Innocuous vs Unjust Systemic Discrimination

It's now widely recognized that problematic discrimination need not involve malicious attitudes: certain political structures might systematically disregard the interests of ethnic minorities, for example, even if nobody involved was "racist" in the traditional sense of harbouring prejudicial attitudes.  Still, sometimes people -- even highly-respected philosophers! -- move from this to the opposite error of assuming that any disparity in group outcomes is in itself constitutive of unjust discrimination against the disadvantaged group.  I've found this especially common in debates about QALYs. (One may, of course, raise reasonable questions about how QALY values are determined in practice: perhaps they fail to accurately track the welfare facts in some cases, adjusting down for certain disabilities that are actually harmless. But my target here is the more sweeping complaint that any form of the metric will be "ageist" and "ableist" simply in virtue of its being systematically disadvantageous for the elderly and (detrimentally) disabled, relative to an alternative system that sought to indiscriminately save as many lives as possible.)

Academic pay cuts vs job cuts

Hopefully the financial situation for universities next year will turn out to be less dire than many fear. And hopefully what cost-cutting measures are needed can largely be achieved by cutting down on non-academic "bloat" together with temporary reductions to discretionary budgets (turning research "travel" virtual, etc.).  But suppose that this isn't enough, and your department needs to spend less on academic salaries.  How should this be done, to minimize harm?

"Lives" are the Wrong Measure

When thinking about triage situations, it's common for people to assume that saving lives (as many of them as possible) should be our moral goal.  But this is wrong, for the straightforward reason that some deaths are vastly more tragic than others.

It's worth bearing in mind that lives can't be saved, but only extended.  So "saving lives" is not even a coherent goal.  You can aim to maximize the number of lives extended (for any period whatsoever), but we can now see that this is akin to trying to blindly maximize the number of patients treated.  By ignoring how much the patients gain from different treatments, you're clearly neglecting what actually matters -- the underlying health benefits that are the whole purpose of medical interventions in the first place.  Willfully blinding yourself to the magnitudes of different interests will lead to predictable injustice: you might foolishly prioritize two patients' papercuts over another's spreading gangrene, for example.  Raw numbers helped is not the important thing.  Moreover, this principle is as true of life-extending treatments as it is of any other.  (This is most obvious if you imagine a treatment that will extend life by mere minutes.)  I don't see how any remotely sensible person could possibly deny this.

Forthcoming in Bioethics

... is my paper, 'Against "Saving Lives": Equal Concern and Differential Impact' [pdf].

It draws on many of my previous blog posts on the ethics of allocation, especially:

* Are QALYs Discriminatory? -- The basic argument against Harris's "discrimination" objection: It isn't objectionably discriminatory to prioritize greater harms/benefits over lesser ones, and that's all that QALYs are about.
* The associated mistake of conflating the worth of and to a person.
* Where Harris' Double Jeopardy objection goes wrong.
* Lives Can't be Saved -- why person-numbers saved have no intrinsic significance, over and above maximizing life-years or other general welfare measures.
* QALYs, DALYs, and Complete Lives -- Why some life-years are worth more to us than others.
* Where QALYs go wrong -- More on why not all life-years (even in perfect health) are equal.

Here's hoping it will lead bioethicists to rethink their lazy reliance upon Harris' objections to QALYs...

Health Improvement vs. Treatment

Appeals to quality-adjusted life-years (QALYs) in medical resource allocation decisions are naturally supported by a broadly utilitarian view of the role of health institutions, i.e. as having the purpose of improving social welfare (via health improvement) as much as possible.  But is that the right view to have? My colleague Mary recently pressed me on an intuitive alternative conception of healthcare as aiming at treating localized health problems rather than yielding global health benefits to patients.  Might that be a better view?

Where QALYs Go Wrong

My paper 'Against "Saving Lives": Equal Concern and Differential Impact' defends the use of QALYs (Quality-Adjusted Life Years) in medical resource allocation against several traditional objections. But along the way, I note several respects in which (it seems to me) not all life years -- even in perfect health -- are equal, and hence a straightforward QALY-maximization approach falls short.  I'll briefly outline them below, and invite readers to suggest any further examples I may have missed...

The "Double Jeopardy" Objection to QALYs

I've previously discussed Harris (1987)'s famous objection that the use of Quality-Adjusted Life Years (QALYs) in medical resource allocation is unjustly "discriminatory". Harris' second objection is that the use of QALYs gives rise to an unfair kind of “double jeopardy” (p.190):

QALYs dictate that because an individual is unfortunate, because she has once become a victim of disaster, we are required to visit upon her a second and perhaps graver misfortune. The first disaster leaves her with a poor quality of life and QALYs then require that in virtue of this she be ruled out as a candidate for lifesaving treatment, or at best, that she be given little or no chance of benefiting from what little amelioration her condition admits of. Her first disaster leaves her with a poor quality of life and when she presents herself for help, along come QALYs and finish her off!

Allocating Asylum

Here's an interesting moral controversy (which my brother brought to my attention).  Suppose that:
(1) There are more English-speaking refugees seeking asylum than there are available "positions" for refugees in your country (let's call it "NZ") given current policy.
(2) Migrants (including refugees) who speak English are more easily integrated into NZ than those who don't already speak the language. Thus, a greater number of English-speaking refugees (only) could be accepted into the country at no greater cost or institutional strain relative to current policy.

We clearly have very strong moral reasons to want to be able to help as many refugees as possible.  Probably, current policy is unconscionable and we should be letting in anyone who is in a genuine state of desperate need. But given that this ideal is not going to happen, should we think it at least an improvement upon the status quo to introduce a policy of letting in a greater number of refugees all of whom are English-speaking?

Conflating the Worth Of and To a Person

Erik Nord, in 'Values for Health States in QALYs and DALYs: Desirability versus Well-Being and Worth', writes (p.126):

I define the worth of a person as the value attached by society to the enhancement of the interests and opportunities of that person relative to the interests and opportunities of other persons. One important form of enhancement of interest is the protection of the person’s life. If society regards two persons as being of equal worth, it means, among other things, that it is willing to do equally much to protect their lives.

This only follows on the false assumption that all life extensions are equal.  If some people have a greater interest in continued living than others, then assigning equal value to the "enhancement of [their] interests" should fairly straightforwardly entail a greater willingness to "protect" the life of the person who would thereby gain more from it.  We would still be "willing to do equally much" to equally benefit either person.  But there's no reason to think that everyone benefits equally from the protection of their (respective) lives.

Nord thus seems to be repeating Harris' mistake of conflating the worth of a person (i.e. what weight we should give their interests) with the worth of a particular life-extension to the person.  Recognizing that people have "equal worth" in the first sense -- that we should count their interests equally -- in no way entails that we should treat all life-extensions as having equal priority.  Quite the opposite, in fact, if some life extensions are more beneficial to their subjects than others.  Valuing their interests equally means preferring a great enhancement to one person's interests over a merely mild enhancement to another's.

Update: Erik Nord clarifies that by "interests" here he is talking about the psychological notion of feeling "interested" in an outcome, rather than the normative concept of one's welfare interests.

Weight Discrimination in Drug Rationing

Suppose we have a severe shortage of a drug that is prescribed on a "grams per kilogram" basis, i.e. a 300 pound patient needs three times as much of the drug as a 100 pound patient.  Should weight then play a role in allocation decisions, such that (all else equal) lighter patients will have priority over heavier patients, or would it be more fair to simply allocate by lottery until the drug runs out?

It seems to me pretty clear that we ought to prefer to help more rather than fewer people, all else equal, even if it means that all those helped have a characteristic in common (low weight).  But I expect that a lot of people would disagree with this, and automatically regard it as "discriminatory" and hence "unfair".  Can such objections be rationally defended?

Catering to Mistaken Morals

According to the "Rule of Rescue", we ought to do all we can to save the lives of identifiable people at risk (e.g. trapped miners), even if this exhausts resources that would otherwise have saved a greater number of ("statistical", or not antecedently identifiable) lives, say by preventing traffic accidents.  This "rule" is, I take it, completely insane, but seems to be fairly widely accepted by unreflective people.  (Our altruistic motivation is more easily engaged by the salient needs of identifiable individuals, after all.)  Does the widespread acceptance of this mistaken moral view provide reason to act in accordance with it?  As Cookson et al write in 'Public healthcare resource allocation and the Rule of Rescue':

A more promising line of argument is that application of the Rule of Rescue by public policy makers can have ‘‘symbolic value’’. Some actions by the state may have indirect and/or long-term benefits in making citizens feel better about the society in which they live, in promoting trust and co-operation, or simply as ‘‘the mark of a civilised and humane society’’. (543)

Suppose it's true that, by unjustly misallocating our resources to rescue a few miners rather than preventing a greater number of traffic fatalities, most citizens in the society will "feel better".  And suppose that a sufficient number receive this happiness-boost to make it the happiness-maximizing option, all things considered.  Does that make it worth doing after all?

Lives Can't be Saved

As I've written before:

We talk a lot about 'saving lives', but we shouldn't -- it's really quite misleading. At best, we may save a few decades of someone's life. Death is never banished; merely postponed. "Reducing" the number of deaths in the world is not a coherent goal: we know there will be exactly one for each life, and there's no changing that (modulo immortality research). What we really mean here is that we aim to extend life. It's worth being clear on this, since not all life-extensions are equal, but a rhetorical focus on 'death' [or 'life-saving'] occludes this fact.

It's an obvious point, but one that seems unjustly neglected in the bioethics literature.  It seems very common for bioethicists to want to balance the two goals of (1) saving the most lives and (2) maximizing life-years (see, e.g., Kerstein & Bognar).  But "saving the most lives" is not, strictly speaking, a coherent goal (especially when contrasted with the goal of extending people's lives as much as possible); talking this way gives an unwarranted rhetorical glow to what actually amounts to simply distributing life-years across a greater number of people.  And I don't see any good reason to take that as an ultimate goal.

Treatment, Prevention, and Bad Bioethics

Macklin and Cowan's (2012) 'Given financial constraints, it would be unethical to divert antiretroviral drugs from treatment to prevention' makes for a very frustrating read.  They heavily cite a very good 2009 paper by Brock & Wikler, 'Ethical Challenges In Long-Term Funding For HIV/AIDS', which argues that various grounds people might appeal to for favouring treatment over (more efficient) prevention don't actually support that conclusion upon further reflection.  It's good stuff -- I'll summarize some of it below.  Macklin & Cowan, however, simply reiterate the previously-discussed principles and assert without argument that these favour treatment over prevention (in many cases completely neglecting to mention, let alone refute, the powerful objections previously raised by B&W).  It's quite extraordinary.

QALYs, DALYs, and Complete Lives

Persad et al's 'Principles for allocation of scarce medical interventions'* offers interesting criticisms of existing theories of just allocation, and proposes a new account that they call "the complete lives system".  I recommend checking out the whole paper, here I'm just going to explore one strain of it.

By way of background: "QALYs", or Quality-Adjusted Life Years, are self-explanatory.  "DALYs", or Disability-Adjusted Life Years, sound like they should be the same thing but (confusingly) also build in an instrumental component, discounting the "unproductive" years of the very young and elderly in favour of the (young-ish) working-age population.

Fine-Grained vs. Indiscriminate Allocation

Reading the American Medical Association's Council on Ethical and Judicial Affairs,* I'm struck by their opposition to making fine-grained discriminations, and their general preference for more indiscriminate -- or "equal opportunity" -- allocation methods.  For example, they recognize that expected differences in magnitude of change in quality of life (approximated by the amount of functional improvement afforded by a treatment) between patients is morally relevant, but "only when they are very substantial" (30).  Due to the imprecision of the measure, they conclude that "considering small differences in functional improvement would often fail to maximize overall benefit to patients" and "would be unfair" to those for whom quality of life diverged significantly from functional status.

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?

Are QALYs Discriminatory?

In 'QALYfing the value of life' (J. Med. Ethics, 1987), John Harris claims that it is unjust "discrimination" to allocate scarce medical resources to the patients that would benefit most from them (in terms of "Quality-Adjusted Life Years", or QALYs). Instead, he says, we should try to save (or, rather, postpone death for) as many people as we can, without regard for how much different individuals stand to gain from continued life. Since each life "counts for one", Harris argues, postponing death for two 90-year olds (by a month) is more important than postponing a teenager's death by scores of years.

There's something strange about insisting that each person's life has "equal moral value", without bothering to assess how much each person stands to gain from continued life.

Aid and Age

Here's a misleading headline for you: 'Treatment based on need not age':

"The BMA is against blanket bans based on age or other arbitrary factors. It is outrageous to suggest that just because someone is old that they would not have a right to be considered for treatment." ... Dr Calland's comments follow reports that in a survey of 870 doctors (carried out by Doctor magazine) one in three said that elderly patients should not be given free treatment if it were unlikely to do them good for long.

Dr. Calland's comments here seem kind of daft. Age is very obviously not an "arbitrary" factor. If resources are scarce, and we have to decide between investing in one patient to grant them an extra couple of years of quality life, or another patient who would gain several decades of quality life, isn't the latter clearly the greater need?

To generalize, I think it is much more important for a society to invest in their youth than in their elderly. This holds across sectors as well as within, e.g., the health sector. (Education should be a higher priority than hip replacements, etc.) It's unfortunate that such trade-offs need to be made, of course. Ideally, we should want everyone to be maximally well-off. But, failing that, we should do the most good that we can. And pretending that these trade-offs don't exist is not the way to achieve this.

Tradeoffs and Medical Values

Newsflash: health policy and medical practice are value-laden, and may involve tradeoffs. That should hardly be news. Yet there are doctors in the news who don't appear to realise that it's true at all! See, for example, this article on active euthanasia for severely damaged newborns (HT: inactivist):

John Wyatt, consultant neonatologist at University College Hospital, [said]: "Intentional killing is not part of medical care... once you introduce the possibility of intentional killing you change the fundamental nature of medicine. It becomes a subjective decision of whose life is worthwhile."

But aren't such decisions ubiquitous in modern medicine? Given the fact of limited resources, doctors can't always provide all patients with the care (or organs, etc) they need. They must make "subjective" (but hopefully reasonable!) decisions about which lives to save, and which to let die. Perhaps in cases of scarcity they can avoid assessing the quality of lives by simply aiming to prolong as many of them as possible. (Though such an approach implicitly assumes equal worth, so it's not as though they can avoid value judgments altogether!) But there's still the issue of passive euthanasia, or withdrawal of life-support -- which might still be desired in some cases even if resources were not an issue -- implying that the machine-supported life is not worth living.

You can argue that there's something importantly different about intentional killing, as opposed to simply "letting die", but the difference isn't the introduction of "a subjective decision of whose life is worthwhile." Sure, the policy would lead to some tough ethical decisions for medical practitioners. But that's nothing new -- bioethics has been around for a while now.

The second example comes from the Canberra Times:

"How do you put a cost on saving anybody's life when prevention is at hand?"

Of course, the existence of opportunity costs reduces this to pure rhetoric. Each dollar the government spends here means one less available for other -- perhaps more effective -- policies. By my rough calculations, the vaccine discussed in the article costs over $1 million per life saved. (Better journalism wouldn't leave this calculation to the reader.) Are there better ways the money could be spent? If we truly value human life, wouldn't we do better to demand, say, a huge boost to the foreign aid budget? I bet that if the federal government gave that money to Oxfam instead, it'd do a whole lot more good. So why don't they?

In a flourishing democracy, such trade-offs between conflicting values would be recognized, and the hard questions about our ethical priorities would be central to public debate. As things stand, they're simply ignored. Such complexities are overlooked throughout the article, starting with the headline, "Women miss out on free lunch cancer vaccine" (oops, my slip), and the rest is no better. For example:

The vaccine costs about $460 for the recommended three doses but will be free if subsidised by the Federal Government through the national immunisation program.

This is a little misleading (especially in the context of the whole, one-sided article). It would be "free" in the sense that the patients are not directly charged for it. But that doesn't mean the costs disappear, of course; they're simply shifted on to other taxpayers. Is it worth it? The article precludes discussion of this key question by pretending that the trade-off doesn't even exist. As if we could judge the merits of a policy by looking at the benefits alone! What sorry journalism.

Categories:

• bioethics
• utilitarianism
• politics