Of course, given limited information we are doomed to "often fail to maximize overall benefit". But isn't a semi-reliable (albeit imperfect) guide better than none at all? How does ignoring a piece of (even weak) evidence increase our chances of maximizing overall benefit? Surely it just means that we'll end up making sub-optimal allocation decisions more often: Whereas tracking fine-grained difference in functional status allows us to identify the greatest improvement in quality of life with reliability at least slightly better than chance, now it is entirely down to chance. Why is such an indiscriminate policy not just as "unfair" to the majority for whom quality of life does correlate with functional status?
In spelling out the implications of their view, the Council claims that it lessens the chances of discrimination against people with disabilities: "[S]ince only very substantial differences in the change in quality of life may be considered ethically relevant, a disabled patient will be given a lower priority only when doing so allows others to receive a much greater improvement in quality of life."
But why shouldn't we also give priority to one patient over another for the sake of a merely moderately greater improvement in quality of life? If much more of a good thing is ethically relevant, why isn't some more also morally relevant (just weakened proportionally)? If it isn't objectionably discriminatory to take large differences in functional status into account for determining quality of life, then I don't see how taking small differences of this same measure into account could be objectionably discriminatory either. In either case we are attempting to track, as best we can, genuine differences in the magnitude of benefit that different patients can expect from a treatment. And there's nothing objectionably discriminatory about prioritizing greater benefits over lesser ones, nor expected greater benefits over expected lesser ones. Even when these judgments are highly fallible, an allocation method that's better than chance is, after all, better than an allocation method that uses chance alone.
Perhaps the most bizarre feature of the Council's paper is its (non-unique) endorsement of weighted lotteries as a means of applying allocation criteria. This way, they explain, "the patients who are the most deserving of treatment according to the ethical criteria would have the best chance of receiving treatment." (34) But why would we ever want to introduce a chance that the most deserving patients would not be the ones to receive treatment? They excuse the inefficiency on the grounds that "this approach would have the advantage of non-abandonment": every patient would at least have some chance of treatment. But why is it any advantage at all, in this context, that we might end up allocating our scarce medical resources inefficiently? I mean, I see that it's pro tanto nice for the low-priority patients to have a chance at treatment, but this is clearly and massively outweighed by the pro tanto awfulness that the high-priority patients risk being denied the treatment that they need so much more.
A less appalling allocation method that the Council also endorses is a "three-tier approach", where patients are divided into "those who are clearly good candidates for treatment, those who are clearly poor candidates, and those who do not fall into either group." (They even endorse a simpler, two-tier, "minimum threshold" approach.) But they then insist on using an indiscriminate method for prioritizing patients within each category. This seems strictly inferior to a weighted ordering approach (at least for the middle group, or near the threshold between patients who will receive treatment and those who won't) -- i.e., like the weighted lottery only without the "lottery" part. A weighted formula combines the various ethically relevant factors into our best "rough guess" of each patient's moral priority for treatment, and then we simply go down the list as far as we can until we run out of resources. Again, this is what would seem to maximize our chances of getting the allocation right -- or at least "closer to being right" than we otherwise would get.
The fundamental difference between the Council's perspective and mine seems to be that the Council implicitly sees an important asymmetry between mistakes of allocation due to incorrect discriminations vs. mistakes of allocation due to excessive indiscriminacy. As I see it, the aim should be to allocate resources as best we can, and the particular cause of any given failure (of fixed magnitude) is not of intrinsic moral significance. But the Council is very concerned about when we try and fail to "maximize overall benefit to patients", and much less concerned about failures to "maximize overall benefit to patients" that are due to our not even trying. This inconsistency strikes me as odd and unprincipled. Would anyone care to defend it? Am I missing something?
* = Specifically, their 1995 publication 'Ethical Considerations in the Allocation of Organs and Other Scarce Medical Resources among Patients', Archives of Internal Medicine 155: 29-40.