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.)