OBLIGATION AND SUPEREROGATION

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Much human behavior in the biomedical sphere is governed by moral principles. Due to their particular importance, medical relationships, in the wide sense of the term, have always been considered to be subject to evaluation in terms of justice, duty, obligation, and rights. Thus, the allocation of medical resources is weighed in terms of justice and fairness; the physician's professional role and powerful status define his or her professional duties; the contractual agreement and the special trust of patients places the doctor under a wide variety of obligations toward them; and the particularly urgent needs and interests of human beings (fetuses, handicapped persons, people in coma, and all sickly people included) grant them the right to be medically treated and respected. The regulation of medical practice under these terms of rights and duties has been acknowledged throughout history and formulated in a series of doctors' oaths. More recently there has been a growing trend to safeguard morally required behavior in medical practice under legal rules, on the one hand, and political (state) control, on the other. This institutionalization of medical relations has led to the effective enforcement of the moral rights and duties of patients and physicians, but also to the depersonalization, even dehumanization, of these relations.

Some forms of heroic sacrifice, volunteering, and beneficence have been traditionally treated as situated beyond the call of duty. This article seeks to establish the important (though limited) role of such behavior in the medical domain, especially against the background of the growing legislation, politicization, and commercialization of medical life. Eager to safeguard universal compliance, impartial distribution, and equal treatment, medical ethicists have tended to ignore the unique virtues of the morality of supererogation as a complement to the morality of duty.

The Theological Sources of Supererogation

The term supererogation derives from the Latin verb meaning "to pay out more than is required." The first source for its use as an ethical concept goes back to the Latin version of the New Testament. In the famous parable, the Good Samaritan offers money to an innkeeper to care for a wounded man found on the road, and promises to repay the innkeeper "over and above" for any extra expenses (Luke 10:35). Consequently, Good Samaritanism has been closely associated with supererogatory behavior.

Yet the parable of the Good Samaritan does not distinguish explicitly between the obligatory and the supererogatory, but rather between the merely legally binding (to which the priest and the Levite in the biblical story seem to be exclusively committed) and moral or truly virtuous behavior (manifest in the deeds of the Good Samaritan). The explicit distinction between two types of moral norms, the commanded and the recommended, is better formulated in the contrast between keeping one's lawful riches and leading a life of total poverty (Matthew 19:16–24), or between lawful marriage and self-imposed chastity (1 Corinthians 7:25–28), or between ordinary religious faith and total commitment to a religious way of life.

Perpetual poverty, perfect chastity, and perfect obedience thus became the paradigm cases of evangelical counsels (consilia), which, in contrast with the religious commandments (praecepta), were considered by the church fathers and medieval theologians (from Augustine to Thomas Aquinas) to be truly meritorious. Other acts, by which one could freely choose to go beyond the religious precepts, included penance, patience, fasting, and martyrdom, as well as mercy (as opposed to justice) and beneficence (as in the bestowal of gifts). Living by the commandments guaranteed salvation, but following the counsels exemplified perfection.

Both the ideal of monastic life and the institution of sainthood were based on the gradually evolving two-level morality of duty and supererogation. Accordingly, two separate systems of norms applied to two categories of believers, ordinary people and those who had a special vocation or a particular moral capacity. In a later stage in the development of the idea of supererogation, it was claimed that the superabundant merit of the acts of those who belonged to the second category of believers (Jesus and the saints) was bequeathed to the spiritual treasury of the church, and could be dispensed by the pope to help sinners achieve salvation. Thus, the two systems of religious morality were linked by a mystical principle of transference of merit, from those who have a surplus to those who are in debt. The system of indulgences was based on the idea that the supererogatory merit of saintly people could compensate for the sins of ordinary folk. But the papal distribution of indulgences, gradually commercialized in the late Middle Ages, became one of the central targets of the reformers' attacks on the Roman Catholic Church.

Martin Luther, John Calvin, and the Anglican Church questioned the theological foundations of the very idea of supererogation. If mortal human beings could not hope ever to carry out the religious precepts or commandments, how could they hope to do more than was required of them? The reformers' belief that salvation could be achieved only through God's grace, rather than through "good works," made the idea of supererogation absurd and blasphemous, a "superabomination." The denial of a two-tier religious morality directly challenged the ideas of sainthood, monasticism, and indulgences. The metaphysical rejection of freedom of the will undermined the Catholic idea of licentia, that playroom for the virtuous exercise of free choice to do more than is required, which served as the condition and moral justification of supererogation conduct. The theological debate over the concept of supererogation not only is the historical source for the parallel philosophical discussion in secular ethics, but also may serve as the model for this discussion. For despite the obvious differences between the two arenas (particularly on the objects of supererogatory acts, God and human beings, respectively), they share the basic features of the issue: the relation between goodness and duty, the limits of duty, the nature of free will, the place of virtue and perfection in a deontological theory, and the question of whether there are two categories of moral agents who are subject to moral requirements of different scope and stringency.

Supererogation in Ethical Theory

The subject of supererogation, rather surprisingly, did not receive much philosophical attention in ethical theory until the 1950s. In his pioneering article, James Urmson challenges the traditional tripartite classification of moral actions into the permissible (what one may do), the obligatory (what one ought to do), and the forbidden (what one ought not to do). Saintly and heroic acts are adduced as typical examples of actions that do not fall into any of these categories but still have a distinct moral value. However, breaking the neat framework of the threefold division of moral action turns out to be a controversial enterprise. For example, it has to overcome the resistance of logicians, who try to draw a systematic analogy between the permissible and the possible, the forbidden and the impossible, and the obligatory and the necessary, thus creating a unified system of logic. If an act is morally good, how can it not be obligatory? And if there are good reasons for leaving it nonobligatory, cannot supererogation be analyzed in terms of the permissible? And finally, should supererogatory behavior not be considered forbidden, as a dangerous illusion of conceited and morally self-indulgent agents, who violate self-regarding duties and the principles of impartiality and fairness?

There are three kinds of answers to these questions regarding the seemingly paradoxical nature of supererogation: anti-supererogationism, qualified supererogationism, and unqualified supererogationism. Anti-supererogationism denies the existence of actions that go beyond the call of duty. Pure deontological theory, such as Kant's doctrine of the categorical imperative, is a typical example of this view. Obligatoriness (moral necessity) exhausts the moral sphere; duty is the only legitimate motive in morality; and universalizability is the ultimate test for the morality of actions. Hence there is no room for the nonobligatory, charity-based personal action that is typical of supererogation. Acts of beneficence or heroic self-sacrifice are either "imperfect duties" (which for Kant are no less binding than their "perfect" counterparts) or cases of moral fanaticism motivated by self-love.

Some forms of utilitarianism are no less anti-supererogationist. Thus, for the eighteenth-century utilitarian William Godwin, promoting the overall good (including the agent's) is the absolute and only moral duty. This view leaves no room for supererogatory action (e.g., doing a favor), since either its beneficiary has a "complete right" over it or it is wrong ("unjust") to do it because of other people's rights (including the agent's). The derivation of "ought" statements from statements about the good (utility, happiness) leads George Edward Moore, too, to a straightforward denial of supererogation.

Modern utilitarian theorists point to the logical difficulty in distinguishing between utility-promoting actions that are obligatory and utility-promoting actions that are not obligatory, since such a distinction requires an appeal to a nonutilitarian principle. The common ground on which deontological and consequentialist anti-supererogationists rest their case seems to be the purely impersonal conception of morality, a conception typically expressed by the universalization principle or the classical utility principle of an agent-independent promotion of overall goodness "in the world." Impersonalism of this kind leaves no room for altruism, personal sacrifice, or the expression of individual preference.

Qualified supererogationism tries to do more justice to our common belief in the value of supererogatory conduct. It concedes that in some abstract or ideal sense every good action is obligatory, but highlights the circumstances that make such a morality too demanding, even absurd. Some utilitarians, like John Stuart Mill, distinguish between the prevention of harm (which is obligatory) and the altruistic promotion of the good (which deserves gratitude, honor, and moral praise). Henry Sidgwick is willing to distinguish between what a person ought to do and what people are justified in blaming him or her for not doing. Thomas Aquinas states that while the commandments apply to everyone, the counsels are directed only to the few who are capable of following them or who have made the life of perfection their special vocation. Rule utilitarians, as well as contract theorists like David Richards, point to the possible decrease in overall happiness through the adoption of a general rule enforcing supererogatory action as a duty, and at the same time to the general social benefit derived from leaving it to individual discretion. Even Kant, in his later ethical writings, acknowledges the existence of "duties of virtue" that "others cannot compel us (by natural means) to fulfill," as they are concerned with the adoption of ends, are binding only in the "internal" sense, and create no corresponding rights in the recipient. Finally, John Rawls and Joseph Raz analyze supererogation in terms of exemption: the exemption that "natural duty" allows in cases of high risk or loss to the agent (Rawls), or that granted by the second-order "exclusionary permission" not to act on the best balance of first-order reasons (Raz).

Qualified supererogationism is reductive in nature: it insists on accommodating supererogatory acts within a deontic framework (i.e., the language of duties and obligations). Every moral action is in principle required, though considerations of exemption, risk, disutility of enforcement, personal (in)capacity, excuses, difficult psychological circumstances, and rights define a supererogatory subcategory. Unqualified supererogationism, on the other hand, insists on placing the supererogatory "beyond duty" in the absolute, nonreductive sense (Urmson; Feinberg; Heyd). Supererogatory behavior is fully optional, that is, it lies beyond any kind of duty, under any condition, and for any moral subject. No excuse is needed for not acting heroically.

Definition and Justification of Supererogation

Most definitions of supererogation display the same general form, pointing to the asymmetry of commission and omission of actions. Thus supererogatory acts are said to be those acts that are good to do but not bad not to do, or right (just, virtuous, praiseworthy) to do but not wrong (unjust, vicious, blameworthy) to refrain from doing. These definitions, however, fail to capture either the special merit of supererogatory acts or their particular optional character. More sophisticated attempts retain the asymmetry but mix the contrasted pairs (e.g., "non-obligatory well doings," according to Roderick Chisholm, or "meritorious nonduties," according to Joel Feinberg). Still, the definition of supererogation, at least of the unqualified version, must refer explicitly to the normative status of the acts in question, to their particular value, and to the person-relative features of these acts (the agent as well as the recipient).

A possible definition contains the following four conditions for an act to be supererogatory:

It is neither obligatory nor forbidden.
Its omission is not wrong and does not deserve sanction or criticism, either formal or informal.
It is morally good, both by virtue of its intended consequences and by virtue of its intrinsic value (being beyond duty).
It is done voluntarily for the sake of someone else's good, and is thus meritorious.

The first condition characterizes supererogatory acts in negative terms (being nonobligatory), but the second emphasizes their purely optional nature. This distinction between the permissible and the optional points to the specific double value of the latter as opposed to the moral neutrality of the former: it is not only the good effect of supererogatory action that makes it praiseworthy; it is its motive, which is completely "free," that is, not even an "ought." This combination of desirable consequences and virtuous motive is the source of the moral merit ascribed to the agent of supererogatory acts.

It should be noted that the goodness of supererogation lies in its leading to consequences that are of moral value, that is, of the same type or on the same scale as those of obligatory action. This is clearly manifest in supererogatory transcendence of duty, such as "going the second mile" or doing more than one's job requires. In that respect, supererogation is continuous with the morality of duty. But the fact that the source of the value of a supererogatory act lies no less in the voluntariness of its motive points to its conceptual dependence on the idea of duty, that is, its being correlative to duty. It should be noted that there are ethical theories that are not based on the concept of duty at all (but rather on the idea of virtue, as in Aristotle). Such theories do not leave room for supererogation as it is defined here.

The general justification of supererogation is twofold: on the one (negative) hand, it has to do with the basic autonomy of individuals to lead their lives in ways not always subordinated to moral principles such as the overall good. On the other (positive) hand, it is associated with the supplementation of the impersonal and universal core of ethical theory with a personal dimension. This is expressed both by the agent's discretion and by the choice of the particular recipient of the beneficent act. Supererogation in that respect is highly important for social cohesion, trust, and friendship in society—values that cannot be fully achieved even in an ideally just society in which every person performs his or her duties and obligations. This justification for unqualified supererogationism is reminiscent of the debate about the legal enforcement of morality: In the same way that there are moral reasons for leaving some moral duties beyond the reach of the law, so there are moral reasons for leaving some morally good acts out of the system of moral duties and obligations. The Good Samaritan first took care of the wounded man (which was not his legal duty but certainly his moral duty); then he offered to pay the innkeeper "over and above," that is, for the expenses involved in housing and feeding the man (which was not even his moral duty).

Typical examples of supererogatory acts are saintly and heroic acts, which involve great sacrifice and risk for the agent and a great benefit to the recipient. However, more ordinary acts of charity, beneficence, and generosity are equally supererogatory. Small favors are a limiting case, because of their minor consequential value. Volunteering is an interesting case of supererogation, because it refers to the procedure by which the agent of an obligatory act is selected. That is to say, someone ought to do the act, but due to its particular difficulty or risk, it is hard to decide who. Finally, there are supererogatory forbearances, in which the agent refrains from taking a morally justified action that would have a negative impact on another. Forgiveness, pardon, and mercy are typical examples: we would have been justified in punishing a criminal, but we decided to exercise mercy or pardon.

Supererogation in Medical Ethics

The place of supererogation in medical ethics has been almost completely ignored, both in the theoretical discussions of supererogation and in the vast literature on medical ethics. This might be explained by the fact that both fields are relatively new, and by the tendency to bind the vital aspects of medical practice and relationship in a firm system of well-defined rights, duties, and obligations. The issues of confidentiality, informed consent, abortion, euthanasia, and allocation of scarce resources revolve around the debate on the rights of patients and the duties of doctors, the principles of justice, or the responsibilities of state and society to their members. However, there are some areas of medical practice in which supererogation has a central role to play, cases that could also help in understanding and justifying the theoretical distinction between obligation and supererogation: the collection and allocation of blood, organ donation, surrogate motherhood, and medical experimentation.

Anti-supererogationists would tend to deny that some medical matters lie beyond the sphere of moral duty and social justice. In their attempt to reduce allegedly supererogatory conduct to one of three categories—the obligatory, the permissible, and the forbidden—they may, for instance, claim that blood donation is a moral duty, that surrogacy arrangements should be completely forbidden, or that participation in medical experiments should be left to the morally neutral (permissible) regulation of the free market. Grounding vital medical relationships in supererogatory altruistic motives offends our moral sense of equality, both in the access to treatment and in the undertaking of risks. Legislation and the market are two powerful alternatives that safeguard impartiality and personal neutrality, which are principal values in the ethics of duty and justice.

Qualified supererogationists would admit that ideally all medical practice should be subjected to universal deontic principles, especially since it deals with matters of life and death in which we want people to have equal chances, rights, and duties. But they point to the limit of what can be expected of individuals by way of giving and taking risks, particularly when the sacrifices required are of the same kind as the health needs of others that create the call for sacrifice. Therefore, when the health of a sick person requires an organ donation that would expose the donor to serious health hazards, one must leave the decision to the personal discretion of the donor. Institutional control or regulation under impersonal rules (such as legislation) is immoral, either because most people cannot make the required sacrifice ("ought" implies "can"), or because it could be counterproductive in utilitarian terms (the sacrifice of the donor being greater than the potential benefit to the recipient). Furthermore, the market mechanism, which is so efficient in much of our economic life, may lead to the exploitation of the poor by the rich or to other morally repugnant consequences related to the commercialization of human life and health.

The unqualified supererogationist shares many of these apprehensions but adds a positive justification for a "moral free zone" in medical life. Beyond the realm of relations of duties and rights, there is in medical practice some room for a totally free exercise of giving. It is a reflection of personal autonomy; it is grounded in a personal interest in another individual, and it creates personal relations; it strengthens social ties and cohesion. Blood donation is a typical example. Collection of blood for medical use in modern society can be based on a free-market system in which blood is freely bought and sold, or on a legally enforced system of duties(e.g., of young people to donate blood once a year), or on a fully voluntary system, as in Great Britain, in which people volunteer to give blood and patients get it free. Economists like Kenneth Arrow favor "the economy of charity," and believe that the market can better handle the needed balance of supply and demand of blood. Furthermore, they claim that altruism is itself a scarce resource, and therefore should be used only when necessary. Richard Titmuss and Peter Singer, on the other hand, argue that the commercialization of blood donation is potentially destructive to society, especially because it concerns a "commodity" that has no price, that is, it is extremely valuable to the recipient and of almost no value to the donor. They add that altruism is not a scarce resource but, rather, a good that grows the more it is exercised. The supererogatory model is thus considered as superior both to the market mechanism and to the political (legal) arrangement of collection and allocation.

The donation of organs (like kidneys) is different in that it is much more costly to the donor than the donation of blood (particularly in the case of living donors). It is also more personal than the anonymous donation of a blood bank, as it usually involves someone personally close to the donor. Unlike blood donation (which may be considered morally obligatory though not legally enforceable), giving away a nonrenewable part of one's body is typically supererogatory, in the "saintly and heroic" sense. Ideals of personal responsibility, family ties, friendship, and particular emotional commitments make personal sacrifices like organ donation valuable beyond their sheer utility (which sometimes is tragically doubtful).

Surrogate motherhood can also be regulated by market mechanisms or left to voluntary, altruistic agreements. Beyond the controversial aspects of surrogacy (having to do with the interests of a third party, the child, and with the possibility of a change of mind by the surrogate mother), we may note that most legal systems prefer to leave it as a supererogatory matter. Thus, agreements on surrogacy are not considered criminal (forbidden) in many countries but are not enforced by the courts (in contrast with ordinary contracts). Commercialization is often treated as undesirable, even patently immoral and illegal.

Finally, medical experimentation on human subjects in most countries is now allowed only on the basis of volunteering. No person, sick or healthy, is required (legally or even morally) to take part in any experiment. On the other hand, participating in the enterprise of medical research and progress is definitely of great moral value. By altruistically giving our share to medical research, we express our gratitude to those in the past who made us beneficiaries of medical progress (Jonas). The supererogatory nature of participation in medical experimentation is typically connected to the case of volunteering, in which it is a moral "ought" that someone (in a group) do the job but no particular individual can be identified as having to do it. As opposed to any selection procedure based on substantive criteria (like merit), or formal criteria (like random devices, which are particularly attractive as a fair means of imposing burdens in risky situations), volunteering is completely supererogatory.

We may conclude, then, by pointing to the special status of supererogation in some aspects of medical ethics as combining the advantages of both morality and the market, as well as avoiding some of the dangers of both. A supererogatory system of blood collection is on the one hand of moral worth (no less, and even more, than its alternative regulation according to principles of duty fairness in a politically centralized system of collection and allocation), yet fully optional (as in the case of buying and selling in the market). On the other hand, it avoids the danger of exploitation, typical of the market mechanism, as well as the danger of compulsion, typical of often-abused political power or of social pressure. Supererogation can partly counter the undesirable trends of both commercialization and politicization of modern medical life by leaving an outlet for the autonomous and spontaneous exercise of supererogatory beneficence.

david heyd (1995)

bibliography revised

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Obligation and Supererogation