Dilemma:
Janet Greene is a forty-four year-old victim of a traffic accident. She was treated fir multiple fracture and abdominal injuries, and was discharged once she recovered sufficiently from renal failure. She was able to live at home despite her lacking kidney function, however she soon developed a second round of acute kidney failure and when readmitted to the hospital, it was clear that her condition urgently needed dialysis. Ultimately, the issue is that both geographically accessible hospitals said that they did not have space to give Janet long-term dialysis. When her physician asked if there was any way to “bump” a patient with a less-dire prognosis in order to make room for Janet they refused; both hospitals had a “first come first serve” rule. So the issue is whether or not this first come first serve standard is the morally just way to run these establishments.
Discussion:
In this case we must distinguish between macro and micro-allocative decisions. While macro-allocative decisions are made when a hospital is tight financially and the hospital administrator has to make the tough decision about what programs they can afford to keep, and what ones they must cut. These kinds of resolutions, however, are impersonal as opposed to micro-allocative resolutions that are a part of the personal environment of clinical decision-making. Micro-allocative decisions come into play when a certain resource’s demand becomes greater than the supply. So the biggest question to face here is, “Who shall have the scare resource when no all can?” A question whose answer is synonymous with a life-or-death decision, and in Janet’s case, withholding the long-term dialysis to treat her condition would be the equivalent of signing her “death warrant.”
We must distinguish between two levels of decision-making in micro-allocation if we are to answer “who shall live when not all can live?” The first level is the Eligibility Criteria. Within this there is the constituency factor, stating, “patients in an outlying region may be denied access in favor of patients who reside in the city in which the hospital is located.” There is also the progress of science factor, “patients could be turned away in a micro-allocative crunch if their particular need for a resource failed to fit with the research interests of the hospital.” And the prospect of success factor, “it would be irresponsible to offer a scare medical resource to a patient who is not likely to benefit from it or is likely only to derive marginal benefit from it.” I agree with all three of these criteria, especially the last one. The prospect of success factor is in line with what Janet’s physician is saying, Janet’s condition is critical and if there is a patient who does not need the resources the hospital is providing, or a patient who is hardly benefitting from a certain resource, I believe it is the moral obligation of the hospital to put their resources to the best use possible – and in this case it would be in saving Janet’s life. The second level of criteria, the selection criteria, includes the criteria of comparative worth, which proposes that when distributing scarce resources at the bedside “the family role factor” must be taken into account. Janet is a single mother with two children, she is their only true source of financial, emotional, and physical support and we cannot know the extent of her situation, but since she and her husband are separated and she is the one taking care of the children, we can assume that the father would be of little to no help if this mother were to pass away, leaving her children stranded.
I believe that the only justified way of “bumping” someone off a machine is if they can sustain a good life without it, or if they are hardly hanging on and the machine/treatment is just elongating their inevitable road to death. In these two situations, I believe that either of the patients should be “bumped” in order to save someone who needs the treatment to live, and once on the machine, can live a happy, healthy life without death being in the near future. However, other criteria like the family role factor is important in a case like this. While I don’t believe that it is right to sacrifice one person in order to save another that has children, I do believe in it being an act of supererogation rather than obligation. Anyone that doesn’t meet the two criteria I listed above should not be “bumped” off of their machine – however if they want to volunteer their machine in order to benefit another, then that is the only way something of this sort would be morally justified.
I believe that “bumping” an individual off of the list can only be justified in extreme circumstances. In the case of dialysis, an individual utilizing this treatment method is in poor health conditions and is in dire need of the treatment. By taking the action and removing an individual from the dialysis list, you are essentially condemning the individual to suffering, and possibly death. The only justified circumstance in which “bumping” ought to be permissible is when an individual has the opportunity to live a long, good life with the treatment of dialysis by taking the place on the list of an individual with no hope of a prosperous life. Even in this case, the decision comes down to utility of the patients rather than actually taking into consideration the individuals themselves. This is an extremely tough situation to deal with justly.
The issue of justice and moral obligation is difficult to accurately define in this case. Like you discussed, it only seems justifiable if the patient that will be doing the “bumping” will die immediately without the treatment, and the person being bumped can sustain a life without it or wouldn’t have much of an effect by the treatment. However, the struggle is where to draw the line. It would be frustrating for someone who thinks they are about to receive treatment to have that pulled away from them, particularly when they also need it. I believe that the only way for “bumping” to be just, there must be overwhelming evidence that the person doing the bumping will benefit to an extreme degree more than the person who is next in line. I also believe that the person being “bumped” should agree to the decision, as it personally affects their life and well-being as well– we shouldn’t leave their autonomy out of the decision either.
I think in this case it’s more of a conflict of morality and reality. Morality is an ideal what we should do given an ideal situation. However as demonstrated in this case reality does not conform with our ideals. On morality we are obligated by non-maleficence to give these patients the treatment they need. In this case dialysis. However since we are bound by the principle of non-maleficence for all we theoretically should not take anyone off dialysis by force. The same applies for the principle of beneficence that drives us to give dialysis to people who might be less desperate than those who will die without it. The only way to justify “bumping” is if we are to accept a utilitarian argument for morality and justice. In this case it seems the hospitals follow a libertarian point of view of first come first serve, the outcome doesn’t matter but everyone has a fair chance to get treatment as it is all chance based. In the case of a utilitarian argument we’d have to make quality of life arguments which as stated in PBE can lead to very bad consequences. In the end your stance that “bumping” someone by force would be unjustifiable only if you accept a libertarian point of view. Since I take a more utilitarian point of view I think there are cases where “bumping” someone off the list would be justified. Such as a criminal on dialysis, in this case because they have given up their autonomy by refusing to act how a citizen should act a person more likely to contribute to society should take precedence.
Hi Mikaila, I would like to comment on the “Constituency Factor” that you briefly mentioned in your post. This factor, cited by Nicholas Rescher, does not sound just to me. Patients who reside in the city (with the hospital) are granted scarce resources over patients who live in an “outlying region”. Is this a preference for urban-dwellers over rural-dwellers? If so, this factor is unjust because some rural-dwellers are not able to finance a home in the city, where cost of living tends to be higher. Also, individuals do not have an input in where hospitals are built. I think the most valid and just criteria for allocating scarce medical resources is the “Prospect of Success”.
Mikaila,
I thought you did a good job taking into account many factors that impact this decision. The factor I most agreed with was the “family role factor”. As you pointed out Janet is the primary care giver to her two children, and if she were to die, the future of the children could possibly change. However, the case did not go into detail about the roles of the other people currently occupying the machines. There could very possibly be another single parent on a machine who could be at jeopardy of being “bumped off”. Furthermore, the case states that Janet was on welfare and had a “serious drinking problem” (p. 261). These factors were not discussed extensively in your case analysis and I am curious how you feel these factors play a role in the decision. Do the principles support bumping someone off of a machine who is relatively stable or not benefiting from the machine (your two criteria for bumping) if this person is paying for the machine, to swap in someone who will not be paying for the machine? Furthermore, although I think it is important to consider the “family role factor,” I think it is also very important to consider that the mother has a serious drinking problem. What quality of care is she able to provide for her children if she is intoxicated the majority of the time? I think these two factors also need to be considered strongly when deciding who to bump and reasons to bump someone off of a machine.