In public health, we think a lot about doing good. More specifically, we aim to do what’s morally right, has the greatest impact, and is sustainable in the long-term. However, it can be difficult to arrive at a universal definition of what ‘doing good’ really means. The more I thought about it, the more questions I had. How should one measure good and bad? How might different cultures perceive morality (the extent to which an action is right or wrong) differently? How do we design interventions or policies that are morally just, both in the short and long term?
Thus, I decided to embark on a little project. Over the next few months, I will be reading two books: Justice: What's the Right Thing to Do? by Michael Sandel and Practical Ethics by Peter Singer in an attempt to answer all the questions I have about what it means to do good. I will then summarise my biggest takeaways in a series of blog posts, in consultation with external sources, such as the Stanford Encyclopedia of Philosophy and journal articles discussing ethics in public health, if necessary.
In the first article of this series, I will be summarising one approach to making moral decisions: the greatest happiness principle, or better known as utilitarianism. If you are someone who feels that the right thing to do is the action which brings the most benefit, you might be a utilitarian. Or if you’ve heard of cost-benefit or cost-effectiveness analyses, you may be familiar with utilitarian principles, which guide many decision-making processes used in companies and governments. [Disclaimer: that this article is not a critical philosophical evaluation of the utilitarian school of thought - though resources can be found at the end of the article for further reading.]
A classic tale1
Theories are often best explained with a story. Where morality is concerned, we can turn to the classic tale of the four English sailors stranded at sea. In this story, there was a captain, a first mate, a sailor and a cabin boy. After their ship sank, they escaped to the lifeboat with two cans of preserved turnips and no freshwater.
They subsisted on small rations of turnips for the first three days, followed by a turtle that they caught and the remaining turnips over the next few days. However, for the next eight days, they ate nothing. Worse still, against the advice of the rest, the young cabin boy drank seawater and fell ill.
Eventually, on the 19th day, the captain suggested drawing lots to determine who would die so that others might live. The sailor refused - and thus, no lots were drawn. Things were looking bad. The next day, the Captain told the sailor (who had refused to draw lots the previous day) to look away while he and the first mate used a pen knife to kill the cabin boy. The three of them then fed on the body and blood of the cabin boy for the next four days. On the 24th day, help finally arrived.
Upon their return to England, they were tried and tested. The sailor became the state’s witness, while the captain and first mate went to trial and subsequently confessed that they killed and ate the cabin boy out of necessity.
Was it right to kill the cabin boy?1
There are many things we could discuss about this story. For now, let’s think of some possible reasons why killing the cabin boy might be justified, and reasons why it might not. I’ve outlined some possible reasons in the table below.
|For||Given the dire consequences, it was necessary to kill one to save three. Otherwise, all four would have died. The benefits of killing one to save three outweigh the costs|
|For||The cabin boy was the logical 'sacrificial' candidate because (1) he would have died soon anayway; and (2) he had no dependents|
|Against||Even if we count the number of lives saved, and the happiness of the survivors and their family, allowing such a killing can have bad consequences for society as a whole by (1) weakening the norms against murder, and (2) increasing people's tendency to take the law into their own hands|
|Against||Even if the benefits do outweigh the costs, it is still wrong to kill and eat a defenseless boy. This is a wrong that cannot be calculated based on social costs and benefits. It feels wrong to exploit another human being's vulnerability, and to take his life without consent, even if it benefits others|
What are the two rival approaches to morality illuminated?1
This story and little exercise help us reveal two rival approaches to morality, and both approaches are compelling in their own ways.
The two arguments justifying that it was right to kill the cabin boy are what we’d call utilitarian arguments. The utilitarian school of thought generally holds the following views:
- The morally right action is the action that produces the most good. The right thing to do is whatever will produce the best state of affairs all things considered.
- Utilitarian theories are consequentialist, in that the morality of any action or arrangement is determined solely on the outcomes they produce.
On the other hand, the two arguments justifying that it was wrong to kill the cabin boy are libertarian arguments. The libertarian school of thought generally holds the following views:
- Consequences are not all we should care about. There are actions that are fundamentally morally right and justified no matter the social consequences.
- In libertarianism, the morally right action is that which respects each of our individual right to liberty - the right to do whatever we want with the things we own, whilst respecting others’ rights to do the same.
In this article, we will dive deeper into utilitarianism. Utilitarianism presents an intuitive way of thinking about how to do good, and currently guides many decision-making frameworks in governments and corporations. We will explore libertarianism in a separate piece.
Utilitarianism: the greatest happiness for the greatest number1–3
If you are familiar with utilitarianism, you might have heard about Jeremy Bentham (1748-1832), an English moral philosopher, legal reformer and founder of the doctrine of utilitarianism.1 Bentham argues that we are governed by pain and pleasure. We like pleasure and dislike pain, and this foundational principle should thus form the basis of our moral behaviour, and by extension, our political and legal decisions.1,2
Therefore, the right thing to do, the good thing to do, is to maximise happiness, which is the overall balance of pleasure over pain. According to Bentham, the right thing to do is whatever will maximise utility: whatever produces happiness, and whatever prevents suffering.1,2
But what exactly is utility - the exact thing we are trying to maximise in order to good? Since the conception of the utilitarian doctrine in the 19th century, many definitions of utility have been proposed. I found the four main conceptions of utility summarised by Bellafleur and Keeling (2016) was helpful:3
‘Utility’ can be understood as:
|1||Pleasure and the absence of suffering|
|2||The satisfaction of individual preferences|
|3||The satisfaction of informed or rational preferences (preferences that individuals would have if they had all the information and cognitive abilities required to make an informed choice)|
|4||The satisfaction of basic interests shared by all (e.g., being healthy, having shelter)|
If the morally right thing to do is the action which maximises utility, doing good would involve calculating the utility of all possible actions, in order to choose the action that produces the most utility. From the political viewpoint, a utilitarian would argue that good governments should calculate the costs and benefits of all their policies, and proceed to do those that will maximise the happiness of the community concerned as a whole.
Utilitarian policies in action
Public health practice in essence aims to prevent disease, prolong life and promote health of populations through the collective efforts of society, and seeks to preserve the health of the maximum number of individuals possible - ideally the entire population.4 Coupled with the field’s attention towards the short- and long-term consequences of any policy, public health has therefore been argued to be guided by utilitarian principles.4,5 Here are some examples of public health policies guided by utilitarian principles implemented in during the COVID-19 pandemic:
- Overriding individual preferences to attain population-level benefits: When Singapore’s renowned Circuit Breaker policy was implemented, mask wearing was mandatory, leaving home was strongly discouraged except to seek essential services, social gatherings with those outside your immediate household were disallowed.6 Overriding individual liberties during the pandemic was seen as necessary in order to limit disease spread throughout the population and prevent the overextension healthcare resources.
- Allocation of scarce resources: A limited global supply of masks at the start of the pandemic saw global recommendations to prioritise masks for healthcare workers on the frontlines, who will be in direct contact with infected patients.7 Protecting healthcare workers meant that more people could be treated, therefore maximise overall utility.5
- Questioning the concentration of resources and power: The pandemic saw high-income countries purchasing and hoarding a majority of the world’s global supply of COVID-19 vaccines. 58 countries, led by India and South Africa, rallied together to propose a temporary waiver of the Trade-Related Aspects of Intelletual Property Agreement (TRIPS), whose primary role was to protect intellectual property (IP) rights worldwide.8,9 If passed, a temporary TRIPS waiver would scale up the manufacture of COVID-19 vaccines, medicines and medical technologies across the globe, thereby increasing equitable access to countries that were previously unable to afford them. We can argue that this proposal was partly guided by utilitarianism: the removal of IP protection (potentially stifling future innovation) to get big pharma companies to share their technology can help the world avoid a prolonged pandemic, countless lives lost and detrimental effects on the global economy.
How is the utilitarian principle helpful to us when deciding to do good?1,3
From the above examples, it is evident that utilitarianism has many strengths.
- It offers us a framework to evaluate how good or bad something is. The greater the amount of utility it offers to a greater number of people, the more morally right the action is. The right thing to do, the good policy, is the one that produces the most utility for the greatest number.
- It is simple to understand. You can explain utilitarianism to someone by summarising it as a principle that aims to maximise good in the world. It is also intuitive to many of us, to weigh the costs and benefits of any actions, before choosing the one that provides the most overall benefit.
- It is particularly useful in collectivist societies. Utilitarianism’s emphasis on the greatest happiness for the greatest number can make it particularly intuitive to communities that emphasise collectivist values (i.e., Asian countries generally), where the interests of the ‘group’ take priority. In such societies, understanding utilitarian principles can help us understand which actions or policies are likely to be perceived as ‘good’ or ‘bad’, and guide us in acting accordingly.
- It provides an impartial framework for decision-making. Utilitarianism treats everyone’s preferences equally. In the utility calculations used to determine the action that best maximises utility, every individual’s preferences or interests, pleasure and suffering, are accounted for.
- It provides justification for redistributive policies. Some of us may feel that the rich should share their goods with the poor. Utilitarianism helps us understand why the redistribution of wealth and resources can be the right thing to do. The law of diminishing marginal utility holds that as we consume more of something, the amount of happiness derived from each additional unit consumed decreases. Utilitarianism can therefore justify a redistribution of resources (e.g. wealth) from those who have the most, to those who need them the most, to maximise utility.
- It provides justification for prioritising common interests over individual ones. During a pandemic, utilitarianism can be used to justify policies that encourage the entire population to get vaccinated; or enforced quarantine of individuals who refuse to get vaccinated. From the utilitarian perspective, the infringement of individual rights can potentially be justified, to derive significant benefits at the population level.
What are the limitations of utilitarianism?1,3
However, the utilitarian principle fails to account for some critical things. Consider this question: is torturing a terrorist suspect ever morally right? Utilitarians may say that, yes, it is morally justified to inflict intense pain on one person if doing so will prevent death and suffering on a massive scale. To the utilitarian, numbers count. If enough lives are at stake, they would argue that we should be willing to override our principles about dignity and rights.
- It fails to respect individual rights. In pursuit of the maximum happiness for the greatest number, utilitarianism could enable actions/policies that violate what we perceive as fundamental norms of decency and respect. In the above example, the utilitarian argument assumes that the suspect is in some way responsible for an impending terror attack - and even if he is not, he is still deserving of the harsh treatment because of his suspected affiliation. However, these arguments fail to account for the problematic fact that torture is a violation of human rights and no individual, should ever be subject to such treatment.
- Surely, the end cannot justify all means? In utilitarianism, the morality of any action is determined solely by the outcomes produced. As long as the outcome increases overall utility, the means deployed to attain it, no matter how unethical they were (to lie, oppress, torture, etc.) does not matter.
- In reality, not all preferences are equal. Utilitarianism may be used to justify policies that discriminate against the minority to benefit the majority. Greatest happiness for the greatest number, right? In such cases, it may be that the preferences of the majority race, class, ethnicity, or political affiliation (whichever trait(s) that defines the majority group in question) are privileged over those of the minority, based on sheer numbers.
- Utility calculations are complex and difficult to execute. Individuals can have varying preferences, and may react differently to the same policy or action. In addition, to carry out these calculations, we would need to measure them on a single scale. One of these scales is money: a cost-benefit analysis is a type of decision-making tool widely used by governments and corporations, which translates all costs and benefits into monetary terms (e.g. weighing the immediate monetary cost of COVID-19 vaccines and lockdowns against the monetary benefits of increased productivity from a population with herd immunity) to compare them on the ‘same level.' Instinctively, the objection is clear. Surely, there are some things that cannot be simply measured by their monetary value (e.g. try to quantify the monetary value of being socially isolated from your loved ones during a lockdown). While the utilitarian principle may be intuitive to many, the complex nature of utility calculations make it inaccessible to put into practice.
That’s a wrap! Above is a summary of how utilitarianism can be a helpful (and not so helpful) tool in thinking about doing good. I had lots of fun diving into the greatest happiness principle, and I hope you did too. One of my biggest takeaways was learning that the utilitarian principle is fundamentally consequentialist in nature and how it was compatible with public health practice. Writing this up also helped me articulate the discomfort that the utilitarianism made me feel - that when taken to its extreme, it may not account for individual rights and can be used to privilege the preferences of the majority. Overall, it is a useful tool to evaluate how moral decisions can be made, and that can be seen by how it actively informs decision frameworks used by governments and corporations. In my next piece, I will explore libertarianism, and how it can guide moral decision-making.
- Sandel MJ. Justice: What's the Right Thing to Do? New York: Farrar, Straus and Giroux; 2009.
- Driver J. The History of Utilitarianism. The Stanford Encyclopedia of Philosophy 2022. [Internet]. Available here (Accessed Apr 2023).
- Bellefleur O, Keeling M. Utilitarianism in Public Health. Montréal, Québec: National Collaborating Centre for Healthy Public Policy. 2016.
- Royo-Bordonada M, Román-Maestre B. Towards Public Health Ethics. Public Health Rev. 2015;36:3.
- Kirkwood K. In the Name of the Greater Good? Emerg Health Threats J. 2010 2:e12.
- Ministry of Health. Circuit Breaker to Minimise Further Spread of COVID-19 [Internet]. Available here (Accessed in Apr 2023).
- Nebehay S., Koltrowitz, S. Masks Should Be Prioritised For Health Workers to Avoid Shortage Against Coronavirus: WHO [Internet]. Available here (Accessed in Apr 2023).
- United States Seeks Answers on COVID-19's Origin While Stepping Up “Vaccine Diplomacy”. Am J Int Law. 2021;115(4):732-739.
- Mendis, S., Regional vaccine production is key to ensuring equity. BMJ. 2021;374.
- Special thanks to Jerald and Jean, friends in law and philosophy respectively, for recommending the two books that I will be devouring over the next few months!
- Huge thanks to Jet, Venny, Sean, Siew Ning and Maike for your comments on early drafts of this piece! <3