Health And Survival Rationing Ethics


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

26 thoughts on “Health And Survival Rationing Ethics

  1. This is just triage on a larger scale. The problem is that we are not REALLY under the kind of rationing of resources that are faced in battlefield hospitals or medical units. Triage in a relatively peaceful environment, in my opinion, boils down to economics. I refuse to believe that the resources couldn’t be made available once corporate survival is taken out of the picture of human survival.

  2. I’ve got a heavy bias against such prisoners as James Holmes where I think a part of his sentence should be “no organ transplants” or even treatments for cancer. I’d give him any treatment if it was for the good of others (suppression of communicable diseases). But let’s not prolong his life unnecessarily.

      • A lot of people would have something to say about that I’m sure. Heck – I’m even the type of person who think we should be like Norway and have a maximum sentence of 21 years for even the most heinous crime. Of course, even in Norway, that can be extended 5 years at a time if they feel rehabilitation has not been achieved.

  3. The Golden Rule isn’t useless. For many people, there is a point where they would prefer that a bad thing be done unto them rather than a worse thing be done unto others. If they had to choose between inflicting a bad thing on one person or a worse thing on another, the Golden Rule would say to inflict the bad thing rather than the worse thing.

    Utilitarianism is flawed, but it is nonetheless useful. Placing “dollar values” on lives seems distasteful, but it is a good thing if it leads to dollars being spent on lives that otherwise would not be saved. Likewise, realizing that, say, ten lives could be saved at the same “cost” of one is useful for ethical considerations. A society which forbade the use of human lives to attain any objective would be a pretty terrible one.

    This problem is also amenable to Rawlsian analysis. For example, imagine a society in which there are two types of people in society, those who need an organ transplant at a young age and those who need an organ transplant at an old age. An observer who didn’t know which type of person they would be might prioritize giving organs to young people on the basis that they would rather die old than die young.

    • Would be interesting to see a society flip its values to spending more on 1 life because it meant they might be able to let 10 people die and they’d do this because of “over-populated” conditions.

      • Interesting in the “may you live in interesting times” sense, perhaps. I wouldn’t want to live in such a society.

        Might make for good science fiction, though. Start the story with, say, the Board of Rationing discussing how to allocate resources and they continually find plausible reasons why one lucky individual should get more and more stuff.

  4. Triage has been operating in hospitals in the USA for a long time. Due to the shortage of organs such as livers, hearts, kidneys, etc., everyone that needs one, gets one. There is a separate list for pediatric transplants from adults. Also an alcoholic who needs a liver and hasn’t abstained from drinking for at least 6 months won’t get one. Yes, illegal aliens will get an organ if they are sick enough and have insurance. Felons in prison probably won’t.

  5. Price of life saving Epipen has gone from $100 to $500-600 since 2008. \
    Amy Klobruchar, whose daughter has a severe allergy and carries the device, is calling for a Senate hearing.
    In Canada the cost is hundreds of dollars less.

  6. Related to the ethics of medicine, but not this article, I just want to share that I have been BANNED (by the founder) from posting anything on the 1,200 member members only mental health Facebook page focused on Trump’s unfitness to be president. The founder of the site, who was mentioned in a NY Times article and been on the Diane Rhem radio show, won’t allow any debate among his mental health professional online members to even debate the exceptions to the Goldwater rule which says psychiatrists should not diagnose public figure from afar no matter how helpful lending their expertise to help public understanding. Instead he wants to use the word “Trumpsim” and dance around making an actual diagnosis. Of course this leave it to anyone interested to plug everything they know about him into the DSM-5, as uncuttable people have done especially for narcissistic personality disorder.

    Psychotherapists want you to believe the profession is open to debating controversial subjects. Unfortunately I find some therapists to be elitist (only THEY can make a diagnosis), arrogant, dogmatic…

    MY latest breaking of the Goldwater rule, in all modest, I think is quite important.

  7. This made me look up The Mick’s wiki page:

    Though Mantle was very popular, his liver transplant was a source of some controversy. Some felt that his fame had permitted him to receive a donor liver in just one day, bypassing other patients who had been waiting for much longer. Mantle’s doctors insisted that the decision was based solely on medical criteria, but acknowledged that the very short wait created the appearance of favoritism.

    He only lasted a few months with his new liver.

  8. Jack,
    “Should an undocumented immigrant be eligible to get a ventilator?” (By the way, that’s illegal immigrant, not “undocumented”)

    I know (I KNOW) you hate the political correcting that went into that phrase, but it’s not entirely inaccurate, either. Especially considering that being undocumented IS illegal. In other words, one could make the argument the two are synonymous.

    Besides, you have to admit it’s not nearly as bad as “justice involved individual.” Personally, I prefer “judicially challenged” or “criminal people.” (if “little people” works, why not other variants?).


    • Like all deceit, it is technically accurate but intentionally misleading and misdirection. They aren’t documented because they broke the law to get here. It’s like calling unlicensed driver “undocumented drivers,” like they left their wallets at home.

    • “Undocumented” isn’t a good term because that implies that our Government hasn’t made any documentation about them. We’ve documented plenty of people, especially through hospitals and schools, who are receiving benefits without the proper immigration process/procedure/law/rule.

      If you were going to give a document to every person in the country despite legal status, what label would you provide to someone who had entered and/or remained in the country contrary to immigration laws?

  9. This touches on a disagreement I have with people who object in strong moral terms to medical costs because they don’t think the rich should disproportionately benefit. I consider it no less moral than any other method of discrimination, and more so than some. In part because one practical benefit of trading money for access is increased availability of the technology to the people who otherwise wouldn’t have access at all.

    That’s also why I think restrictions on paying money to donors or their estates is on net harmful. This would probably require some explanation, but the short version is that financial rewards for ones family would provide a concrete reason to sign up, which would be much more effective than just making them feel better about themselves.

    I can see flaws in the policy, but I am not convinced allowing such payments would be worse than what we have now. I’m looking forward to cloned individual organs to make the whole issue moot, if that’s ever actually achievable.

  10. Many of the participants, we are told, favored lotteries and coin flips, because that was “fair.” No, that’s called ducking responsibility.

    “You thought we could be decent men in an indecent time…but you were wrong! The world is cruel. And the only morality in a cruel world is chance. Unbiased, unprejudiced, fair.”

  11. If we’re on a massive, sinking ship and it’s total chaos, I’m partial to “women and children first.” The men can herd everyone else onto the boats in an orderly fashion, ensure that their progeny survive at least, and since women and kids are generally smaller, you can save more lives total. It’s also a better look than dudes trampling women and kids (few of whom would beat them to the boats.) The latter is closer to what we’d likely get if the Titanic were to sink in 2016.

  12. “Heck, I bet Michelle will pull the plug herself!”

    She might at that. Seriously. It would be her choice.

    In a situation so awful that triage is necessary, one should always give the patient the right to refuse treatment so someone they and they alone think more worthy should be allowed to live (assuming mental competence, informed consent etc).

    One might do all one can to persuade them they’re wrong: but in the end, their decision.

    “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.”

    Agreed. It sucks. Trust me on that.

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