Establishing outer-sphere ethical precepts

The two precepts in the outer sphere, under any system of healthcare rationing, present us with an ethical dilemma. You cannot have both perfect societal beneficence and perfect distributive justice simultaneously. You've got to pick which one takes precedence.

Assuring fairness vs. maximizing good

If we have to ration healthcare, we want the rationing process to do two things. We want it to be fair (that is, we want to adhere to the precept of distributive justice), and we want it to yield the maximum amount of healthcare benefit for the dollar (that is, we want to adhere to the precept of societal beneficence.) Unfortunately, we cannot maximize both of these goals at the same time.

Consider the following illustration: Two men, both fifty, are diagnosed with the same rare form of cancer. A treatment exists to cure this type of cancer, but the healthcare system can only afford to treat one of these men. The first man is otherwise healthy and if cured can be expected to recover fully. The second happens to be bedridden with severe multiple sclerosis (MS); if he is cured of cancer, he will remain severely disabled and will probably have a reduced life expectancy due to that disability. To which man should society offer treatment?

Some would say that, obviously, society should treat the man who is otherwise healthy, as we would be buying him a high-quality life of substantial duration. If we treated the other man, we would be saving a relatively low-quality life, and for a shorter duration. Treating the otherwise healthy man would therefore clearly maximize the good (societal beneficence) society achieves with its money.

But others would point out that the second man (the one with MS) wants to live just as much as the first, that his life has the same intrinsic value as the other man's, and that withholding therapy from him just because of his MS would be unfair. Discriminating against people with MS-or any other disability-is a flagrant violation of the principle of distributive justice. Fairness dictates that all individuals should have an equal claim to the benefits of therapy.

It should be obvious that we cannot have it both ways. How we decide to distribute society's resources in this case (and in every case) depends on how we prioritize the two conflicting ethical principles. We might decide that maximizing fairness should predominate over maximizing good. The only way to absolutely maximize fairness, in fact, would be to withhold therapy from both men (this would be the only option that would equalize the results). But then both would die, and our adherence to strict fairness would reduce the amount of good we've achieved to zero. On the other hand, if we decide we want to maximize beneficence (the total amount of good we can buy with society's money), we would have to treat the otherwise healthy man. But by choosing to do this, we would be removing the patient with MS from consideration altogether, reducing fairness to zero.

Whatever we do, we cannot both maximize good and maximize fairness. So, if we're going to devise a scheme for the open rationing of healthcare, we have to choose explicitly between these two ethical precepts or decide specifically how to distribute our priorities between them.

The basic ethical dilemma inherent in devising a rationing scheme is of more than just theoretical importance. The way we balance fairness and good determines whether open rationing ends up being a significant improvement over what we have now or ends up as bad as many fear it might.

An argument for giving primacy to fairness

While we ought to get as much bang from society's healthcare buck as possible, that is, maximize societal beneficence, we should not do so by subordinating the principle of distributive justice. In rationing healthcare, we should avoid discrimination against individuals or groups by virtue of their race, sex, nationality, genetic makeup, or diseases and disabilities.

Why should assuring fairness predominate over maximizing good? Because if we agree to limit societal beneficence in the name of distributive justice, we will strive to expand covered medical services for everyone and thus to expand the overall good we're achieving. Our tendency will be to find new ways of biasing the total goodness upward (while maintaining fairness), by collecting better cost-effectiveness data, finding new efficiencies, discovering new treatments and technologies, or choosing to divert more funding into the healthcare system.

On the other hand, if we hold maximum good to be the dominant standard and treat fairness as a secondary consideration, we will always be tempted to bias fairness downward, that is, to expand the categories of patients whose lives are judged relatively valueless based on disease or disability, as this would be the simplest path to achieving more total good per healthcare dollar spent. Once we set a precedent of maximizing good at the expense of fairness it will be difficult to turn back but easy to advance. We should not assume that we will be significantly more resistant to such behavior than other cultures have proven to be.

Most of us, I think, would rather live in a society that takes the former path rather than one that takes the latter.