Residents with dementia in long-term care facilities (LTCFs) often receive antipsychotic (AP) medications without clear clinical indications. One non-clinical factor influencing the use of APs in LTCFs is low staff levels. Often, using APs is viewed and rationalised by healthcare professionals in LTCFs as a lesser evil option to manage low staff levels. This paper investigates the ethical plausibility of using APs as a lesser of two evils in resource-constrained LTCFs. I examine the practice vis-à-vis the three frequently invoked conditions (...) of lesser evil justifications as specified in the wider philosophical literature. These conditions include (1) the necessity condition, (2) the condition of sensitivity to both deontic (ie, constraint-based) and non-deontic (ie, outcome-based) considerations and (3) the commensurability condition. I argue that there are considerable difficulties in demonstrating that the practice in question satisfies the conditions of lesser evil justifications. In particular, there are major difficulties in satisfying the condition of sensitivity to deontic and outcome-based considerations, and the commensurability condition. I also argue that the current philosophical debate on lesser-evil justifications is not straightforwardly applicable to the practice of using APs for non-clinical purposes in LTCFs. I contend that caregivers are not so-called ‘generic’ agents, and the assumed rarity of lesser evil cases is questionable. I conclude that until further work is done to resolve these issues, the lesser evil reasoning cannot be, at least routinely, used to formulate robust moral justifications for the practice in question. (shrink)

Much philosophical attention has been paid to the question of whether, and why, one may divert a runaway trolley away from where it will kill five people to where it will kill one. But little attention has been paid to whether the reasons that ground a permission to divert thereby ground a duty to divert. This paper defends the Requirement Thesis, which holds that one is, ordinarily, required to act on lesser-evil justifications for harming for the sake of others. Cases (...) in which we have lesser-evil justifications of harming for the sake of others are rescue cases. Ordinarily, an agent is under a duty to rescue unless doing so imposes too great a cost on her, or violates someone else's rights. When neither of these defeating conditions obtain, one is required to rescue even if this involves causing harm to innocent people. (shrink)