Wednesday, December 02, 2015

Saving little Himmler

I'm going to respond to some comments that Lydia McGrew left on this post:

First, there is the issue of the doctor-patient relationship. A person who happens to be a doctor may also, wearing a different hat, be an executioner (for example), but he shouldn't be both at once. 

What about execution by lethal injection? Isn't the executioner a physician? 

Qua doctor treating a patient, he is obligated to set aside questions of whether the patient is a good or evil person and do what is best for the patient. That is his duty as a doctor. It is of the essence of the doctor-patient relationship, which it is important not to corrupt. This is why, for example, doctors should not be saying that they don't want to save a patient's life because nobody loves that person, or his life is pretty miserable, or whatever, and hence the utilitarian judgement is that their resources are "not well spent" saving that person. The doctor's job qua doctor is not to make those decisions but rather to treat the patient before him. Anything else is completely corrupting to the medical profession. It is the utilitarian ethicists that are trying to undermine this and involve the doctor in deciding what is "best for the community" etc. rather than having this special and exclusive responsibility to the patient as a person under his care. We shouldn't help them out with that.

There's a lot to sort out:

i) When I was a kid (60s-70s), many doctors were in private practice. To my knowledge, they had lots of leeway in terms of which patients to take. Not that they normally turned down patients, but I believe they were at liberty to pick and choose, if they so desired. 

Nowadays, many physicians work for hospitals. It may be the case that they are required to treat whatever patients are referred to the hospital. Likewise, I believe there are laws that mandate the ER to stabilize a patient with a life-threatening condition (regardless of his ability to pay). 

Mind you, this is about rules and laws and policies rather than what's morally obligatory. Of course, what's morally obligatory can overlap with laws and policies, but they are not interchangeable. 

ii) Some ERs go broke because they are required to give care to patients who can't pay or won't pay. The result is not to treat everyone, but to treat no one. Everybody loses out. 

iii) A basic problem with Lydia's response is that it begs the question. To stipulate that physicians should never discriminate assumes the very issue in dispute. Obviously, I disagree. So it amounts to the tendentious assertion that she's right and I'm wrong. That does nothing to advance the argument. 

Now maybe she'd say my own position begs the question. Fine. In that case we have a stalemate, because I don't share her moral intuitions, and vice versa, on this issue. 

iv) In fairness, I think she offers a sketchy supporting argument. When she talks about corrupting the doctor-patient relationship, I take that to mean my position would undermine patient trust in their doctor. They can't count on their doctor to act in their best interests. Hovering in the background is euthanasia. The bioethics of Peter Singer and his epigones. The kind of thing that Wesley J. Smith documents over at Human Exceptionalism. 

v) Apropos (iv), first thing I'd say is that there's a tension in her argument. On the one hand, she rejections utilitarian appeals to the common good, viz. what is "best for the community." Whether their resources are well spent on that individual. 

On the other hand, her valuation of a trusting doctor-patient relationship seems to be a common good appeal. Is it her position that it's intrinsically wrong to deny life-saving medical care to Himmler and Escobar? If so, I need to see more of an argument.

Or is it her position that even though, considered in isolation, it would be justifiable to deny them care, we can't make exceptions like that because we can't contain it to exceptions like that. 

If so, then her own argument is a consequentialist argument. And in that case it comes down to competing common goods. On the one hand, the common good of not undermining a patient trust in their doctor. On the other hand, the common good of cutting short the mass murderous career of Himmler and Escobar. 

vi) Sorry, but I don't think Himmler and Escobar are morally entitled to feel safe in the hands of physicians. There are murderous dictators who become paranoid because they don't know who they can trust. They've made so many enemies. And they richly deserve to be fearful. 

vii) I'm afraid Lydia's position reminds me of zero tolerance policies, where we trap ourselves in a set of arbitrary rules that requires us to punish all "offenders" alike, without regard to extenuating circumstances. A mechanical application of "the rules." I consider that ironic in a discussion of medical ethics, since you can't have ethics without ethical discrimination. 

viii) Apropos (vii), I think Lydia's compartmentalization is amoral. A morally blind policy of treating unlike alike. 

ix) There are some patients who are more deserving of care than others. Take Mickey Mantle. He destroyed his liver through alcoholism. He received a liver transplant, and died a month later, at 63. What about the twenty-something who never engaged in high-risk behavior, needed a liver transplant, but died because the organ went to Mantle? 

Let's be clear: I'm not condemning Mantle. What he did with his life is none of my business. I'm not responsible for his lifestyle choices. I'm not saying he deserved to die.

What I am saying is that if there aren't enough livers to go around, Mantle should be at the bottom of the waiting list. He started out life with a perfectly good liver. He blew his chance. What about another patient who, through no fault of their own, never had that chance? Why give Mantle a second chance at the cost of another patient who never got a first chance? 

x) The comparison with arguments for euthanasia is only as good as the examples. My examples aren't analogous to hers. 

xi) Finally, Lydia's description is too generic. I didn't make this a case of good patients v. evil patients. My examples were more specific: patients who, if cured, will take the lives of many innocent people. That is not, in the first instance, a character judgment, but a consideration of their actions. Not about what they are like, but what they do.

Second, about executions: The fact that a person deserves to die doesn't just make him fair game for anyone who happens to come along. If I happen to know that the guy across from me at dinner has done something heinous and deserves to die, that doesn't make it okay for me to drop a dollop of cyanide into his drink, and if I do so, I'm not an executioner but a vigilante. A society in which any old body can kill somebody because he's a bad guy, or he's planning later to do something evil, etc., is not a well-ordered polity but a state of anarchy, and that's not a good thing.

i) I'm not sure what she's referring to. With respect to Himmler and Escobar, the physician doesn't "execute" them. He doesn't kill them by lethal injection. Rather, he lets them die of natural causes. Does Lydia think there's never a difference between doing harm and allowing harm? I find that odd, since her own theodicy depends on that distinction.  

Admittedly, this is a tricky issue, for sometimes the two morally distinct, and something the two are morally equivalent. That means you can't say in general that they are either distinct or equivalent. It's context-dependent. 

For instance, suppose a passenger on a boat falls overboard, into shark-infested waters. I'm a strong swimmer, but I'm a husband with two young kids. I might be able to fish him out in time, but I don't take the risk. As a result, the sharks get him. I let him die, but I didn't kill him, much less "execute" him. 

ii) Isn't Lydia's appeal to a well-ordered polity a common good argument? How is that different from the consequentialism she repudiates?

iii) Even on her own terms, wasn't Pablo Escobar's career pretty disruptive to a "well-ordered polity"? The Medellín cartel wreaked havoc with Columbian society. 

iv) This also goes to the question of comparative worst-case scenarios. Isn't Himmler's S.S. a worst-case scenario? What makes vigilantism worse than letting Pablo Escobar die on the operating table? What makes vigilantism worse than the Third Reich? True, anarchy is not a good thing. Neither is the Gestapo. Or Auschwitz. 

v) Apropos (iv), how does Lydia feel about the French and Italian Resistance movements? That's classic vigilantism. That was directed against Fascism and Nazism. How is that worse than what it opposed?

vi) Vigilantism isn't synonymous with lynch law or extrajudicial executions. I gave an example of what I considered to be justifiable vigilantism. A hypothetical involving Microsoft counterattacking Chinese hackers. That doesn't kill anyone.

Moreover, executions must be done in a way that recognizes the imago dei in the person being killed. This is not pacifism, since it acknowledges the rightness and justice of execution, rightly done. But no execution should turn the person executed into a mere object or thing. This is why it is wrong to use executed criminals (even those who deserved to die) for cannibalistic feasts. This is why it is wrong to torture to death even those who deserve to die. This is why it is wrong to carry out medical experimentation upon people on death row. And this is also why it is deeply wrong to take the organs of executed prisoners, even those who deserve to die, so that their bodies get "used up" for others--yes, even those they harmed. All such activities are a form of dehumanization of the criminal. And no matter how wicked the criminal is, and even if he can be rightly executed, he must never be dehumanized.

I assume she's alluding to this hypothetical:

Suppose jihadists shoot up a synagogue full of worshipers. Suppose the synagogue has security guards who return fire. Both jihadists and security guards are wounded in the melee. The security guards have irreparable damage to their liver and kidneys. They need organ transplants to survive.  
In that situation, I think physicians would have a right to euthanize the jihadists and harvest their organs to save the lives of the security guards they shot. 

i) If that's what she has in mind, then it's a category mistake for Lydia to classify that as an "execution." I'd define an execution as judicial punishment. But in my hypothetical, the treatment of the jihadists isn't punitive. It isn't designed to give them their just deserts.

It does involve an element of justice. A distinction between guilt and innocents. There's a prima facie right to life. However, human agents can act in ways that forfeit their presumptive right to life. 

In this case, because the jihadists have forfeited their presumptive immunity from harm, and because their gunshot victims need organs, it is poetic justice to make the gunshot victims profit by death of the jihadists. The jihadists intended to kill them, and, in fact, mortally wounded them. But now the jihadists will die to give their victims a second lease on life. 

But that's not judicial punishment, for in my scenario, the jihadists would not be euthanized unless their organs were needed to restore their victims. Their culpability is a necessary condition. But that alone isn't what makes them fair game. 

From what I can tell, Lydia's position is not only based on deontology, but Kantian deontology in particular, where you must never use people as means, but only as ends. If so, that's not morally self-evident to me. 

By the way, patching Himmler up in the ER doesn't "insure" genocide, any more than giving Himmler a drink of water or giving birth to Himmler "insures" genocide. Himmler is the one who commits genocide, not the person who gives him life in some context or other.

That's willfully nearsighted, by turning a blind eye to the foreseeable consequences of one's action. I just can't accept her compartmentalized morality. When we think of "Himmler," the immediate association is his role as head of the Gestapo. In that capacity, he was instrumental in the Holocaust. If he's wheeled into the ER with a life-threatening condition, curing him means he returns to his office a week later and continues feeding Jews into the gas chambers. 

If a doctor is responsible for Himmler's genocide because he patched him up in the ER as an adult, why isn't his mother responsible for his genocide because she gave him food as an infant? 

i) Because at that stage in his career, Himmler is known to be a leading agent of the Holocaust (at least in my hypothetical). His mother lacks that foresight.

ii) In addition, it's unreasonable to expect a mother to strangle her baby in the crib, even if she foresaw how he'd turn out. That imposes too much on a mother. But a physician doesn't have the same emotional attachments or natural duties. 

If it's okay for a doctor to refuse (on the grounds of the evil actions Himmler will otherwise carry out) to patch Himmler up as an adult when the doctor is confronted with him in the ER, would it also be okay for a fireman with prophetic powers to leave him to die in a burning building at the age of three?

i) Before attempting to answer that question, I'd turn it around. Is it okay for a fireman to let Himmler as an adult  (i.e. head of the SS) die in a burning building? Not only would I say that's okay, I'd say a fireman has a duty to let him perish. It would be wrong for the fireman to rescue him.

ii) As for the prophetic fireman's responsibilities in reference to a 3-year-old Himmler, that's not easy to answer. The fireman would feel conflicted. There's a natural prima facie duty to rescue the young. Yet the fireman might well balk at that considering the end-result. Does the fireman have the right to save Himmler at the cost of 6 million innocent Jews?

iii) At that age, Himmler himself is innocent of wrongdoing with respect to the Holocaust, so he can't be directly blamed for what his future self will do (or would do). 

iv) Conversely, collateral damage is sometimes a necessary evil in war. And that's warranted in double effect situations.

v) The fireman might view his prescience as a heaven-sent opportunity to avert the Final Solution. Divine authorization. 

vi) Conversely, advance knowledge of Himmler's future gives the fireman many opportunities to intervene during Himmler's formative years to redirect his course in life. There are alternatives to letting him die. Depends on how much we insulate the hypothetical. 

(Depending on what the fireman does or doesn't do, that's either foreknowledge or counterfactual knowledge.) 


  1. I'll try to work through this gradually:

    I'm not saying in an extremely broad sense that no doctor should "discriminate" in which patients he takes or that ERs should be used as doctor's offices.

    I am, however, saying that when a patient is taken into an ER, a doctor has a professional responsibility to set aside whatever else the doctor knows about the patient and think of him *as a patient* rather than as a person who has done this or that evil thing, or has these or those evil plans. Qua patient, it might be that he could and should be told that he cannot be treated for his non-life-threatening condition because his very act of coming to the ER is an abuse of the system. That's an entirely different matter, however, from saying that he's so-and-so (the evil head of a genocidal campaign) and that _for that reason_ we're going to let him die. The latter is a refusal to think of him qua patient and to think of oneself in one's professional capacity qua doctor. Rather, it is mingling one's role as doctor with some other role--purifying society of evil people, or something of that kind. It's wrong, yes, I would say _intrinsically_ wrong, for a doctor to interpret his role in such a way that people who are evil "richly deserve to feel fearful" when they are in his hands. That's just not what and who a doctor is.

    Concerning doctors who do executions, I will say that I would prefer that executions were carried out by non-doctors for this very reason. It would be trivially easy, if the method of execution is lethal injection, to train a non-doctor in the technique. I myself tend to favor humane, neck-breaking hanging instead, a shot to the back of the head, or some other method of the kind, precisely to avoid the medicalization of execution. No doctor should be _required_ to participate in an execution. If someone is a doctor and does participate in an execution, I would say categorically that he is _not_ participating qua doctor. That is to say, he happens to be a doctor, but at that moment neither he nor anyone else should consider him to be acting _as_ a doctor, because he is killing someone, not treating him. The person being executed is not a patient. The person who happens to be a doctor is there acting as an executioner who happens to know a particular technique because of his medical training.

    I would respect any doctor who refused, precisely because of a possible ambiguity, to participate in medicalized executions.

    When he confronts a patient in the ER, however, he is a doctor and is absolutely required to act professionally as a doctor.

    (Compare the situation where Ronald Reagan joked, "I hope you're all Republicans" before going into surgery after being shot. The liberal Democrat surgeon joked back, "Mr. President, today we are all Republicans." That's professionalism in medicine.)

    1. Just a quick comment or two:

      1. Lydia mentions she favors "humane" methods. But I'm not sure if "neck-breaking hanging" or "a shot to the back of the head" are more "humane" than a lethal injection? If properly administered, then a lethal injection should render a person unconscious. Fast asleep. That's because (to my knowledge) the first agent administered in a lethal injection is an induction agent (e.g. sodium thiopental, which is very similar to propofol).

      2. On the one hand, physicians (anesthesiologists) can administer lethal injections.

      On the other hand, because there aren't enough physicians (anesthesiologists) around, lethal injections are usually administered by others with limited medical training.

      However, the fact that people with limited medical training administer lethal injections often (or often enough) results in botched lethal injections (e.g. Clayton Lockett), which the media pounces on, which is then used by some to argue against the death penalty.

  2. On "discrimination" in organ transplants. There are a lot of other issues there, such as whether vital organ donation can ever be carried out morally. I tend to question whether it can. Let's set that aside and assume that it can. There is a triage system for organ transplant, and a person's past history would affect that triage system, but not for the reason you give. It is not that the person is "morally not entitled" to a liver donation because he ruined his previous liver but that he is not a good candidate because of a) probable later behavior that would render the transplant unsuccessful and b) other harm to his body that has the potential to render the transplant unsuccessful. So a person in Mantle's situation probably wouldn't be considered a good candidate, indirectly because of his past behavior, but not because he is morally undeserving.

    Again, this should be a medical decision. I categorically reject the idea that people making triage decisions in transplant situations should be evaluating the moral worth of the prospective recipients, because that is contrary to their role as medical decision-makers. It is, rather, an attempt to involve them in deciding who _deserves_ to live or die, which is, frankly, a wicked corruption of the medical profession.

    There really is such a thing as professional essentialism.

  3. You expressly carried your position to the point of saying that the doctors should _kill_ the jihadists actively. You used the term "euthanized," by which you presumably meant "killed humanely."

    You say this isn't execution. Well, in that case, you have just removed the only opportunity you might have had to fit your recommendation that doctors bump of their wicked patients into existing categories of justified killing. Presumably you don't want to call this murder. But you don't want to call it execution, either. You can't call it self-defense, as the jihadists aren't attacking the doctors. There are a fairly limited number of categories for justifiedly killing people. I guess you're trying to invent a new one. Perhaps we should call it "medical assassination of bad guys" or something.

    If anything, your rejection of the execution label only makes your recommendation that doctors actively kill their patients more obviously morally dubious. But in any event, all the same objections apply. What you are talking about here is an *even worse* corruption of the medical profession than simply not treating the patient. You're talking about telling doctors to become killers of those brought to them *as patients*, on the grounds that the patients deserve to die, and using those patients as objects (via taking their organs) for the sake of others. This involves extra-judicial killing of a helpless person coupled with the pre-meditated intent to cannibalize the person's body for spare parts (the killing is even carried out for that purpose). Worse, it's being done to patients by doctors. There is so much wrong with that recommendation that, if you can't see it from what I've said already, I'm at a loss to do much more. I say as much as I have said because it's a heinous recommendation at a Christian blog and because I think I need to speak up.

  4. On little Himmler: "Because at that stage in his career, Himmler is known to be a leading agent of the Holocaust (at least in my hypothetical). His mother lacks that foresight." I should have been clearer. Suppose that the mother is given information (several of your recent examples have turned around such foresight) of his later career. Is she then "insuring genocide" (the phrase you used of the doctors) by caring for him? The point I was making is that _neither_ of them is "insuring genocide." Himmler goes on to carry out his own acts afterwards. Whatever people know or don't know about him when they do a good action to care for him, feed him, patch up his medical wounds, etc., that doesn't make them responsible for his later actions. It doesn't even guarantee his later actions.

    " In addition, it's unreasonable to expect a mother to strangle her baby in the crib, even if she foresaw how he'd turn out. That imposes too much on a mother. But a physician doesn't have the same emotional attachments or natural duties."

    Whoa. This _sounds_ like it's saying that _if_ a mother knew that her child were going to grow up to do monstrous wrong, it might be okay for her to kill him as a baby, but she just lacks the emotional detachment to do so.

    You _might_ be saying that the mother actually _shouldn't_ kill him as a baby because she has natural duties to him. Very well, then, suppose that we are talking about a person who happens to pass through a daycare where the child is being cared for. This visitor has prophetic powers and suddenly realizes that the baby in front of him is going to grow up to commit some terrible evil if he is allowed to live. The visitor has no natural attachment to the baby. Is it morally okay to strangle him?

    I've gotta say, this is morally pretty crazy talk.

    You seem to have a host of conflicting intuitions about the fireman, but as near as I can figure, you think it might be just fine for the fireman to let three-year-old Himmler die in the flames if the fireman actually knows what he will grow up and do.

    I consider that an ethical reductio of your approach.

    You ask if I think a fireman should let the adult Himmler die in a fire. Qua fireman, no. Again, we have to distinguish roles. If you're talking about a soldier, bomber pilot, etc., then of course one could blow up a military target where Himmler is located and not try to rescue anybody. By definition it's a military target, and Himmler is a justified part of that military target. But if you're a civilian fireman whose job is to put out fires, and you would normally go in and get person X who happens to be sleeping in a bedroom, and you are told that person X is a murderer who is planning to commit later murders or even will go on to commit later murders, that's not supposed to be relevant to your decision as a fireman. Your decision should be based on the normal considerations--probable success of rescuing the person without harming anyone else, etc. Firemen are not executioners anymore than doctors are.