Friday, February 05, 2021

The Absurdity of "Undue Inducement"

Have you heard that it's "unethical" to pay people for janitorial work?  After all, the poor have greater need of money, and so would be more likely than the rich to take up such an offer.  To protect them from this "undue inducement", we should outlaw payment for janitorial work, and hope that enough (preferably middle-class) folks volunteer in their stead that we aren't wallowing in filth.  Sure, we can predict that things will be a bit filthier as a result, but it's worth this social cost to protect the poor from janitorial jobs.  I'm sure that our current janitors would appreciate being put out of work, right?

Bioethicists seem to treat this notion of "undue inducement" as a very serious ethical objection to allowing financial incentives for medical research participation, kidney donations, and other pro-social but individually-costly medical activities.  I'm not sure whether anyone really believes it, or if it's just something that people say in order to appear "serious" since there is at any rate a generally-recognized norm by which you can signal your moral seriousness and egalitarian bona fides by insisting that we must under no circumstances allow the poor new ways to earn more money.  Either way, I've always found this completely daft.  Obviously, the reason why the poor would be more likely to take up the offer is because they benefit more from the financial reward.  That is, it's more likely to constitute a worthwhile offer for them.  The egalitarian has taken this pro-poor feature of the policy, and confused themselves into regarding it as somehow objectionable.

In truth, the objection relies upon a dubious paternalism: the egalitarian believes the poor to have unavoidably poor judgment.  He does not trust them to accurately judge for themselves whether the financial benefits are worth the medical risks.  I think there are two legitimate ways to guard against this moral risk: (i) take care to ensure that the medical risks are communicated as clearly as possible, and (ii) increase the reward to help ensure that it offers fair compensation for whatever level of medical risk might be involved.

In practice, bioethicists tend to opt for the opposite of (ii).  They insist that financial rewards be kept as low as possible (just covering the costs of participation, perhaps, while minimizing any additional incentive effect).  To be clear, offering less payment is not truly friendly to the interests of the poor.  Misjudgment could go both ways here, after all: while bioethicists worry about neglecting medical interests of the sake of more money, I think we should be similarly concerned about thwarting the (likely much stronger) financial interests of the poor for the sake of "protecting" their medical interests.  The potential harm here strikes me as at least as significant as the potential harm of misjudging in the other direction, but the objector seems not to have considered it at all.

By banning monetary incentives for pro-social medical services, we force the poor to give lexical priority to their medical interests no matter whether they would have been overall better-off with the money.  Forcing a fixed outcome a priori, no matter the details of the tradeoff, is obviously unhelpful.  If we're worried about unreliable judgments, we should do what we can to improve accuracy (and reduce the cost of mistakes), not force a fixed outcome that might be just as harmful to their interests.

Can anyone offer a (non-idiotic) counterargument on behalf of the "undue inducement" objector?

15 comments:

  1. I'm also unconvinced by this argument, but I think the most persuasive variant of it appeals to exploitation (or something similar). The idea is that researchers and other benefactors are taking advantage of the volunteers for these experiments in an unfair way: if these financially disadvantaged people were in a better bargaining position, they would not put their health at risk in this way, and it's wrong to exploit them for the benefit of others.

    Now there are circumstances where I think an argument of this structure can work. If I see you slipping into quicksand and offer to save you but only on the condition that you surrender your life savings to me, there's a strong case I'm doing something wrong, even if you'd rather be alive and broke than dead. I just shouldn't be taking advantage of your circumstances in that way. But there are obviously asymmetries to this scenario and financially compensating someone for donating a kidney or volunteering to help test an experimental drug. (Perhaps one of the biggest is that decisions about the latter cases need not be made under extreme duress.) I tend to think, as you suggest, that the undue inducement objection entails an overreach of paternalism and a failure to properly respect the autonomy of the poor.

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    1. Yeah, I mean, you also shouldn't refrain from saving my life while asking me to donate my life savings regardless; nor should you offer something less in exchange like only saving me after a few minutes of suffocation have caused irreversible brain damage.

      In general, I'm in favour of offering people more rather than less in exchange for doing what (pro-social things) we want.

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  2. PART 1

    I have a few half-baked thoughts that amount to a “counterargument on behalf of the "undue inducement" objector”, as you asked, and, though I am unsure whether my thoughts are philosophically silly, I am sure they are not idiotic in the sense that you (rightly, in my mind, if I understand you correctly) deplore: they did not emerge in my head as a response to a signaling norm geared to convey “moral seriousness”, they are coming from a more “skin-in-the-game” part of my brain, a part that has been agitated greatly since our Covid response in March.

    Here is how I imagine a possible argumentation coming from the undue inducement objector henceforth “objector”): the objector to instances of kidney donations could try to locate the wrong-making feature of the exchange not in the harm done to the donor, but somewhere around the quality of the will of the recipient and, a fortiori, of the medical doctor involved. The argument could go along the lines that under normal circumstances in a good society no person would be motivated to harm his own body in this grave way, and that the warranted emotional response upon learning of or witnessing such an exchange of a kidney is horror at the bodily harm and extreme disapprobation of the society that has let poor people down to such a degree that the poor came to lose their natural instinct for health preservation. The doctor who would effect the transplant and the recipient, in allowing themselves to become causally relevant to the exchange via a doing (not via allowing), are displaying an insensitivity towards the “near-sacredness” of the norm of respecting the bodily integrity of individuals. Such an insensitivity, the argument would go, is guaranteed to lead us to moral stagnation, because good societies cannot be built unless people develop characters/dispositions geared to how things are meant to be in those (close to) ideal societies. If we do not develop now such emotional dispositions, we stand no chance to build such societies. Better to ignore those short-term gains in utility that will come from allowing such kidney exchanges, so as to maximize the long term gains inherent in building our preconceived good societies, such building being dependent on our prior nurturing of the appropriate emotional dispositions.

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    1. There was a salute at the top of PART 1,somehow it escaped PASTE:

      "Hi everyone, hi Prof Chappell".

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    2. Interesting! I agree with your response (in "part two") that we should not be insensitive to the poor person's needs and wishes here. We might also add the interests of the donor recipients here, many of whom suffer greatly reduced quality and quantity of life due to these restrictions.

      I don't really think it makes much sense to view organ donations (or medical research participation?) as violating sacred values, because we welcome voluntary donations (whether from relatives or altruistic strangers). Given that there is a medical need, I think that in a good society people would be motivated -- by altruism -- to undergo such procedures. So I don't think we should view them with "horror" at all -- any more than we should view life-saving surgery with horror. (Surgery is horrible in a way, of course, but this is a very superficial respect, and certainly wouldn't warrant banning surgery for the sake of protecting the sacred inviolability of bodily integrity!)

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  3. PART 2

    My objection to the objector would be inspired along tu quoque lines, except my objection will indeed be targeting the morality of the objector’s impositions: if the doctor who would effect the exchange is indeed causing long term harm in becoming insensitive to the norm of respecting the bodily integrity of the individual (and it seems to me the objector has a pro tanto strong point here), how much more insensitivity would the objector be displaying towards the immense frustration of the donor who begs her, not to perform the operation, but merely to allow it become legal? If there is someone playing God in my hypotheticals, it is not the doctor who would effect the transplant, it is the objector who would be dismissing the donor with a “sorry, in my ideal society you would never have been so desperate, so I am going to prohibit by law the exercise of your right to treat your body in ways I do not approve of, even though I can see these ways would make you better off in this life. I am concerned with your counterfactual well-being, not with your actual one. And stop being so selfish, there are other counterfactual persons that will benefit in the counterfactual future if only I stop you, and poor devils like you, from exercising control over your bodily integrity”.

    Now, if the near-sacredness of the norm of respecting the bodily integrity of individuals is meant to cultivate something good in us, this good must have something to do with our being sensitive to the pain of the other, a sensitivity that ex hypothesi is conceived as indispensable for constructing our future ideal societies But if the doctor shows some such insensitivity if she performs the transplanting (I believe she does show insensitivity), the objector is displaying far more insensitivity in frustrating the actual project of the poor person who’s begging the objector to allow him to have an operation (by some or other consenting doctor, not by the objector) and thus become better off by his own (i.e. the poor man’s) lights. After all, almost no one (I am guessing) would decide to let go of a kidney unless he is under immense distress, a distress that ex hypothesi causes him more pain than letting go of the kidney. I can’t see how the objector can justify her stance. In other words, I think the doctor who would perform the operation is doing something pro tanto wrong, but I think that the legal prohibition of allowing consenting doctors-recipients-donors to engage in their common project is far more wrong. Societies where people are exchanging kidneys are morally failed societies. Societies that legally prohibit these exchanges are even worse.

    This is a fascinating subject, I have never before thought of such bioethical issues, thanks to Prof Chappell who has a blog that stimulates our thinking so much!

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    1. The speech that i have the hypothetical doctor make was this:

      "And stop being so selfish, there are other counterfactual persons that will benefit in the counterfactual future if only I stop you, and poor devils like you, from exercising control over your bodily integrity”.

      I now see it is a mistake to call the future counterfactual,the way to express my thought should have been:

      "And stop being so selfish, there are other future persons that will benefit in the far future if only I stop you, and poor devils like you, from exercising control over your bodily integrity”.

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    2. PART A

      Prof Chappell I had prepared yesterday the comment that I am about to post, but I hadn’t noticed that you have just posted a new entry that is relevant to some of the things you are saying in your new entry:

      https://www.philosophyetc.net/2021/02/against-anti-beneficent-paternalism.html

      I am now posting the comment I prepared yesterday, and get ready to read your new entry:

      Prof Chappell my comment is biggish, and mostly reports intuition, so I wouldn’t have posted it under normal circumstances so as not to add to the load that must be accumulating in your email (you have cautioned visitors that they’d rather refrain from ranting when commenting), but I figured you might be interested to hear contrarian intuitions that come from people who not only are not speaking from the standpoint of trying to signal moral seriousness in this case, but who are also moved by the more authentic part of their selves to report their intuitions on the subject of organ markets (bodily health has been my major concern for the last 20 years). So I am posting it. My general view is that there shouldn’t be any legal duty attaching to any of the participants (donors, recipients, doctors) and, if unenforceable moral duties are a thing, then the participants are under no enforceable duty to refrain from participitating (i.e. no third party has the right to frustrate their attempt to participate in such a scheme), they may have though an unenforceable duty to refrain from participation. If on the other hand duties are by definition enforceable, the participants in the organ sale have no duty to refrain, though I see something morally defective in the participation of the doctor or the recipient, so it must be something other than a duty violation.

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    3. PART B

      Coming now to my first comment, I was so eager to signal my notional alliance with you against paternalism that in my first comment I ended up making a small-talkish talking point, as opposed to a more analytically philosophical one: Of course you are right that if, as my sentences implied, mere violation of bodily integrity is objectionable, then undergoing life-saving surgery would be objectionable. I will come back to this a little below but I would like to get something out of the way first: the setting that I had in mind when I was writing was monetary exchanges for organs. I do not see any blameworthiness whatsoever with one’s being incentivized to put herself in harm’s way for the sake of medical research in general, or for human challenge trials for vaccines in particular, and I can see at least one reason for this that is lacking in the case of monetary exchanges for organs: the reason is that medical research is meant to save a huge number of people, maybe millions, whereas the organ donor saves one person only, so the difference in net benefit in the two types of action we are discussing (organ donation vs participation in potentially harmful-for-the-participant medical research) is pointing to a lesser-evil justification of the willing participation in research. In the excellent discussion that you and Prof Ben Bramble had at PEA soup (1) my intuitions were instantaneously and unreservedly on your side on this issue, the volunteers should be allowed to take part in human challenge trials. Whatever “horrors” (sorry if I sounded overdramatic) may or may not be appropriate upon witnessing organ donations in exchange for money, they are not at all appropriate in the case where volunteers are saving many people in ways that the unanimous scientific consensus deems efficacious. There’s no actor for us to fittingly be horrified at. I think this holds too to a lesser degree for volunteers who get paid by the government. In such cases the government is not acting immorally in paying them –maybe the objector to incentivizing medical research would be satisfied to view the paying as permissible but blameworthy, i.e. suberogatory?

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    4. PART C

      Now let me come back to this unfortunate expression of mine, the “near-sacredness” of the norm of respecting the bodily integrity of individuals. Maybe if i add the caveat “the bodily integrity of individuals such that they are not seeking therapy through the temporary violation of their own bodily integrity, or individuals who are not morally legitimate targets of proportional&necessary self defense ” I am saved from the surgery objection? But, if yes, how about the challenge trials? It seems to me the “near” of the “near-sacredeness” prototypically caters for such cases where the consensual violation of the bodily integrity saves huge numbers of people. But then there are the other cases that you mentioned, cases that I hadn’t thought of: the altruistic donations from strangers or relatives. I will report intuition: none of these cases seems to me to be providing all-things -considered reason for the doctor to refuse to conduct surgery. As far as the other actors are concerned, in the case of the stranger I would need to hear more details (especially with regard to whether and how heartbreaking the story of the recipient is and the personal history of the altruistic donor) to decide if there is any defective quality of will on the part of the altruistic stranger donor. It seems to me perfectly permissible exchange, but I can’t shake the feeling that the donor is “selling” himself short. Of course, he is not selling anything, ex hypothesi he is doing it altruistically, i mean that I see a (prudential? Is this the right word? It is certainly not moral) defect in the way he treats his own body. He disrespects his body. One could think that my judgment is the judgment of someone who may be too squeamish with his own bodily health/integrity, and in my case this is true, I am obsessed with maintaining a healthy lifestyle, but at best this means that I fall on the excess side of the golden mean, it doesn’t mean that the donor does not fall on the deficiency side – but as I said, I would need to hear the specific details of the recipient, there will be cases where the donor is appropriately moved, but I speculate (without having encountered real life examples in my own life) they will be very rare. I have no clue what happens in real life with organ donations of this sort. In the case of relatives, it seems to me that it is clearly permissible for the father or the mother to donate to the children. I also can’t see anything defective in the quality of will of the daughter who accepts a loving gesture by dad, that’s what parenthood is for, to give unconditional love to the children. And the dad is not in any way defective in (indeed) disrespecting his body, because bodily integrity does not trump the love for one’s daughter. But i remember a story that I read in the Atlantic, where a dad asked the son for a donation—I mean, the son would be the one to give the organ to the dad. I see the dad’s quality of will as defective (and I am at a loss as to what the son should have done, given that he initially had some doubts. It feels to me as if the dad betrayed to a degree his son by putting him in such a predicament). The doctor though is impeccable in offering his services. In my ideal society the psychological Gordian knot in all such cases is cut by being disposed to simply taking the course of Nature for granted, no one adverts to whether she can live longer if only she could find a healthy donor, nobody cares about living longer at the expense of a healthy person, no one is willing to sell or buy organs of healthy people, so there’s no market, we all live very healthy lifestyles and hope for the best – and people secretly gossip that they shouldn’t become so monomaniacal with preserving their health as I am 😊. Meanwhile, donors&recipients&doctors are welcome to come and live among us if they want to, maintaining their full rights to donate or receive organs in a monetary exchange. And we invite them for dinner, we are not scolds 😊.

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    5. PART D

      It seems then, Prof Chappell , that what mainly drives my intuitions is the presence of money. My initial conception of the organ-donation situation concentrated only on such cases, that was the first type of situation that popped in my mind. It must be the case that money is (mainly) what elicits my intuitions of wrongness. For in the case of money exchange I see the doctors’ surgery as somehow objectionable, whereas in the non-monetary cases I don’t see them as complicit in something objectionable, even as I see certain cases as involving defective qualities of will on the part of either the donor or the recipient. Then again, this was against a background where I imagined that the doctors can always say to the donor “please go to some other doctor, I can’t do it myself”, i.e. I am assuming that donations of organs for money are either legal or easily effected in black markets (in which case it is certain that there will be doctors to save our objector doctor from the dilemma). But what happens if (unlikely, due to the absence of black markets) no other doctor is willing to do it? Well I guess in such cases it is permissible for the objector doctor to do it. After all, the donor is not merely consenting, but we have stipulated that his well being will be increased if he donates the organ. Now where would I locate the defect I see in the case of monetary exchange? Prof Jason Brenan responded recently to one argument made by objectors, namely that the monetary exchange somehow assaults the dignity of the donor. Here is Prof Brenan:

      https://200proofliberals.blogspot.com/2021/01/if-you-can-sell-kidney-to-yourself-why.html

      Thus, it appears that selling a kidney is not even the problem—it does not strip us of dignity or violate our dignity. What must introduce the problem then is selling to the kidney to someone else. But now we wonder why. After all, the very considerations that count in favor of the permissibility of your older, richer, but sicker self paying your younger, poorer, but healthier self for a kidney seem to count in favor of allowing older, richer, but sicker people pay younger, poorer, and healthier people for their kidneys. Why would it be reasonable for such people to think themselves entitled to a highly profitable gift from the young and healthy, without similarly offering the young and healthy the change to also benefit from exchange, if they can? Indeed, in most cases like this, the seller will gain far less than the buyer gains.

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  4. PART E

    Having thought about the case a little more these days (first time in my life I thought about bioethical matters regarding organ sale), I would introduce the problem not as the selling of the kidney to someone else, (as the objectors do), but as the buying of the kidney from someone else. The issue maybe can be construed as not necessarily related to dignity. The problem, maybe, is in the quality of the will of the buyer. But what is it that could make me object to the buyer’s quality of will, and not to the recipient’s quality of will who accepts it as a gift? I think what I am sensing as inappropriate when I think about the type of action (buying human organs) is the fact that the buyer shows himself to be overly preoccupied with preserving his health, so much preoccupied that he is willing to cause another person to sacrifice her own health by selling the organ to him (2), and the offering of money makes this fact salient, it makes it look that the buyer is making an effort, is willing to go to great lengths to fulfil his desire. Surely, he does recognize that he is causing (via a doing, not via an allowing) something bad to the body of the donor. He thus reveals himself as akratic when it comes to preserving his health. So, I am guessing, this could be the psychological ground where the condemnation of the recipient stems from in my eyes (and maybe in the eyes of the of the objectors?).

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  5. PART F

    Of course, not all akratics are perceived as equally defective: as I confessed, I belong to this category of people willing to go to great lengths to preserve their bodily health, but my vice is that no meal of mine will ever fail to be vegetarian organic, or that I try make sure that I won’t ever miss my daily 20-minute session of exposing naked arms and face to sunlight (for Vit D), or that I have been following strictly for 20 years this year’s Bloomberg advice re indoor sanitizing (I only use olive oil soap, Bloomberg doesn’t offer its own alternative to the sanitizers it condemns) (3), or that I will follow every single one of the hundreds of the injunctions –most of them evidenced-based, the rest impossible to do any harm even if they are useless—injunctions regarding how to stay healthy, from good sleep to regular moderate exercise, to… you get the picture. Yes I am “one of those” with the holistic natural lifestyles 😊. As I jocosely put it above, in my ideal society the inhabitants (people who, among other things, lead holistic healthy lifestyles like me, but who are not as obsessed as I am with health preservation) are good-naturedly smiling at my obsession, perceiving it as a defect. But my defect is harmless to others, and others too perceive it as harmless. The organ recipient’s akrasia though seems of a dangerous variety, in that it seems more intense and insensitive to others’ pain, as evidenced by the recipient’s willingness to accept the result of having to harm the body of another person, and taking action to make it happen (offering of money). I think the doctor who would refer a recipient/donor to another doctor who is ok with performing the surgery (assuming that such markets are legal, as they should be, even though they would be symptoms of the societal malaise of poverty), is doing the right thing in refusing to conduct the surgery herself, and saying so to them – “I don’t want to be part of this, fortunately for you there are other doctors who can help you”. I guess part of my intuitions could be summed up by saying that I value bodily health as near sacred. But even if my axiology re bodily health is objectively true and applicable to all, I obviously don’t have the right to interfere and frustrate the informed choices of consenting adults by instituting prohibitions, even if these adults are in some respect mistaken in not valuing their bodies as much as ex hypothesi they should (this would be the donor) and are demonstrating a defective quality of will (the recipient, whose akrasia leads him to trample the ex hypothesi near-sacred value of bodily health of the donor). What worries me more though is not the quality of will of the recipient, who after all engages in a consensual transaction, but the quality of the will of the objector theorist who officially prohibits the exchange of organs and not only imposes her will via state power upon non-consenting individuals, (without increasing short term utility and while evincing a callousness towards the frustration of the desires of donors&recipients that she herself causes via prohibing them to find other doctors who are willing to perform the surgery), but also does so inebriated with a feeling of moral righteousness. It is this person that looks more dangerous to me, not the recipient. The one brandishes his wallet, the other brandishes the Law. And the latter is under the mistaken assumption that she’s promoting the common good even though it is arguable that the very aspect of the common good she wishes to promote (protecting the poor) can be better (and indirectly) promoted by the opposite policy, i.e. by legalizing the markets (4).

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  6. FOOTNOTES


    1) http://peasoup.us/2020/08/pandemic-ethics-part-1/#comment-24496


    2) maybe that too is an additional reason why the dad struck me as doing something defective in asking the son to donate an organ to the dad? The fact that dad “pushed” for the exchange to take place?


    3) https://www.bloomberg.com/news/features/2020-12-16/covid-pandemic-microbiomes-could-be-key-to-stopping-spread-of-future-viruses


    4) if the assumption is that the donors are victims of poverty (which sounds true to me), the root cause of the malaise (poverty) of the societal body is the absence of sufficient action against poverty. Now, suppressing one of the symptoms of the disease (in this case the symptom is the willingess of healthy people to sacrifice their organs to alleviate their poverty) is never the best way to cure the disease, it might even be indirectly counterproductive as it likely is in our case: by making the markets illegal, the donors and the recipients meet in black markets, where there is no public monitoring. If the organ markets were legal then, no doubt, some of the heart-breaking stories that already are happening under the journalistic radar (say, a young donor student dying, or suffering immense unexpected side effects from the surgery) do not come to the forefront of public consciousness. Revolutions have started because one man set himself on fire in public, but the equivalent in the case of organ donations (i.e. a death that happened that might have excited the public opinion if only it were a public death) is unintentionally (via delegalization) kept away from public perception. As a result, the objectors to the donations, who are genuinely moved by the desire to help the poor, are missing the chance to hold a mirror to society and say “that’s who we are as a society, by leaving some people behind that’s what we are causing”. Imagine how effective in altering public opinion some tragic events that have already happened in black organ markets would have been if only the markets were legal and thus the tragic events were more easily monitored by journalists. In suppressing the symptom (willingness of the desperate poor to sacrifice their bodies) we are missing the chance to cure the root cause (poverty) by letting the public be motivated enough to want to see change in the situation. The road to Hell is paved with good intentions that suppress the symptoms of the societal disease, to put it in slogan form.

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    1. In Part A i messed up the begining paragraph, it should have been instead:

      Prof Chappell I had prepared yesterday the comment that I am about to post, but I hadn’t noticed that you had already posted yesterday a new entry that is relevant to some of the things i am saying in the present comment of mine.

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