Tuesday, February 09, 2021

Against Anti-Beneficent Paternalism

In a previous post, I argued that "undue inducement" worries are typically deeply misguided, and that banning good compensation is contrary to the interests of the very people that it's intended to help.  In this post, I want to raise a different objection: that even if allowing and/or incentivizing beneficent actions (such as kidney donation, or challenge trial participation) would "induce" some people to perform beneficent acts that they might later regret (or that they wouldn't have agreed to if thinking more clearly), it may nonetheless be the case that banning this would be morally even worse.

First: I grant that it is absolutely a pro-tanto moral cost if someone makes a personally-regrettable decision.  But a question that is rarely asked is: how great of a moral cost is this?  How does it compare to the moral costs of status-quo harms (e.g. people dying for lack of a kidney transplant, or lack of a promptly-developed Covid vaccine) that are relieved by the transaction, or even just the costs to other participants who truly wish to participate (some of whom may benefit greatly from being well-compensated)?

As a general rule, it seems to me that we should not intervene to prevent people from performing beneficent acts (acts that help others more than they harm the agent themselves).  Reasonable people can dispute the conditions under which individuals might be forced to sacrifice their own interests to better promote the general good. But this alternative view, that individuals might be forced, for their own good, not to promote the general good, strikes me as entirely unreasonable.  No sane person should have opposed Covid challenge trials out of concern for the participants, for example.  We should all recognize that such a position is morally outrageous.

What about concerns regarding imperfect consent?  I agree that it would be wrong to deliberately misinform or mislead individuals into "consenting" to participate.  Good-faith efforts must be made to communicate the risks as clearly as possible.  Absolutely.  But it would not be a grave moral evil if our best efforts fell short in some instance, and some participants' consent was the result of some unwitting confusion.  We should not treat perfect consent as having lexical priority over all other moral goods, especially not when many thousands of lives are on the line.  It is in fact a much graver moral error to allow such fears to paralyze us during a pandemic, condemning us to the immense (yet avoidable) harms of the status quo.

In ordinary (non-pandemic) circumstances, the stakes are not so extraordinarily high, but status-quo harms are still far from trivial.  So we have very strong reason to want more people to perform beneficent acts.  Ideally, we should all perform such acts from good will and altruistic concern for others.  Failing that, a mutually-beneficial exchange (as in kidney markets) remains a pretty good thing.  And failing that, an unwittingly irrational act of beneficence remains tolerable -- or, at any rate, not worth striving to prevent at all costs.

I focus here on the institutional / policy question of whether we should blanket ban certain classes of (beneficent) transactions in order to guard against the risk of confused consent.  In many such cases, it will be clear that the risk of confused consent is relatively small (there's no basis for assuming that most participants would regret their choice, for example), whereas the expected moral gains from participation are very significant (many QALYs per kidney donation; orders of magnitude more than that per challenge trial participant).  I think it would be difficult for a reasonable person to face these tradeoffs squarely, and yet insist that protecting against the small risk of confused consent is what's most important.  Such a lopsided view seems incompatible with treating the victims of the status quo with anything remotely approaching equal consideration.

A more interesting question concerns the personal ethics of agents who are in a position to intervene in a specific case where they have reason to expect that a particular would-be participant's consent is rooted in confusion. Going back to my general principle, I think that an uninvolved bystander probably should not intervene.  After all, anyone ideally should volunteer to perform beneficent acts anyway, so if someone confuses themselves into doing what they ideally ought to do, that seems all to the good. (The pro tanto moral cost of innocent confusion, over and above whatever pro tanto personal costs are involved in the case and outweighed by benefits to others, seems small.)

But "involved" agents seem morally different.  If agents of the "recruiting" institution (e.g. medical researchers, or transplant doctors or recipients) become aware that their participant's consent is confused, and allow them to proceed even so, the confusion is no longer purely "innocent" but something that they are deliberately exploiting.  Non-utilitarians might reasonably regard this as a significant moral cost (sufficient to outweigh the benefits of the one's participation -- not sufficient to shut down the entire institution).  And utilitarians might point to the value of public trust in the relevant institutions as sufficient grounds to want to avoid any appearance of nefariousness or underhandedness. The vast bulk of the value of such institutions can be realized without taking such risks.

To be clear, then, I do not endorse any deliberate exploitation on the part of our institutions or their representatives.  Nonetheless, I think people have tended to grossly overweight the moral significance of innocently confused consent.  People of good will should not be trying to blanket ban whole types of beneficent acts out of concern for the occasionally-confused would-be altruist.  Such impulses reveal an unfortunate lack of concern for all those who would be gravely harmed by such a ban.


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