James F. Childress is a philosopher who has studied ethical issues involving scarce life-saving medical resources. He wrote about his findings in his article “Who Shall Live When Not All Can Live?”, published in Soundings, Vol. 53, No. 4 (Winter, 1970).
He believes that we can choose — ethically — who shall live in a situation where only four hearts are available and 10 people need them. In making this choice, Childress proposes two stages.
Stage One: Identifying the Medically Acceptable
First, we need to identify the medically acceptable. By medically acceptable, Childress does not mean those who can afford the operation. Instead, he means those who will benefit substantially if they have the operation. Thus, if there are a limited number of hearts and one person will die soon even if he or she receives a heart, Childress would deny a heart to that person. Instead, Childress would give the heart to a person who is likely to be in perfect health after receiving the heart.
Stage one is utilitarian; that is, it brings about the greatest amount of happiness for the greatest number of people. Greater benefit will result if we give a heart to a person who will be able to live a long time than if we give the heart to a person who is likely to die within a few months even with a new heart.
Stage Two: Utilitarianism Rejected
Once we have rejected those who are not medically acceptable, we still have to decide who will get the hearts (assuming that people still need more hearts than are available). This raises some problems. In stage one, we used utilitarianism; in stage two, should we continue to use utilitarianism? If we do, then we have to decide such things as which people, if they continue to live, will bring the greatest amount of happiness into the society they live in.
Childress rejects utilitarianism in stage two. Instead, he advocates randomness; that is, casting lots to decide who will receive hearts. Thus, chance will be used to determine who lives and who dies. Childress gives seven arguments for using randomness in the second stage.
1: Randomness preserves human dignity by providing equality of opportunity.
If we believe that all human life is valuable, then we can treat it as valuable by not ranking the quality of lives according to social utility.
2: Randomness safeguards the relationship of trust between the physician and the patient.
If you were a patient, would you want your physician snooping around trying to determine whether you are a socially valuable person so he or she can decide whether you shall live? Probably not; instead, you’d want your physician to be on your side, doing everything possible to keep you alive.
- Randomness would be the method selected as the most rational and fairest by persons who were self-interested, who were summoned to plan for themselves and their families, and who were ignorant of their own value to society.
Let’s try a thought experiment. Let’s assume that we have to decide who shall live when not all can live. As a way to make this decision absolutely impartial, let’s assume that everyone is ignorant of his or her position in society. (That way, I can’t argue that professors are incredibly valuable people, and thus I should get a heart.) If we were covered by this veil of ignorance, how do you think we would decide to distribute the hearts? Probably by throwing lots; that way, everyone would have an equal chance at getting a heart.
- Rejection on the basis of randomness would generate less psychological stress for the rejected candidate than would rejection on the basis of inadequate social worth.
Let’s assume that you don’t get a heart. Your physician comes into your hospital room and says, “Sorry, but we gave the hearts to people we consider more worthy than you.” Alternatively, your physician says, “Sorry, we threw lots and your number wasn’t one of the lucky ones.” What would you rather hear? That you aren’t regarded as being valuable, or that you weren’t lucky?
- Randomness is already practiced in the allocation of scarce life-saving medical resources, and thereby its value is tacitly recognized.
This is self-explanatory.
- Randomness would remove the need for selection committees charged with the responsibility of weighing the relative social worth of applicants for scarce life-saving medical resources.
These committees have a heavy responsibility that should be removed if it is ethical to do so. Also, these committees suffer from the problems involved in trying to determine the social worth of individuals. For example, members of these committees could be biased by the societies they live in. If you live in the logging state of Oregon, you may not highly regard the social worth of an environmentalist.
- Randomness might cause the powerful and wealthy to commit their resources to the removal of the scarcity of life-saving medical resources in order to insure their own access to them.
If the wealthy become aware that they can’t simply buy a heart, but may have to submit to the casting of lots, the wealthy may donate more of their money to providing life-saving medical resources for everybody.
An Argument Against Childress
I agree with much of what Childress has to say. I do agree that in the first stage, we ought to determine who is medically acceptable. If a person won’t benefit much from receiving a heart, we ought to give that heart to someone who will benefit substantially more from it.
However, I disagree with total randomness in the second stage. I believe that we can be utilitarian even here — in extreme cases. For example, what if a person who needs a heart is a famous cancer researcher on the verge of a major breakthrough that could save the lives of thousands of people? Since this person is in a position to save so many lives, I would make sure this person gets a heart.
Another example: What if a person who needs a heart is a rapist? Wouldn’t it be an affront to justice if the rapist gets a heart and people who are law-abiding citizens don’t? (Suppose one of the rapist’s victims doesn’t get a heart because the rapist gets one?) Because of these considerations, I would make sure that the rapist does not get a heart.
Here’s how I would decide who gets hearts that are needed for transplants when there are not enough hearts for everyone to get one:
Stage One: Identifying the Medically Acceptable.
Suppose a person will die within a few months even if she receives a heart; I would deny that person a heart since the other applicants will benefit much more if they receive the heart.
Stage Two: Utilitarianism Used to Identify Exceptional Cases.
Suppose a person is a cancer researcher on the verge of a major breakthrough. I would make sure that person received a heart because that person may be able to save many thousands of lives if that person can complete the research.
Suppose one candidate for a heart is a convicted serial rapist. That rapist has brought misery to many lives. I would deny that person a heart.
Stage Three: Randomness.
For whatever hearts are left, I would cast lots to determine who gets the hearts.
Note: The quotations by James F. Childress that appear in this essay come from his article “Who Shall Live When Not All Can Live?”, published in Soundings, Vol. 53, No. 4 (Winter, 1970).
Copyright by Bruce D. Bruce; All Rights Reserved
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