hand, it does propose a solution to the question of distributive justice, by proposing a cost-benefit approach to the question of how to distribute scarce resources among a population. Utilitarian approaches propose that resources should be distributed in a way that you obtain the most utility from your resources across the population, such as is illustrated by the CF drug example. This is to some extent what organisations like NICE, the UK National Centre for Clinical Excellence, are doing: they evaluate health care products and interventions with regard to how much they cost and how much benefit they are going to achieve for that cost. Only interventions that achieve a sufficiently high cost-benefit ratio based on available evidence are going to be approved by NICE. When distributing resources a Utilitarian approach would draw on such evidence to compare which potential healthcare interventions are most effective in bringing about benefit, and will choose those which are more effective in bringing about benefit.

For example, in the case of the CF drug, it is not sufficient that it has a substantial benefit, but the benefit must be sufficiently high to be proportionate to the money spent. While Kalydeco has been approved by NICE and is being covered by many payers, a newer CF drug combination by the same company that is targeted at a different subgroup of CF sufferers, the combination of Ivacaftor/Lumacaftor (Orkambi), has come on the market with a similar price tag. In contrast to Kalydeco, the new drug has not been recommended by NICE, because its beneficial effects appear to be comparatively small in relation to its price.

While such an approach certainly matches some of the intuitions that we have about how healthcare resources should be distributed, it also has some significant problems. In particular, aggregation across individuals raises problems with regard to the treatment of minorities. One of the probably most well-known concerns about Utilitarianism is that Utilitarian reasoning might justify treating minorities badly due to the lower impact on overall utility that their bad treatment would have. In the healthcare context, a Utilitarian approach to the distribution of resources is likely to disadvantage some minorities, especially those that require particularly costly treatment or care for their health conditions, such as persons with rare diseases for whom medication can often be extraordinarily expensive. They may have significant health needs and be particularly vulnerable, but on the Utilitarian model their case may not merit expenditure if compared to other groups, as the benefit derived from the intervention is too small in comparison to its cost.

Strengths, Limitations and Contributions of a Utilitarian Perspective for Nursing and Healthcare Practice

Utilitarian approaches are used quite commonly in bioethics, and some of the most well-known bioethicists internationally are Utilitarians. Utilitarians have been particularly influential in the reflection on the use of new or future technologies, often endorsing more technology-friendly views and being more optimistic about their potential to change society for the better. In contrast, deontological and virtue ethical theories tend to take more cautious positions. Utilitarianism has also been influential in relation to addressing issues of wider societal concerns, for example issues of global justice or animal rights. With regard to questions of healthcare delivery, Utilitarian discussions have been particularly prominent in some of the following areas:

  1. 1.

    End of life decision-making: Utilitarians have been arguing against the distinction between killing and letting die with regard to the question of euthanasia and assisted suicide (Glover 1990). They have argued for the importance of considering the suffering experienced by persons in end-of-life situations where medical decisions to “let die” without causing death may cause significantly more suffering than an active intervention would (Rachels 1975).Footnote 4 Utilitarian authors have also highlighted the importance of quality of life measures for treatment decisions, including the argument that if a foetus – or even, in some cases, a newborn – has a condition that will not allow them to have sufficient capacities and quality of life, then it might be ethically permissible to end their life (Kuhse and Singer 1985; Singer 1993).

  2. 2.

    Reproductive decision-making: Utilitarian authors have argued for the permissibility of a wide range of reproductive interventions, from abortion to the use of new technologies. They have supported the use of a variety of interventions to allow parents new choices with regard to their embryos, including allowing saviour siblings (Alghrani and Harris 2006). They have also supported the use of pre-implantation genetic diagnosis (PGD) to avoid implanting embryos with genetic diseases, or even more controversially, the selection of children on the basis of non-disease characteristics during IVF (Savulescu 2001).Footnote 5

  3. 3.

    Human enhancement: Utilitarians have been widely supportive of enhancements, which is the use of healthcare interventions not for treatment but for improvement of persons within the normal range to improve specific characteristics about themselves (Harris 2010; Savulescu and Bostrom 2009). Enhancements drawing on existing health care interventions include, among others, doping (Foddy and Savulescu 2007) or cognitive enhancement, for example by means of Ritalin (Greely et al. 2008).

  4. 4.

    Research involving embryos: Utilitarians have argued for the importance of advancing research to cure diseases. They have supported the use of embryonic stem cells in research, on the basis of the argument that this research appears to have the best chance of obtaining positive results (Harris 2004). They have also supported the use of cloning in embryo research, under restricted circumstances.

  5. 5.

    Research participation: Utilitarians have argued for the obligation of all patients to participate in research in order to widen the evidence base for evidence-based medicine and improve the available knowledge base (Harris 2005).

  6. 6.

    Resource allocation: Utilitarians have argued that the application of the principle of utility means that resources in the healthcare system should be allocated on the basis of obtaining the most utility for the costs spent. Cost benefit analysis is a basic health economic technique and is based on Utilitarian reasoning (Torrance 1987). It can be applied to all areas of healthcare resource allocation. One area where the role of Utilitarian principles for allocation decisions have been discussed extensively is in the area of organ transplant decisions (Persad et al. 2009). Particular problems are also raised by assumptions of some Utilitarians that lives of individuals with cognitive disability are less valuable than those of cognitively normal individuals (Vehmas 1999).

Conclusion

Utilitarians have not been shy in taking controversial positions with regard to healthcare and research. Opinions among healthcare ethicists on Utilitarianism are strongly divided. On the one hand, the basic Utilitarian assumption that consequences matter morally clearly has appeal for healthcare professionals, whose job largely consists in trying to make a positive difference to their patients’ lives. Utilitarianism acknowledges that patients’ experiences need to be taken into account to understand the moral significance of healthcare delivery. Utilitarianism also insists that moral decision-making does not merely take place between a patient and a healthcare professional but that a wider range of stakeholders need to be taken into account. In particular, it addresses the pressing issue of decision-making on resource allocation under resource constraints.

On the other hand, in everyday healthcare decision-making Utilitarianism is not easily applied, given the complexities of the practical assessment of consequences. In contrast, deontological and virtue ethical decision-making provide more easily applicable guidance. Utilitarianism also does not fully acknowledge the specific ethical qualities of caring relationships in which the healthcare professional has a particular responsibility towards each individual patient, to safeguard their vulnerability and dignity. The application of Utilitarian reasoning in resource allocation contexts in particular shows little consideration for the specific needs of each individual.

Key Learning Points

  • Utilitarianism is a moral theory that focuses on the overall balance of positive and negative effects of a healthcare professional’s actions; all actions are considered on the basis of consequences, not on the basis of fundamental moral rules and principles or with regard to character traits.

  • Utilitarianism, as an approach, can be particularly helpful when considering decisions in which the quality of patients’ experiences as well as the impact of decisions on other stakeholders is at issue.

  • Utilitarianism as an approach is also often used when making decisions on the allocation of resources, especially with regard to the use of cost-benefit reasoning.

  • Utilitarianism tends to be open to substantially changing existing human practices and, for example, allowing the use of new and controversial technologies if there appears to be a substantial likelihood of overall positive consequences.

  • Utilitarianism has been criticised for not acknowledging the absolute dignity of human life, for example in the context of disability rights or end-of-life decision-making.

  • Utilitarianism advocates for decision-making that looks at whole population groups over individuals, and might at times leave certain individuals or groups worse off in order to use resources to achieve a greater benefit for a larger number instead.