Dental Ethics, History of Medical Bioethics, and Philosophy in Dentistry
- History of Medical Ethics
- Dental Ethics: Review of Bioethical Principles
- The Case Against Bioethical Decision-Making Model
- Philosophical Exploration of Dentistry
History of Medical Bioethics
Medical bioethics has a long history from ancient times. We are, however, left with vague memes in the medical and dental communities. Healthcare professionals are given diluted overviews and casuistic decision making models in schools. Ethics is a rich field of study that promotes moral independency and agency. The goal of this section is to spread better understanding of ethical principles through history and philosophical connection.
Health professionals take an oath during school that establishes them as part of a profession. Many of these oaths are related to the one Hippocrates gave to his students in ancient Greece. As the father of medicine, Hippocrates had great influence in establishing memes like “do no harm” in the medical and dental fields. All doctors recognize of the importance of health and to put the patient first.
Not all doctors take the same oath, however, and not all doctors are required to consent to its stipulations. The original Hippocratic oath made doctors swear to Apollo and promise never to do surgery (not as safe as today). Health professional oaths are current to medical advances but individualized to each school. An unstandardized oath inhibits consistent communication amongst medical professionals.
Also, there is little justifiable reason to expect a doctor to follow an oath that is not understood or consented to. Everyone does what she believes to be the best thing to do. A doctor can be given rules to follow by authority figures. If she doesn’t believe in them, she will only follow the rules out of fear of authority or punishment. Doctors are moral agents, not instruments of moral bureaucracy.
The Nazi medical experimentation is the worst case of doctors simply following orders and acting for the greater good. People where placed in barometric chambers, for example, to learn the effects of extreme pressure conditions. Much of our early understanding of deep sea and space exploration comes from these medical experiments. Using knowledge gained through unethical experimentation is still a highly debated topic today.
The holocaust was gross violation of human dignity. The Nuremberg Code was a direct reconciliation of the Nazi doctor trials. It expressed the utmost respect for patient consent and reduction of human suffering. You can see the direct influence on how human clinical trials are evaluated by The International Review Board.
Most doctors aren’t doing experiments, but some ethical considerations of research still apply to doctors when testing out new procedures and technologies. We also do not want dentists forcing treatment like when Nazi dentists forcefully removed gold restorations from prisoners. Patient well-being and consent in western bioethics due to unethical medical experimentation done historically.
Lessons from history are soon forgotten, sad to say. Until 1972, the medical community intentionally kept around 400 black men untreated for syphilis. The study went for 40 years. Even though there was a cure, the doctors misdirected infected patients to see the longterm side affects. This study violated standards of racial and economic justice because it deliberately targeted poor, uneducated black farmers.
The problem did not consist of a few bad apples. The study was recognized for awards upon publication in a medical journal. The experiment was also openly discussed by medical professionals in major government departments and national organizations. Gross violations of human right is not a problem of the distant past.
The Tuskegee Experiments makes aware of how intersectionality is important in ethics. Patients in the study were not chosen merely because they were uneducated or black. They were chosen specifically because they are poor, black, and male. These societal categories are used to justify violations of autonomy.
The Belmont Report
Published in 1978, the Belmont Report outlines the four ethical principles intended mainly for medical research. Medical schools adapted the principles for medical students and dental schools for dental students.
The benefit of the bioethical-decision making model is that it offers a central standard independent of the different religious, political, and cultural values students are brought up with before entering the medical and dental fields. The model is also casuistic enough that students can still express their religious, political, and cultural opinions in discussions. The authors of the Belmont Report even acknowledge that the principles are just a guide because they often contradict each other.
Below is an explanation of the four bioethical principles used in medicine and dentistry. Its casuistry makes it versatile for healthcare professionals but philosophically problematic.
Review of Bioethical Principles
Dental professionals should be aware of the following bioethical principles in dental ethics:
- Justice – treat everyone fairly and equally
- Beneficence – maximize patient well-being and professional expertise
- Maleficence – minimize suffering and do no harm
- Respect for Autonomy – consider the patient consent
Some ethicists like to include veracity, confidentiality, etc. in the list. These extras, however, are not universality recognized by medical professionals or derivatives of the above four principles. The next few sections explain the four main bioethical principles in dentistry. Readers will become aware of the casuistry of bioethical analysis upon further reading.
Plato discusses how a just man behaves in The Republic, the greatest work of western philosophy. Justice is historically conceived as a type of virtue, a character trait that promotes flourishing when nurtured. For Plato, justice is a type of regulation amongst the different castes in a state towards its betterment or amongst the psyche of the man toward happiness. He rejected the traditional conception of justice, help your friends and harm your enemies. Plato claimed that justice, as a virtue, only improves so never involves harm. Everyone seeks to live life well, so every one must seek to be just.
Today, most people are familiar with justice as a form of judicial resolution or socioeconomic redistribution. The law dictates that one should not discriminate based on race, gender, etc. One must remember that things like slavery were legal and some laws contradict each other. Some laws are unjust and a just man never follows an unjust law.
Justice is sometimes synonymous with core values like equality or fairness. To promote equality, we may try to redistribute wealth by offering free services to the disenfranchised. Others might find this policy to be unfair since it may benefit free riders or devalue productivity. It is obvious that different policies may seem just or unjust depending on competing conceptions of justice.
We all have a duty to always the right thing. However, this is different from doing good or helping. You can help a theft commit a crime, but this is obviously not a moral thing to do. The principle of beneficence reminds us to help others, but we not not morally required to help everyone in every particular situation. We must draw a distinction between moral good (what we must ethically do) and beneficiary good (what we can do to help).
While being altruistic does not necessarily mean being moral, being selfish does not mean you are being immoral. Often dentists will provide free treatment to deserving patients. If a dentist only provided free treatment, her practice would soon go bankrupt and she could not help anyone. Aristotle pointed out that a friend to all is a friend to none. Dentists must invest in themselves and their businesses.
Kant characterized the duty to help others as an imperfect duty. An imperfect duty is one that can obligate us but does not in every situation or time. The principle of beneficence reminds us that we should help others as mush as we can. However, it does not specify when we must do so and to what extent.
The principle of non-maleficence reminds healthcare professionals that they should reduce pain, suffering, and harm. There is a clear difference between hurting someone and harming them. A dentist hurts a patient when she gives injections for surgery, but doesn’t harm a patient overall when an infected tooth is extracted. While pain involves sensory nerve transduction, harm involves a patient’s wellbeing.
Pain is sometimes a psychological response of the body. It can tell a patient she needs to see a dentist. Doctors can even stimulate pain fibers to facilitate healing. The complexity of dealing with patient pain involves evaluating its subjective conscious experience. Different amounts of stimulus corresponds to different levels of pain experience. Even individuals of different genders and cultures deal with pain differently.
Hippocrates decries that health professionals should never do harm. When you nurture a patient back to health, the person returns to function. When you harm a patient, their well-being diminishes. Harm reduces another person’s ability to function and live life well. Many philosophers think that the purpose to life is to maximize happiness or well-being. Since, harming is the exact opposite of how one should act, we should never do any harm. Measuring maleficence is difficult since people feel differently about pain and what things cause harm.
Respect for Autonomy
In greek, autós stands for self and nómos stands for law. To be autonomous is to live life by one’s own laws. This is not to say one cannot listen to others. To act heteronomously (hetero meaning other) is to merely obey orders blindly. To act autonomously is to understand the necessity of proposed ethical rules and to act upon them with motivated intention.
Kant claimed that people act as free autonomous agents not by just following any old rule but the moral law. One formulates a moral principles placing oneself as the legislator of the moral law through a rational will. One evaluates if the rule is morally obligatory using practical reason and acts upon it once recognizing first hand a rule that one must actually follow. Rules that all moral agents must follow are categorical imperatives.
Kantian ethics provides a rational bases for respecting autonomy (its obligatory to all rational agents). The principle of respect for autonomy usually states that a provider must value the deliberative process of the patient including arbitrary preferences, emotions, or opinions. We must also respect those with diminished autonomy (children, unconscious, etc.). It is easy to understand that this principle avoids forced treatment like in the holocaust. However, if we are following a rule merely to avoid consequences, then we must admit that there actually is no rational reason to respect or value such a rule categorically (in and of itself).
The Case Against Bioethical Decision-Making Model
The bioethical decision-making model consists of a guide to problem solving in clinical situations for healthcare professionals. The guide is too vague to answer complex moral dilemmas and there is not reason why one must follow any of the principles in the first place. Let us first look at the steps of the model.
Bioethical Decision-Making Model
- Identify the ethical dilemma
- Outline different possible solutions to the dilemma
- Consider the four bioethical principles
- Evaluate which ethical principles conflict in each solution
- Consider legal implications
- Act upon the solution that uphold bioethical principles
Patient requires crown lengthening for adequate restoration of a tooth with a crown. The patient wants the crown but rejects crown lengthening due to cost. Three possible solutions to this treatment plan dilemma come to mind:
Only restore upon full acceptance
Beneficence: refusal of care
Maleficence: avoids causing perio issues
Just do the crown
Maleficence: causes perio issues
Autonomy: follows patient’s decision
Do the crown lengthening for free
Justice: is not fair to paying patients
Beneficence: free service to patient
Bioethics is an Arbitrary Moral Decision-Making Model
Three different people can view this same situation and each would go for a different possible solution using the bioethical decision-making model. I would venture to say a single dentist has followed all three solutions (in the example above) at different points of her career.
Is any solution more wrong than another? A solution would be obviously bad if it violated all the bioethical principles. This is a complex scenario with multiple solutions that violate a different number of principles while upholding others. If the situation was simple, the answer would be obvious. We need ethical reason when the situation is complex to answer, but the bioethical-decison making model does not always give objective answers.
Each principle only acts as a suggestion for the doctor to consider. There is no reason these principles as vague as they are described obligate healthcare professionals in a moral sense. You will lose your license if you violate them. However, obligating someone through punishment signifies a rule is not moral in-itslef but rests on arbitrary consequences.
Objections: Case for Bioethical Principles
The flowing objections are taken from Raanan Gillon, professor of medical ethics at Imperial College London.
Objection #1 – The principles are prima facie.
What is prima facie common sensical and do not appear to have epistemic fault. It seems clear to anyone that one should be just, help other, do not do harm, take respect people’s choices. However, common sense does not make a moral theory true or valid.
This especially important when the conceptions of the bioethical principles are so vague they self-contradict. For example, justice can be expressed as both appeal to equality or fairness. Income redistribution promotes equality but not fairness. The principle of justice is so inclusive that it is self-refuting. It appeals to everyone because it expresses everyone’s contradictory intuitions.
Beneficence tells us to help but not clearly in what cases, maleficence tells us to reduce suffering but not to what extent, and autonomy tells us to respect things that are not worthy of respect. It is not adequate rational or moral justification for a moral theory just to be prima facie. It is not clear that the bioethical principles even are since they have so many philosophical objections.
Objection #2 – They are Designed for Healthcare Profesisonals
The four principles seem simple to use in fast-paced healthcare environments. However, the decision-making model doesn’t always give clear answers (example above). So, if multiple professionals are involved in a situation, they are still left in ethical conflict.
Bioethical principles supposedly avoid specific religious, political, or cultural standards, so doctors of all backgrounds can use them. We must remember, however, that the bioethical principles are a direct reaction to medical testing during the holocaust. So, they are inseparable from western religious, political, or cultural values historically.
It is claimed that health professionals still need simple principles even if they are general rules because they have so much to learn already. Without complex ethical education, health professionals are simply guessing at answers. We don’t hold doctors to easy guesswork when it comes to diagnosis or treatment. We should not hold them to casual moral reasoning when it comes to what is most important: doing the right thing.
Objection #3 – The Principles Avoid two Extremes: Moral Relativism and Moral Imperialism
Moral imperialism is the idea that there is only one way of doing ethics. Bioethical principles are flexible to allow for introjection of personal religious, political, and cultural values. Maybe there are multiple ways to do ethics validly and there is no one absolute method. However, to be one objective standard amongst many, you must still get consistent answers. People can correctly use the bioethical decision-making model and come to contradictory conclusions, each equally valid.
Moral relativism is the idea that any ethical opinion will do. Bioethics gives a standard for communication for healthcare professionals who have such different political, religious, and cultural backgrounds but are subject to a rational framework. The issue is that not everyone agrees on the principles themselves as they have no justifiable metaphysical grounding (i.e., establishment of truth or validity).
Common sense is not what answers complex ethical questions. If its a complex or perplexing question, it doesn’t by definition have an obvious answer. Bioethical principles are simple but health professionals are smart and can handle rigorous ethical contemplation.
The principles as outlined are designed to be simple and open to interruption. What is seen as a valuable is actually a philosophical crutch. It is apparent that bioethical principles while avoiding absoluteness become vague and while proposing an objective standard fails to provide any objective justification.
The principles have to be clarified, not just new additions. The hope is a more rigorous model striving toward objectivity and rational grounding. Philosophy is a tool to search for objective truth in the face of skepticism. Ethics is a philosophical pursuit since ancient times and healthcare bioethics needs a philosophical re-awakening to be more functional and decisive.
Philosophical Exploration of Dentistry
Philosophy is the “love of wisdom” as coined by the mathematician Pythagoras. Wisdom is the propensity to come to correct conclusions to any specific problem using the correct principles, given theoretical or practical. Pythagoras observed that philosophers were those that seek truth to life’s most difficult questions. What is the right way to live, what is the human condition, etc. They would even take pleasure at mystery and seek knowledge for its own sake.
This may sound like a scientist to many. Science and what is now academic philosophy were both once the same endeavors. While science now studies the empirical world through the scientific method, philosophers study reality through the human construct using rational inquiry mainly. Philosophy is divided into three main areas (metaphysics, epistemology, and philosophy of language) and multiple subjects (esthetics, science, ethics, etc.). We do metaphysics to identify universal principles that give us answers to all particular conundrums. We do epistemology to evaluate the truth of those principles and how they were derived (human certainty). We express those principles in accordance to considerations in the philosophy of language.
Many people think metaphysics is what is transcendental, what is “beyond the physical” or “outside spacetime.” Laypeople get this impression from pseudo-intellectual hippies. Academics get this impression from an etymological misunderstanding of “meta” and “physics.” Metaphysics, however, is the study of first principles: a set of propositions that explain the nature of reality as a whole.
The works of Aristotle have a big influence in western philosophy. His chapter on metaphysics directly follows his chapter on physics. Hence, the chapter on first principles was named because it literally is “beyond” or “after” the chapter on physics. Metaphysical discussions often involve discussion of non-physical or supernatural entities, but traditionally it has been the examination of the nature of reality.
Thales was the oldest recorded western metaphysician. Back then, philosophers were concerned with the scientific examination of the physical world. Living near the ocean, Thales observed empirically the importance of water in the ecosystem. Clouds (vapors) form rain (liquid) and seawater dries into salt (solid). He extrapolated that everything consists of water because everything relates to evaporation or condensation in some way. For Thales, the principle that governed reality was water.
How do we know if Thales was correct or incorrect? Questions that ask the certainty of a belief is in the realm of epistemology: the study of knowledge (episteme is greek for knowledge). Academic philosophy is mainly concerned with epistemology (e.g., how do we know we are not in the matrix) now-a-days. While thought experiments can be quite dry, we have to remember Socrates that used the dialectical method to examine his life and be a gadfly for the state
In epistemology, we are concerned with examining the viability of a method or gaining certainty. One of the most deeply root debates is between rationalism and empiricism. Roughly, rationalists (think of mathematicians) trusted pure reason to illuminate truth and considered the senses to be deceitful. Empiricists (think of observational scientists) tend to find meaning in only what can be seen, touched, etc. and find facts about the physical world to be inaccessible by reason alone. However, it is difficult to peg any philosopher solitary in one champ.
Rationalism and empiricism are perspectives that kind us to evaluate different modes of reasoning in different matters. We cannot be precise in our calculations if we measure the angles of a physical square object (but we know it to be 90 degrees by reason alone). It is also impossible to know the number of cusps of a first molar without every seeing one before in a human. Both the senses and reason seems to have difficultly in establishing knowledge (certainty).
Reason and Philosophy of Language
The last major division of philosophy is philosophy of language: how to express philosophical enlightenment. One greatest area of importance is logic symbolism. “n” stand for and and “u” for or are common examples of the development of logic. I will not give an in-depth course on first order formal logic but however I will focus on some logical principles and methods.
An argument is divided into premises and conclusions. The conclusions are derived from the premises through logical operations. For a deductive argument to be valid, the conclusion cannot be false if the premises are all true. If the conclusion could be false to any degree, the premise do not logically entail the conclusion. If an argument is valid and sound (i.e, the premises are all true), then the concussion must be true.
In speculative reasoning, we can be certain that a fact is true if the premises from which it is deductively derived are also true. The problem is to determine true premises also. Offering further axioms in proof of the original premises would entail further proof of those axioms. See the dilemma? Socrates used the dialectical method to somewhat help the situation.
Aristotle – Virtue Ethics
Speculative Reason Vs Practical Reason
Aristotle makes the distinction between theoretical or speculative reasoning and practical reason. Theoretical reason in traditional logical studies such as math is where axioms are presented and conclusions are deductively derived; knowledge is the product of theoretical reason. The reason this distinction is made in the first place is that some philosophers claim that no moral truths can be derived using theoretical reason since only unsupported axioms can be provided (premises have to have their own premises infinitum) and while argumentation goes forever, humans cannot. A seemingly infinite regress in speculative reasoning favors contemplation using practical reasoning. As the name suggests, practical reasoning is not about axioms and logical deductions but the matter is concerned with maxims and action as an end product. In moral reasoning, we want to analyze deliberative processes that end in action since if a moral prescription were to be found true by speculative reason, there may not be any necessity for that action to be undertaken; in practical reason, the conclusion of deliberation cannot be conceived without action. The human will, having the same result and consisting in the process of deliberative, is practical reason.
Some virtue theories claim that goodness of an agent is not determined by what action is performed but found in performing one’s function. Aristotle is a well-developed proponent of this thinking so it is important to considered his ideas. He claims that the good for a human being is found in the performance of a human function or activity well and since what is done well is in accordance with excellence (virtue), human good is performing human function with accordance with virtue (NE 1.7, 1098a25-b5). The function for human being is claimed to be rationality by Aristotle since it is what is unique compared to plants that do basic life functions and animals that also have experiences. For Aristotle, being a person is one that reasons and being a good person is one that reasons well, according to virtue.
If performing actions or preforming one’s function well does not determine a person goodness, then maybe the procession of virtues determine the goodness of a person. The more virtues or the better developed they are, the better the person is said to be compared to another. The virtue conception of being a good person runs into the same problem as the function conception; having well developed virtues is not always good for the virtuous person. Some traditional virtues are wisdom, courage, temperance, and justice. Xenophanes illustrates that being wise may cause another wanting to make you a slave for your reasoning skills, being courageous may result in an early death when a commander places the most courageous in the frontlines, temperance may prevent you from quick flight resulting in death from a vicious animal attack, etc. ().Either the traditional virtues that happen to sometimes cause misfortune are not virtues – which no one would argue – at all or we must reject the virtue conception of being a good person since we know that being a good person must also improve or increase the agents value.
One objection to the dilemma that may be raised by an Aristotelian with a more modern theory of virtue ethics. She would insist that the right action is one in accordance with a geometric mean between excess and deficiency with respect to all virtues involved applied at the right time and right place. ()A wise person would be humble and avoid attention from a slave keeper, a courageous person would choose her battles wisely by avoiding too dangerous battles, a temperate person also knows when to trust her instincts knowing when to flee, etc. Xenophanes considers virtues individually, but for the truly good person, virtues are applied based on what is required of a particular situation to achieve the maximum good possible. On the other hand, take for example a cruel conquer who sets up a test for the defeated civilization: solve a complex puzzle to demonstrate your wisdom and you will be a slave and if the puzzle cannot be solve you will be put to death as there is no room for the weak minded. It does not matter what the wise person would do in this situation because the results are both not in the interest of the person; one may be better for the person but the Good is not what is better than two options but what improves and adds value. Actions guided by virtues are always restricted by luck, the possible circumstances surrounding an event. The possibility of bad luck (bad outcomes in all possible scenarios) illustrates that being good (virtuous), does not necessarily result in good for oneself.
John Stuart Mill – Utilitarianism
Immanuel Kant – Categorical Imperative
You do your duty not because for the sake of some external purpose or from volition but because you recognize that you are obligated to follow that duty; you align yourself with a good will not for an external effect but because it is good in reference to no other, good-in-itself. When something is done for the sake of something else, its value, worth, or goodness is dependent on the external event obtaining (so limited in kind and thus of finite value, worth, or goodness), but when something that is intrinsically valuable, worth for its own sake or good-in-self, we must consider the worth of the thing infinite, since it is unqualified by another (no limit) and something cannot limit its own conception with respect to kind without self-contradiction. The only such good that can be found to be good-in-itself and unqualified by no other is the good will.
Only what is done after evaluation by reason can something be said to be good, instrumentally or intrinsically. Determination of value is calculative and requires mathematical reason, to say one is worth more than the other in quantity. Since number is an aspect of form, not content, the goodness of a thing is found in analysis of its form using reason (reason deals with the form of things). The form of a thing is combined with quantitative interruption to evaluate its goodness. What is good-in-itself is evaluated by analysis with reason; the formal reality of what is good-in-itself, with respect to goodness, is only dependent on and in reference to itself and not another. Since what is good-in-itself is unqualified by another, an unconditioned good, it is of infinite quantity in interference to value (something cannot limit itself in kind without contradiction in conception). Though theoretical reason involves quantitative analysis, practical reasoning ends in action so the action derived from practical reason can be said to be from an intention good-in-itself and can be considered definitively good even with an infinite chain of further effects. Reason cannot say if an action itself is good (since actions can only be conceived in an indeterminate chain of events), but it determines the goodness of an action when it is done from a good will.
Let us examine how practical reason operates and explore classical terminology. Practical reason, the will, evaluates ends which are given to us and means to achieve those ends through operation of different faculties, such as memory, imagination, spatiotemporal reasoning, mathematical reasoning, and conceptual processing. When a means is incorporated with a given end, it is called a maxim, and when this conception involves the conception of “shall” or “should,” it is a command or imperative. There are hypothetical imperatives (usually in the form of “if x, then do y” statements since they are conditional) and categorical imperatives (usually in the form of “do x” since they are unconditional). It is not the sentence structure that differentiates between hypothetical and categorical imperatives when practical reasoning takes place but the analysis of the form of the means to the end; categorical imperatives are unconditioned and hypothetical imperatives are conditioned. Examine the sentences (1) “If I want to taste chocolate, I should eat a vanilla cake” and (2) “I should eat vanilla cake to taste chocolate.” These are both hypothetical imperatives as the means and ends are identical but stated in different sentence structures; they are conditioned statements since the means will not actually necessarily obtain the end. Notice that sentences 1 and 2 are both imperatives as they involve the conception of “should” or “shall.” The sentence (3) “I should eat chocolate cake” is categorical but not an imperative at all so cannot be used in practical reason to result in action (it is not prescriptive). It is not sentence structure but the constituent parts of the maxim and their relation to each other that is involved in deliberations of will.
The form of a maxim must be of an end-in-itself (must be regarding itself as the source of the moral claim in self-reference and not another). A maxim of the form “end-in-itself” contains the means, which references the action to take, and the ends contain the motivation and direction to proceed in action. Universality is found in the conception of a law and the consideration of oneself as the source of reality to particular moral claims. Necessity is found in the relation between the means and the ends, not in the ends as ends implies contingency. Something is necessarily related to another if one implies the other and no other possibility. Impossibilities are violations of the principle that governs the reality of the situation, such as the law of contradiction. Kant understood practical contradictions as logical contradictions in speculative reasoning, but this not always demonstrated in his examples or necessarily in the way practical reasoning takes place. Practical reasoning relies on consistency of concepts involved in the means and ends, e.g., consistency of will(disregarding agency as the source of moral claims) and consistency of practice or thought(scheme upon which the reality of the maxim is grounded) involved in the conception of the imperative. Application of practical reason involves not one single method but understanding of the different essential aspects of correct practical reasoning allows us to obtain an imperative or law to follow from the myriad of subjective ends.
There are four formulations of the categorical imperative, not understood as identical but are instrumental for the understanding to determine how to live life:
- The Formula of the Universal Law of Nature – Act only according to that maxim whereby you can at the same time will that it should become a universal law (Grounding421).
- The Humanity Formula – Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means (Grounding429).
- The Autonomy Formula – The idea of the will of every rational being as a will that legislates universal law (Grounding431).
- The Kingdom of Ends Formula – A systemic union of different rational beings through common laws (Grounding 433)
The derivation of contradictory duties from these laws in due to misunderstanding of the ground for these formulations. Once each formulation is understood in meaning, contradictions are resolved. The first three formulations are variations of the same moral law in different words and the forth is combination of the previous three in relation to a set of wills in a world of moral agents. Each must be understood to allow us to live a life worth living.
Remember that no final cause can be found in the external world as it contains only necessary relations. Ends are product of how general contingency arises – through the spontaneity of the imagination. It is the imagination that is the source of moral claims and the combination of different faculties, e.g., quantitative reasoning, intuition or sensibility, conceptual reasoning, formal language, etc., of our minds that allow us to be sources of objective moral claims.