Friday, March 20, 2020

Ethicists on the dilemma of who should get treated

A friend pointed me to this piece, which is noteworthy mostly for how bad it is. Its main message seems to be that different moral theories all agree on trying to save as many lives as possible. However, this is not necessarily the case.

First, utilitarianism:

Utilitarianism, for example, argues that morality is determined by the consequences of actions, and so we should strive to create the maximum good for the maximum number of people.

The trouble with this is that the greatest good need not coincide with the most lives saved. We might instead think of life years saved. Suppose, for instance, we have the choice between saving two 70 year olds, each of whom will live another ten years, or one 40 year old, who will live another forty years. It's certainly plausible that the latter does more good.

Incidentally, the same paragraph quotes Lydia Dugdale*, saying "It’s not fair to distribute scarce resources in a way that minimizes lives saved". I guess not, but it's not clear what relevance this has here. Is anyone arguing that we ought to minimize the number of lives saved? I rather doubt it. The question is whether we ought to maximize the number of lives saved. Denying that is not the same as saying that we ought to minimize lives saved. (Also, it's questionable what role the notion of fairness is playing here.)

Next, they turn to social contract theory, here quoting Joshua Parker* who - they say - has an article in the Journal of Medical Ethics (in fact, so far as I can see, it's only a blog post) and Alex John London*. After briefly explaining Rawls's veil of ignorance, they say:

Such agents [behind a veil] might agree that in a pandemic, when not everyone can be saved, health care systems should use their resources to save as many lives as possible—because that is the strategy that allows each person a fair chance of being able to pursue their life plan.

Again though, this is contentious. Does this really give everyone a fair chance? Not obviously, when compared to something like a lottery or, perhaps, priority to the young. Harsanyi's version of the original position would result in this utilitarian-style reasoning, but Rawls's social contract isn't really designed to be applied to plicy decisions like this in the first place and, if it were, they might prefer a lottery to gambling on a policy of 'saving as many lives as possible' which appears to ignore the separateness of persons (this was Rawls's famous critique of utilitarianism).

Despite this, they go on to suggest that "“even the most die-hard deontologist will usually agree” that it’s wrong to treat people who are unlikely to benefit while others are in need" - the quotation is attributed to Brian D. Earp*, though it's not clear whether this accurately represents whatever he told them, given that they've re-worded whatever it is that the deontologist is supposed to agree with.

Anyway, supposing this is accurate, all it says is that it's wrong to engage in futile treatment. But this doesn't mean that we must save as many lives as possible either. Suppose we can try to treat Person A or Persons B and C, each of whom would receive a (likely) benefit from treatment. It's consistent with what Earp says to treat A. Even though this may lead to more deaths overall, A is not someone 'unlikely to benefit'.

(Incidentally, this recalls John Taurek's famous discussion of whether it's better to save one person, whom he calls David, or five others. Taurek suggests that he would toss a coin in such a case, since each person has their own life to live or lose.)

Quoting Dugdale again, they do mention some alternatives: first-come first-serve, lottery, physician clinical judgment, and prioritizing certain patients such as health care workers were explored but found to be either too subjective or failed to save the most lives. (A point that gets reiterated a few paragraphs later.)

But pointing out that these measures fail to save the most lives is question begging (in the proper sense of that term), because what's being discussed here is whether or not that should be our objective in the first place. Someone advocating a lottery, on the ground that it gives each (prospective) patient an equal chance to receive treatment, is unlikely to be moved by the fact that it 'fails' to save the most lives. It doesn't do this, but that isn't really a failure when it was never the objective in the first place. They might as well reply that a policy of saving as many as possible fails to give everyone an equal chance.

I've not commented on everything, but there's a lot of bad philosophy in this short piece.

*I've named various ethicists quoted in the article but, just to be clear, I don't mean to attribute any errors to them. It's entirely possible that their words are taken out of context or misunderstood by journalists.


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