Imagine that bird flu hits the United States, and you’re a doctor at a hospital filled with 700 infected patients who all need ventilators to help them breathe. You have 100 ventilators. How do you allocate them? To the sickest? the youngest? the oldest? the most likely to live? the ones most likely to die without one?
The choices would be unthinkable, as Bernard Williams and Martha Nussbaum have suggested. We should be doing much more to avoid them, or at least make them less stark. But as this article from the NYT shows, we are instead doing very little:
Right now, there are 105,000 ventilators, and even during a regular flu season, about 100,000 are in use. In a worst-case human pandemic, according to the national preparedness plan issued by President Bush in November, the country would need as many as 742,500. To some experts, the ventilator shortage is the most glaring example of the country’s lack of readiness for a pandemic.
Now aren’t you happy that market forces got rid of all that “excess hospital capacity” in the 80s and 90s? According to one doctor from the Mayo Medical School, “Families are going to be told, ‘We have to take your loved one off the ventilator even though, if we could keep him on it for a week, he might be fine.’”
Given various budgetary crises, we can’t expect much help from government. Is there any creative solution? I’d like to suggest one: Let individuals buy ventilators to dedicate for themselves and their families (at nearby hospitals), in exchange for their donation of one ventilator for each one they dedicate. Here’s some “figures”….
According to the article, ventilators cost about $30,000. According to Stephen Rose’s Social Stratification in the United States, at least 160,000 families have yearly incomes above $300,000 per year, and another 150,000 have annual incomes above 1 million per year. (That book was written in 2000–certainly there are more in each category after the Bush tax cuts.) If only about half of these folks opt in, we can double the number of ventilators.
I think this proposal is win-win, especially because a) there is no way for a wealthy individual to “dedicate” a ventilator now and b) the relevant decisionmaking bodies are completely opposed to auctioning access off. Sure, some people wealthy enough to buy one ventilator (but not two) will complain. But they’d have been no better off in a system where there is no allocation according to ability to pay.
Now, is this an ideal solution? Of course not–this should obviously be addressed as a collective responsibility….just as much of Europe has Tamiflu for 25% of its population, and we have stockpiles for about 2% of ours. But in an age when government is constantly made out to be the “problem,” not the solution, creative responses to public health threats are essential.
PS: Kudos to Richard Posner’s Catastrophe for giving us a sense of how little we realize the benefits of advance planning for situations like this. And kudos to Clifford Geertz for balancing Posner’s quantitative analysis with some humanistic insight on disaster.
PS: here’s a fuller account of why Williams would believe the choices to be made “unthinkable,” and reject any effort to “cut the Gordian knot” of the allocation problem via bioethical standards like QALYs:
One important misunderstanding can arise fairly naturally from Williams’ two famous examples [in Utilitarianism: For and Against 97-99) of “Jim”, who is told by utilitarianism to murder one Amazon Indian to prevent twenty being murdered, and “George”, who is told by utilitarianism to take a job making weapons of mass destruction, since the balance-sheet of utilities shows that if George refuses, George and his family will suffer poverty and someone else—who will do more harm than George—will take the job anyway. It is easy to think that these stories are simply another round in the familiar game of rebutting utilitarianism by counter-examples, and hence that Williams' integrity objection boils down to the straightforward inference (1) utilitarianism tells Jim to do X and George to do Y, (2) but X and Y are wrong (perhaps because they violate integrity?), so (3) utilitarianism is false. But this cannot be Williams' argument, because in fact Williams denies (2). Not only does he not claim that utilitarianism tells both Jim and George to do the wrong things. He even suggests, albeit rather grudgingly, that utilitarianism tells Jim (at least) to do the right thing. (UFA: 117: “…if (as I suppose) the utilitarian is right in this case…”) Counter-examples, then, are not the point: “If the stories of George and Jim have a resonance, it is not the sound of a principle being dented by an intuition” (WME 211). The real point, he tells us, is not “just a question of the rightness or obviousness of these answers”; “It is also a question of what sort of considerations come into finding the answer” (UFA: 99). “Over all this, or round it, and certainly at the end of it, there should have been heard ‘what do you think?’, ‘does it seem like that to you?’, ‘what if anything do you want to do with the notion of integrity?’” (WME 211).
Again, despite Williams' interest in the moral category of “the unthinkable” (UFA: 92-93; cp. MSH Essay 4), it is not Williams' claim that either Jim or George, if they are (in the familiar phrase) “men of integrity”, are bound to find it literally unthinkable to work in WMD or to shoot an Indian, or will regard these actions as the sort of things that come under the ban of some absolute prohibition that holds (in Anscombe's famous phrase) whatever the consequences: “this is a much stronger position than any involved, as I have defined the issues, in the denial of consequentialism… It is perfectly consistent, and it might be thought a mark of sense, to believe, while not being a consequentialist, that there was no type of action which satisfied [the conditions for counting as morally prohibited no matter what]” (UFA: 90).
from the Stanford Encyclopedia of Philosophy.