[3.] Stopping AIDS.

 

This unit of material considers the moral issue of stopping the spread of HIV/AIDS, and it uses as a case study the story of Paul Farmer, given throughout Pence ch.4.

 

Pence uses the issue of HIV/AIDS to examine the following moral issues:

·         the relevance of motives to morality;

·         the moral basis of triage medicine;

·         the responsibility of the developed world for saving lives in the developing world;

·         distributive justice with regard to scare medical resources; and

·         medical research using human subjects.

 

 

[3.1.] Statistical Background.

 

According to the World Health Organization:

·         an estimated 33 million people are living with HIV, including 2 million children under the age of 15;

·         an estimated 2 million people died from AIDS in 2007, including 270,000 children under 15;

·         an estimated 2.7 million people were newly infected in 2007.[1]

 

These numbers have all decreased in recent years, due in part to PEPFAR (U.S. President’s Emergency Plan for AIDS Relief), initiated by G. W. Bush in 2003. The program initially committed $15 billion to be spent in its first five years. The program estimates that it has prevented more than 16 million cases of mother-to-child HIV-transmission and has provided life-saving retro-viral treatments for more than 2 million HIV+ individuals, the majority of whom reside in sub-Saharan Africa.[2]

 

“If an effective strategy could be found and implemented, more lives could be saved by curing AIDS than by all other surgery, drugs, and public health efforts combined.” (Pence 81)

 

The prevalence of AIDS in some countries (Pence mentions Botswana and Zambia) has dramatically reduced life expectancies in those places and has resulted in a wild imbalance in life expectancy in developed countries versus that in less developed countries.[3]

 

[3.2.] Motives and Medical Saints.

 

According to Pence, the view of motives most commonly held by medical professionals is that motives matter: “it makes a difference whether a physician listens because she really cares about patients or because she’s found that satisfying patients is an effective way to maximize income.” (86)

 

This view is connected to the assessment that virtue ethics gives of the work of Paul Farmer, viz. that he is a “medical saint.”

 

The three theories of normative ethics we’ve considered have different ways of thinking about motives.

 

 

[3.2.1.] Utilitarianism: Motives Are Not Important.

 

Any form of consequentialism, including any form of utilitarianism, is a teleological theory:

 

teleological theories: (df.) theories that focus on goals, ends, outcomes, how things turn out.

 

For this reason, such theories seem unable to accommodate motives. If someone does something with the intention of bringing about bad consequences, but inadvertently brings about good consequences, then utilitarianism, strictly understood, has to say that he has done something morally right. But this does not seem quite right; we want to say that a person’s motives are relevant to the morality of his actions.

 

• For example, suppose that I am due to inherit a lot of money from my great aunt when she passes away. Impatient, I tamper with the brakes on her car in the hopes that they will fail while she’s on the highway and cause a fatal accident. As it happens, the breaks give out when she first backs out of her driveway, and she rolls harmlessly into a vacant lot across the street. When she goes back inside to call AAA, she notices a natural gas leak—so she quickly calls the gas company to come repair it. As it turns out, had she not been stuck at home because of her failed breaks, she would not have noticed the gas leak, and her house, as well as all the houses on her block, would have been destroyed! So my attempt at murdering my aunt had unintended good consequences.
• On a strict utilitarian standard, what I did was morally right—even though my motives were reprehensible. This illustrates that if a theory focuses purely on consequences, as does utilitarianism, it does not leave any room for motives… and thus has implications that violate moral common-sense.

 

This does not mean that utilitarians must deny that motives matter at all. They can still maintain that in general, it is good for people to act from good motives (and bad for people to act from bad motives). But they must explain why this is by saying that, in general, people who act from good motives cause good consequences (and, in general, people who act from bad motives cause bad consequences). On the utilitarian view, motives can never be good or bad in themselves.

 

 

 

 

[3.2.2.] Kant: Motives are Very Important.

 

Kant held motives to be extremely important. On his view, the only thing good without qualification is a good will. Health, wealth, intellect, etc. are only good insofar as they are used well, used by a person who is operating with good intentions.

 

The good will’s only motive for doing the right thing is that it is the right thing to do. In other words, the good will acts out of duty for the sake of duty, not because of any consequences that doing one’s duty might have. For example,

• A shopkeeper who gives correct change, but not necessarily for the right reasons. If he gives correct change just because he wants his customers to think he is honest and to continue patronizing his business, then he is not acting from a good will. But if he is doing it because he believes that it is the right thing to do, then his motives are good.
• A friendly person who frequently helps others may be doing the right thing but not for the right reasons. If he simply enjoys behaving nicely towards others, and if that is the only reason he is doing it, then he is not motivated by a good will. In this case, Kant says, he is simply acting from inclination. No one chooses to be inclined to act a certain way, and actions that result from a good will must always stem from a free choice on the part of the agent. But if he is nice and helpful because he knows that he should be, then his motives are good.

 

 

[3.2.3] Virtue Ethics: Motives are Very Important.

 

Virtue ethics takes character traits such as compassion to be deeply important, especially for physicians. And these traits must be genuine. It is not enough for a doctor simply to act as if she really cared for her patients’ welfare. To be a moral physician, one must truly feel for one’s patients and genuinely desire to help them for the sake of helping them, not because doing so will improve one’s business.

 

Pence offers a reason why this is so important from the perspective of virtue ethics:

 

... it is not enough for the physician to just go through the motions of caring for patients. Eventually her patients will see the difference between just going through the motions and really caring. You can’t fake real virtue. (Pence 86, emphasis added)

 

But this just raises the question: what difference does it make whether the patient believes his doctor is genuinely compassionate or not? Why is it important, from the point of view of ethics, if the patient can tell the difference between real and faked concern on the part of the physician?

 

The most plausible answer is that the patient will be worse off if he knows this. But this answer goes beyond virtue ethics... it’s actually how a utilitarian would argue that doctors need to be genuine. As Pence says, “many utilitarians would ... agree that a good person determined to do good has high utility in the world and should be emulated.” (86)

 

Further, consider the case of the doctor who is faking her concern but doing so really well, so that her patients cannot tell. Their health is not affected by the doctor being less than genuine. In this case, why would being genuinely compassionate matter?

 

One plausible answer is that “faking it” amounts to treating the patient with disrespect, treating him as a means to an end (viz., making more money). But of course, this answer goes beyond virtue ethics as well: it is how Kant would argue that it is wrong to be less than genuine with one’s patients.

 

This is another example of the criticism with virtue ethics that we saw earlier: virtue ethics seems to be incomplete, in that it raises questions which can only be answered by appealing to another normative ethical theory.

 

 

[3.3.] The Maximization Principle and Triage.

 

Pence discusses a principle that is in harmony with utilitarian thinking, but that in some circumstances can have horrific implications:

 

The Maximization Principle (MP): “it is better to save more people than fewer.” (87)

 

If this principle is true for all circumstances, then it will always be at least morally permissible, and perhaps even obligatory, to sacrifice one person in order to save two or more. In some situations, this might be acceptable. Pence lists these examples (87):

·         “...Nazi generals who tried to kill Hitler in 1944 at Wolf’s Lair were justified.”

·         “...on the expedition to the South Pole in 1913, Commander Robert Scott should have allowed his crew member with the gangrenous leg to die, rather than slowing down the whole party by taking turns carrying him, which resulted in the death of all.”

·         “...if an FBI shooter saw a terrorist about to detonate a bomb in a bus full of innocent people, the sniper should shoot the terrorist.” (Or, analogously, a fighter pilot who shoots down a full passenger airliner which is about to be flown into the White House.)

 

As Pence points out, MP is also plausible when we are thinking about worldwide public health crises:

 

With tens of millions of people infected, and equal numbers at risk, talk about treating each person as “an end in himself,” and giving him or her the highest standard of medical care seems an outdated luxury, especially if the opportunity cost [i.e., the cost in terms of lost opportunities] of this high care for an individual is no care for many others. Perhaps utilitarianism has finally found its time. (Pence 87)

 

MP is a guiding idea of triage medicine:

 

triage (df.): the sorting or prioritizing of patients according to how badly each needs care, in a situation such as an emergency room or battlefield when it is not possible to help everyone who needs it.

 

Utilitarianism endorses this approach to treating patients:

 

...a physician should not treat each patient equally, but should focus only on those whom he can actually benefit. ... A physician should abandon those who will die anyway, even if he could soothe their pain, and just as ruthlessly, abandon those who will live anyway without his help. He should help only those who waver between life and death and for whom he can make a difference. The goal is to save the most lives. (Pence 89)

 

But Pence also asks us to consider the following, far less plausible implications of MP:

·         The lifeboat metaphor (see Pence 89). The captain is obligated to save the strongest rowers, as well as to kill innocent people attempting to climb aboard and whose doing so would cause the boat to sink. [In this instance, putting a Kantian view into practice will— paradoxically—result in fewer lives beings saved. The Kantian will be obligated not to throw overboard anyone who makes it to the lifeboat. But this policy will eventually result in the lifeboat sinking, drowning everyone on board.]

·         Suppose a couple has three children, two of whom are in desperate need of organ transplants, but the other of whom is perfectly healthy. MP implies that it would be permissible for the parents to kill the one healthy child in order to take his organs and transplant them into the other two children, thus saving their lives.

 

In each scenario, a utilitarian view that accepts MP will be lead to violate the principle of the sanctity of human life, according to which each individual life is morally valuable and may never be purposefully sacrificed.

 

So it seems unlikely that MP is true across the board, in all situations. But neither does it seem that Kant’s approach is plausible for every situation.

 

 

Stopping point for Wednesday January 21. For next time, continue reading Pence ch.4 (pp.90-96).