Jeremy R. Garrett claims that the nature and scope of our rescue duties cannot be properly understood and addressed without reference to social context or institutional background conditions. In my comment I focus not on social or institutional but on psychological background conditions that are also necessary for the conceptualization of rescue cases. These additional conditions are of crucial importance since an entire paradigm of “rescue medicine” is founded, as Garret notices, on the powerful and immediate “impulse to rescue” (Garrett (...) 2015). I understand this “impulse” as the preference toward identified victims, and I argue that it may sometimes distort genuine moral judgments in rescue cases. (shrink)

Many authors in ethics, economics, and political science endorse the Lottery Requirement, that is, the following thesis: where different parties have equal moral claims to one indivisible good, it is morally obligatory to let a fair lottery decide which party is to receive the good. This article defends skepticism about the Lottery Requirement. It distinguishes three broad strategies of defending such a requirement: the surrogate satisfaction account, the procedural account, and the ideal consent account, and argues that none of these (...) strategies succeed. The article then discusses and discharges some remaining grounds for resistance to these skeptical conclusions, as well as the possibility of defending a weaker version of a normative lottery principle. The conclusion is that we have no reason to believe that where equal claims conflict, we are morally required to hold a lottery, as opposed to simply picking one of the parties on more subjective grounds or out of pure whim. In addition to the practical consequences of this skeptical view, the article sketches some theoretical implications for debates about saving the greater number and about axiomatic utilitarianism. (shrink)

In this paper, I defend the existence of a moral duty to disobey the law and engage in civil disobedience on the basis of one of the grounds of political obligation—the Samaritan duty. Christopher H. Wellman has recently offered a ‘Samaritan account’ of state legitimacy and political obligation, according to which the state is justified in coercing each citizen in order to rescue all from the perilous circumstances of the state of nature; and each of us is bound to obey (...) the law, as the state demands, because we each have a responsibility to help rescue others when this assistance is not unreasonably costly. Though Wellman recognizes that there can be reasons for disobeying the law and resisting injustice in otherwise legitimate states, he overlooks the possibility that at least some of these reasons could be Samaritan in nature, grounded in the duty to rescue people from peril. As I shall argue, the Samaritan duty supports obligations to disobey the law, when the law prohibits Samaritan rescues, and to engage in civil disobedience, when unjust laws and practices contribute to endangering people. The discussion proceeds as follows. After a brief overview of the Samaritan duty, I articulate my case for Samaritan duties to disobey the law, and duties to engage in civil disobedience when unjust laws, institutions, or practices enable what I call ‘persistent Samaritan perils’. I then examine and respond to several objections to my account: first, that the costs of law-breaking are unreasonable, and thus cannot be morally required; second, that individuals’ particular acts of protest and civil disobedience do not appear to make any difference to the rescue, and thus cannot be required; third, that I stretch the Samaritan duty beyond recognition; and fourth, that the Samaritan duty binds us to help people in need or peril anywhere, not particularly at home. I consider in conclusion the advantages and limits of my account of citizens’ Samaritan duties in the face of injustice. (shrink)

Waiting time is widely used in health and social policy to make resource allocation decisions, yet no general account of the moral significance of waiting time exists. We provide such an account. We argue that waiting time is not intrinsically morally significant, and that the first person in a queue for a resource does not ipso facto have a right to receive that resource first. However, waiting time can and sometimes should play a role in justifying allocation decisions. First, there (...) is a duty of fairness prohibiting line-cutting where a sufficiently just queue exists. Second, waiting time has several morally attractive features that can justify its incorporation into allocation schemes. Where candidates are in relevantly similar circumstances, allocating by waiting time is relatively efficient, maximizes distribution equality relative to other Pareto efficient distributions, and treats candidates fairly. The claim that allocation using waiting time is fair is controversial. Some have claimed that formal lotteries are a fairer way to select among equal beneficiaries. We argue that lotteries are no fairer than allocation based on waiting time when it is equiprobable how a prospective queue will be ordered. In practice, lotteries share many of the disadvantages of queues; which is fairer will depend on contingent features of the allocation scenario. The upshot is that first-come, first-served is in fact a just way to allocate resources in many of the cases where it seems pre-theoretically compelling, and waiting time has unique normative properties which frequently justify its incorporation into resource allocation schemes. (shrink)

According to psychological research, people are more eager to help identified individuals than unidentified ones. This phenomenon significantly influences many important decisions, both individual and public, regarding, for example, vaccinations or the distribution of healthcare resources. This paper aims at presenting definitions of various levels of identifiability as well as a critical analysis of the main philosophical arguments regarding the normative significance of the identifiability effect, which refer to: (1) ex ante contractualism; (2) fair distribution of chances and risks; (3) (...) anti-aggregationist principles that recommend the distribution of bad effects and the concentration of good ones. I will show that these arguments, although connected with interesting philosophical problems regarding e.g. counterfactuals, aggregation, or probability, are unconvincing. (shrink)

Interpersonal aggregation involves the combining and weighing of benefits and losses to multiple individuals in the course of determining what ought to be done. Most consequentialists embrace thoroughgoing interpersonal aggregation, the view that any large benefit to each of a few people can be morally outweighed by allocating any smaller benefit to each of many others, so long as this second group is sufficiently large. This would permit letting one person die in order to cure some number of mild headaches (...) instead. Most non-consequentialists reject thoroughgoing interpersonal aggregation despite also believing it is permissible to let one person die in order to prevent many cases of paraplegia instead. Non-consequentialists defend this asymmetry largely on the basis of intuition, and some rely on the notion of relevance to formalize the grounding intuitions. This article seeks to clarify and strengthen the non-consequentialist notion of relevance by engaging with three objections to it. (shrink)

Contrary to popular belief, population-wide preventive measures are rarely cost-reducing. Yet they can still be cost-effective, and indeed more cost-effective than treatment. This is often true of preventive measures that work by slightly reducing the already low risks of death faced by many people. This raises a difficult moral question: when we must choose between life-saving treatment, on the one hand, and preventive measures that avert even more deaths, on the other, is the case for prevention weakened when it works (...) by reducing many healthy people’s already low risks by a further tiny amount? I argue the answer is no. (shrink)

This thesis is about the moral reasons we have to do less than best. It consists of six chapters. Part I of the thesis proposes, extends, and defends reasons to do less than best. In Chapter One (“The Conditional Obligation”) I outline and reject two recent arguments from Joe Horton and Theron Pummer for the claim that we have a conditional obligation to bring about the most good. In Chapter Two (“Agglomeration and Agent-Relative Costs”) I argue that agent-relative costs can (...) justify permissions to less than best in a far greater range of decisions contexts than we currently believe. In Chapter Three (“Risk and Aggregation”) I discuss how anti-aggregative moral theories deal with risk, whilst proposing an argument in favour of ex-post moral theories. -/- In Part II of the thesis, I discuss longtermism, presenting a series of reasons to believe we have both significant permissions and obligations to prioritise those in the short-term. In Chapter Four (“Listening to Future People”) I criticise a recent argument presented by Andreas Mogensen for the claim we cannot have obligations grounded in the wellbeing of future people. I then show that, even permitting the existence of obligations to future people, we still have significant reasons to resist longtermism on the grounds of partiality. In Chapter Five (“The Complaints of Future People”) I argue that scepticism about aggregation is inconsistent with an obligation, or indeed even a permission, to help far future people. In Chapter Six (“Leaving the Present Behind”) I explore the moral significance of “dooming”, whilst arguing that we have a pro tanto reason of fairness to prioritise aiding those currently in existence. (shrink)

Given that biases can distort bioethics work, it has received surprisingly little and fragmented attention compared to in other fields of research. This article provides an overview of potentially relevant biases in bioethics, such as cognitive biases, affective biases, imperatives, and moral biases. Special attention is given to moral biases, which are discussed in terms of (1) Framings, (2) Moral theory bias, (3) Analysis bias, (4) Argumentation bias, and (5) Decision bias. While the overview is not exhaustive and the taxonomy (...) by no means is absolute, it provides initial guidance with respect to assessing the relevance of various biases for specific kinds of bioethics work. One reason why we should identify and address biases in bioethics is that it can help us assess and improve the quality of bioethics work. (shrink)

Recent literature in experimental philosophy has postulated the existence of the abstract/concrete paradox : the tendency to activate inconsistent intuitions depending on whether a problem to be analyzed is framed in abstract terms or is described as a concrete case. One recent study supports the thesis that this effect influences judicial decision-making, including decision-making by professional judges, in areas such as interpretation of constitutional principles and application of clear-cut rules. Here, following the existing literature in legal theory, we argue that (...) the susceptibility to such an effect might depend on whether decision-makers operate in a legal system characterized by the formalist or particularist approach to legal interpretation, with formalist systems being less susceptible to the effect. To test this hypothesis, we compare the results of experimental studies on ACP run on samples from two countries differing in legal culture: Poland and Brazil. The lack of significant differences between those results suggests that ACP is a robust effect in the legal context. (shrink)

Tom Dougherty (2013) argues that the following moral principles are inconsistent: (α) it is impermissible to benefit many people slightly rather than save someone’s life, and (β) it is permissible to risk someone’s life slightly to benefit them slightly. This inconsistency has highly counterintuitive consequences for non-consequentialist moral theories. However, Dougherty’s argument, the “Repetition Argument,” relies on a premise that ignores a morally important distinction between acting with statistical knowledge and acting with individualized knowledge. According to this premise, if it (...) is permissible to make it near certain that a distribution obtains, then it is permissible to bring about that distribution. I will argue that this premise proves too much for the Repetition Argument, and so we should reject it. Finally, to further motivate my own objection, I show that a recent objection to the Repetition Argument by James R. Kirkpatrick (2018) does not resolve the inconsistency. (shrink)

Residential aged care facilities (RACF) are sites of high antibiotic use in Australia. Misuse of antimicrobial drugs in RACF contributes to antimicrobial resistance (AMR) burdens that accrue to individuals and the wider public, now and in the future. Antimicrobial stewardship (AMS) practices in RACF, e.g. requiring conformation of infection, are designed to minimise inappropriate use of antibiotics. We conducted dialogue groups with 46 participants with a parent receiving aged care to better understand families’ perspectives on antibiotics and care in RACF. (...) Participants grappled with value trade offs in thinking about their own parents’ care, juggling imagined population and future harms with known short term comfort of individuals and prioritising the latter. Distributive justice in AMR relies on collective moral responsibility and action for the benefit of future generations and unknown others. In RACF, AMS requires value trade-offs and compromise on antimicrobial use in an environment that is heavily reliant on antimicrobial drugs to perform caring functions. In the context of aged care, AMS is a technical solution to a deeply relational and socio-structural problem and there is a risk that carers (workers, families) are morally burdened by system failures that are not addressed in AMS solutions. (shrink)

Advances in genetic diagnostics lead to more patients being diagnosed with hereditary conditions. These findings are often relevant to patients’ relatives. For example, the success of targeted cancer prevention is dependent on effective disclosure to relatives at risk. Without clear information, individuals cannot take advantage of predictive testing and preventive measures. Against this background, we argue that healthcare professionals have a duty to make actionable genetic information available to their patients’ at-risk relatives. We do not try to settle the difficult (...) question of how this duty should be balanced against other duties, such as the duty of confidentiality and a possible duty not to know one’s genetic predisposition. Instead, we argue for the importance of recognising a general responsibility towards at-risk relatives, to be discharged as well as possible within the limits set by conflicting duties and practical considerations. According to a traditional and still dominant perspective, it is the patient’s duty to inform his or her relatives, while healthcare professionals are only obliged to support their patients in discharging this duty. We argue that this perspective is a mistake and an anomaly. Healthcare professionals do not have a duty to ensure that their patients promote the health of third parties. It is often effective and desirable to engage patients in disseminating information to their relatives. However, healthcare professionals should not thereby deflect their own moral responsibility. (shrink)

Thirty years of debate have passed since the term “Rule of Rescue” has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It (...) has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one’s fellow creatures. The present article argues against both objections. It suggests that the debate’s focus on consequences should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice. (shrink)

Often, a health resource distribution (or, more generally, a health policy) ranks higher than another on one value, say, on promoting total population health; and lower on another, say, on promoting that of the worst off. Then, some opine, there need not be a rational determination as to which of the multiple distributions that partially fulfill both one ought to choose. Sometimes, reason determines only partially, intransitively, or contentiously which of the many “compromises” between these two values is best or (...) most choiceworthy. Norman Daniels, Ruth Chang, Martijn Boot, and Anders Herlitz affirm this opinion, which I shall call “value incommensurability,” “rational underdeterminacy,” or “reasonable disagreement.” To decide between the multiple reasonable compromises on health resource distribution, these philosophers recommend a deliberative democratic process, on two main grounds. First, in such situations, deliberation can produce the determinacy needed for decisionmaking. Second, by treating respectfully and justly even those patients or communities for whom the distributive compromise selected is bad, deliberation shields the legitimacy of that policy. Increasingly, practically-oriented bioethics recommends democratic deliberation even more expansively than these philosophers do—for nearly every decision on health resource distribution and not only when values are incommensurate—on these two grounds and on others. And one could propose a more modest variant on this expansive move as the justification of democratic deliberation. I argue that none of these moves warrants democratic deliberation on health policy. (shrink)

Lockdown measures in response to the COVID-19 pandemic involve placing huge burdens on some members of society for the sake of benefiting other members of society. How should we decide when these policies are permissible? Many writers propose we should address this question using cost-benefit analysis, a broadly consequentialist approach. We argue for an alternative non-consequentialist approach, grounded in contractualist moral theorising. The first section sets up key issues in the ethics of lockdown, and sketches the apparent appeal of addressing (...) these problems in a CBA frame. The second section argues that CBA fundamentally distorts the normative landscape in two ways: first, in principle, it allows very many morally trivial preferences—say, for a coffee—might outweigh morally weighty life-and-death concerns; second, it is insensitive to the core moral distinction between victims and vectors of disease. The third section sketches our non-consequentialist alternative, grounded in Thomas Scanlon’s contractualist moral theory. On this account, the ethics of self-defence implies a strong default presumption in favour of a highly restrictive, universal lockdown policy: we then ask whether there are alternatives to such a policy which are justifiable to all affected parties, paying particular attention to the complaints of those most burdened by policy. In the fourth section, we defend our contractualist approach against the charge that it is impractical or counterintuitive, noting that actual CBAs face similar, or worse, challenges. (shrink)

Priority setting is inevitable to control expenditure on expensive medicines, but citizen support is often hampered by the workings of the ‘identified victim effect’, that is, the greater willingness to spend resources helping identified victims than helping statistical victims. In this paper we explore a possible cognitive debiasing strategy that is being employed in discussions on healthcare priority setting, which we call ‘empathy counterbalancing’ (EC). EC is the strategy of directing attention to, and eliciting empathy for, those who might be (...) harmed as a result of one-sided empathy for the very ill who needs expensive treatment. We argue that governments have good reasons to attempt EC because the identified victim effect distorts priority setting in ways that undermine procedural fairness. We briefly outline three areas of application for EC and suggest some possible mechanisms that might explain how EC might work, if at all. We then discuss four potential ethical concerns with EC. First, EC might have the counterproductive effect of reducing overall citizen support for public funding of expensive medical treatments, thereby undermining solidarity. Second, EC may give rise to a ‘competition in suffering’, which may have unintended side effects for patients who feature in attempts at EC. Third, there may be doubts about whether EC is effective. Fourth, it may be objected that EC comes down to emotional manipulation, which governments should avoid. We conclude that insofar these concerns are valid they may be adequately addressed, and that EC seems a promising strategy that merits further investigation. (shrink)

The National Institute for Health and Care Excellence, the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies programme. It argues that although NICE in all likelihood does not act because (...) of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker. (shrink)

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale (...) allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic. (shrink)