1.1 Transplant case Healthy person walks into a hospital. Doctor has five patients who will die if they do not receive five (different) organs. If she painlessly kills the healthy person, she could save all five. May she do it? Should she do it? 1.2. Ambulance case About 33 people a year die of ambulance crashes. Hundreds of thousands may be saved.* Do those saved justify the death of the 33? If yes, why? Is this case different from Transplant case? How? 2. Act vs. Rule Utilitarianism Act utilitarianism: each person should act so as to promote (or maximize) the good. Therefore: Doctor should kill the healthy patient; easy to justify ambulance Rule Utilitarianism: each person should act according to the rule, that, if generally internalized, would promote the good. Therefore: If doctors generally killed healthy people that may be worse than if they generally did not; thus, doctor should not kill patient. But she may as an exception and in secret. 3. Expected vs. actual results Ex.: one of the persons who doctor kills happens to be super-surgeon or: the person needing the organ is a mass murderer 4. Mill on Utilitarianism “actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness” (90R) 4.1. Promoting Happiness “pleasure, and freedom from pain, are the only things desirable” (91L) “a doctrine worthy only of a swine” (91L)? 4.2. Whose Happiness? “…the happiness which forms the utilitarian standard of what is right in conduct is not the agent’s own happiness but that of all concerned. As between his own happiness and that of others, utilitarianism requires him to be as strictly impartial as a disinterested and benevolent spectator.” (92L,R) Ideal perfection of utilitarian morality: “To do as you would be done by” and  “love your neighbor as yourself” (92R) Question: What does this mean for transplant case? Answer: You have to be willing to walk into that hospital and have yourself be killed (or kill yourself) so that the doctor can harvest your organs. But is this not too demanding? “laws and social arrangements should place the happiness or the interest of every individual as nearly as possible in harmony with the whole” “education and opinion…should…establish in the mind of every individual an indissoluble association between his own happiness and the good of the whole” (92R)   “human nature is so constituted as to desire nothing which is not either a part of happiness or a means of happiness” (94R)   Is Mill’s answer to the transplant case identical to the “standard” utilitarian one? That depends on how the calculation (of results) goes: 4.3 Utility and Justice Justice as a challenge to the idea of utility – why? Five Different Definitions of Justice: (1) “Just to respect, unjust to violate, the legal rights of anyone” (95L, orig. emph.) (2) Injustice “consists in taking or withholding from any person that to which he has a moral right” (95L, orig. emph.) (3) Just desert with regard to having acted rightly or wrongly (4) Unjust to break faith, violate engagement, break promise/contract (5) Injustice as being partial What is the mental link? = Idea of a personal right Justice vs. beneficence (generosity) No one has a moral right to our beneficence Right: “valid claim on society to protect him in the possession of it, either by the force of law, or by that of education and opinion” (96R) Rights protect you from being used in a utilitarian scheme. A has a right to be protected by society against harm by B, C, D, E Why should society “defend” the rights of persons? “I can give him no other reason than general utility” (96L) Social contract theory cannot explain, for instance, why punishment is legitimate (because everyone consented?) and how much of it is proportional (eye for an eye, equal to amount of guilt, or amount required for deterrence, etc.?). The principle of utility, by contrast, can (97L).  Mill does not answer the Transplant case in the same way as other utilitarians. Doctors should refrain from killing healthy people.

Transplant: Healthy person walks into a hospital. The doctor has five patients who will die if they do not receive five (different) organs. If she painlessly kills the healthy person, she could save all five. May/Should she kill the healthy person? Exploring Kant: From the Good Will to the Categorical Imperative (CI) Good Will – good without qualification (48L) Alternatives: (1) Talents of the mind (high IQ) can be abused, (2) gifts of fortune (wealth, being healthy) may badly influence your character (3) other virtues (moderation, self-control) are valuable only if they are in the service of a good will The good will is the will that chooses to let itself be determined by the moral law. Example: It is generally known that one can get more out of a batch of medication if one dilutes it with water. Sarah considers this and figures the patients would not notice. She only refrains from diluting the medication because she worries that she might be caught. Anna always gives undiluted medication because she thinks it would be wrong to mislead her patients.   From an act-utilitarian perspective, there is no difference. From a Kantian perspective, only Anna acted morally. Only she had a good will, only she acted freely. If the good will does what is right simply because it is right……what is “right”? How do we know?   Imperatives: Hypothetical and Categorical Animals and angels do not need imperatives. Animals can't be driven by what is right. Angels do it naturally. Human beings do. Why? Hypothetical Imperatives: an “ought” that follows from the pursuit of some end (I want ice cream. I thus ought to buy or make some) Categorical Imperatives: I “ought” because this is my duty. First formulation of CI “Act only on that maxim whereby thou canst at the same time will that it should become a universal law.” Four Illustrations: to ourselves                to others Perfect       no suicide       no lying promise   Imperfect      no neglect of      no indifference   talents          to the fate of       others   Contradiction of will vs. contradiction of concept Suicide fails the universalization test (CI): contradictory to intend the same feeling (self-love) to be the cause of improving life as well as destroying it. Lying promise fails CI (contradiction of concept): if everyone had the maxim of making lying promises, nobody would believe any promises. Neglect of talent fails CI (contradiction of will): he cannot will to neglect his talents since, as a rational being, he necessarily wills that his faculties be developed. Nonbeneficence fails CI (contradiction of will): If one ever had need of kindness from others, one would deprive oneself of any hope of receiving any. This has often been misinterpreted as consequentialist reasoning! Does: “may I kill one to save five” violate the universalization test? Not necessarily! This is an impartial rule that I could (if I was a utilitarian) plausibly want to be a universal law. Second Formulation of CI: “So act as to treat humanity, whether in thine own person or in that of any other, in every case as an end withal, never as a means only.” (53L) Rational beings (persons), i.e., beings who are not solely subject to inclination, are ends in themselves. All objects of inclination (animals) have only conditional worth, objects without even inclinations have no worth (stones). Suicide, false promise, neglect of talents and nonbeneficence all fail second formulation of CI – why? Suicide: treats myself and humanity within myself as means False promise: treats other as means Neglect of talent: fails to advance humanity Nonbeneficence: fails to harmonize positively with humanity as an end formula. Does “may I kill one to save five” violate the humanity formula? Yes! Kant would categorically rule out killing a person, no matter how many others may be saved by doing so.

Harris: The Survival Lottery Imagine two people – Y & Z - needing organs:  you only need to kill (“disorganize”) one healthy person – A - to obtain these organs and to save two lives. Preliminary observation If two dying patients could be saved by doctor but doctor refuses – we would say doctor is cause of patients deaths. By contrast: If doctor could not save patients, we would not say doctor is cause. Two reason why doctor may be unable: 1.“natural” causes (no organs, no skill, etc.) 2.normative constraints (e.g., against killing)   What if Y and Z refuse to accept normative constraints? Their claim: accepting the normative constraint against killing is “just a decision to prefer the lives of the fortunate to those of the unfortunate.” (437R) Argument in Favor P1: One ought to save the greater number of innocent lives Harris claims that Y & Z are as “innocent” as A—what does he mean? P2: Either A is killed and Y & Z are saved or Y & Z are killed and A is saved Controversial. Usual description of situation: Either A is killed and Y & Z saved or  Y & Z are left to die and A is not killed = Since killing is impermissible and letting die permissible, Y & Z should be left to die C: A should be killed to save Y & Z Killing vs. Letting Die Why is killing usually held to be impermissible and letting die to be permissible? Possible answer 1 (victim centered): when you kill you deprive someone of something she would have had without you When you let someone die you do not deprive someone of something she would have had without you Possible answer 2 (agent-centered): Killing (frequently) requires an action, letting die (frequently) an omission. Exceptions: What if you lure someone into engaging in a dangerous activity and then refuse to help them?    What if letting die would require switching off a machine? Possible answer 3 (Tooley, agent-centered): killing intentional, whereas letting die is not. Someone who knowingly kills another is more likely to be seriously morally defective than someone who fails to save another’s life (33R) But: What if you let someone die you could have helped and would have otherwise killed (or just really wanted dead)? Back to Harris… Refusing Y & Z organs amounts to killing them, since they could be helped (if normative constraints were disregarded). Thus, Harris reformulates question as: Shall we save two lives at the cost of one or one life at the cost of two? (And not: may we kill one to save two?) The answer then seems obvious: We should save two at cost of one. Advantage of this system More lives would be saved overall. Each individual's chance of being saved is greater. (438R) Implication of this system…   No one is “considered to have an absolute right to life or freedom from interference” everything is “always done to ensure that as many people as possible ...enjoy long and happy lives” (439L)     "A man who attempted to escape when his number was up or who resisted on the grounds that no one had a right to take his life might well be regarded as a murderer.” (439L) Problems with this system (a)terror and distress knowing that, at anytime, (b)some doctor has power to harvest your organs (c) asking doctors to do what is wrong, namely to kill healthy person. (d) treats individuals as interchangeable units (e) form of playing God (f) killing one person is intentional, disease of other two is not (g) asking people to sacrifice themselves for others is overdemanding Harris’s Proposed Solutions (a)Terror and distress: education and propaganda (b)Overly powerful doctors: lottery (c)Killing: it is murder to let two people die whose life you could save (d)Interchangeable Units: Why is individuality of one person more important than that of two? (e)Playing God: We do that neither or either way. (f)Killing not intentional, just removal of organs (DDE) (g)Overdemanding?: ethics of self-sacrifice could be established Exceptions and Caveats (1) We should not generally kill young people to save the old (438R) (2) We should not provide organs to people who are to blame for their organ failure (smokers, alcoholics, etc.)(439L) (3) Caveat: We should not rule out use of third-parties since using only Y and Z would be discriminatory/violate their right to equal concern.

1. Three ways of thinking about the permissibility of abortion 1.Presence/absence of morally relevant properties (pro-life and pro-choice) 2.Special connection with morally relevant properties (pro-life) 3.Women-fetus relationship: kind of aid required (pro-choice) Tooley: Self-Consciousness Requirement Basic questions: 1. What properties are required for having a serious right to life/personhood? (normative) 2. Does embryo have these properties? (descriptive/factual) Human being vs. person: what’s the difference? Person = right to life having rights vs. having right to life Not every entity that has rights has the right to life: kitten (may have right not to be tortured but does not have right not to be killed) “What properties must something have in order to be a person, i.e., to have a serious right to life?” (26R) Preliminary question: what is required for an entity to have rights? What are rights: Ascribing rights to individuals means asking other individuals to act (or refrain from acting) in ways that respect the desires of the rights holder. Having rights, then, requires that entity in question has desires of some sort. Having any particular right requires that entity in question has a desire for whatever that particular right protects: “Thus if an individual asks one to destroy something to which he has a right, one does not violate his right to that thing if one proceeds to destroy it.” (26R) What sort of desire? A behavioral disposition? Does a machine searching for an electrical outlet have a desire to have its batteries recharged? No: Desires “are states necessarily standing in some sort of relationship to states of consciousness...” (27L) In order for an entity to have the right to life, this entity has to have the right sort of desire for the right kind of life. A has a right to life = A is the sort of thing that is subject of experiences and other mental states, A is capable of desiring life, and if A does desire life, then others are under a prima facie obligation to refrain from actions that could deprive him of it. (27L). Any kind of life? No. Consider a person whose brain had been reprogrammed: her right to life would be violated although her biological organism continues to exist. Thus: what right to life really protects is “the right of a subject of experiences and other mental states to continue to exist” (27L) “what must be the case if something is to be capable of having a desire to continue existing as a subject of experiences and other mental states?” (27R) since one cannot desire that certain proposition is true unless one understands it and since one cannot understand it without possessing the concepts involved in it It follows: the desires one can have are limited by the concepts one possesses (27R) “an entity cannot be the sort of thing that can desire that a subject of experiences and other mental states exists unless…it possesses the concept of such a subject [and] …it believes that it is now such a subject.”(27R) Problem: is it really plausible to ascribe rights only to those individuals who desire it (in the complex way just described)? What about (i)people suffering from temporary depression (ii)people who are asleep, drugged or in a coma, or (iii) people who have been indoctrinated? Caveats: An individual’s right to X can be violated not only when he desires X, but also when he would now desire X were it not for one of the following: (i)he is in an emotionally unbalanced state (ii)he is temporarily unconscious (iii)He has been conditioned to desire the absence of X Self-Consciousness Requirement Having a right to life presupposes that one is capable of desiring to continue existing as a subject of experiences and other mental states. This in turn presupposes both that one has the concept of such a continuing entity and that one believes that one is oneself such an entity. (28R) Embryos and newborns thus do not possess a right to life = both abortion and infanticide are permissible

Marquis (Future Like Ours Argument): We need a theoretical account of the wrongness of killing Is it wrong because  it brutalizes the one who kills? others might experience your absence as a great loss? No! More obvious answer: It‘s wrong because of the great loss it causes you. Five cases: (1)Embryo(2)Infant (3)Suicidal Teenager (4)Temporarily comatose adult (5)You and me Both defenders of pro-life and pro-choice agree that killing in cases (2)-(5) is wrong Q1 (normative): What property makes killing wrong in these cases? Q2 (descriptive):Does the embryo share this property? What makes killing you and me (5) wrong? The loss of one‘s life The loss of all those activities, projects, experiences, and enjoyments which would otherwise have constituted a person‘s future life (53L) To what extent do (3) Suicidal Teenager (4) Temporarily comatose adult have a future like ours? Question: What makes a future like ours valuable? (a) Is it that someone actually values it? (b) Is it that it is presently of value to someone? (c) Is it that it will be of value to someone in the future (if she does not already value it)? Marquis: both (b) and (c) "When I am killed, I am deprived both of what I now value and which would have been part of my future personal life, but also what I would come to value“ (53L) Then we can explain why it is wrong to kill (3) Suicidal Teenager (4) Temporarily comatose adult (5) You and me What about (2) infant (1) embryo? Questions: If the value of our future matters, would it worse to kill a fetus than a five year old child or a 60 year old adult? How is this not an argument about potential? (54R) How does Marquis rule out contraception as a wrong?

Three ways to think about Moral Status of Embryo Focus:  2. Category of argument about abortion (or other questions about treating the embryo): Special connection with morally relevant properties (pro-life tendency) Three arguments for why personhood begins at conception, despite the embryo not being a person (a)Embryos are identical with later person (b)There is a continuous development between embryos and persons (c)Embryos are potential persons (a) Argument from Identity it is wrong to kill an unborn human being because she is identical to an entity that, at some time later in her development, everyone agrees it is wrong to kill. What makes any one of us identical over time? Would you be identical to a perfect copy of yourself? What property might you share with the embryo from which you developed? Is that property morally significant? (b) Argument from Continuity “Life…exists…from the 14th day after conception (nidation, individuation). (. . .) The process of development which has begun at that point is a continuing process which exhibits no sharp demarcation and does not allow a precise division of the various steps of development of the human life.” Defending the claim: If you are unwilling to kill a newborn baby,  would you be willing to kill it a minute before? If not, would you be willing to kill it one minute before that?... Objection: day/night Problem: moral status does not come in degrees, light does Further objection: Just because there may only be one bright line to draw, does not mean that we ought to draw it there… However, premise might already be mistaken: conception is not an event that marks a bright line. Like everything else, it is a continual process (taking about 22 hours to complete (c) Argument from Potential The fertilized egg already possesses the potential to be a fully self-conscious being…it is potentially, just like us, so we cannot deny it any rights or other forms of protection that we accord ourselves Two readings possible Weak version: We ought not stand in the way of the embryo developing into someone like you or me Strong version: We should treat the embryo as if it already was you or me......thus support its development (c) an entity will/could, if nothing happens, become/ develop into another entity (deontological argument). This requires identity over time. This kind of potential „attaches only to distinct individuals which [sic] preserve their identity over time“ (98). (d) an entity will/could, if nothing happens, contribute to producing another entity (consequentialist argument). Central locus of moral value: not present potentialities but future realities Whether an embryo is worth preserving depends on the future state of affairs that will be achieved by preservering it (as opposed to not preserving it). Question: What about Sperm and Egg on these two accounts? Buckle‘s answer: Unlike the fertilized egg, sperm and egg only contribute to producing a human subject (98) Does the fertilized egg have the potential to become a person? "it is necessary to show that the fertilized egg is the same thing (…) as the human subject at the other end of the developmental process“ (99) Buckle claims that the fertilized egg does not yet have the potential to become a human subject/person – why? How is potential to become different from identity argument? Is potential to become version of potentilty argument really a category 2 argument? Tooley’s objection: moral symmetry thesis Process C leads to E. A initiates C B stops process C. There is moral symmetry between A and B (if motivation and effort are the same) Ex. Jones wants Smith dead (a)fails to warn him of bomb (b)shoots him Tooley: Thus, if we hold both motivation (33R) and effort (34L) constant in both cases we see that there is no difference between (a) and (b) Objection to potentiality argument (using moral symmetry thesis): If kittens could (by chemical injection) be transformed into humans, it would not be wrong (a)not to inject newborn kittens with the chemical or (b)interfere with the process of the kittens developing into cats with human properties and kill them instead.

Usual Argument Against Abortion The fetus is a person…and has a right to life...it is, therefore, wrong to have an abortion. Thomson: That does not necessarily follow! Usual Anti-Abortion Argument P1: Fetus is a person P2: Every person has a right to life C 1: Fetus has a right to life P3: A woman has a right to control her body P4: The right to life outweighs the right to control one‘s body P5: Abortion ends the life of a fetus C2: Abortion is impermissible Thomson: There is something very wrong with this argument. Example of Violinist. Thomson: It would be very nice to do this. But it seems perfectly ok to unplug yourself. Similarly, it seems that a woman may cease her assistance to the embryo if it is due to rape....but how can that be, if fetus is a person? Extreme view. Abortion always wrong, even if it would be required to save a woman‘s life. But: Tiny house example (40R) Thomson: Can‘t be. Surely woman can defend her life. But may a third party (doctor) do so? Thomson: Yes (since woman “owns” the house), but does not have to Suppose a woman‘s life is not at stake. Does this mean that the right to life of the fetus automatically trumps? One‘s right to life does not entail access to everything one might need to support it. So while the fetus may have a right to life, it does not necessarily have a right to the use of a woman‘s body. As long a woman does not grant fetus the right to the use of her body, the fetus does not have that right. Chocolate given to both older brother and his younger sibling (42R) If both brothers were jointly given the chocolate then it is unjust of the older brother to withhold it from his younger brother. But the violinist and you were not jointly given the use of your kidney so it is not unjust if you withhold use of your kidney from him. Fetus only has right not to be unjustly killed.(43L) Thus far, we have covered cases where woman‘s life is at stake or where she has definetely not given fetus right to use of her body  - rape. What about other, non-rape, cases? How voluntarily do women invite a fetus „in“? People seeds. Two kinds of Samaritans Minimally Decent Samaritan: may not provide help herself but will exert some effort to insure help is on its way. Good Samaritan: Will go our of her way to provide help an assistance. In US… …nobody has the obligation to be even a Minimally Decent Samaritan. There is only one exception: Women are regularly expected to be Good Samaritans. 2. In what sense is violin case analogous to pregancy case? (a)Kidnapping? Tacit Consent Objection Suppose you join a particular club. You know that 1 in 100 members may be selected for hazing. By joining: have you tacitly consented to being hazed?          (b)Fetus = Stranger? Responsibility Objection Two kinds of responsibility: (1)You are responsible for another person existing (2)You are responsible for a person (who exists independently) being in need of your assistance Imperfect Drug I: You provide violinist drug that cures. But after ten years leads to kidney ailment that only you can help him with. Imperfect Drug II: You have the perfect drug that has no side effect. From laziness you give the violinist the imperfect one.

Why do we need human embryonic stem cells? They are the „master cells“ of the human organism =  great therapeutic potential They provide valuable insights into early embryonic development = great research potential What is the problem? Problem 1 …until several years ago, the only way to obtain human embryonic stem cells was by destroying the embryo. Today: induced pluripotent stem cells. Unclear whether they have the same potential. Why or for or whom is the fact that embryos are destroyed a problem? Problem 2 The most promising therapeutic uses of human embryonic stem cells involve cloning the embryo. Potential danger: that one of these cloned embryos is implanted and carried to term Problem 3 Stem cells may be used to repair damaged cells or tissue. But if that works they could conceivably also be used for enhancement purposes. Proponents of abortion? Generally, one might think that proponents of abortion could have nothing against stem cell research But: that may depend on the reason for why one supports abortion... If it is because of the special relationship between woman and fetus, then position on stem cell research is unclear. Proponents of Assisted Reproduction? Similar: In both SCR and ART many embryos are created at least some of which are not left to develop into born children. Different: ART creates embryos for reproduction. Foreseen but unintended side-effect of increasing efficiency: many embryos are left indefinitely frozen. Goal: Birth of genetically related child SCR: Embryos may or may not be especially created. They are killed in the course of extracting stem cells. Goal: cure, basic research McMahan’s Argument Two assumptions underlying arguments against killing even very early embryos (509L): (1) The embryo is the earliest stage in the existence of someone like you or me. That is, we were once embryos. (2) We have the same moral status at all times at which we exist. We mattered just as much when we were embryos as we do now.   Three objections (a-c): a. How we treat individuals also depends on their nature. Embryo has different nature from adult (509L).                         b. Conflicts with our practice of ART…where more embryos are created than end up being used. Left-over embryos are indefinitely frozen  Compare to: natural conception (509 L)&  stem cell research (may require creation, requires killing) Frozen children example (if we really thought that embryos had the same moral status….)                         c. Conflicts with our practice of dealing with monozygotic twins. When an embryo (symmetrically) divides, it ceases to exist. It gives rise to two new individuals. If the embryos is someone like you are me we should think of twinning as tragic, since someone like you or me ceases to exist. (513L) (1)The embryo is the earliest stage in the existence of someone like you or me. That is, we were once embryos. This view entails two claims: (i) that an embryo is a human organism at the earliest stage of its life and  That may or may not be true. If we think of the whole organism as a succession of cell-divisions that starts when we are a once-cell embryo, then embryo is a human organism. (513R) But, it is more plausible to think of early embryo a collection of qualitatively almost identical cells living within a single membrane – i.e., more like a sack of marbles and not like a human organism. (514 L) (ii) that you or me are essentially human organisms Two arguments against:  (a)Identical twin accident: your brain lives on in the body of your identical twin: who has survived? If it is you, you are not a human organism. (b) Dicephalic twins: two heads living atop one body. Either neither or both are the human organism which they need to survive. Thus, (a) and (b) show that we are not human organisms. Even if a human organism starts to exist at conception, therefore, this does not show that we started to exist at conception. When you and I began to exist “A human organism is conscious only by virtue of having a conscious part. We are that part. We are that which is nonderivatively the subject of consciousness”(518L) …We are ‘‘embodied mind.’’…”We begin to exist when the fetal brain develops the capacity for consciousness…sometime between twenty-two and twenty-eight weeks after conception…” Only then “is there anyone who can be harmed, or wronged, by being killed.” (518R) Potential Six day old embryos has no more potential than sperm and egg to become you or me…it can, like sperm or egg, only produce you or me. (519L) But that kind of potential “is not a basis for high, intrinsic moral status” (519L)

Macro-Allocation of Resources Should any of our national budget be devoted to health-care or should health-care be left to individual consumer to purchase? How much of the national budget should be devoted to healthcare (as opposed to building roads or schools)? How should resources be allocated to different areas within healthcare (maternal vs. neonatal care, treatment vs. prevention)? Micro-Allocation of Resources Deciding between individual patients Michael Lockwood We should allocate scarce resources to where they do the most good. But where is that? Length of life alone? Lockwood: Critically evaluates QALY – quality adjusted life years: Is this a good way to address the allocation of scarce resources? Idea of QALY: balancing the quantity and quality of expected life years after treatment Beneficial health care activity: one that generates a positive amount of QALY’s Efficient health care activity: cost per QALY is a low as it can be. Example (of trade-off between quality and quantity of life): Laryngial carcinoma. Surgery: 60 % five-year survival rate, but incompatible with normal speech Radiotherapy: 30-40 % five-year survival rate, but preserves normal speech In case of laryngial carcinoma patients can be asked which trade-off they want to make. But in micro-or macro allocation contexts asking individual patients is not possible. So how are trade-off decisions made? By looking at feelings and considered judgments of average representative patient QALY applied to macro level might suggest that scarce resources should be allocated to heart transplantation procedures (or, even better: hip-replacement surgery) rather than to life-saving renal dialysis. Applied to micro level, QALY will have tendency to favor (a) younger patients over older patients (b) generally healthy people over people with other health conditions (e.g., arthritis). QALYs measured by individual’s preferences. Other welfarist factors determining aggregate benefit: Subjective: (a)material and social circumstances (b)psychological make-up of individuals Objective: (c) social worth (genius artist with horrible character or mediocre but morally decent doctor) (d) economic considerations (prosp. earnings, dependents) This will favor the white middle class What QALY does not take into account: Justice Justice: has something to do with equality and with giving appropriate weight to certain sorts of moral claim (45) Justice: asks us to be responsive to need = we should give to her who needs the most, regardless of the aggregate benefits Contrast between: To each according to what will produce the most QALYs and To each according to their need. (45) QALY might favor funding cosmetic surgery over hip replacements and hip replacements over renal dialysis. It will also favor giving treatment to the already fortunate, who do not suffer from any additional ailments. Lockwood agrees that people with more serious disease may have intrinsically stronger claim However, in case of two patients with a similar disease, but one needing more expensive treatment: person whose care is cheaper should be treated Because: if cheaper patient is treated, more patients can be treated. This can be defended on non-consequentialist grounds. Lockwood: it is not true that justice does not allow systematic disadvantaging of one group… …otherwise we could not explain why we allow better people to get better jobs. Further considerations relevant to justice: (a)irresponsible behavior (no free will) (b)age (fair innings) (c)dependents (whose needs may depend on welfare of patient) Lockwood thinks that welfarist and justice-based reasons will converge on the last few points But what in those cases where they come into conflict? In large middle range of cases where costs of giving justice are not enormous, justice may prevail over welfarist considerations Justice therefore constraint on welfarist pursuits But: “…there comes a point where differences in prospective distress and disability are so great that it would be morally irresponsible not to take them into account, on welfarist grounds” (52) =Justice ok as long as it does not cost too much.

Micro Allocation How do we decide between patients? Veatch: Should Age Count? Two ways to argue about this: (1)on consequentialist grounds (2)on non-consequentialist (justice-based) grounds Consequentialist arguments for age mattering: We need to insure greatest good for greatest number. As a general rule, allocating resources to elderly is inefficient. Consequentialist arguments against age mattering: we should look at individuals, not groups such policy might create anxiety about ageing such policy might create anxiety for elderly family members Veatch: consequentialist reasons against not persuasive. Thus, consequentialist should be in favor of age mattering (216). What about claims of justice? Don’t they necessarily have to argue against age mattering (since they would presumably insist on spending resources on the worst off for reasons of equity)? No, there are arguments from justice in favor of age mattering. Two examples (of justice-based theories that think age matters): 1. Callahan: Life has natural end-point, after which resources should only be spent in a very limited, palliative way. Problems: Position rests on an arbitrary view of the value of life after certain age. Position requires specifying cut-off point (75 or 85, for instance). Seems arbitrary. Can’t explain why any resources should be spent on those over the cut-off point             2. Daniels: Prudential life-span account.  Age should be viewed from intrapersonal standpoint. We have to allocate our personal share of healthcare over our life-span in a prudential way. This means taking into consideration our “age-specific normal opportunity range” Problem: What of those who never reach old age? Isn’t this scheme unfair to them? Veatch: we should have two different principles for determining who is worse off to insure equal treatment: (a)over-lifetime allocation (less extreme cases, chronic condition that does not threaten personal identity over life-time) (b)slice of life allocation (extreme cases: severe pain separating oneself from personal identity/life history)

Should Frontline Workers be Prioritized? Current Covid-19 situation different from situations where standard triage protocols can be applied: “too many patients are equally likely to benefit from a resource after standard triage criteria are applied. This triggers the need for additional selection criteria applied to patients who share a similar prognosis” (129L) Suggestion for additional selection criteria: After triage: 1.Healthcare-workers on the frontlines 2.Non-healthcare workers on the frontlines Arguments: 1. Caring for healthcare-workers also benefits all those the healthcare worker will help once recovered (narrow social utility). But: If they require ventilation, it is unclear both if and when healthcare worker will return. But: If pandemic goes on long enough, some will return and be of benefit. 2. Healthcare workers fall ill because of their service to society and society thus has special obligations to them (social contract). But: How are healthcare workers different from grocery store stackers and teachers? What about doctor who contracts virus at a party not her line of work? 3. Society has a duty to those who give back to society. Party-goers should not be prioritized But this seems to apply to more than just front-line workers. Nonmedical front-line workers should be next in line because… 1.of their (narrow) social utility 2.respect for persons But why should they not be first in line?

Macro and micro allocation decisions: when it makes no sense to ask patients themselves…but what about cases where we can and should ask patients about a certain course of treatment? John Stuart Mill “The only part of the conduct of anyone, for which he is amenable to society, is that which concerns others…” “…In the part which absolutely concerns himself , his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.” (631L) Rational Desires and the Limitation of Life-Sustaining Treatment Savulescu: “There are good reasons to believe that normal people, when evaluating whether it is worth living in a disabled state in the future, will undervalue that existence, even in terms of what they judge is best” (665L) Patient Autonomy Savulescu: Ask not “What would the patient now desire if she were competent?” but rather “What would she now rationally desire if she were competent?” Is President’s Commission Report right in proposing that:  treatment of incompetent patients ought to be limited if the patient in question would now desire to have treatment limited, if she were competent? Savulescu: “what the patient would now desire” is insufficient to determine whether life-sustaining treatment should be limited. What we need is autonomous choice, not a mere desire For a choice to express a rational desire/be autonomous it has to have at least three elements: (1)knowledge of the relevant, available information about all available options   Exception: autonomous (not fear or dread)   rejection of facts (667L) (2) no errors of logic (3) vivid imagination of all available options Possible error of logic: P1: There is a risk of dying from anesthesia (true) P2: I will require anesthetic if I am to have amputation (true) C: If I have amputation I will die (false) Difference between A who is mistaken about the facts and B who chooses not to know the facts? Objective versus subjective options: Suppose you are locked in a room and mistakenly think that you do not have the key: you have objective but not subjective  alternative. Autonomous choice requires subjective alternatives It also requires vivid imagination, as far as possible, what both alternatives would mean for the person choosing. Example of person who fails to imagine vividly: John, who wants to chart the interior of Africa and stay alive but fails to take appropriate precautions…and has not separately decided that he wants to live a life of spontaneous, frequently ill-conceived, plans Ex.: Ulysses: what does it show? Obstructive desires. Sometimes it is necessary to frustrate some of a person’s desires if we are to respect her autonomy Case of Mrs X who initially refuses to have her leg amputated but ends up having it amputated…was that the right thing to do? Hurdles to evaluation: loss aversion, contrast and discounting Savulescu: Her expressed desire to rather die than have her leg amputated was an obstructive desire This shows that a competent person sometimes will express non-autonomous choices Thus, we should not only ask: was patient competent? but rather: Is her desire an expression of her autonomy?/ What would patient rationally desire? What if we do not know what patient would now rationally desire (autonomously choose)? Then we should promote patient’s best interest “It is necessary […] to go beyond what people have said, or written,to how they have lived their lives, what they have thought important, what their goals and rational desires are, that is, to what they have rationally evaluated is the best life for themselves.” (674R) If we do not know about a person’s values, we ought to treat her according to her best interest: what is that? Four possible accounts: 1.Hedonistic 2.Desire-Fulfillment 3.Objective List Combination of 1-3 Difference between medical and other sorts of interests: cure of deafness vs. membership in deaf community. When should treatment be limited in person’s best interest? Once it falls below a certain threshold of well-being. Autonomy and false beliefs Let’s suppose JW holds false belief (that they will go to hell if they receive a blood transfusion) – can a choice made on account of this belief be autonomous? a. instrumental irrationality b. instrumentally valuable false beliefs c. descriptive and non-descriptive beliefs If a JW holds an instrumentally valuable false belief and/or one that is non-descriptive, his choices based on her belief are autonomous. If JW holds an instrumentally irrational belief and/or one that she takes to be descriptive, then her choices based on her belief are not autonomous.

The Human Right to Health 12 (1) The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. (United Nations 1966) What may such a right entail? Is this right too demanding or does it demand the wrong sorts of things? Five Objections: 1. Human right to health is too vague Problem: what does “highest attainable” mean? Proposed solution: Protection against standard threats to health. But: what are standard threats to health? Is HIV a standard threat? “A condition seems to be a standard threat to health where, first it is serious enough to count as a threat, and second a solution could reasonably be expected to be in reach, either because treatment could be made available on a routine basis, or because the condition is widespread and urgent and there is every reason to think that the normal processes of scientific research would lead to a solution.” (6) 2. Human Right to Health does not allocate duties correctly Problem: Difficult to allocate duty holders But: While this may be difficult, why not view it as a work in progress?  3. The Human Right to Health is Unnecessary Why not just leave it at arguments for humanitarian aid? Because rights are what allow unjust structures to change: “If we believe that the world order should change in such a way that developing countries must be able to take charge of their own fates, then there is good reason to recognize human rights.” (8) 4. The Human Right to Health distorts efficient spending Easterly critique, part I: “the human right to health diverts resources to those who shout the loudest and have the best connections, so increases inequality and distorts cost-effective planning.” (9) While cost-effectiveness may be a relevant consideration in wealthy country’s it cannot be so in poor countries. Mozambique: so poor that nearly none of the necessary treatments are cost-effective: “Mozambique’s GDP per capita, according to the World Health Organization, is $770 and spending on health per person $50 (WHO n.d.1). The equivalent figures for the UK are $36,240, and $3,399 (WHO n.d. 2). The UK can afford a QALY threshold of £20,000 or above, because we are a wealthy country, and relatively few of us are seriously ill. It is easy to see why supplying ARVs in the developing world has often been said to be not cost-effective.” (11) 5. The Human Right to Health is damaging Easterly critique, part II: Too much focus on vertical health programs, that is, programs focusing on particular diseases (Aids, Malaria). But: 1. issue is being addressed and 2. not specific problem for human right to health.

Access to medicines: problems Global disease: Disease affecting both those in rich and in poor countries (e.g.: cancer) Problem: medicines too expensive for poor Neglected disease: Disease primarily affecting people in poor countries (e.g.: malaria, diarrheal diseases) Problem: pharma companies have little incentive to produce Selgelid: A Full-Pull Program for the Provision of Pharmaceuticals Critically evaluates Pogge’s Health Impact Fund (HIF): Seeks to increase access to medicines by incentivizing pharma companies to produce and deliver affordable medications to the poor by rewarding them according to the “health impact” their drugs actually end up having.   Selgelid mentions two problems with this idea: 1.Patent-reform (which HIF ultimately requires) is only part, possibly only a very small part, of what causes global health crisis. Poor patients cannot even afford very cheap medications 2.The HIF is designed to address the development of new drugs. It would be more effective if it applied its reward system to already existing, off-patent drugs and other determinants of health       Alternative (Kremer and Glennerster): To supplement “push programs” (which pay money to companies upfront to stimulate research and development but do nothing to incentivize drugs actually getting to the market) by making “advanced purchase commitments” so that it makes sense for companies to make dugs market-ready. Problem: still lacks incentive to actually get marketed drug to patients (last mile problem). (136) Objection to (both original and expanded) HIF: Real problem is unwillingness of wealthy countries and donors to spend much money on global health. If there were more money for that end (which HIF assumes) then we would not need HIF. “If large sums of money were spent on improving global health, then the new market that the full-pull program aims to create would already exist—and the incentive to innovate would already be in place.”(137) Yes, pharma companies would probably be more excited about governments generally pouring more money into global health, but  “governments …would be more likely to support funding of global health via the full-pull program …given that (1) there would be no monopoly pricing for the drugs in question and that (2) spending would be tied to impact—and also because (3) a fullpull program would provide health benefits to citizens of wealthy countries themselves.” (137) Practical problems with (original or expanded HIF): Measurement. It is unclear how to precisely measure the health impact of particular drugs in poor countries. “The impact of greater drug provision will depend on other, natural and non-natural, factors affecting the population in question. Fluctuations in climate, nutritional status, water supply, education, economic status, behaviours related to health risk, availability of other drugs and medical care, and so on, may all affect the impact that increased provision of any particular drug will have in any given population.” (138) It is also unclear what health metric to use: DALY’s” Disability Adjusted Life Years”: “In the case of life expectancy, the ideal…is 83 years. If a woman succumbs to a disease that kills her 10 years earlier…then 10 DALYs are attributed to her premature death from this disease. If a person spends 10 years with a disability that reduces the functioning or quality of her life to half of perfect health, then five DALYs are attributed to the disability.” (138) Problems with DALY’s: 1.How should severity of a disability be measured? 2.Age-weighing (life-years lost at younger age weigh more than life-years lost at later age)? 3.Time-discounting (life lost in future is weighed less than life threatened here and now) Selgelid: While 2. and 3. may be appropriate when it comes to allocation questions, they are not appropriate when it comes to measuring disease burden. Problems of Causation: 1.Disease burden measurement: if 40 year old women dies in Africa from TB, then TB is assigned 43 DALYs. But: living in Africa, this woman would have probably died by the age of 50 anyway. So while it may be correct to assign 43 DALYs, it is wrong to assign these to this particular TB infection. It would thus be wrong to reward company that had developed successful TB drug for health impact of saving 43 years of life. Possible solution: take local life-expectancy into account - either in the measure of DALYs or in the measurement of global disease burden more generally. Implication: It would weigh much more heavily if a woman in Japan died of TB at 40 than if a woman in Africa did. But very few 40 year olds fall ill of TB in Japan Most serious measurement difficulty: Causal attribution:  “This is the problem of determining the extent to which any reduction in GDB—or the burden of any particular disease—is the result of one intervention as opposed to another.” (140) “Imagine that someone who would have died from malaria ends up living because she receives a partially effective vaccine and gains access to a mosquito net. Even with perfect data availability, it may then be dubious to say that it was either the vaccine or the mosquito net that saves her life—and it may be dubious to say that there are some numbers X and Y such that her survival is X% caused by the vaccine and Y% … caused by the net.” (14) Possible solution: counterfactual analysis: We ask how many more deaths would have occurred, holding everything else equal, had particular drug or intervention not been present. But: problem of not always achieving “additive decomposition”: the number of lives attributed to different causes need not add up to the total number of lives that are saved” (140-1) Example: Drug A saves 20 %, drug B 30 % of given in isolation. Together, they save 100%. Counterfactual analysis impact of drug (post-intervention): if A had not been provided 70 people (of 100) would have died Counterfactual analysis impact of drug B (post-intervention): if B had not been provided 80 people (of 100) would have died Number of averted deaths of A + B= 150 (!) Way around this problem of over-counting is to use ratio between A and B as basis for research : 7 to 8. Given $100 reward, this would translate in t $47 for providers of drug A and $53 for providers of drug B. Which Baseline Example above uses post-intervention baseline. What if we used pre-intervention baseline? Drug A averts 20 death, drug B 30 deaths (although 100 would be saved if both were given together) Ratio 2:3. Providers drug A: $ 40, Providers drug B: $60. Time of Intervention Baseline? Drug A at time t1: saves 20. Drug B at time t2: saves 80 Drug A + drug B= save 100. Problem: incentive to hold off on providing treatment because benefits of synergistic effects would be attributed solely to later provider. On the table: three sorts of baseline. 1.Pre-Intervention baseline (2:3) 2.Post-Intervention baseline (7:8) 3.Time of Intervention baseline (20, 80) Post intervention baseline: Drug A: 5% Drug B: 5% A+B: 100% Drug C: 100% Drug A: 95% Drug B: 95% Drug C: 100% Better: Drug A (if provided with B): 50% Drug B (if provided with A): 50% Pre-Intervention Baseline Drug A: 5% Drug B: 5% A+B: 100% Drug C: 100% Drug A: 5% Drug B: 5% Drug C: 100% Problem: No incentive to give A and B together. Synergistic effects ignored. General lesson from these cases: 1.Examples can be construed that have counter-intuitive results 2.Depending on which baseline is used, profits would be divided very differently ●Selgelid thinks time-of intervention baseline holds most promise: incentive it provides is proportional to value of intervention Since problem is so serious, we should just try to do the best we can.

The Problem: health-care workers emigrate from developing countries to developed countries… …often leading to very unfavorable doctor/patient ratios in poor countries with highest burdens of disease. …so that those needing urgent care and medicine most often do not have access to either Doctors/Nurses per 10000 people: Africa: 0.2 or fewer (Somalia: 1.1 nurses) US: 24/98 UK: 27/101 Australia: 30 “The WHO estimated that healthcare systems with less than 23 health-workers (doctors, nurses, midwifes) per 10000 people are unable to deliver essential health services.” (1) Benefits of brain drain? Country of origin: (a)money sent back home (limited) (b)knowledge transfer of returning migrants (limited) Destination country (a) economic benefits (substantial) Is medical brain drain an ethical issue? Three views according to which it is: (a)It is symptom of underlying global injustice between rich and poor countries (b)It violates the human right to an adequate standard of health (c)Healthcare is special, comes with special obligations ●Thus, there seems to consensus that medical brain drain is unethical Ethical issues in the context of addressing medical brain drain: (a)May we restrict the individual choice of health workers to leave their home country? (b)Do health workers have special obligations to their compatriots? (c)Do receiving countries have duty to stop “poaching” or engaging in “reverse foreign aid”? What can be done? Destination countries should: (a)become self-sufficient in production of health workforce (plus provide development assistance for source countries) (b)grant only temporary work visas (c)compensate countries of origin for loss (d)recruit ethically (or not at all) Source countries should (where possible): (a)close wage gap (b)improve health systems (c)establish staff retention schemes (enabling vs. disabling) (d)establish “return of talent” programs (e)establish exit requirements (compulsory service or tax) Buyx and Kollar suggest employing multiple methods in a three-step process, moving from the least controversial ( ex.: asking destination countries/beneficiaries to pay) to the most controversial (ex.: asking migrants to pay back what their country has invested in them plus the potential loss their emigration will amount to) Hidalgo There is nothing wrong with actively recruiting healthcare workers from developing countries: It is morally permissible for organization A to recruit and hire person B for a job if (i)B voluntarily consents to the employment contract, (ii)the terms of employment and working conditions are fair, and (iii)A’s hiring of B avoids violating the moral claims of any third parties Nobody really worries about: (i)B voluntarily consents to the employment contract, (ii)the terms of employment and working conditions are fair Thus, topic of paper is critical discussion of: (iii)    A’s hiring of B avoids violating the moral claims of any third parties Basic presumption in favor of choice:We have moral prerogative to shape our lives in our own way, even if our choices fail to bring about maximally good consequences for other people Two principles against: 1.Enabling Harm. Organization A’s recruitment of person B is impermissible if this organization’s recruitment of B causes B to refrain from helping person C and, as a result, C suffers serious harm Ex.: only doctor in rural neighborhood is recruited away. But: Does emigration really lead to detrimental health effects in developing countries? (a)not necessarily. Statistics may be misleading. Sometimes healthcare workers emigration may not be a cause but rather be caused by growing numbers of deaths (b) various other factors (such as infrastructure, access to medicines and literacy levels) determine health outcomes (c) Health worker migration may have positive, compensating, effects: remittances, increased incentives to become medical professional (d) basic medical attention provided not necessarily by nurses and doctors but by medical officers and administrators (e) many healthcare workers unemployed in developing countries – despite the need for them Thus: medical emigration probably has negative effects only in some cases (606R)             2. Facilitating Wrongdoing. Organization A’s recruitment and hiring of person B is impermissible if B has an obligation to person C and A’s             recruitment of B would cause B to violate B’s obligation to C  But: Do health workers have special duties to their compatriots that are violated when they are encouraged to emigrate? Why would they? Because they benefited from receiving an education. This benefit may give rise to (i)duties of compensation or (ii)duties of reciprocity (fair play and gratitude) Against (i): no compensation for knowingly having been given benefits for which no compensation was contractually arranged Against (ii): (a) fair play. Health workers can pay their fair share of the burdens in other ways than not emigrating (they may return or send remittances) Moreover: what is fair share of the burden? (Ex. Annie who chooses to become musician instead of doctor after finishing her training) Against (ii): (b) gratitude. Imperfect/ indeterminate duty Hidalgo’s conclusion: “Although the active recruitment of health workers may be objectively wrong on occasion, recruiting organizations are not usually culpable for this wrongdoing.” (609L)