Moral judgments and medical resource scarcity

By Daniel A. Kaufman

This is second in the series that began with Dan Tippens’ “A short note on the ethics of liver transplantation”

Dan Tippens has started an important conversation – one that we must have, given that we live in a society whose population is aging and whose medical costs seem capable of rising without end.  Having read Dan’s opening remarks, I suspect that we are going to have some disagreements on the subject, but in this first round of my own, I want to expand things a bit and get at the more general issues at hand, with regard to which philosophical analysis may provide some insight.

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First – I don’t think that we should limit the conversation to organ transplants, which raise unique questions that may obscure the more general ethical issues surrounding medical resource scarcity.  Organs are scarce in a way that other medical resources are not.  Money cannot increase the number of kidneys, but it can increase the number of hospital beds, so scarcity with respect to kidneys is of a different sort than scarcity with regard to hospital beds. (1)  And just as hard cases make bad law, I am disinclined to let the distinctive and especially difficult problem of organ scarcity define the much larger problem of medical resource scarcity and thereby, blind us to potential remedies.

Second – With regard to the utilitarian calculations that Dan T. mentions, their scope is far too small, at least given the manner in which they are addressed in the source he cites.

It is largely uncontroversial that limited resources should be allocated where they will do the most good…If we are going to try to invest our resources in ways that generate the greatest return, we could ask what medical considerations would be relevant to this assessment. Two jump out as obvious: likelihood of success and life expectancy. Starting with likelihood of success, we might reasonably postulate that, all else equal, we should invest our finite resources in cases where the investment is likely to be most effective.  (2)

Notice that the conception here of “the most good” and “greatest return” is entirely in terms of the usefulness of the medical intervention – whether it be an organ transplant or the employment of any other medical resource that is scarce — to the patient receiving it.  On whom is the use of the resource most likely to bear fruit?  Who will benefit from it the longest?  But this only represents a tiny fraction of the considerations that one should find in a utilitarian analysis, whose conception of “the most good” and “greatest return” is in terms of the effects of an action on the general welfare, not just the welfare of the immediate actors.  Once one recognizes this, it doesn’t take much thought to imagine considerations that would strike most people as quite objectionable.  Suppose, for instance, that between two people, A and B, A will benefit the most from the resource, but he is an insignificant character whose death will make little difference to the general welfare.  B, meanwhile, will benefit much less from the medical resource – maybe he’s seventy five years old, while A is thirty five – but he also happens to be the top scientist in America working on Alzheimer’s research and is on the cusp of discovering a cure, one that he swears he will bury if not given the medical resource.  On the utilitarian view, under these circumstances, B should be given priority over A, because saving B will demonstrably serve the general welfare to a much greater degree than will saving A.

Third – Whether one characterizes the prioritization of one person over another in terms of punishing the denied person or rewarding the chosen one, it is based in part upon determining whether one of the parties has done various things that have led to his needing the scarce medical resource — the smoker needs cancer treatments because of his smoking, the alcoholic needs the liver transplant, because of his drinking, etc.  This dimension of the choice is not changed by the fact that Dan T. wishes to characterize the prioritization itself in terms of the desert of the person who has not done these things and has, at least in that regard, taken better care of himself.  That this is a distinction without a relevant difference – giving John the liver transplant over Bill because John deserved to get it versus giving John the liver transplant over Bill, because Bill deserved not to get it – quickly becomes evident, when you adopt Bill’s position and ask yourself whether you’d feel any better at being told you were going to die, because someone else deserved to live more, rather than because you deserved to live less.

Fourth – It seems quite clear to me that regardless of which variant on this rationale for prioritization one advances, it is not being applied with any kind of generality or consistency.  Those who ride motorcycles are engaged in an activity that raises their risk for traumatic injury and death, and Emergency Room resources are scarce, yet we don’t deprioritize Emergency Room services for motorcycle wreck victims in favor of non-motorcycle drivers.  Of the enormous number of the people in the US with diabetes, a hefty percentage of them have the disease due to excessive and unhealthy eating habits, yet we don’t deprioritize them with respect to the use of scarce medical resources, in favor of others who have non-self-inflicted illnesses.  It seems to me that we engage in this sort of desert-based prioritization only with respect to those whom society currently holds in contempt, which, today, consists almost entirely of smokers, drinkers, and drug users, although you don’t have to go very far back in time to find a similar sort of deprioritization being applied to those suffering from AIDS.

Fifth – One of the indirect, but damaging effects of a regime of moral prioritization is that it gives us an excuse not to make scarce medical resources more plentiful, by spending more money on them.  We see this sort of logic at work, in the discussion on prison reform.  Activists will point out the abominable conditions in American prisons, conditions that obtain because of a lack of resources, but when any proposal is made to spend more money on correctional institutions, in order to improve the conditions of the prisoners therein, it is quickly nixed to a loud chorus of moral condemnations: “They deserve to suffer!”  “Lock ‘em up and throw away the key!”  “Can’t wait until Bubba makes him his bitch!” and the like.

So, why spend more money to make medical resources less scarce, when we can simply deny those resources to bad people who deserve to die anyway or at least, don’t deserve to live as much?  If we were all in this equally together – if we imagined some sort of Rawlsian veil of ignorance, in which we would have to decide on medical resource allocation, without knowing in advance how well or poorly off we’d be, in terms of the healthiness of our lifestyles – would our medical resources still be so scarce?  Or would we be spending enough money to make sure that they are not?

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Just to state my own view, without elaboration – I’m sure we will get into it, as the discussion develops – I do not think that moral considerations should play any role whatsoever in the allocation of scarce medical resources.  Prudential and practical considerations should always be overriding, and I think there is a way of construing the “who will benefit the most from it” principle of prioritization in prudential, rather than moral terms.  Beyond that, medical resources should be provided on entirely value-neutral grounds, such as random selection, “first come first serve,” or some other such basis.

Notes:

  1. This may not, in fact, be quite as categorical as it sounds. If it was legal to sell one’s organs, money might solve the organ-scarcity problem or at least, mitigate it.
  2. http://journalofethics.ama-assn.org/2005/09/oped1-0509.html

Categories: Essay, Essays, Uncategorized

9 Comments »

  1. Money cannot increase the number of kidneys

    Unfortunately, that is, I think, not true. The free market can supply all ;_(

    When Steve Jobs needed a liver, he got a liver…and it was wasted!

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  2. Dan K: “Beyond that, medical resources should be provided on entirely value-neutral grounds, such as random selection, “first come first serve,” or some other such basis.”

    That’s a good salvo, IMO. Of course, so far as I can tell, no one has even taken into consideration whether the donor might have a say in any of these matters. So far as I know, if one’s organs meet some medically acceptable criteria for donorship, it’s a “no strings attached” matter. If one is allowed to choose what charity get’s one’s money, why not one’s organ(s)? I realize that this subject can further complicate the issue, but it seems pertinent, nevertheless.

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  3. TJ: I don’t know that you can’t do what you describe. A friend of mine needed a kidney and his wife created an internet-campaign in order to try and find a donor, which eventually succeeded. I have no idea about all the legalities and such, however.

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  4. Dan,

    I was going to make your third point myself in comment to Dan T’s article, but I’ve been short on time this week. It’s a clever but unrealizable distinction with considerable social and political ramifications beyond the present issue. One historic moment to reflect on: In deciding Brown v. Board of Education, Warren told the other justices that, given the available resources and the obvious bias in their distribution, there was no way to decide in favor of segregation on some presumed basis of (an unenforceable) “separate by equal” principle, without relegating Blacks to second class citizenship. This was a moment when the law was rightfully decided on the basis of justice rather than on rhetoric.

    And its hard to see how one can get a utilitarian consequentialism without considering the pragmatic consequences – if the end result of ‘rewarding’ one increases the benefit to that one while denying benefit to another, I would say that still looks suspiciously like punishment of the latter to me.

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  5. “a tiny fraction of the considerations that one should find in a utilitarian analysis…”: that is a slippery slope in that the general welfare might be to contributors to a health fund, citizens of a country, or of the world. Harsanyi (eg Bayesian Decision Theory and Utilitarian Ethics, Am Econ Rev 1978, 68:223) would argue there is no difference between prudential and utilitarian concerns, once the relevant society of rational individuals has been specified.

    And I think a spell checker has eaten your desert.

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  6. Harsanyi may say that, but I don’t think the view is sustainable. The distinction between moral and prudential considerations has been pretty standard in moral philosophy since Kant, for good reason.

    Yes, WordPress does some odd autocorrections. I appreciate your calling it to my attention.

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  7. Points four and five strike me as especially strong, given Kaufman’s citing of the lifestyle hypocrisies and the awful conditions of prisons in the US as a manifestation of moral prioritization. Sexual violence (particularly toward juveniles) we rightly abhor, but once we move into a discussion of prisons, such concern seems to dissipate quickly. Re: point four, given the explosion of extreme sports and associated injuries, one wonders if smokers and drug users should just relabel what they do as a kind of extreme sport. Or, they could just call it football.

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  8. Hi Dan, given what I said in response to Dan T’s essay I obviously agree with your position and arguments. Here are some additional comments for each point you made…

    1) “Organs are scarce in a way that other medical resources are not… I am disinclined to let the distinctive and especially difficult problem of organ scarcity define the much larger problem of medical resource scarcity and thereby, blind us to potential remedies.”

    This is a great point, though as I mentioned in the other thread the particular nature of organ scarcity can make a good proxy for medical situations where resources are scarce in the immediate/local sense regardless of adequate funding in general. For example after a multiple car pile-up or a natural disaster local resources may be strained well past what would make sense to have on hand at all times (even as reserves). This would especially be true for first responders and emergency rooms.

    2) “With regard to the utilitarian calculations that Dan T. mentions, their scope is far too small, at least given the manner in which they are addressed in the source he cites.”

    Agreed. I am interested to see Dan T sketch out what utilitarian model he was/wants to employ. I was thinking he might not have been going for a full blown utilitarian model, but rather addressing a specific situation where some level of limited utilitarian concerns might be employed.

    3) “That this is a distinction without a relevant difference – giving John the liver transplant over Bill because John deserved to get it versus giving John the liver transplant over Bill, because Bill deserved not to get it – quickly becomes evident, when you adopt Bill’s position and ask yourself whether you’d feel any better at being told you were going to die, because someone else deserved to live more, rather than because you deserved to live less.”

    Exactly. That point really deserves repeating.

    4) “Those who ride motorcycles are engaged in an activity that raises their risk for traumatic injury and death, and Emergency Room resources are scarce, yet we don’t deprioritize Emergency Room services for motorcycle wreck victims in favor of non-motorcycle drivers”

    This is the exact example I was planning on using later (as essays continued). Of course if said motorcycle driver was Evel Knievel (I saw what you did there) a full blown utilitarian account might demand we prioritize him over some poor schmuck he might have landed on.

    5) “We see this sort of logic at work, in the discussion on prison reform. “

    Same for any social welfare program. Opponents usually trot out the no-good free-rider boogeyman who we can imagine to be doing all sorts of “bad things” on top of just plain “being lazy” which of course demands we not invest anything at all.

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