Some Final Thoughts on Medical Resource Scarcity and Morals

by Daniel A. Kaufman

This is last in the series that began with Dan Tippens’ “A short note on the ethics of liver transplantation” and is a reply to “Should moral judgments enter into medical decisions?”

Dan Tippens inadvertently makes a good part of my point for me, in his most recent response.  By this, I do not mean to suggest that he has unwittingly come to agree with my view that moral considerations should not be taken into account, when we are confronted with medical resource scarcity – I know that he has not – but rather, that he has provided precisely the sort of example that was instrumental in the development of my own position: that of the organ-needy criminal.

Monies for discretionary spending are a scarce resource in the United States.  The conditions in our prisons are abominable, from crumbling facilities to acute shortages of crucial programs – education, vocational training, psychological and social counseling, etc. – to an outright rape epidemic, in which inmates are allowed to rape other inmates and are raped by prison staff.  And yet, spending for the purpose of improving the conditions under which our prisoners live is deprioritized.  Why?  Because prisoners are “bad people,” who “deserve what they get.”  Because — as I mentioned in my first round — ours is the type of society in which we say of criminals “Lock ‘em up and throw away the key!” and “Can’t wait until Bubba makes him his bitch!”

So, I find Dan’s example chilling.  The felon he mentions was sentenced to x number of years in prison.  He was not sentenced to being raped or otherwise assaulted.  He also was not sentenced to death, by organ failure.  He was sentenced to x number of years in prison, and that is the only punishment that he deserves, given our system of law (compared to which it seems our collective moral attitudes and sentiments are lagging behind).  It strikes me as wrong to subject those in our custody to violent assault and other intolerable conditions on the grounds that they “deserve to be treated badly” or “deserve less than others to be treated well” – and it strikes me as equally wrong to deprive people of life saving treatments on the grounds that they “deserve to die” or “are less deserving of life than someone else.”

With respect to my examples re: the utilitarian calculus, Dan and I appear to have very different underlying intuitions.  To him, the utilitarian selection of the more important among us for life and the less important among us for death is intuitive and makes perfect sense.  (Hence his response to my example of the doctor with the Alzheimer’s cure.)  To me, it demonstrates everything wrong with Utilitarianism as a moral framework.  Indeed, I use precisely this sort of merciless sorting – as represented in the form of “lifeboat cases” — as one of the more powerful arguments against Utilitarianism, when I teach Ethics to  introductory level students.

Dan wants to suggest that my stance is the result of an overreaction – specifically, to past abuses of desert-based prioritization schemes  — and observes that practical, prudential considerations can also be applied in a callous manner.  Certainly, he is correct in pointing out that prudential considerations may be resented every bit as much as moral ones, by those denied the relevant resource.  But beyond this, there is no likeness whatsoever between distributing scarce medical resources in a way that is sensitive to prudential concerns and using those resources as an instrument of moral judgment.  If we fail to do the former, we will squander the resource, in which case, it will not be available to anyone, moral status notwithstanding.  In short, such considerations are necessary, in that they represent the conditions on which having the resource depends.  The same is not true with respect to the application of moral considerations.  Once we’ve obeyed the relevant prudential imperatives, we waste our medical resources no more by distributing them on a random or other value-neutral basis than we would if we distributed them on a moral one.  The decision to distribute scarce medical resources on moral grounds is entirely elective and thus, subject to precisely the sort of criticism that I have expressed.   The decision to distribute scarce medical resources, in deference to prudential considerations is not, because if we fail to do so, we will not have medical resources to allocate.

Finally, whether or not deprioritizing someone because “someone else deserves to live more than you” is any nicer than deprioritizing someone because “you deserve to die” is clearly a subjective matter, and I am happy to leave it to readers to decide whether they think it represents a relevant, positive difference or not.  Dan tries to take this out of the realm of the subjective by arguing that things will be  better, overall, if doctors, nurses, and medical administrators think of the deprioritized as less deserving of life than as deserving to die, but I find myself unconvinced.  Remember that I also described what I think are some broader, negative societal effects of moralizing medicine in this way.  To the extent that we can justify denying scarce resources to people because they are bad or have done something bad, we are less likely to be willing to spend the sort of money that would render the resource less scarce.

So, I remain opposed to this kind of moralizing of medicine.  I do not believe that life-saving medical resources – scarce or not – should be used as an instrument of justice, whatever our conception of justice may be and whichever may be the dominant one at the moment.







9 responses to “Some Final Thoughts on Medical Resource Scarcity and Morals”

  1. I agree with the bulk of this essay and would like to thank both writers in this series.

    Regarding prisons, what if it was possible for withdrawal of access to medical treatment to be used against prisoners who commit violent crimes in prison?

    This could be useful as a deterrent for those who already have life sentences without parole and cannot be punished further by the usual means.

    I doubt that this would work in any sense, but would be interested in others thoughts on this.

  2. Mark, obviously, given what I’ve said throughout this exchange, I am opposed to using medical care as a bargaining chip. We are obligated to provide enemy war combatants with medical care, when they are in our custody. I don’t see how we can have less of an obligation with respect to our own citizens who are incarcerated.

  3. davidlduffy

    I sometimes consider the question of where (bio)medical ethics separates from more general questions – the differences I can see are in the larger effects on life and death, and fiduciarity. I don’t see much difference re engineering good roads (each life saved is apparently costed at ~$1M in our civil engineers’ cost-benefit analyses currently), putting guards on dangerous machinery, or washing your hands before preparing food. So the example of medical care for enemy combatants is jarring, in that it is better understood in terms of acquiring reciprocal benefits for your own soldiers, rather than something magical about medicine. That is, it is prudential rather than moral. From the social contractualist viewpoint, I guess it easier. Once you are a citizen, then part of the contract is eschewing moral judgement in the medical care offered to you, just as it is in the case of City Hall deciding which road needs fixing next.

  4. marc levesque

    I enjoyed the series.

    I’m wary of ethical claims in general and if I thought they were important to take into account in the situation of medical resource scarcity I have trouble seeing how they could be applied in a just and consistent fashion; and I agree with Dan Ks understanding of the the rapist example, I also have the impression that doing otherwise would lead to a bigger hit on social cohesion.

  5. I am still torn on this issue. I Agree wholeheartedly with Dank that we should provide proper medical care for enemy combatants and those who are incarcerated. I am not all an advocate for justice through punishment.

    Yet it seems to me a somewhat different question under conditions of scarcity. I don’t think it is possible to completely avoid taking some kind of moral position when the resource to provide care is fundamentally limited. To take the stand that care when limited in resource should be randomly allocated to either the rapist or the victim feels like a moral stand to me. It feels this way to me not because I want the rapist punished through denial of care, but because the victim feels more deserving if only one can be served. I doubt that a medic on the battle field would first give care to an enemy combatant if an equally wounded member of his own unit was also in distress. I understand the difficulty in any kind of systemic application other than the random approach, and also the huge opportunity for abuse. At the same time it feels wrong to me to completely override our empathic intuitions in the most extreme cases. In any case thanks for the series of posts.

  6. Seth wrote:

    To take the stand that care when limited in resource should be randomly allocated to either the rapist or the victim feels like a moral stand to me. It feels this way to me not because I want the rapist punished through denial of care, but because the victim feels more deserving if only one can be served.


    Yes, this is the intuition that Dan T. is banking on. I won’t deny that it is a strong one and cannot be dismissed, even though I ultimately reject it.

  7. dantip

    Hi Dan K,

    Just two final remarks:

    1. I think Seth Leon states exactly what my reaction to your take on the rape case is.

    2. You make another argument – the prisoner argument – which goes something like this:

    There is a tendency for people to use arguments about “who deserves what” as an excuse for spending less on certain groups of people,. which is unjust. So, you caution the readers to not even begin going down the road of “desert talk” as it is precisely this kind of talk that gives us the aforementioned excuse.

    I’m very skeptical. Again, my position is that in *some* cases, this happens, sure. But in others it doesnt, when we implement things well and don’t engage in the “desert-based practice” for punishment-based reasons (which I wouldn’t advocate doing).

    Consider euthanasia. It is precisely the thought that certain terminal patients *deserve* to choose when they ought to die which motivates us to legalize euthanasia or physician assisted suicide (first note that this really seems like a *moral* argument motivating a certain *medical* practice, which I think you would want to allow).

    However, a classic argument given by many catholics was that if we legalize euthanasia, it gives us an excuse to not spend money to take care of people with terminal illness (who cares about terminal people? they can just opt for euthanasia when things get bad!).

    On my view, failing to give people the option to end their suffering because it *might* lead to less spending on such people was either a) a smokescreen for their bias against the practice of euthanasia or 2) an argument that was too extreme given the circumstances, and actually did lead to something unjust (the stalling of legal euthanasia/PAS).

    (just to be clear, there has been no correlation to my knowledge – and I was just reading several papers on this subject – between decreased spending on terminal patients and legalization of euthanasia or PAS. So empirically the catholic argument was just false.)

    So I think two criticisms can potentially be launched against you.

    First, I doubt you are inclined to agree with the catholics that we should *not* legalize euthanasia (and moralize medicine in this way) because it looks like it will be used to give us an excuse to not help this group of people. Why? Because you can see that in this case we arent implementing euthanasia because we societally disapprove of the group that is in question (terminal patients), and so legalizing euthanasia wouldn’t be an excuse to not help these people. This opens up room for the idea that we can do the same thing in the case of organ transplanatation – we can authorize deprioritization of a group *without* using it as an excuse to not help them, just so long as we implement things well, and aren’t doing it because we societally disapprove of this group (which is what my distinction from the first essay preserves).

    Second, its possible that certain “excuse-based” arguments can lead to *unjust* states of affairs, such as denying people the right to be euthanized or to use PAS. Again, I feel that no deprioritization at all because of the “excuse-based” argumement could lead to certain unjust states of affairs, like those we have mentioned in the past few essays.

  8. Dan T.: I would be very, very concerned about a legal euthanasia regime, so I’m afraid that example really doesn’t move me much.

    I should also say that predictions about possible bad social effects down the road are not my main reason for opposing the use of moral criteria in determining the distribution of medical resoureces.

  9. davidlduffy

    “certain terminal patients *deserve* to choose”: as in “certain people deserve to vote”, or “deserve to be allowed an abortion”? I think “deserve” is being used in the sense of unconditionally deserve in these kinds of context.

    ‘You’re undeserving; so you can’t have it.’ But my needs is as great as the most deserving widow’s that ever got money out of six different charities in one week for the death of the same husband. I don’t need less than a deserving man: I need more. I don’t eat less hearty than him; and I drink a lot more. I want a bit of amusement, cause I’m a thinking man. I want cheerfulness and a song and a band when I feel low. Well, they charge me just the same for everything as they charge the deserving. What is middle class morality? Just an excuse for never giving me anything.

    As for Dan K’s concerns re euthanasia – we already have a legal euthanasia regime allowing withdrawal of sustenance, withdrawal of commonplace medical treatments, and the “double effect” usage of opiates – these don’t necessarily impress me as the most kindly options in all cases.