Utility versus Wisdom
Updated: May 31, 2020
The BC government released ethical guidelines on deciding who should get treatment if resources are stretched during a pandemic. Included in these guidelines is very nice talk of principles such as respect, fairness and flexibility.
But trumping the latter 'principles' is the need for “utility” — where resources are to be distributed “such that the maximum benefit to the greatest number will be achieved.”
Applied strictly this utility criterion would tend to permit the practice of refusing to treat older people, the homeless or impoverished with pre-existing conditions or poor health since the latter have less chance of recovery should they contract COVID-19.
Provincial health officer Dr. Bonnie Henry has said that this new 'ethical framework' “...respects the value of every individual life”. That tells you right off she has a rather limited understanding of the implications of abstract utility calculations which are based on sheer numbers versus ethical decisions based on the intrinsic value of every single life. The moment you invoke 'utility' you pretty much jettison any considerations of intrinsic values such as respect and fairness.
No doubt health-care specialists, doctors, and family members are often faced with practical considerations regarding end-of-life situations, but typically these determinations are based on open dialogue where patients are the final arbiters.
There are also situations during a pandemic when resources are limited and not everyone will be able to be treated in a timely manner. Epidemics have a tendency of bringing the difficulty of ethical decision-making into relief. Who among us would want to be faced with the decision to remove a ventilator from one person to give to another person who had a slightly higher chance of surviving? What if the sicker person was a promising inventor, a great physicist, doctor or humanitarian? The question will always remain: What makes one life more worth saving than another?
In such situations, many would agree that priority should be given to those who have the best chance of surviving. Others will argue that medical intervention decisions should not be based on utility but upon an egalitarian ethic: that everyone should count equally, or, again, a more altruistic ethic that the sickest and most vulnerable people should always be treated first. In any case, the life and death decisions made by physicians in the context of a pandemic will be agonizing simply because they almost inevitably end in the tragic death of a human being.
We Canadians often use more polite language--in this case the language of utilitarianism--but the end results are not less disturbing or brutal than Texas Lieutenant Governor Dan Patrick, concluding that those most at risk, should volunteer to die to 'save the economy,' or the utilitarian argument that we need to create 'herd immunity'--which is another way of saying that a certain percentage of the population must be allowed to be infected for there to be general immunity. Typically, herd immunity is achieved when enough people are vaccinated. In the case of COVID-19 where no vaccine has been discovered herd immunity is theoretically achieved when a certain percentage of people contract the virus and build up 'natural immunity'. Those promoting this approach are arguing that herd immunity will (theoretically) achieve 'the maximum benefits to the greatest number'.
And therein lies the problem with invoking an abstract (and many would claim, dehumanizing) calculation of utility. The fact is that this sort of moral theorizing actually disables wise decision-making. The exercise of wise judgment in life or death situations is always revealed in very concrete situations faced by health-care professionals. They must honour their oath to do no harm and summon all their experience, their knowledge, their compassion in order to make a decision about what to do in this or that situation. Such a decision will not follow from a top-down theoretical utility perspective, but rather from a ground-up judgement of what this particular situation demands.
Unfortunately, as health care systems are overwhelmed with more patients than they can feasibly treat, physicians are pressed into ethical dilemmas that they should simply not be confronted with.
At the end of the day, our Canadian health professionals would likely not be facing the ethical dilemma's that the present situation forces them into because we would have in place a robust and fully-funded health system that was prepared in advance for the reality of a pandemic--a reality that scientific research has been telling us for years was certain to occur.