Abstract
Ruth Tallman has recently offered a defense of the modified youngest first principle of scarce resource allocation [1]. According to Tallman, this principle calls for prioritizing adolescents and young adults between 15–40 years of age. In this article, I argue that Tallman’s defense of the modified youngest first principle is vulnerable to important objections, and that it is thus unsuitable as a basis for allocating resources. Moreover, Tallman makes claims about the badness of death for individuals at different ages, but she lacks an account of the loss involved in dying to support her claims. To fill this gap in Tallman’s account, I propose a view on the badness of death that I call ‘Deprivationism’. I argue that this view explains why death is bad for those who die, and that it has some advantages over Tallman’s complete lives view in the context of scarce resource allocation. Finally, I consider some objections to the relevance of Deprivationism to resource allocation, and offer my responses.
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Notes
It is important to note that I am not talking about bedside rationing. Following Tallman, I am adopting a macro-perspective on resource allocation, and the case of Mary and John should therefore be read as operating on a macro-level. Thus, I want to imagine that Mary and John represent two large patient groups, Group 1 and Group 2, each comprising thousands of individuals. Mary represents the average person in Group 1, while John represents the average person in Group 2.
Ronald Dworkin discusses the simple loss view in [8, pp. 84-89]. I will return to his criticism of this view later, in the last section.
Persad et al. draw heavily on an argument made by Ronald Dworkin. He claims that ‘It is terrible when an infant dies but worse, most people think, when a three-year-old dies and worse still when an adolescent does’, and this is because ‘the adolescent’s death frustrates the investments she and others have already made in her life’ [8, p. 87].
I believe conditions (1) and (2) more or less capture condition (3), so I will not comment specifically on the third condition.
As pointed out to me by an anonymous reviewer for this journal, Tallman is not necessarily committed to the view that age in itself is an indicator of whether an individual is in the midst of a complete life. Instead, she may claim that age is a measureable proxy for being in the midst of a complete life. Although I think this is correct, for Tallman, age will nevertheless be an important indicator of whether an individual is in the midst of a complete life or not, or an indicator of the degree of completion of a life. My disagreement with Tallman is not necessarily on the moral relevance of age to resource allocation, but rather, with the role age plays in the complete lives approach. Contrary to Tallman, I believe that individuals younger than 15 years of age fulfill her complete lives criteria.
It could be argued that, even if Tallman would be forced to move the age down to 10 years, it does not necessarily follow that her modified youngest first principle risks collapsing into a strict youngest first principle. This is because the basis for the modified principle is very different from a strict principle, and even if it could include 10-year-olds, it would obviously not include infants. But it may be up for discussion exactly where to set the appropriate lower threshold for the modified youngest principle. Perhaps it will include individuals younger than 10 years, although it is less likely to include 5-year-olds. I thank an anonymous reviewer for helpful comments on this point.
I am paraphrasing Tallman here, who makes the same claim with regard to an outsider’s failure to identify the life-goals of normally functioning young adults. My point is that a similar claim can be made with respect to the life-goals of young children.
I will have more to say about the moral relevance of cognitive development later when discussing the Time-Relative Interest Account on the badness of death in the second subsection of the last section.
By ‘frustration’, Dworkin means a more complex measure of the waste of life. By ‘investment’, he means ambitions and expectations, plans and projects, love and interest and emotional involvement with others.
This is the view of Epicurus. It goes beyond this article to discuss the objection from Epicurus that death cannot be bad for the one who dies. For a discussion of the Epicurean view on death, see [12].
Other variants of DA will emphasize that it is not only the loss that matters, but it also matters to whom the loss belongs. Consider all those potential people who never came into existence because of infertility or the use of contraceptives. We do not grieve over those losses. For a loss to be significant there must be someone who owns the loss in question. In other words, the future must belong to the one who dies for the loss to matter to the individual. When is it reasonable to suppose that an individual has acquired ownership to the future such that the loss will belong to the individual? The crucial question for DA is when one begins to exist or when one acquires personal identity. Although this is an interesting issue, space prevents me from discussing it in detail here.
I am grateful to Carl Tollef Solberg for helpful discussions on these issues.
Jeff McMahan does not draw this conclusion explicitly from his TRIA, but it is nevertheless a reasonable stipulation given his theory about psychological connectedness. But depending on how one interprets TRIA, the badness of death curve could easily be moved slightly in either direction; see [20] for an alternative interpretation of McMahan’s TRIA.
It is important to note that Tallman and I are on the same side in rejecting the moral relevance of age simpliciter. Both of us accept the use of age as a marker for something of moral importance. For Tallman, age is an important indicator of the degree of completion of a life. According to TRIA, age is a marker for the degree of psychological connectedness of individuals. For example, a 10-year-old will be more psychologically connected to his future than a 5-year-old.
Note that Jeff McMahan also thinks that having goals and projects for the future is relevant to the badness of death; see [16, pp. 176–177]. It is, however, unclear what role he ascribes to such life-investments as part of his TRIA.
I claim that TRIA is preferable to DA. One reason for this is that DA, with its claim that death is worse the earlier it occurs, will imply that the death of a fetus is worse than the death of an infant. But this is counterintuitive. Another reason is that TRIA’s emphasis on psychological connectedness suggests a gradualist view that is more plausible than DA’s non-gradualist view.
There are many things that can be said about the value of the life that is lost when death occurs, but I will not discuss different theories of value. My interest is rather with the very fact that our evaluation of the badness of death is based, at least partly, on assessments of the value of the life that death precludes.
References
Tallman, R. 2014. Valuing lives and allocating resources: A defense of the modified youngest first principle of scarce resource distribution. Bioethics 28(5): 207–213.
Kilner, J.F. 1990. Who lives? Who dies? Ethical criteria in patient selection. New Haven, CT: Yale University Press.
Daniels, N. 1985. Just health care. New York: Cambridge University Press.
Brock, D. 2002. Priority to the worse off in health-care resource prioritization. In Medicine and social justice, ed. M. Battin, R. Rhodes, and A. Silvers, 362–372. New York: Oxford University Press.
Daniels, N. 2007. Just health: Meeting health needs fairly. New York: Cambridge University Press.
Ottersen, T. 2013. Lifetime QALY prioritarianism in priority setting. Journal of Medical Ethics 39(3): 175–180.
Parfit, D. 2002. Equality or priority? In The ideal of equality, ed. M. Clayton and A. Williams, 81–125. Palgrave MacMillan.
Dworkin, R. 1993. Life’s dominion: An argument about abortion, euthanasia, and individual freedom. New York: Alfred A. Knopf.
Persad, G., A. Wertheimer, and E.J. Emanuel. 2009. Principles for allocation of scarce medical interventions. Lancet 373: 423–443.
Kerstein, S., and G. Bognar. 2010. Complete lives in the balance. American Journal of Bioethics 10: 37–45.
Sayeed, S. 2010. Assessing the modified youngest-first principle and the idea of non-persons at the bedside: A clinical perspective. American Journal of Bioethics 10: 52–54.
Rosenbaum, E. 1986. How to be dead and not care: A defense of Epicurus. American Philosophical Quarterly 23(2): 217–225.
Silverstein, H. 1980. The evil of death. Journal of Philosophy 77(7): 401–424.
Feldman, F. 1991. Some puzzles about the evil of death. Philosophical Review 100(2): 205–227.
Feit, N. 2002. The time of death’s misfortune. Noûs 36(3): 359–383.
McMahan, J. 2002. The ethics of killing: Problems at the margins of life. Oxford: Oxford University Press.
Bradley, B. 2007. How bad is death? Canadian Journal of Philosophy 37(1): 111–128.
Bradley, B. 2008. The worst time to die. Ethics 118(2): 291–314.
Nagel, T. 1970. Death. Noûs 4(1): 73–80.
Millum, J. 2015. Age and death: A defence of gradualism. Utilitas 27(3): 279–297.
Parfit, D. 1984. Reasons and persons. Oxford: Oxford University Press.
DeGrazia, D. 2012. Creation ethics: Reproduction, genetics and quality of life. Oxford: Oxford University Press.
Acknowledgements
I am especially grateful to Carl Tollef Solberg for valuable comments on previous versions of this article. I would also like to thank Kristian Skagen Ekeli, Ole Koksvik, Reidar K. Lie, Joseph Millum, Ole Frithjof Norheim, Trygve Ottersen, Govind Persad, as well as two anonymous reviewers for this journal and the journal’s editor for helpful comments on an earlier version of the article. I also presented this article at a Priorities 2020 workshop at the University of Pennsylvania, May 2013. Thanks to the audience for helpful comments.
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Gamlund, E. What is so important about completing lives? A critique of the modified youngest first principle of scarce resource allocation. Theor Med Bioeth 37, 113–128 (2016). https://doi.org/10.1007/s11017-016-9358-8
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DOI: https://doi.org/10.1007/s11017-016-9358-8