Whose Life Should We Save When Technology Is Scarce?
Life is seldom fair. Babies are born with crippling diseases. Cancer strikes randomly. So it has always been. But recent medical technologies--artificial hearts, heart transplants, multiple-organ transplants, artificial-kidney machines--have taken some of the randomness out of life. And death.
The very nature of these breakthrough medical technologies has introduced the economists’ classic problem of scarcity as an unfortunate side effect. The highly trained teams of doctors, enormously complex equipment and availability of organs--whether human or artificial--are scarce resources from the standpoint of availability to patients. But whose lives to save?
We have reached a point, as a society, where we must be willing to play God, as it were. If we refuse to accept this responsibility, finding it arrogant or odious, future patient selection will either be random or will favor the rich and the well-connected over the poor and powerless. While life is seldom fair, as a society entering a new age of medical possibilities we have a moral obligation to act as wisely and as fairly as we can.
This issue is ultimately not so much a medical choice as a social choice. And it requires that lay people and physicians--adhering to clear and reasonable rules--make ethical evaluations and difficult, often agonizing decisions.
A sensible selection of patients for exotic medical therapies would consist of a two-stage process: first, determining all possible candidates to be given serious consideration for a given therapy; then, comparing these candidates case by case.
In the initial screening process, various pragmatic considerations would predominate. A hospital or medical institute would be justified in considering treatment only for those within a defined constituency. An Army hospital, for example, could regard college professors as outside its sphere.
The needs of medical research itself provide another principle for inclusion. It may be important for the progress of medical science (and thus of potential benefit to many patients in the future) to determine how effective a therapy is with diabetics or persons over 60 or those with negative Rh factors.
Finally, it may also be that a certain treatment has been established as highly effective only with patients in certain categories--for example, females over 40 of a specific blood type. The prospect for success represents a legitimate criterion for consideration of exotic life-saving therapy.
The first stage of selection, then, is fairly straightforward. But, now, how to choose among all the qualified candidates, perhaps 50 or 100 times too many for an available treatment? Four additional criteria should be evaluated and taken into account:
The life-expectancy factor-- The age and general health of a patient, and their effect on the duration and quality of life, must be considered.
The family role factor-- A person’s life is important on its own terms, but also in relationship to others. All things being equal, the mother of four must take priority over a middle-aged bachelor.
The potential-contributions factor-- In choosing to save one life over another, it is valid to consider such factors as age, talent and training. An egalitarian society may be reluctant to decide between a brilliant surgeon and a skillful laborer. But could not a case be made for society choosing the surgeon who in turn will be able to save many other lives?
The services-rendered factor-- For example, a hospital at which a particular nurse or a doctor had served on the staff for a number of years would have a responsibility to provide life-saving treatment for that patient.
What I am recommending ultimately is a point system combined with an element of chance. The point rating would weigh medical and non-medical factors equally. Patients with the most points would qualify for final selection by lottery--admittedly a lottery of life and death. Allowing chance to have the final say in the allocation of life-saving therapy is only appropriate. It is a tacit admission that the entire selection system, while eminently reasonable, is imperfect. There are limits to human application of objective criteria. Diseases strike randomly, so in the end the most qualified patients are also dependent on good or bad luck.
Even the most rational of human arrangements cannot cover the dilemma of saving lives in situations of scarcity. As fallible human beings, we must make the best decisions that we can, recognizing that life itself is seldom fair.
