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.
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?
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.
- 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.