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.

A vaccine/pandemic reading list

A few years back, I spent a week of my ethics of public policy (PAIR6040) module on vaccines. I'd originally planned to focus on compulsory vaccination, but wasn't able to find much written on that at the time, so I ended up covering how to allocate vaccines in case a pandemic led to scarcity. I've since dropped the topic from the module entirely, but it might be worth reintroducing it next year.

In any case, here's a copy of the reading list:

Marcel Verweij (2009) ‘Moral Principles for Allocating Scarce Medical Resources in an Influenza Pandemic’ Journal of Bioethical Inquiry 6: 159—169.

Ezekial J. Emanuel and Alan Wertheimer (2006) ‘Who Should Get Influenza Vaccine When Not All Can?’ Science 312: 854—855.

Hugh V. McLachlan (2012) ‘A Proposed Non-consequentialist Policy for the Ethical Distribution of Scarce Vaccination in the face of an Influenza Pandemic’ Journal of Medical Ethics 38: 317—318.

Alasdair Wardrope (2012) ‘Scarce Vaccine Supplies in an Influenza Pandemic should Not be Distributed Randomly: Reply to McLachlan’ Journal of Medical Ethics 38(12): 765—767.

Kristy Buccieri and Stephen Gaetz (2013) ‘Ethical Vaccine Distribution Planning for Pandemic Influenza: Prioritizing Homeless and Hard-to-Reach Populations’ Public Health Ethics 6(2): 185—196.

Martin Peterson (2008) ‘The Moral Importance of Selecting People Randomly’ Bioethics 22(6): 321-327.

Matthew K. Wynia (2006) ‘Ethics and Public Health Emergencies: Rationing Vaccines’ American Journal of Bioethics 6(6): 4-7.

Jeroen Luyten, Antoon Vendevelde, Pierre Van Damme, and Philippe Beutels (2011) ‘Vaccination Policy and Ethical Challenges Posed by Herd Immunity, Suboptimal Uptake and Subgroup Targeting’ Public Health Ethics 4(3): 280—291.

Unfortunately, most if not all of this will be 'quarantined' behind journal paywalls, unless any of them are being particularly good at opening this research to the public (as some journals are doing with Covid19 work).

UPDATE:
There's a crowd-sourced, interdisciplinary reading list here.

New look

Amazingly, this blog is approaching 15 years old. I don't update as actively as I used to, but I still plan to keep it, if only as a repository of useful links for my own benefit. Anyway, I thought the layout and design was starting to show its age - and often rather cluttered.

I've selected a new theme, which to my mind looks a lot cleaner. It seems to have come at the loss of my 'blogroll' but many of those links were dead anyway. If there are actually any readers out there, then any comments on the new look at welcome. Especially any relating to navigation on other devices. (I assume the standard templates should be fine, but I haven't been able to test this myself.)