tag:blogger.com,1999:blog-6789188.post846352890247895695..comments2024-03-27T17:15:37.606-04:00Comments on Triablogue: WindfallRyanhttp://www.blogger.com/profile/17809283662428917799noreply@blogger.comBlogger17125tag:blogger.com,1999:blog-6789188.post-79875362515834084692015-12-05T10:51:56.774-05:002015-12-05T10:51:56.774-05:00It looks like the debate has moved over here.It looks like the debate has moved over <a href="http://triablogue.blogspot.com/2015/12/typhoid-mary.html" rel="nofollow">here</a>.rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-47442382541422244412015-12-04T22:58:49.027-05:002015-12-04T22:58:49.027-05:00Lydia, While I am not necessarily in full agreemen...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?Anonymoushttps://www.blogger.com/profile/08998157753766043378noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-37346664505307832232015-12-04T16:31:40.801-05:002015-12-04T16:31:40.801-05:00By the way, there may be degrees of care for a pat...By the way, there may be degrees of care for a patient.<br /><br />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? <br /><br />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?rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-81349425938114925372015-12-04T15:55:52.347-05:002015-12-04T15:55:52.347-05:00"Moreover, if you are a doctor and show up on..."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."<br /><br />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? <br /><br />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? <br /><br />And what if I don't want to help them? <i>Must</i> I help them if I do not consent to helping them?<br /><br />If so, what obligates me to help them without my consent? <br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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:<br /><br />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. <br /><br />Bottom line is inpatients are admitted under a particular physician's care until they're discharged to go home. <br /><br />In this respect, the physician has agreed to enter into a physician-patient relationship. <br /><br />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.<br /><br />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.rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-3225753019335092652015-12-04T13:59:59.104-05:002015-12-04T13:59:59.104-05:00"His action won't be the only cause of th..."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. <br /><br />(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.”)"<br /><br />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.<br /><br />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. Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-52135395247518958852015-12-04T12:33:51.912-05:002015-12-04T12:33:51.912-05:00"There are certainly situations where a docto..."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."<br /><br />1. As I mentioned earlier, the only situation where I can see this, at least in the US, is under EMTALA.<br /><br />2. But of course there are also situations where the doctor isn't in such a position.<br /><br />"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."<br /><br />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?<br /><br />"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."<br /><br />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. rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-29505034456045942782015-12-04T12:33:35.941-05:002015-12-04T12:33:35.941-05:00Lydia
"I'm afraid that doesn't make ...Lydia<br /><br />"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."<br /><br />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? <br /><br />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.<br /><br />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.<br /><br />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.rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-82706049435874588712015-12-04T12:10:30.925-05:002015-12-04T12:10:30.925-05:00Lydia
"In terms of spending time, possibly--...Lydia<br /><br />"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."<br /><br />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).<br /><br />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).<br /><br />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?<br /><br />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.<br /><br />"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."<br /><br />1. I'm not sure why you think this is unrealistic:<br /><br />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? <br /><br />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. <br /><br />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.<br /><br />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.<br /><br />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.rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-47650505099904291522015-12-04T11:23:56.744-05:002015-12-04T11:23:56.744-05:00" But I didn't advocate that example. Tha..." 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.<br /><br />"Furthermore, by saving this child's life, he's taking the lives of other children (hundreds of thousands) in the future."<br /><br />"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. "<br /><br />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?<br /><br />"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? "<br /><br />Because you're a fireman who took on the role of being a fireman and who has shown up at this fire.<br /><br />Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-68074687778123753802015-12-04T11:13:25.644-05:002015-12-04T11:13:25.644-05:00"You may think that in reality, patching him ..."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."<br /><br />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.<br /><br />"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."<br /><br />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.<br />Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-11376001140392308282015-12-04T11:09:14.795-05:002015-12-04T11:09:14.795-05:00"Once again, it's ironic that Lydia uses ..."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. <br /><br />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."<br /><br />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.<br /><br />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.<br /><br />"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?"<br /><br />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.<br /><br />"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.<br /><br />"Actually, I believe I used the phrase "ensuring genocide," not "insuring genocide."<br /><br /><br />The OED gives definition #1 of "insuring" as "making sure of something" and definition #2 as "= ensure."<br /><br />Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-56615346156496623942015-12-04T10:57:33.294-05:002015-12-04T10:57:33.294-05:00"However, I think the real question is, if we..."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?"<br /><br />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.<br /><br />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.<br /><br />But in any event, this moderate all-else-being-equal statement is not Steve's position, as far as I can tell.Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-85621080652077204532015-12-04T10:56:23.555-05:002015-12-04T10:56:23.555-05:00"If the patient violates their duties towards..."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. <br /><br />If so, then it's further possible the doctor-patient relationship no longer exists. <br /><br />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."<br /><br />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!<br /><br />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.<br /><br />"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)? <br /><br />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."<br /><br />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.<br /><br />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.<br /><br />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. <br /><br />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.Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-23883170838737001742015-12-04T10:26:58.365-05:002015-12-04T10:26:58.365-05:00Hi Lydia,
Thanks for what you've written. If ...Hi Lydia,<br /><br />Thanks for what you've written. If it's okay with Steve and yourself, I'd like to weigh in please:<br /><br />"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."<br /><br />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. <br /><br />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. <br /><br />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. <br /><br />If so, then it's further possible the doctor-patient relationship no longer exists. <br /><br />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. <br /><br />Perhaps it's arguable committing acts of terrorism or the like can break the doctor-patient relationship.<br /><br />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)? <br /><br />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. <br /><br />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? <br /><br />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.<br /><br />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. <br /><br />What's more, EMTALA is what's mandated by law, not necessarily what's morally or ethically required. <br /><br />As an aside, there are plenty of physicians who disagree with EMTALA for a variety of reasons. But that's neither here nor there.<br /><br />"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.'"<br /><br />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. <br /><br />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?rockingwithhawkinghttps://www.blogger.com/profile/10550503108269371174noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-91106957634421554612015-12-04T09:36:26.821-05:002015-12-04T09:36:26.821-05:00" Does Lydia have the same principle for inte..." 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"?"<br /><br />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.<br /><br />"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.<br /><br />" 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."<br /><br />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.<br /><br />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."<br /><br />More later.Lydia McGrewhttps://www.blogger.com/profile/00423567323116960820noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-69376685635668574922015-12-04T09:22:32.339-05:002015-12-04T09:22:32.339-05:00Excellent post!Excellent post!DannyMhttps://www.blogger.com/profile/11539247340940041068noreply@blogger.comtag:blogger.com,1999:blog-6789188.post-35945055561960464612015-12-03T21:32:26.386-05:002015-12-03T21:32:26.386-05:00I've been reading these exchanges, really exce...I've been reading these exchanges, really excellent dialogue. Good grist for the ol' mill.CRhttps://www.blogger.com/profile/03231394164372721485noreply@blogger.com