Beginning in 2012, Dr. Lee Daugherty Biddison, a critical care physician at Johns Hopkins and some colleagues have held public forums around Maryland to solicit the public’s opinions about how life-saving medical assistance should be distributed when there are too many desperately ill patients and not enough resources. The exercise was part of the preparation for Biddenson’s participation in preparing official recommendations for state agencies that might end up as national guidelines regarding when doctors should remove one patient from a ventilator to save another who might have a better chance of surviving, or whether the young should have priority over the old.
Ethically, this is pure ends justifying the means stuff. The Golden Rule is useless—How would you like to be treated? I’d want to be left on the ventilator, of course!–and Kantian ethics break down, since Immanuel forbade using human life to achieve even the best objectives…like saving a human life. Such trade-offs of life for life (or lives) is the realm of utilitarianism, and an especially brutal variety….so brutal that I doubt that it is ethics at all.
When Dr. Biddenson justifies his public forums by saying that he wants to include current societal values in his life-for-a-life calculations, she is really seeking current biases, because that’s all they are. On the Titanic, it was women and children first, not because it made societal sense to allow some of the most productive and vibrant minds alive to drown simply because they had a Y chromosome, but because that’s just the way it was. Old women and sick children got on lifeboats; young men, like emerging mystery writer Jacque Futrelle (and brilliant young artist Leonardo DiCaprio), went down with the ship. That’s not utilitarianism. That’s sentimentalism.
The New York Times article mostly demonstrates that human beings are incapable of making ethical guidelines, because Kant was right: when you start trading one life for another, it’s inherently unethical, even if you have no choice but to do it. Does it make societal sense to take away Stephen Hawking’s ventilator to help a drug-addicted, habitual criminal survive? Well, should violating drug laws sentence a kid to death? TILT! There are no ethical answers, just biased decisions.
Many of the participants, we are told, favored lotteries and coin flips, because that was “fair.” No, that’s called ducking responsibility. If a decision can be made using rational considerations that maximize the benefits or potential benefits of the results, then it is irresponsible and cowardly to default to chance. Sophie has to make her choice; she can’t flip a coin to determine which child dies and say she did the right thing. She doesn’t want to “play God”—this was an oft-mentioned consideration in the forums—but that’s just a rationalization: we all “play God” any time our actions change someone else’s life. Leaving such crucial decisions up to “God” is ethically indefensible, because if one had the power to do less harm ( whatever that means), one has an obligation to try to exercise that power, knowing that moral luck always lies in wait, ready to make good decisions look bad and vice-versa.
Rationing is ethically tangled, but it is also unavoidable. There have to be policies for allocating scarce organs for transplant, just to avoid chaos. Doctors sometimes have to choose among cancer patients for proven chemotherapy treatments, and among surgical patients for the most effective anesthetics. They must sometimes choose among patients who need treatment in intensive care units, which may be filled to capacity. The excellent TV medical drama “Code Black” is often about such choices, and the real lesson is that whatever standards there are, they choices must be made: the only unethical choice is to refuse to make one.
The Maryland forums were designed with the help of Carnegie Mellon University’s program for deliberative democracy, and tended toward favoring the saving of most lives or years of life by prioritizing people who were expected to survive their maladies or live the longest after being treated. But there have to be other considerations too, correct? The Times writes that the forums generated “unexpected questions,” such as “Should an undocumented immigrant be eligible to get a ventilator?” (By the way, that’s illegal immigrant, not “undocumented”) and “What about a drug or alcohol abuser, or a prisoner?” Why were those questions “unexpected”? They are necessary questions.
A facilitator responded to one of these by saying that “discrimination would not be allowed, ” a fatuous and dishonest answer. The entire issue is about what discrimination we accept as being in the best interests of society, as we choose among such competing categories as age, health, strength, intelligence, talent, life accomplishments, responsibilities (should the sole parent of six children be given priority over a childless mother who eschewed children to fight climate change, or because she didn’t want to burden taxpayers?), citizenship, honesty, character, wealth, power, status and perceived value to society.
No discrimination, you say! So when the binary survival choice comes down to a teenage illegal immigrant with a criminal record and a drug habit, and, say, Michelle Obama, naturally Michelle will be allowed to die? Suuure she will. Sure! Of course! Don’t doubt it for a second. Rules are rules. Heck, I bet Michelle will pull the plug herself!
These exercises are valuable, if at all, for the sole purpose of letting the public believe they have some input in the process, and that those who will make life and death decisions care what they think. It is, in other words, a public relations tactic, and little more than that.
Like “women and children first,” any and all protocols for life-rationing decisions will be imperfect, unjust from the viewpoint of the losers, subject to bias, and subject to intervention and reversal when a decision-maker doesn’t like the result. The best we can hope for such lose-lose calls to be decided as rationally as possible, using guidelines that will make sense more often than not, with as little manipulation as possible.
In the end, there is no ethical way to sentence an innocent human being to death.
Pointer and Facts: New York Times