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.