Consequentialism, reasons, value and justice

Bioethics

Volumn 12, Issue 3, 1998, Pages 212-235

  Savulescu, Julian ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGE; ANALYTICAL APPROACH; ARTICLE; ETHICAL THEORY; ETHICS; FREEDOM; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HUMAN; HUMAN RIGHTS; PATIENT SELECTION; PERSONAL AUTONOMY; PHILOSOPHICAL APPROACH; PHILOSOPHY; PROGNOSIS; RESOURCE ALLOCATION; SOCIAL JUSTICE; SOCIAL PSYCHOLOGY;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH; PHILOSOPHICAL APPROACH;

AGE FACTORS; DELIVERY OF HEALTH CARE; ETHICAL THEORY; ETHICS; FREEDOM; HEALTH CARE RATIONING; HUMAN RIGHTS; HUMANS; PATIENT SELECTION; PERSONAL AUTONOMY; PHILOSOPHY; PROGNOSIS; RESOURCE ALLOCATION; SOCIAL JUSTICE; SOCIAL VALUES;

EID: 0032107586     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/1467-8519.00109     Document Type: Article

References (75)

1. I would like to thank David McCarthy, Derek Parfit, Tony Hope and especially Klemens Kappel for helpful comments on earlier drafts.
2. J. Harris, 'What Is the Good of Health Care?' Bioethics 10 (1996), pp. 269-291. All page references in parentheses refer to this work.
3. A. Sen, 'Utilitarianism and Welfarism' Journal of Philosophy 76 (1979), pp. 463-89.
4. A. Sen, Choice, Welfare, Measurement, (BasilBlackwell, Oxford, 1982), pp. 28, 227.
5. A. Sen and B. Williams, 'Introduction' in A. Sen and B. Williams, Utilitarianism and Beyond. (Cambridge University Press, Cambridge, 1982), p. 4.
6. See below and J. Broome, Weighing Goods, (Basil Blackwell, Cambridge, Ma, 1991), p. 7.
7. Sen and Williams, 'Introduction', pp. 4-5.
8. J. Rawls, A Theory of Justice, (Oxford University Press, Oxford, 1972), p. 26.
9. See for example, his: 'QALYfying the Value of Life', Journal of Medical Ethics, Sept 1987, pp. 117-123; 'More and Better Justice' in ed. J.M. Bell and S.M. Mendus Philosophy and Medical Welfare, (Cambridge University Press, Cambridge, 1988); The Value of Life, (Routledge, London, 1985).
10. See for example, his: 'QALYfying the Value of Life', Journal of Medical Ethics, Sept 1987, pp. 117-123; 'More and Better Justice' in ed. J.M. Bell and S.M. Mendus Philosophy and Medical Welfare, (Cambridge University Press, Cambridge, 1988); The Value of Life, (Routledge, London, 1985).
11. See for example, his: 'QALYfying the Value of Life', Journal of Medical Ethics, Sept 1987, pp. 117-123; 'More and Better Justice' in ed. J.M. Bell and S.M. Mendus Philosophy and Medical Welfare, (Cambridge University Press, Cambridge, 1988); The Value of Life, (Routledge, London, 1985).
12. Consequentialism can be stated in a negative form: to act so as to prevent the most harm. In the life-boat case, the choice is between preventing 13 people dying and preventing 6 people dying. Negative consequentialism requires that we prevent the 13 dying. In the medical example, the choice is between 20 people dying and 13 people dying. Negative utilitarians would prevent the 20 people dying.
13. There are other problems with consequentialism as a theory of distributive justice. See for example, Rawls, A Theory of Justice., Sen and Williams, 'Introduction'. and W. Kymlicka, Contemporary Political Philosophy, (Oxford University Press, Oxford, 1990), Chapter 2.
14. There are other problems with consequentialism as a theory of distributive justice. See for example, Rawls, A Theory of Justice., Sen and Williams, 'Introduction'. and W. Kymlicka, Contemporary Political Philosophy, (Oxford University Press, Oxford, 1990), Chapter 2.
15. M. Lowe, I.H. Kerridge, K.R. Mitchell, '"These sorts of people don't do very well": race and allocation of health care resources' Journal of Medical Ethics 2 (1995), pp. 356-60.
16. 'QALYfying the Value of Life'
17. Ian Cooke, personal communication. Michael Lockwood envisaged this general possibility in 'Quality of Life and Resource Allocation' in Bell and Mcndus, Philosophy and Medical Welfare, p. 44.
18. Ian Cooke, personal communication. Michael Lockwood envisaged this general possibility in 'Quality of Life and Resource Allocation' in Bell and Mcndus, Philosophy and Medical Welfare, p. 44.
19. Full-blooded egalitarians could argue that Harris' own intuition that we should save the 13 in the life-boat example is another instance of de facto discrimination: 'little boatism' in which people are denied rescue because they happen to be in a little boat rather than a big boat, through no fault of their own.
20. Thanks to Derek Parfit for this example and observation.
21. While strictly speaking, it is these states which provide opportunity which are good, for brevity I will write as if opportunity itself were the good of health care.
22. This passage illustrates that Harris assumes that all versions of consequentialism are maximising. On my taxonomy, this is not the case.
23. 'More and Better Justice', p. 95.
24. Ibid., pp. 94-5. This is in response to a similar challenge from Michael Lockwood ('Quality of Life and Resource Allocation', p. 54). This is like John Broome's suggestion that we should trade some good for fairness ('Good, Fairness and QALYs' in Bell and Mendus, Philosophical Medical Welfare.)
25. Ibid., pp. 94-5. This is in response to a similar challenge from Michael Lockwood ('Quality of Life and Resource Allocation', p. 54). This is like John Broome's suggestion that we should trade some good for fairness ('Good, Fairness and QALYs' in Bell and Mendus, Philosophical Medical Welfare.)
26. Ibid., pp. 94-5. This is in response to a similar challenge from Michael Lockwood ('Quality of Life and Resource Allocation', p. 54). This is like John Broome's suggestion that we should trade some good for fairness ('Good, Fairness and QALYs' in Bell and Mendus, Philosophical Medical Welfare.)
27. Utilitarians can attribute intrinsic value to both the outcomes of an act and the act itself (S. Scheffler, The Rejection of Consequentialism (Oxford University Press, Oxford, 1982), pp. 1-2; Broome, Weighing Goods, p. 4).
28. Utilitarians can attribute intrinsic value to both the outcomes of an act and the act itself (S. Scheffler, The Rejection of Consequentialism (Oxford University Press, Oxford, 1982), pp. 1-2; Broome, Weighing Goods, p. 4).
29. The Value of Life, p. 11. Strictly, this example is not relevant. It demonstrates that the fact that something will lose value does not justify treating it as if it has already lost that value. However, we are interested in the claim that because something will have a certain value it should be treated now as if it has that value.
30. Ibid.
31. Ibid., p. 159.
32. This is similar to Kamm's suggestion that 'we count equally each individual's preference, understood not as the object of his preference but as the fact that he prefers it' and that the fact that he prefers some state of affairs should make a difference in the process of deciding whether to bring that state of affairs about (F.M. Kamm, 'Equal Treatment and Equal Chances', Philosophy and Public Affairs, 14 (1985), pp. 177-194, esp. p. 181).
33. The Value of Life, Ch. 1 and 2.
34. Though more plausibly the contrast with death enhances the value of life. The psychological heuristic of contrast is described in D. Kahneman and C. Varey, 'Notes on the psychology of utility,' in ed. J. Elster and J.E. Roemer, Interpersonal Comparisons of Well-Being, (Cambridge University Press, Cambridge, 1991), pp. 127-63.
35. H. Sidgwick, The Methods of Ethics. (Macmillan, London, 1963), p. 111; T. Nagel, The Possibility of Altruism. (Clarendon Press, Oxford, 1970), pp. 60, 72.
36. H. Sidgwick, The Methods of Ethics. (Macmillan, London, 1963), p. 111; T. Nagel, The Possibility of Altruism. (Clarendon Press, Oxford, 1970), pp. 60, 72.
37. D. Parfit, Reasons and Persons, (Clarendon Press, Oxford, 1984), p. 117.
38. J. Savulescu, 'Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients', Journal of Medical Ethics 21, 6 (Dec 1995), pp. 327-31 J. Savulescu, 'Liberal Rationalism and Medical Decision-Making', Bioethics, 11 (1997), pp. 115-129.
39. J. Savulescu, 'Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients', Journal of Medical Ethics 21, 6 (Dec 1995), pp. 327-31 J. Savulescu, 'Liberal Rationalism and Medical Decision-Making', Bioethics, 11 (1997), pp. 115-129.
40. F.M. Kamm, Morality, Mortality, Part I (Oxford University Press, New York 1993).
41. Broome, J. Weighing Goods, Chapter 1.
42. See for example the works by Kamm previously cited.
43. 'More and Better Justice,' p. 86. This view is shared by Dan Brock ('Ethical Issues in Recipient Selection for Organ Transplantation' in ed. D. Mathicu, Organ Substitution Technology: Ethical, Legal, and Public Policy Issues, (Westview Press, Boulder, Colorado, 1988).
44. 'More and Better Justice,' p. 86. This view is shared by Dan Brock ('Ethical Issues in Recipient Selection for Organ Transplantation' in ed. D. Mathicu, Organ Substitution Technology: Ethical, Legal, and Public Policy Issues, (Westview Press, Boulder, Colorado, 1988).
45. J.M. Taurek, 'Should the Numbers Count?' Philosophy and Public Affairs, 6 (1977), pp. 293-316. Kamm's response to this paper in both the works cited outlines several other non-consequentialist procedures such as various gambles and majority rule, which claim to treat people as equals without necessarily according everyone an equal chance of being saved.
46. In particular, her principle of majority rule (Morality, Mortality pp. 116ff and 'Equal Treatment and Equal Chances') would justify Harris' intuitions about the life-boat and medical case, if the interests of all those involved in receiving treatment or being saved were the same. However, I have questioned whether the interest in treatment of a patient with a brain tumour (who has a 50% chance of surviving with treatment) is the same as the interest of a person with appendicitis (who has a 100% chance of surviving). I will argue that their reasons for action arc the same strength, though the expected value of those actions is different. Kamm herself gives some weight to outcome (at least length of life - 257-260) in the distribution of scarce medical resources. She does not directly address prognosis or chance of good outcome.
47. If duties provide reasons, this becomes a very broad reading of consequentialism which encompasses much of deontology. For a similarly broad interpretation, see D. Sosa, 'Consequences of Consequentialism', Mind, 102 (1993), pp. 101-22.
48. Provided, of course, that there are no negative interactive effects between p and q. Both C3 and C4 concern only the agent-neutral component of reasons, as we shall see.
49. Our intuitions about this example would change if the 13 were patients with terminal cancer expected to die in the next week and the 6 were healthy.
50. T. Nagel, The View from Nowhere, (Oxford University Press, New York, 1986), p. 153.
51. M. Smith, The Moral Problem, (Blackwell, Oxford, 1994), p. 169.
52. D. Parfit, 'Innumerate Ethics', Philosophy and Public Affairs, 7 (1978), pp. 285-301 at p. 287. Parfit uses the term agent-neutral in a later work (Reasons and Persons). This distinction is in some ways unhelpful. All reasons are relative, in that they arc relative to the relevant features of the circumstances including relevant features of the agent and his or her relationships. However, all reasons are agent-neutral in that they apply to any agents (irrespective of identity) in those circumstances. Thus if I have reason to save my child rather than two strangers, any father (in relevantly similar circumstances) has reason to save his child rather than two strangers. If you have a reason to save two strangers rather than one stranger, any person has a reason to save two strangers rather than one stranger. These reasons arc both agent-relative and neutral.
53. Other things being equal, which they would not typically be because distributors of public resources have special duties to B-F which other individuals would not have.
54. There may of course be other agent-relative reasons but I am not referring to these.
55. I am not distinguishing in this paper between the strength of reason, the rationality of a reason and the amount of reason.
56. J. Savulescu, 'The Present-aim Theory: A Submaximizing Theory of Reasons?', Australasian Journal of Philosophy, forthcoming.
57. Parfit, Reasons and Persons, p. 122.
58. Ibid., p. 131.
59. Ibid., p. 119. Framing CP in terms of desires and aims is potentially misleading. CP is an objective theory of reasons for action. What generates a reason is the objective value of the object of that aim.
60. Savulescu, 'The Present-aim Theory: A Submaximizing Theory of Reasons?'
61. M. Slote, 'Satisficing Consequentialism', Proceedings of the Aristotelian Society, Suppl. 58 (1984) pp. 139-63. M. Slote, Common-Sense Morality and Consequentialism, (Routledge and Kegan Paul, London, 1985). M. Stocker, Plural and Conflicting Values, (Clarendon Press, Oxford, 1990), Part IV.
62. M. Slote, 'Satisficing Consequentialism', Proceedings of the Aristotelian Society, Suppl. 58 (1984) pp. 139-63. M. Slote, Common-Sense Morality and Consequentialism, (Routledge and Kegan Paul, London, 1985). M. Stocker, Plural and Conflicting Values, (Clarendon Press, Oxford, 1990), Part IV.
63. M. Slote, 'Satisficing Consequentialism', Proceedings of the Aristotelian Society, Suppl. 58 (1984) pp. 139-63. M. Slote, Common-Sense Morality and Consequentialism, (Routledge and Kegan Paul, London, 1985). M. Stocker, Plural and Conflicting Values, (Clarendon Press, Oxford, 1990), Part IV.
64. P. Pettit, 'Satisficing Conscqucntialism', Proceedings of the Aristotelian Society, Suppl. 58 (1984), pp. 164-76.
65. For a number of examples, see Savulescu, 'The Present-aim Theory: A Submaximizing Theory of Reasons?'
66. Ibid.
67. An alternative explanation of these intuitions is that in each case the chance of life is so much greater in value than providing for one's family that setting aside one's family tells us nothing of the relative reason-giving force of the chosen alternative. But this does not seem to me to be a case of this kind. In each case, the alternative of bequeathing the money to the family is roughly of similar reason-giving force to taking a chance on prolonging one's own life. That is why it is a dilemma for each man.
68. Kamm, Morality, Mortality, p. 148.
69. Ibid., p. 153.
70. Taurck, 'Should the Numbers Count?'
71. Parfit, 'Innumerate Ethics'.
72. Kamm, Morality, Mortality, p. 154. She states that 'an arm and a life do differ too radically.' While Kamm's approach is non-consequentialist, mine is conscqucntialist. Our views may differ in other ways. On Kamm's preferred analysis of interests, subjectivism, for the losses of A and B to be comparable, what A would lose must be as important to A as what B would lose would be to B (and these losses are roughly objectively comparable, Ibid., p. 154). On Kamm's view, if A happens to care less about the loss of his legs than B (say, he is more stoic), though A still most wants to keep his legs, there is a reason for a distributor of public resources to give preference to B because B's loss is more important to him. On my view, the loss of one's legs in relevantly similar circumstances provides an equal reason for action (provided that a person cares more about that loss than other alternatives). Our views differ on the life-boat case, with Kamm's preferred analysis of interests, subjectivism, requiring that everyone be given equal chances or proportional chances ( Ibid., p. 156).
73. Kamm, Morality, Mortality, p. 154. She states that 'an arm and a life do differ too radically.' While Kamm's approach is non-consequentialist, mine is conscqucntialist. Our views may differ in other ways. On Kamm's preferred analysis of interests, subjectivism, for the losses of A and B to be comparable, what A would lose must be as important to A as what B would lose would be to B (and these losses are roughly objectively comparable, Ibid., p. 154). On Kamm's view, if A happens to care less about the loss of his legs than B (say, he is more stoic), though A still most wants to keep his legs, there is a reason for a distributor of public resources to give preference to B because B's loss is more important to him. On my view, the loss of one's legs in relevantly similar circumstances provides an equal reason for action (provided that a person cares more about that loss than other alternatives). Our views differ on the life-boat case, with Kamm's preferred analysis of interests, subjectivism, requiring that everyone be given equal chances or proportional chances ( Ibid., p. 156).
74. Kamm, Morality, Mortality, p. 154. She states that 'an arm and a life do differ too radically.' While Kamm's approach is non-consequentialist, mine is conscqucntialist. Our views may differ in other ways. On Kamm's preferred analysis of interests, subjectivism, for the losses of A and B to be comparable, what A would lose must be as important to A as what B would lose would be to B (and these losses are roughly objectively comparable, Ibid., p. 154). On Kamm's view, if A happens to care less about the loss of his legs than B (say, he is more stoic), though A still most wants to keep his legs, there is a reason for a distributor of public resources to give preference to B because B's loss is more important to him. On my view, the loss of one's legs in relevantly similar circumstances provides an equal reason for action (provided that a person cares more about that loss than other alternatives). Our views differ on the life-boat case, with Kamm's preferred analysis of interests, subjectivism, requiring that everyone be given equal chances or proportional chances ( Ibid., p. 156).
75. Is this still a version of consequentialism? I am not sure. It may be that the satisfaction of rational claims of differing strength are non-comparable goods and that consequentialism can accommodate a lexical priority to goods. That is, if A and B are non-comparable goods, and A has lexical priority to B, we should maximise A before we maximise B.