Thursday, December 03, 2015

Windfall


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


I'll begin with a general observation. Lydia has recast my original position. I didn't suggest that the duty of a doctor is to sort out good guys from bad guys and then impose rough justice. Rather, I've discussed what's morally permissible for a doctor to do, using some hypothetical limiting-cases. 


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.

i) Well, that's basically a paraphrase of what Lydia said before, so it does nothing to advance the argument. Again, what I find ironic is her morally compartmentalized view of moral obligations. That a physician has a moral obligation to be morally blind in the treatment of his patients. That strikes me as incoherent. 

ii) Problem is, "the patient" isn't just a patient, and the doctor isn't just a doctor. The doctor is a moral agent, and in this case, the patient is a mass murderer who will kill again if healed. I don't see that doctors have a duty to put moral blinders on when treating patients. Again, I'm not discussing garden-variety patients. 

iii) One of my basic principles is that we should treat like alike and unlike unalike. I don't begin to see how we're intrinsically obliged to treat morally unlike situations as if they're alike. Does Lydia have the same principle for international bankers who financed the Wehrmacht or an arms dealer who supplies a drug cartel? The arms dealer knows the drug cartel will kill many innocent people with the armaments that he retails. Does he get off the hook by saying "That's not my department"? 

iv) Likewise, I consider it an elementary principle in moral decision-making that we take the predictable consequences of our actions into account. Results are not all that matters, but we often have a responsibility to consider the impact of our actions on others. 

(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.)

i) Which doesn't work as well if we swap out Reagan and swap in Pablo Escobar. Ordinarily, physicians should focus on the well-being of the patient, but a patient like Himmler or Escobar is not entitled to well being. Not to mention the threat that his life poses to the innocent. 

One of the moral deficiencies of Lydia's analysis is her myopic focus on the well-being of "the patient," regardless of who the patient is. But that disregards the well-being of other affected parties. What is good for Escobar is bad for his prospective victims. 

ii) Furthermore, isn't just a quantitative comparison, where the good of the many outweighs the good of the few. Rather, this is a qualitative comparison, where what's good for the innocent takes precedence over what's good for mass murderers. So it's not utilitarian. In fact, if push comes to shove, what's good for a few innocents outweighs what's good for many mass murderers. 

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.

i) To begin with, Lydia fails to distinguish between medical protocols and normative ethics. The question at issue isn't what criteria happen to used for organ recipients, but what ought to be the case. The status quo isn't a moral arbiter. After all, there are European countries with protocols in place for euthanizing the elderly or developmentally disabled. But Lydia wouldn't appeal to the system to justify the system. So that's beside the point.

ii) Likewise, I didn't say Mantle was morally undeserving of a transplant. Rather, I said a patient who never indulged in high-risk behavior is more deserving. Take two patients: one with congenital liver disease and one with cirrhosis of the liver from alcoholism. Why is Mantle entitled to two chances when another patient never got one chance? Even if that's not one of the criteria, or even if there's additional criteria, it ought to figure in the decision. 

iii) Lydia says "deciding who _deserves_ to live or die, which is, frankly, a wicked corruption of the medical profession." But if there are not enough donated organs to go around, then that's inevitable. You will have winners and losers, and someone must decide. What is Lydia's preferred alternative? If everyone who needs it can't have it, is it better that everyone die rather than saving some?

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.

Honestly, is Lydia even trying? What about the category of saving other lives? And, yes, that's a category of justified killing. Take a police sharpshooter who caps the sniper in the clocktower to prevent him from killing pedestrians who are pinned down. The sniper isn't attacking the sharpshooter. And it's not an execution. 

If anything, your rejection of the execution label only makes your recommendation that doctors actively kill their patients more obviously morally dubious. 

No, it means I reject deceptive terminology. 

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.

i) Once again, it's ironic that Lydia uses morally neutral language like "a helpless person" in discussing ethical situations. Problem is, the moral status of the respective patients isn't neutral. On the one hand you have jihadists who shoot up the synagogue with the intention of taking as many innocent lives as they can. On the other hand, you have the security guards who return fire with the intention of protecting innocent lives. But Lydia feeds both kinds of patients through her morally equalizer. 

Sorry, but to simply describe the wounded jihadist as "a helpless person" is a morally deranged characterization, as if how he acquired that condition is ethically irrelevant. Wounded terrorists can't make the same moral claims on us. 

Same thing with the morally neutral language of cannibalizing "the person's" body for spare parts. Well, no doubt the jihadist is a person. But because he's a personal agent, persons can do things that affect how they ought to be treated. The jihadist who was wounded in an attempt to murder Jewish worshippers is not in the same moral category as the security guard who was wounded by the jihadist in the guard's attempt to protect Jewish worshipers from wrongful aggression. 

It's interesting that Lydia feels her position is self-evidently right despite glaring differences in the moral actions and moral status of the respective parties. I don't share her sympathy for the sacrosanctity of the perpetrator's bodies. Why should they be nursed back to health while the innocent gunshot victims are allowed to die? In what moral universe is that a just outcome? 

ii) BTW, it would still be a case of "cannibalizing the person's body for spare parts" even if this was a voluntary organ donor who died of natural causes. So it's unclear what the odium attaches to. 

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.

i) Actually, I believe I used the phrase "ensuring genocide," not "insuring genocide."

ii) I don't know what you mean by saying it "doesn't even guarantee his later actions." I'm considering one point in a timeline. An earlier link in a chain of events. That's how it plays out. 

iii) Are you operating with a view of libertarian freedom in which, every time we rewind the tape, the outcome might be different? Even if that follows from a libertarian theory of the will, the supposition of my hypothetical is different. You may think that in reality, patching him up doesn't ensure that outcome, but thought-experiments needn't be realistic to establish a point of principle. 

iv) There's such a thing as moral complicity in the actions of others. I can share responsibility for what another agent does even if I'm not solely responsible or the one who carried it out. Do I really need to give examples? 

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.

i) There can be some things that are right to do, but it's wrong for certain people to do them, or be made to do them. It is right to execute a convicted serial killer. It would be cruel to make his teenage son flip the switch. 

ii) There are situations when it might be right for a parent to kill a child. Suppose my son is a violent juvenile delinquent. Suppose he pulls a knife on his mother. I respond my drawing a gun. I don't want to shoot my son. But if need be, I will shoot him to protect my wife. I won't shoot to kill, but when you shoot someone, there's a significant risk of killing them, even if that's not your intention. 

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.

i) But I didn't advocate that example. That's your example (or counterexample), not mine. In your original example, the fireman doesn't kill Himmler. There's a difference between taking his life and letting him die. The fireman didn't put him in mortal danger. 

ii) Furthermore, by saving this child's life, he's taking the lives of other children (hundreds of thousands) in the future. 

iii) That's different than killing the child in the daycare. There are many evils we have no moral opportunity to prevent. In that case, we must let them happen. If they are to be prevented, God must prevent them, because he hasn't given us a morally licit opportunity to do so. 

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.

i) Well, there's an ethical reductio to your alternative. You're myopically focussed on the well-being of that one child to the detriment of hundreds of thousands of other children who will die if he survives. The well-being of more than one child is at stake here. Sure, it's appalling to let him die, but it's appalling to let the other kids die instead. 

We can't always avoid appalling outcomes. Sometimes it comes down to a choice between lesser and greater appalling outcomes. 

ii) If, moreover, the fireman rescues him, then the fireman is causing the death of hundreds of thousands of future children at Himmler's hands. So it wouldn't be morally outrageous if the fireman is hesitant to bring that about. His action won't be the only cause of that outcome, but it will be one link in a chain of events leading up to that catastrophe. A precipitating event. 

(As David Lewis defines it, “We think of a cause as something that makes a difference, and the difference it makes must be a difference from what would have happened without it. Had it been absent, its effects — some of them, at least, and usually all — would have been absent as well.”)

iii) To say it might be "just fine" is inappropriately sarcastic in a context where whatever he does will have tragic consequences. Do you think it might be "just fine" when Himmler grows up to be a genocidal maniac? 

iv) I didn't state that he had a duty to let the child die. Rather, I suggested that he doesn't have a clear-cut choice. And I mentioned complications which you ignore. 

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.

i) Your decision should be based on normal considerations when normal considerations apply. All things being equal, a fireman should rescue people from burning buildings. But treating morally unequal situations equally is illogical and unethical.

ii) Keep in mind, too, that this isn't even a case of killing Himmler. The question, rather, is whether to intervene in an ongoing situation. If Himmler is in danger of dying in a fire, why not regard his predicament as a providential windfall? A boom for his prospective victims?  

17 comments:

  1. I've been reading these exchanges, really excellent dialogue. Good grist for the ol' mill.

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  2. " Does Lydia have the same principle for international bankers who financed the Wehrmacht or an arms dealer who supplies a drug cartel? The arms dealer knows the drug cartel will kill many innocent people with the armaments that he retails. Does he get off the hook by saying "That's not my department"?"

    No, I don't, because there is no special, ethically enormously important, relationship between bankers and people who borrow money or between arms dealers and people who buy their stuff. My position isn't just in general to say, "That's not my department." My position is that there is something enormously special about certain life-saving or life-giving occupations that puts them in a special relationship (I keep looking for a word similar to "fiduciary trust" or something, mutatis mutandis, for doctor-patient, fireman-trapped-person, but nothing is coming immediately to mind) to those they help. This is not a _general_ statement that everybody who sells a product or a service just should "do their thing" and not worry about anything else.

    "What is Lydia's preferred alternative? If everyone who needs it can't have it, is it better that everyone die rather than saving some?" My preferred alternative is the use of _medical_ criteria for triaging, criteria that assume that the goal is to help as many patients as possible, not criteria concerning "just desserts." There are plenty of the former to permit make the relevant decisions.

    " What about the category of saving other lives? And, yes, that's a category of justified killing. Take a police sharpshooter who caps the sniper in the clocktower to prevent him from killing pedestrians who are pinned down. The sniper isn't attacking the sharpshooter. And it's not an execution."

    You are here including "defense of the innocent" as a category. It's true that I didn't happen to include that in my list of possible categories. But "defense of the innocent," like "self-defense," is always (and should always be) applied to _immediate threat_, not to assassination of a person already neutralized as a threat. There are categories for killing people who are not an immediate threat: One such category is execution. Another is attacking a military target in war. Some would also say that assassination is sometimes justified. That was why I used "medical assassination" as a possibility. Because it gets at the fact that the person is not presently a threat, whereas "defense of the innocent" blurs that and, in fact, accesses intuitions concerning neutralizing an immediate threat.

    I take it that your position _is_ that assassination is not always morally wrong, which is why it is a little surprising that you are annoyed by my use of "medical assassination."

    More later.

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  3. Hi Lydia,

    Thanks for what you've written. If it's okay with Steve and yourself, I'd like to weigh in please:

    "My position is that there is something enormously special about certain life-saving or life-giving occupations that puts them in a special relationship (I keep looking for a word similar to 'fiduciary trust' or something, mutatis mutandis, for doctor-patient, fireman-trapped-person, but nothing is coming immediately to mind) to those they help."

    1. I think in general what you say may well be true. But at least as far as I can tell the debate doesn't seem to be about the general cases. We're really talking about the blurry boundaries, I think.

    2. Of course, a doctor-patient relationship is a two-way street. A physician may have certain duties towards their patient. But a patient may have certain duties towards their physician.

    If the patient violates their duties towards the physician, then it's possible the patient has broken the "fiduciary trust" in the doctor-patient relationship.

    If so, then it's further possible the doctor-patient relationship no longer exists.

    If the doctor-patient relationship no longer exists, then the physician doesn't necessarily have any further duties or obligations towards the person who is no longer their patient.

    Perhaps it's arguable committing acts of terrorism or the like can break the doctor-patient relationship.

    3. Let's take a step or two back. The physician isn't necessarily required to enter into the doctor-patient relationship in the first place, is he (or she)?

    If a physician doesn't enter into the physician-patient relationship, then I don't see how he or she is required to treat or manage the patient.

    Say I'm a surgeon. Say a patient asks me to perform a life-saving surgical operation on him because he's dying of cancer. Should I be ethically required to enter into the doctor-patient relationship with him? Must I operate on him? Is it my ethical duty to operate on a cancer patient? If so, why?

    If not, then I don't need to perform the surgery for him. If so, then, though it may sound heartless, there might not be anything unethical about letting him die of cancer.

    4. The only major exception which comes to mind to the physician-patient relationship not necessarily being mandatory is EMTALA. However, EMTALA is basically to stabilize the patient, not necessarily to go any further in terms of treatment and management.

    What's more, EMTALA is what's mandated by law, not necessarily what's morally or ethically required.

    As an aside, there are plenty of physicians who disagree with EMTALA for a variety of reasons. But that's neither here nor there.

    "My preferred alternative is the use of _medical_ criteria for triaging, criteria that assume that the goal is to help as many patients as possible, not criteria concerning 'just desserts.'"

    1. I agree in general we should take the medical aspects into primary consideration in a triage situation. For example, age, comorbidities, physiological status (e.g. level of consciousness), etc.

    2. However, I think the real question is, if we have two patients who are otherwise equal in terms of trauma classification, but one is a young mother with dependant little children, while the other is a terrorist dying of self-sustained injuries because the terrorist tried to blow himself up while on a school bus but failed, then is it unethical for a doctor to prioritize the mother above the terrorist in the triage?

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    1. "However, I think the real question is, if we have two patients who are otherwise equal in terms of trauma classification, but one is a young mother with dependant little children, while the other is a terrorist dying of self-sustained injuries because the terrorist tried to blow himself up while on a school bus but failed, then is it unethical for a doctor to prioritize the mother above the terrorist in the triage?"

      In terms of spending time, possibly--just getting to one person first before you move on to treat someone else. In terms of deliberate neglect to the point of death, no.

      It's also important to remember that such all else being equal scenarios virtually never arise in real life. Medical triage considerations are generally sufficient for decision-making.

      But in any event, this moderate all-else-being-equal statement is not Steve's position, as far as I can tell.

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    2. Lydia

      "In terms of spending time, possibly--just getting to one person first before you move on to treat someone else. In terms of deliberate neglect to the point of death, no."

      1. Well, to be fair, I didn't frame it this way. I'm not talking about a situation where we have enough time to sequentially treat one patient after another. I'm talking about a time-sensitive situation (or similar).

      Nor am I talking about a situation where a doctor is deliberately neglecting a patient to the point of death. The doctor doesn't want to deliberately neglect any patient, but his hand is forced by limited time (or similar).

      I'm talking about if there is no time (or similar) to decide between two people who are about to die in a matter of minutes, if push comes to shove, if the unwelcome choice is forced upon the doctor, if the doctor has to decide who gets treated and who doesn't, knowing full well choosing one over the other ensures one lives while the other dies, if there are no other options available, etc., is it unethical to prioritize the mother over the terrorist?

      2. It's not just about time. It can be about other things as well. Such as resources. Sometimes a medical facility may not have the resources to treat multiple patients at the same time. Sometimes a medical facility may only be able to treat one over another. Say if there's only enough transfusable blood available to save either the mother or the terrorist. Say if a hospital is understaffed and there's only one or two doctors available. That's the sort of thing I'm referring to.

      "It's also important to remember that such all else being equal scenarios virtually never arise in real life. Medical triage considerations are generally sufficient for decision-making."

      1. I'm not sure why you think this is unrealistic:

      a. For instance, it can and does happen in developing nations. Take the situation of Ebola many months ago. There weren't enough resources to offer supportive care to everyone with Ebola. Let alone more serious treatment like the experimental treatments offered to Dr. Kent Brantly for example. As a result, many people have died of Ebola. Say if there were a mother with dependant children dying of Ebola vs a terrorist dying of Ebola, and only enough resources to treat one or the other, not both. Would it be unethical to prioritize the mother over the terrorist?

      b. It can happen in emergency situations. Such as in a time of prolonged war with medical rationing and so forth. Similarly, it's easy enough to imagine a severe and widespread enough terrorist attack that could overwhelm a city or region. Maybe even a nation such that the nation would have to call for assistance from other nations. Maybe other nations can't help in time either.

      The fact that a developed nation like the US hasn't yet been overwhelmed is a testament to our emergency and disaster medicine preparedness, to our wealth, and so on. But it's not in the realm of the impossible to consider this as a viable possibility under the right (horrible) conditions.

      2. Nevertheless, whether or not such a scenario could realistically arise isn't the fundamental point. It's valid in ethical discourse to use hypotheticals to help better discern and adjudicate ethical principles and the like. Heck, medical dramas and other shows on tv and in movies do this as well.

      3. In addition, there can be different triage criteria depending on circumstances. Thus far we've largely been considering civilian scenarios. If we consider a wartime scenario, then the military triage criteria are (very roughly) to prioritize individuals most likely able to return to fight the enemy. Moreover, our military would not prioritize the injured enemy over our soldiers. It's not simply about "saving as many lives as possible." This could arguably parallel doctors treating Himmler or Escobar.

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  4. "If the patient violates their duties towards the physician, then it's possible the patient has broken the "fiduciary trust" in the doctor-patient relationship.

    If so, then it's further possible the doctor-patient relationship no longer exists.

    If the doctor-patient relationship no longer exists, then the physician doesn't necessarily have any further duties or obligations towards the person who is no longer their patient."

    I'm afraid that doesn't make any sense. Saying that a person did such-and-such to other people prior to being hurt and being put before you as a doctor, or that the person intends to do such-and-such evil action and will likely carry it out if he is healed are poor reasons for saying that the patient has violated some sort of tacit duties to the doctor and hence has "broken" the doctor-patient relationship. Remember, this reasoning is meant to support the conclusion that, in virtue of the patient's being Himmler with such-and-such evil plans, the doctor is justified in non-treatment. It's incredibly strained to argue that being Himmler with such-and-such evil plans breaks the relationship between Himmler and all potential doctors who might otherwise operate on him!

    If the patient *right now* threatens the doctor, while the doctor is trying to treat him, and if this constitutes a credible threat (in which case presumably the patient isn't in such bad shape), _that_ is the kind of thing you are thinking of. But "being Himmler" or "being a terrorist" is not that kind of thing.

    "Let's take a step or two back. The physician isn't necessarily required to enter into the doctor-patient relationship in the first place, is he (or she)?

    If a physician doesn't enter into the physician-patient relationship, then I don't see how he or she is required to treat or manage the patient."

    There are certainly situations where a doctor puts himself into a situation where he's supposed to treat "everybody who comes through here." In that case, he doesn't get to pick. Moreover, if you are a doctor and show up on a scene, then put yourself in a position where you are going around helping the wounded, you are implicitly taking a professional stance toward everyone on that scene.

    In other circumstances, where there's time to think about it and decide who operates or what-not, a doctor might do the judicial equivalent of "recusing himself" from some surgery because he has strong personal feelings about the person--for that matter, either for or against. That could even be a legitimate medical consideration, because the doctor might be unable to operate objectively. It could be an argument for not operating on someone you love just as much as not operating on someone you have strong negative feelings about.

    However, let's remember that Steve's position is much stronger than, "Some given doctor could be justified in not operating on Himmler." His position is that it would be justified for all doctors to enter into an agreement deliberately to let Himmler die by jointly boycotting operating on him. Moreover, his position is that doctors are morally justified in _actively killing_ certain evil people such as jihadists (and presumably, Himmler) and even doing so in order to take their organs for their victims.

    So what he's talking about is not some kind of case-by-case doctor decision but rather generalized medical intent either to let die or even actively to kill.

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    1. Lydia

      "I'm afraid that doesn't make any sense. Saying that a person did such-and-such to other people prior to being hurt and being put before you as a doctor, or that the person intends to do such-and-such evil action and will likely carry it out if he is healed are poor reasons for saying that the patient has violated some sort of tacit duties to the doctor and hence has "broken" the doctor-patient relationship. Remember, this reasoning is meant to support the conclusion that, in virtue of the patient's being Himmler with such-and-such evil plans, the doctor is justified in non-treatment. It's incredibly strained to argue that being Himmler with such-and-such evil plans breaks the relationship between Himmler and all potential doctors who might otherwise operate on him! If the patient *right now* threatens the doctor, while the doctor is trying to treat him, and if this constitutes a credible threat (in which case presumably the patient isn't in such bad shape), _that_ is the kind of thing you are thinking of. But "being Himmler" or "being a terrorist" is not that kind of thing."

      1. Sorry, I may have been unclear. What I mean is, assuming a patient is already in a doctor-patient relationship, what if the patient does something unethical to break the doctor-patient relationship?

      Yes, I agree, if the patient physically attacks the doctor enough times or in a life-threatening manner, then it could be grounds to end the doctor-patient relationship. But what if the patient lies to the doctor enough times, or lies about important enough information? Couldn't this arguably be grounds to break the doctor-patient relationship? What if the patient threatens the lives of others, and the threat is real and imminent, then couldn't this arguably be grounds to break the doctor-patient relationship? Etc.

      In other words, I'm just saying, it seems to me it's possible for the doctor-patient relationship to be broken by the patient's unethical actions and/or perhaps intents. If so, then the doctor isn't necessarily required to treat the patient. They may do so out of the kindness of their heart or what not. But there's no ethical duty to do so if the doctor-patient relationship is justly broken, at least as far as I can tell.

      2. However, my more important point is that the doctor doesn't necessarily have to enter into the doctor-patient relationship in the first place, I don't think. Except perhaps in EMTALA, but that's more of a legal debate, rather than strictly moral or ethical.

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    2. "There are certainly situations where a doctor puts himself into a situation where he's supposed to treat "everybody who comes through here." In that case, he doesn't get to pick."

      1. As I mentioned earlier, the only situation where I can see this, at least in the US, is under EMTALA.

      2. But of course there are also situations where the doctor isn't in such a position.

      "Moreover, if you are a doctor and show up on a scene, then put yourself in a position where you are going around helping the wounded, you are implicitly taking a professional stance toward everyone on that scene."

      I'm honestly not sure what this "implicitly taking a professional stance" actually means. Does it mean if I'm a surgeon I'm required to operate on a cancer patient that isn't my patient just because I show up and scrub into the OR while working on an entirely different surgical list?

      "In other circumstances, where there's time to think about it and decide who operates or what-not, a doctor might do the judicial equivalent of "recusing himself from some surgery because he has strong personal feelings about the person--for that matter, either for or against. That could even be a legitimate medical consideration, because the doctor might be unable to operate objectively. It could be an argument for not operating on someone you love just as much as not operating on someone you have strong negative feelings about."

      I agree with this. But then I don't see how this couldn't similarly apply in a situation where Himmler or Escobar approach me and ask me to operate on their cancer.

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    3. "Moreover, if you are a doctor and show up on a scene, then put yourself in a position where you are going around helping the wounded, you are implicitly taking a professional stance toward everyone on that scene."

      1. If this means, say, I'm walking on a street and happen on an unconscious person, or someone who looks like they need medical aid, or something along those lines, then I wonder, is there an ethical duty for me to help them?

      Sure, if I help them, then I may be a good Samaritan. Sure, if I help them, it may be supererogatory. But is there an ethical duty or obligation for me to help them?

      And what if I don't want to help them? Must I help them if I do not consent to helping them?

      If so, what obligates me to help them without my consent?

      Perhaps one could argue based on virtue ethics that it'd make me a less moral person if I refuse to help someone in such dire straits. But this a bit of a double-edged sword. What if I have a good reason not to consent to help someone in dire straits? What if my helping them significantly endangers my own life, and I have other dependants to care for? Anyway, there are many different ways by which one could play this out. It seems to me it really depends on the specific case at hand.

      However, if there is no ethical obligation for me to help them, then there's no ethical duty for me help someone without my consent.

      As such, if I see Himmler and Helga both unconscious, then I'm not necessarily morally or ethically obligated to help Himmler if I don't want to, whereas if I want to, then I can help Helga.

      2. Speaking legally for a moment, since there have been good Samaritans who have been sued, there seems to be some risk involved by helping. Good Samaritan laws are meant to protect first responders in these situations, but sometimes these laws aren't enough to protect good Samaritans from clever lawyers and their clients.

      3. If this means I'm a doctor working in a hospital, not the ED, but on the floors or wards, then I'll just quickly explain how admitting patients into a hospital works in case people might be unfamiliar. I'll simplify:

      Inpatients are admitted under the care of a specific physician (along with their team). If the attending physician leaves the hospital while their patients are still in the hospital, then there will still be a physician on call to take care of the patients. This other physician may be the same physician who admitted them, it may be a hospital-employed physician on call for that night, it may be another physician from the same practice or group as the original admitting physician, if it's an academic teaching hospital then it may be a resident on call for the night, etc. It really depends how everything is set up, and there are multiple ways to do it.

      Bottom line is inpatients are admitted under a particular physician's care until they're discharged to go home.

      In this respect, the physician has agreed to enter into a physician-patient relationship.

      But the flipside is, if the physician refuses to admit a patient under their care, then they do not enter into a physician-patient relationship.

      At least I believe this is (more or less) how it works in developed nations like the US, Canada, the UK, etc. I can't speak as well for developing nations, though I am a little bit familiar with some.

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    4. By the way, there may be degrees of care for a patient.

      As such, where do we draw the line about how much or what sort of care the doctor (and other health professionals and medical facilities) is ethically obligated to give?

      For example, a doctor may be ethically obligated to stabilize a terrorist, but does this necessarily mean the doctor is likewise required to treat or manage the terrorist to full health?

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  5. "Once again, it's ironic that Lydia uses morally neutral language like "a helpless person" in discussing ethical situations. Problem is, the moral status of the respective patients isn't neutral. On the one hand you have jihadists who shoot up the synagogue with the intention of taking as many innocent lives as they can. On the other hand, you have the security guards who return fire with the intention of protecting innocent lives. But Lydia feeds both kinds of patients through her morally equalizer.

    Sorry, but to simply describe the wounded jihadist as "a helpless person" is a morally deranged characterization, as if how he acquired that condition is ethically irrelevant. Wounded terrorists can't make the same moral claims on us."

    If we were talking about a) self-defense, b) defense of the innocent, or c) execution, I would agree with you. I am often pointing out that guilt vs. innocence makes a difference.

    But when it comes to enlisting doctors to kill their patients (which is what you are doing), then a serious line has been crossed, and that is an _abuse_ of the guilt vs. innocence distinction. It is not that I do not make that distinction. It's that I think you are using it in the wrong context.

    "Why should they be nursed back to health while the innocent gunshot victims are allowed to die? In what moral universe is that a just outcome?"

    Because organ transplant is _massively_ extraordinary treatment, hence, it is possible to refrain from carrying out that treatment while still treating the patient as an intrinsically valuable entity. It is possible, and indeed mandatory, for doctors to treat both the victims and the perpetrators as intrinsically valuable beings, made in the image of God, and this is possible to do while not carrying out an organ transplant from one to the other. Indeed, it is _impossible_ to do while using the bodies of one group for the benefit of the other.

    "So it's unclear what the odium attaches to." The special odium in this case attaches to the _absolutely unequivocal_ treatment of the "donors" as _mere_ objects, as _mere_ means to an end, as _mere_ sources of spare parts.

    "Actually, I believe I used the phrase "ensuring genocide," not "insuring genocide."


    The OED gives definition #1 of "insuring" as "making sure of something" and definition #2 as "= ensure."

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  6. "You may think that in reality, patching him up doesn't ensure that outcome, but thought-experiments needn't be realistic to establish a point of principle."

    No, I'm working with a concept of free will according to which the free individual is an irreducible part of the causal chain. As long as his actions are free (he's not just a zombie or a hypnotized robot or something), _no_ other cause or set of causes that precedes his choice _guarantees_ (that is, deterministically makes it the case) that he will make that choice. Otherwise his choice would not be free.

    "There are situations when it might be right for a parent to kill a child. Suppose my son is a violent juvenile delinquent. Suppose he pulls a knife on his mother. I respond my drawing a gun. I don't want to shoot my son. But if need be, I will shoot him to protect my wife. I won't shoot to kill, but when you shoot someone, there's a significant risk of killing them, even if that's not your intention."

    Again, defense of the innocent from imminent threat from an active attacker. That isn't what we're talking about with baby Himmler, and it isn't what we're talking about with Himmler who is out cold and needs surgery. Or jihadists, either.

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  7. " But I didn't advocate that example. That's your example (or counterexample), not mine." My active killing examples are meant to be relevant to your claim that it is morally justifiable for doctors (not state executioners) actively to kill a wicked person in order to prevent his future evil actions. Note that you _reject_ the characterization of this as an execution and also that you specifically argue for _doctors_ qua doctors to do it. I would agree with the death penalty for the jihadists, or for Himmler, but you are talking about having people in a doctor-patient relationship with him kill him when he does not constitute an imminent threat, and you justify this on the basis of preventing his later evil. I therefore think killing a young child based on special ESP that he will otherwise grow up to do evil constitutes a relevant counterexample to the principles you are invoking.

    "Furthermore, by saving this child's life, he's taking the lives of other children (hundreds of thousands) in the future."

    "If, moreover, the fireman rescues him, then the fireman is causing the death of hundreds of thousands of future children at Himmler's hands. So it wouldn't be morally outrageous if the fireman is hesitant to bring that about. His action won't be the only cause of that outcome, but it will be one link in a chain of events leading up to that catastrophe. A precipitating event. "

    Taking the lives? That's the kind of moral confusion that arises from treating a person who helps someone as morally responsible for the evil that person goes on and does. I'm afraid I regard it as simply crazy talk to say that a fireman who saves a child, even, yes, a fireman with ESP who knows that the child will grow up to kill other people, is "taking the lives" of those the child grows up and freely kills. Perhaps this shows what happens when one denies free will?

    "If Himmler is in danger of dying in a fire, why not regard his predicament as a providential windfall? A boom for his prospective victims? "

    Because you're a fireman who took on the role of being a fireman and who has shown up at this fire.

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  8. "His action won't be the only cause of that outcome, but it will be one link in a chain of events leading up to that catastrophe. A precipitating event.

    (As David Lewis defines it, “We think of a cause as something that makes a difference, and the difference it makes must be a difference from what would have happened without it. Had it been absent, its effects — some of them, at least, and usually all — would have been absent as well.”)"

    This is a concept of a contributing cause. I have no problem with talking about contributing causes sometimes. It's a useful and an interesting concept. But it is an extremely broad concept and simply cannot sustain the moral weight being placed on it. E.g. "Taking the lives," etc.

    In _this_ broad sense of "cause," Himmler's great-grandfather's act of conceiving his grandmother was also a link in the chain of events. Everyone who ever gave Himmler necessary care as a child was also a link in the chain of events. This sense of "cause," though relevant in some contexts, just cannot bear the weight of justifying deliberately letting someone die when you are in such a position that it is normally your responsibility to care for or help that person.

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  9. Lydia, While I am not necessarily in full agreement with Steve, I do not understand why you believe that doctors have a moral obligation to save the life of anyone brought before them in need of emergency care. Why must doctors *always* do what is in the best interest of their patients? In the military doctors are not always able to do what is in the best interest of their patients. Sometimes they must do what is best for the mission instead. For example when supplies are limited there are times when doctors must treat those who can return to combat *first* even though this means that others with more serious injury, who could otherwise be save, *will* die. A real world example of this happened when doctors gave penicillin to those with venereal diseases in WWII rather than to patients with more serious illnesses like pneumonia. This meant that more people were able to return to combat quickly as effective fighters but it also meant that some people who *would* have lived in normal triage circumstances died. I don't believe this is wrong. I think that sometimes there are other considerations that are more important than the doctor patient relationship. Why must a doctor always act in the best interest of patient using only medical considerations in their triage?

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  10. It looks like the debate has moved over here.

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