My Sister's Keeper

Introduction, and Thesis: Preimplantation Genetic Diagnosis (PGD) to provide a genetically matched donor for an older sick child and to use the organs of the younger to the medical benefit of the elder is not morally justifiable using rule utilitarian ethical theory. This principle is not justifiable due to both the nature of the proposed rule regarding PGD and, primarily, to the nature of utilitarian ethical philosophy in general.

Arguments Supporting Thesis: Rule utilitarianism is a moral philosophy holding that general rules for moral guidance should be developed that will act as an aid in making ethical decisions.

For example, one such rule might by that one ought to keep promises. Given this general rule, when faced with a moral decision, an individual should look at the list of rules and see if any of these rules apply to the current situation. Using the above example, if the situation involves keeping a promise or not, then one should keep the promise.

According to this philosophy, even if the consequences of a particular act of promise keeping are bad, the person behaving in accordance with the established utilitarian rule is morally not at fault. However in an attempt to establish a new utilitarian moral rule, each individual event will affect the attempt to establish a moral rule.

This ethical theory requires development of rules of action based on the potential rule’s likelihood to bring about the most good for the most people. For the purposes of this discussion a reasonable rule would be: parents should use PGD to provide a genetically matched donor for an older child and use the expendable organs of the younger child to repair life threatening medical conditions of the older.

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For the sake of argument, this paper assumes that any procedures that would necessarily result in the death of the younger child would not be performed. For example, if the elder child needs a heart transplant, this rule could not be used to justify the death of the younger by removing the younger sibling’s heart and transplanting it into the elder.

The suggested rule makes use of other, more fundamental utilitarian rules such as one shouldn’t cause pain or one should prevent pain. Neither of these rules in itself is sufficient to establish the more specific utilitarian rule suggested in the preceding paragraph. To determine if this potential utilitarian rule should be adopted, some cases, using Picoult’s novel My Sister’s Keeper as a springboard should be examined.

The first case to examine is the simplest case. If the proposed rule proves inadequate for a simple application, it is unlikely that more complex, and more realistic scenarios will be adequately served by the proposed rule. The simplest case within this context would be the case originally conceived of by Kate’s parents, Sara and Brian Fitzgerald.

In this scenario Sara and Brian had two children, the elder, Jesse, is approximately seven years old. His little sister, Kate is a about two years old when she is diagnosed with acute promyelocytic leukemia (APL). Since Jesse is not a compatible donor, her parents elect to use PGD to produce a genetically compatible donor as a potential solution for their daughter’s health problem. Initially, the younger daughter, Anna, is to be used to donate blood cells from the umbilical cord to provide needed blood cells for Kate. Theoretically, these cells would put Kate’s APL into remission and that would be the end of medical treatment. All three children would be healthy, have little or no memories of the procedure and the Fitzgerald family would live happily ever after.

Does this scenario provide the greatest good for the most people? Although others are involved in My Sister’s Keeper, such as the nurses, surgeons, and hospital staff, it is reasonable to consider just the impact of the Fitzgerald family. It appears that the most people have received the greatest good. Kate has her normal life expectancy back, Jesse now has not one, but two little sisters to tease and torment, while Sara and Brian have three happy, healthy children. It appears to be a winning situation for everyone. This scenario provides support that the proposed rule may be a viable utilitarian rule, at least in this simplified situation.

Unfortunately, all the cases this proposed rule are to be applied to aren’t this simple. The Fitzgeralds’ experiences provide an example where the simple case doesn’t prevail and the situation is complicated by other events. Initially in My Sister’s Keeper, it appears the umbilical cord blood cells take at Anna’s birth have done the job. Kate goes into remission for five years. However, at this point Kate’s APL flairs up and lymphocytes are drawn from Anna three times and inserted into Kate. Again this appears to work for the short term, but ultimately, the procedure fails. For the next eight years the process is repeated over and over again; Kate becomes ill, Anna donates something which should help her get better, the treatment works for a while but then stops working and a new, more invasive and painful donation and treatment is attempted.

The situation during this period is not so simple and clear-cut. In the process, everyone in the family suffers: physically, emotionally, financially, and/or socially within the family and outside the home. Both Kate and Anna suffer physical pain with each procedure. Jesse begins to act up in an attempt to get attention from both his parents. The relationship between the parents suffers as Sara becomes more and more obsessed about the physical needs of Kate. The family is not the happy unit anticipated in the simpler case. In fact, at the time of Anna filing the lawsuit for medical emancipation, the only good that has resulted is that Kate’s life as been extended for twelve or thirteen years. All of the benefits of the Kate’s continuing to live have come at the expense of the rest of the family and of Kate herself, who suffers considerable pain during the process. In these more complicated circumstances it is not so easy to determine the net good or the net harm.

It is no longer so clear that a rule utilitarian imperative can be established to justify PGD and the subsequent harvesting of organs. As long as the medical procedure works, it is more easily justified on a rule utilitarian basis. When the procedure fails, the amount of good, if any doesn’t appear to outweigh the amount of harm.

This points out a fundamental weakness in moral rule utilitarianism as an ethical theory. It does not have much utility. First, calculating the potential harm and the potential good resulting from a proposed medical procedure is difficult, perhaps even impossible, to calculate. In the simple case, it is easy to calculate the net good because only two people are involved in the process: Anna the donor doesn’t suffer at all, and Kate has her pain relieved for five years. It is clear that more good than harm results from the PGD, birth of Anna, and Kate’s used of the cord blood cells from Anna is a good thing on an utilitarian basis.

However, with every additional complication, the calculation of net good becomes more difficult. When lymphocytes are drawn from Anna three times at the age of five, it is clear she feels pain and is at some amount of risk of life due to the use of general anesthesia. It is also clear that Kate receives some benefit from the donated cells. What isn’t clear is how much physical pain Anna suffers and how much benefit Kate receives. There are no clearly quantifiable measures of pain. There are scales of pain used by physicians to try and measure pain, but they are estimations by the patient and extremely subjective.

Suppose, to salvage the utilitarian principle, one were able to establish a unit measure of pain and relief of pain. Suppose Anna reports that she has pain at a level three for twelve hours for a total of thirty-six “pain hours,” level two for six hours for twelve “pain hours” and pain level one for 3 hours for three “pain hours”. This gives Anna a total of fifty-one “pain hours”. Presumably, on Kate’s side, if one assumes a one for one exchange of pain values between Anna and Kate, as long as her net relief of pain is greater than fifty-one “pain hours” the procedure is justifiable from a rule utilitarian point of view. This result is remarkably similar to the conclusion above in that as long as the medical procedure is successful, the performing of the procedure add credence to the establishment of a new moral rule.

This is not a satisfactory moral principle. It fails to consider far too many aspects of the entire situation and bases the moral evaluation purely on the result. For example, as any medical provider knows from personal experience, sometimes people die regardless of the treatment they have received. In the above case, suppose that Kate, after receiving the lymphocytes, and despite the fact that the medical team is well qualified and performed the procedure in accordance with the best established procedures, dies shortly after the procedure. Autopsy and postmortem investigation finds no particular reason for the death. For all intents and purposes, Kate randomly dies when she was expected to live. According to rule utilitarian ethics, this procedure was a failure and should not be used to support a potential rule for future behavior and presumably should count against the potential rule. However this wasn’t the fault of the procedure and, intuitively, shouldn’t count against PGD and the subsequent use of donor tissues.

A second objection to utilitarian rules is that it is unclear when a new rule becomes established. Except for fundamental rules which lack substance, such as truth telling is good, loyalty is good, promise keeping is good that are already established, when does a proposed rule have enough evidence to be a new moral imperative. There isn’t a Governing Board of Utilitarian Theory (GOUT) that meets periodically and either approves or denies potential utilitarian rules of ethics.

One wonders then if a utilitarian rule can ever be established beyond basic, fundamental rules such as those mentioned above. It is counterintuitive to think that an ethical rule can only be established when it has been tested a sufficient number of times. The whole point of ethical rules is to give people ethical guidance. If one is forced to rely on only the more basic rules such as “causing pain is bad” and “relieving pain is good” until the new rule has been established with sufficient data, one is often at a loss since such rules are extremely general and can be, and often are, contradictory. In the case of My Sister’s Keeper to relieve Kate’s pain, Anna must be caused pain. This is essentially a wash that really leaves one with no answer at all.

Objections that Rule Utilitarian Cannot Justify PGD: The biggest objection to the conclusion that rule utilitarianism cannot justify using PGD to provide a potential donor for a critically ill child is that if feels like one should be able to use rule utilitarianism to make this decision. One ought to be able to look at this issue and say “yes it is moral to provide a potential donor for a child using PGD” or “no, it is not moral do so.” If one cannot use rule utilitarianism to help make a decision what good is it?

Response to Objection: That is precisely the point. Rule utilitarianism, in fact even act utilitarianism as well, is inherently flawed. Instead of looking at the entire issue of is it moral to perform an act it shifts the focus to will performing such an act result in a net positive value instead of dealing with the social issue the person who posed the ethical question, utilitarianism deals with an unwieldy ethical system of bookkeeping. This is unsatisfactory because it skirts the real issue.

Human ethics is not bookkeeping. Results of an act are important in evaluating the morality of an act, but this is only one part of the entire equations. Equally important, and oftentimes more important are other factors that ought to be considered: motive of the people involved, capabilities of those involved and the rights of those involved are essential ingredients in making ethical decisions and rule utilitarianism makes no allowance for these vital concerns. In fact, it is the question of the rights of Anna Fitzgerald that is central to this novel. It is these other factors that are most revealing and the most interesting from an ethical and sociological point of view.

Summary of Paper: Rule utilitarian ethics is unable to establish the rule that using a PGD child to provide a transplant source for an older, critically ill child. This is due to rule utilitarianism ethics not being a particularly viable ethical system. The unwieldiness of trying to calculate the net good or bad makes rule utilitarianism impractical. In addition, rule utilitarianism fails to account for anything other than the results which are a small, uninteresting part of any ethical dilemma. This bookkeeping approach to ethics is inadequate. A moral dilemma is not easily solved and is never solved without considering, the agent, the act and the reasonably expect consequences of the act. It is for this reason that utilitarianism cannot, in fact, justify itself as an ethical system.

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My Sister's Keeper. (2017, May 09). Retrieved from

My Sister's Keeper
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