Ethics began when humans first asked whether it was right or wrong to perform some action. Most human behavior is morally neutral, but there are some acts that we intuitively know to be wrong, such as the willful murder of an innocent person. The Greeks first began the organized study of this "oughtness", or the ethics, of human actions.

It should be noted that ethics does not exist in a vacuum but is intimately related to one's | basic understanding or philosophy, however explicitly or implicitly expressed, of what reality is and how we know that reality. We begin with some basic assumptions. We, and objects outside ourselves, exist. We, as persons, have in our intellect knowledge of these objects and, with our wills, make choices, some of which can be better than others. There is a variety to reality and a hierarchy of ends, or purposes. In other words, the purpose for an animal's existence is different from that of a stone and especially of a human | person.

We also understand intuitively that we are free, that is, we can choose between two i objects, and that these choices have consequences. We can choose to eat to sustain life or not to eat and to starve, and the former is better than the |atter. These decisions are composed of the act itself, eating; the consequence or end, sustaining life; and the circumstances, our ability to obtain food. "Circumstance" in a moral context means that some factor extrinsic to the act itself so enters into the act that it affects its rightness/wrongness or its degree of moral responsibility.

Given these self evident assumptions we will outline a too brief overview of 1) philosophy, 2) ethics and, 3) medical ethics. We will mention the major errors of each which have resulted in i serious moral dilemmas for physicians today. First, in philosophy the idealist understanding of knowledge led to a confusion regarding the objectivity of truth. Second, in ethics utilitarianism led to a focus on the outcome of behavior rather than the acts themselves. And thirdly, in medical ethics attention was deviated from what the doctor actually did to the apparently short term satisfaction of the patient. Medicine has left the Hippocratic tradition and felt compelled to embrace utilitarian ethics. The following sections discuss these issues.

While there were several schools of Greek philosophy, there evolved two schools of thought which have continued over the centuries and which persist today: realist and idealist. The major thrust of Western thought over the past 2500 years has been realist or Artistotelian. That is, objects exist outside of our mind and we can know these objects. A correct knowledge of reality is a truth. A parallel idealist school of thought tended to put reality into the mind of the knower rather than externally in the object.

In general, the realist school predominated through the medieval period until the modem period began, when it was challenged by Descartes. Rene Descartes was rationalistic. The starting point of his philosophy was human reason, not external reality, and he was therefore basically an idealist. Descartes ultimately triggered two influential modem philosophical schools whose ideas have influenced contemporary ethical thinkers. The idealistic branch was developed by Leibnitz and Kant. Descartes' mechanistic view of the world led to the second or empiricist trend initially developed by Hobbes, an English mechanist and expanded by Locke and Berkeley and an emphasis on emotion by Hume. Kant's philosophy led to: 1) the further extreme idealism in Hegel: 2) positivism in Comte. The theme of modern philosophy is that reality is the product of the mind and can be therefore be altered by human ideation.

The philosophy of the last one hundred years has been more pragmatic in nature and a reaction against the extreme of Hegelian idealism and the anti-intellectualism of positivism. Abstract philosophy gave way to a realization of existence as noted by Kierkegeard. More recent efforts to recapture a realist position has been undertaken by the phenomenologists. This idea is continued in the exposition of human experience in Husserl's phenomenology. These attempts to counter extreme idealism have not been entirely successful and in some ways have led to systems of feelings and will such as that developed by Nietzche, which led to the horrors of the second World War. The current fad of deconstructionism is the ultimate result of denying the ability to know external reality. Rationalism has been deconstructed and now for Rorty and Derrida no knowledge is possible. A broad understanding of these philosophical currents is necessary if one is to understand contemporary ethics and ultimately medical ethics.

In general, ethical theory follows philosophy because the concept of right and wrong depends upon an understanding of metaphysics, psychology, and epistemology. Aristotelian ethics assumes real object existing external to a knowing person who with his intellect understands the attributes of those objects, which include truth and goodness. The acting subject appreciates the goodness of a specific behavior and with his will chooses it, or conversely knows the inappropriateness of an act and chooses that. The former is ethically good and the latter is ethically bad.

A human moral act is made up of three components: the appreciation of what is involved, the decision to act, and the ends for which the action is taken. The relationship between the knowing subject and the good chosen is the heart of ethics. The desired ends also are important. To know someone is innocent and to kill him is morally wrong even to save the lives of other people. The idealists' denial of objective truth led to a shift from the act itself to the desired outcome. The determining factor of the moral rightness/wrongness of a human act had shied from a consideration of the act itself circumstance lend to the sole consideration of the end of the act.

Modem philosophy, with its turn to idealism, broke the relationship between the knowing subject and the external object. For Kant, because we cannot know external reality itself, we cannot choose it as a good. Instead, he posits an internal mental categorical imperative to do good. The more pragmatic philosophers following Kant, particularly in England, J. Bentham and John Stuart Mill developed utilitarianism: the greatest happiness for the greatest number. Moral goodness now does not reside in the act itself but rather on its utility, which is determined on the act's capability of effecting the greatest good for the greatest number of people.

The currently popular division of ethics is into either deontological or teleological schools. The deontological or naturalistic ethics, is also known as duty, or legal ethics. It defined the moral good by identifying it with pleasure, well being, obedience to the ten commandments, to conformity to natural law. Teleological, or utilitarian ethics is also known as means and ends ethics. It considers the consequence of human behavior. Proportionalism is situated here because it considers the circumstances and results of acts and not just the act itself.

In summary, utilitarianism is the dominant ethical influence in the United States today and therefore the industrialized world. It is a product of the Enlightenment which developed from Descartes' rationalism. It is basically idealist and therefore I relativistic. The basic utilitarian principle of the greatest good for the greatest number has logically shifted to the greatest gratification for the knowing isolated intellect, or the autonomous-self. It serves well our self centered and indulgent culture.

However, utilitarian ethics invariably bumps into unfortunate facts of reality. People are intelligent and realize that there is objective truth. Nowhere is this more apparent than in the area of life issues: conception and death. Medicine is at the cutting edge of his process because physicians are closely involved with abortion and euthanasia.