Abstract
This chapter recalls an ancient model of applied ethics that distinguishes between four different moral roles and can thereby help clarify the structure of the institutional setup, as well as individual action under conditions of resource scarcity. Even if material questions remain open, there is an independent gain in the structural analysis, from which especially the importance of judgment (phronesis) emerges strengthened. In this sense, it also represents a defense of the practice of ethical reflection through case discussions.
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Notes
- 1.
I here rely on the traditional (e.g. Aristotelian) distinction of three sorts of goods: goods of the soul, goods of the body, and external goods. Classical ethical theory holds that there is a hierarchy: Goods of the soul (moral goodness, virtues) are proper moral goods and are in this respect more important than goods of the body (e.g. health, strength) or external good (e.g. wealth, honor).
- 2.
In an ICMM course on Military Medical Ethics in Times of Armed Conflict (MME) (held in Spiez, Switzerland), one participant brought up an example that is perhaps even more emotionally drastic: Let’s imagine a woman is raped but defends herself with the result that both the rapist and the woman are seriously injured and in need of urgent medical attention. Who should a doctor give it to first - given scarce resources? It seems that moral intuition is clear here too.
- 3.
The thesis that moral responsibility for the situation is the first factor in any distribution under resource scarcity is not based on metaphysical assumptions but could be founded on a hypothetical consensus under “a veil of ignorance” just as well.
- 4.
There are different kinds of “Revisionist Just War Theories”: All of them agree about the asymmetry of unjust combatants and just combatants. But the basis of the distinction can be seen differently, e.g. moral responsibility or culpability or causal nexus. The theory is called “revisionist” because it revises the standard approach of International Humanitarian Law and Michael Walzer’s “Just and Unjust Wars” (5th ed., New York 2015).
- 5.
Helen Frowe: Defensive Killing, Oxford 2014, 123.
- 6.
In this sense RevJWT is fully consistent with General Principle 1 of the widely endorsed Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies which says: “Ethical principles of health care do not change in times of armed conflict and other emergencies and are the same as the ethical principles of health care in times of peace.”
- 7.
Cf. Jeff McMahan: Killing in War, Oxford: Oxford University Press 2009.
- 8.
Imagine a car driver with poor eyesight: For sure he is not responsible for his poor eyesight (on the contrary: he is to be regretted), but if he nonetheless drives his moral responsibility for any accident based on his poor eyesight is amplified. But many factors of this kind may not be discernible, especially not in the urgency situation itself. But the same thing applies with triage criteria like “remaining life years” (cf. the famous SIAARTI-Recommendations on triage (March 2020) in Recenti Progressi in Medicina 111/4 (2020), 207–211; https://www.recentiprogressi.it/archivio/3347/articoli/33183/ [15.03.2023]): A base jumper may be young but none the less may the number of his remaining life years be reduced. The number of “remaining life years” under ordinary conditions as a base jumper may be smaller than that of a bookkeeper the same age.
- 9.
There are some advantages of a decision by sortition, e.g. somebody could argue that human beings in general lack moral responsibility of the relevant kind, because they lack moral agency of the relevant kind. – There is a prominent argument that flipping a coin or throwing dices grants the same dignity to every person involved, but that would be a dignity which leaves moral features of a person out of consideration. Moreover decision-taking by lot is only fair if for all people concerned the same thing is at stake. This again brings back considerations of remaining life years etc.
- 10.
It is assumed that the second patient arrives a little bit later. If reckless patient 1 knocked patient 2 fully out there would be no distribution problem anymore, and patient 1 would get the respirator. The deliberation is about resource distribution, not about punishment.
- 11.
A brief comment on the criterion of remaining years of life: On the one hand, the quantity of years alone cannot be a suitable criterion, since the quality of the years also plays a role. Additional years of physical suffering are probably to be evaluated differently than years of fresh falling in love etc. Quality-of-life assessments are problematic because it is unclear what standard they can be based on in the first place. Michael Quante distinguishes the “naturalistic standard”, the “social standard”, the “sub-subjective-rational standard” and the “personal standard”. (Michael Quante: Menschenwürde und personale Autonomie. Demokratische Werte im Kontext der Lebenswissenschaften, Hamburg: Meiner, 22014, 33 ff.). With Bernard Williams (Moral Luck in: B. W.: Moral Luck, Cambridge: Cambridge UP, 20–39) one can still add the temporal factor: The quality of the years depends retrospectively on the value convictions to which one adheres at the time of the evaluation of the past life. Thus, in retrospect, one may regret years of life that were perceived as trouble-free. The assumption “Old people are rich in years of life and privileged, young people are poor in years of life and severely underprivileged, should they die” (Mannino op. cit., p. 46; 54) is only true from a certain value standpoint, which is taken at a certain point in time. Someone may feel that they have lived “bad” years, but that “good” ones are now coming. Another expects only “bad” years after the “good” ones. Again, it would seem that a life is good if it is a morally good life.
- 12.
In fact, however, the problem of teleologically justified triage criteria goes even further, as can be well illustrated by the popular model of basing triage criteria on the medical likelihood of success. In Germany, this model has met with great opposition from disability associations (cf. i. a. Annette Dufner: Welche Leben soll man retten? Eine Ethik für medizinische Hilfskonflikte, Berlin: Suhrkamp 2021, 229 ff.; Adriano Mannino: Wen rette ich – und wenn ja, wie viele? Über Triage und Verteilungsgerechtigkeit, Stuttgart: Reclam, 2021, 43–45): If the “prospect of medical success” were to become a decisive criterion, then disabled people would be structurally disadvantaged because their prospects of success might be somewhat limited due to their disability. But this would mean that disabled people are doubly disadvantaged: First, by the disability itself, and second, by being downgraded in prioritization in obtaining scarce resources. Indeed, one could argue that non-disabled people have already had a relatively better life compared to disabled people and should therefore take a back seat in the distribution. On the other hand, however, giving preference to disabled people would mean that the (scarce) resources would not be fully exploited, i.e. wasted, so to speak. It seems to me that this consideration shows that all attempts to base triage criteria only on extra-moral considerations (and both disability and medical chance of success are extra-moral considerations) lead to paradoxical situations.
- 13.
I would argue that moral responsibility is not only the first factor in triage-decisions but also in other resource scarcities like the distribution of donated organs etc.
- 14.
- 15.
“We must also grasp that nature has endowed us with what we may call a dual role in life. The first is that which all of us share by virtue of our participation in that reason and superiority by which we rise above the brute beasts.” (transl. Walsh, p. 37).
- 16.
Thomas Nagel calls this “luck in one’s circumstances.” Thomas Nagel: Moral Luck. In: Moral Questions, Cambridge: Cambridge University Press 1979, 22nd printing 2018, 24–38, here 33 f.
- 17.
Walsh translates: “by our own choice” (p. 40).
- 18.
In that way it narrows down the gap between reasons and motivations.
- 19.
Arthur Isaak Applbaum: Ethics for Adversaries. The Morality of Roles in Public and Professional Life, (Princeton University Press) Princeton, NJ 1999, 64.
- 20.
Applbaum, fn.19,. 75.
- 21.
World Medical Association, Ethical Principles of Health Care in Times of Armes Conflict and Other Emergencies, online: https://www.wma.net/wp-content/uploads/2017/02/4245_002_Ethical_principles_web.pdf [15/03/2023].
- 22.
Tom Beauchamp/James Childress: Principles of Biomedical Ethics, 8. Edition, New York: Oxford University Press 2019, cf. “Allocating, Setting Priorities, and Rationing”, pages 300–313. “Triage decisions usually appeal to medical utility rather than social utility. For example, disaster victims are generally sorted according to medical need. Those who have major injuries and will die without immediate help, but who can be salvaged, are ranked first; those whose treatment can be delayed without immediate danger are ranked second; those with minor injuries are ranked third; and those for whom no treatment will be efficacious are ranked fourth. This priority scheme is fair and does not involve judgements about individuals’ comparative social worth.” (p. 312). But note: The issue here is disaster victims, not victims of accidents with a human cause.
- 23.
The question of a moral criterion for the distribution of medical resources has recently also been discussed by Michael Gross: Military Medical Ethics in Contemporary Armed Conflict, Oxford: Oxford University Press 2021, 265ff. – Note that the moral responsibility account, as shown here, does not require punishment: It is a theory of the distribution of scarce resources. If there are enough resources for everyone involved in the emergency, everyone will be treated. – Therefore, the position put forward here does not presuppose “metaphysical freedom” but would also be defensible with compatibilism, because it is not a question of punishment based on free fault, but it remains a question of distribution.
- 24.
Karl Marx: Kritik des Gothaer Programms. In: Karl Marx/Friedrich Engels: Werke, Band 19, Berlin: Dietz Verlag 1982, 11–32, 18.
- 25.
In Kant’s view humans are to be understood as “citizens of two worlds”: As beings of the senses (“homo phaenomenon”), humans are subject to the laws of nature and can be examined by empirical means, as beings of understanding (“homo noumenon”) they belong to an intelligible world. As intellectual beings, human beings ask for the principles of their actions and cannot be examined by empirical means. The central source for knowledge of the quality of the homo noumenon is basically the introspection of the person concerned (‘heart-’ or ‘soul-searching’).
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Koch, B. (2023). Cicero and the Problem of Triage: Why There Is No Moral Algorithm in Distributing Scarce Resources. In: Eagan, S.M., Messelken, D. (eds) Resource Scarcity in Austere Environments. Military and Humanitarian Health Ethics. Springer, Cham. https://doi.org/10.1007/978-3-031-29059-6_11
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