[Note to future readers: this was written in the midst of the 2020 Coronavirus (COVID-19) pandemic.]
The stories coming out of Italy over the past two weeks have been chilling. With their healthcare system overwhelmed by COVID-19 cases, Italian doctors are facing tragic triage decisions on a daily basis. In severe cases of COVID-19 patients need ventilators to survive. But there are only so many ventilators to go around. What if you don’t have enough? Who should you save? The 80 year old with COPD and other medical complications or the slightly healthier 50 year old without them? The 45 year old mother of two or the 55 year old single man? The 29 year old healthcare worker or the 38 year old diabetes patient?
Questions like these might sound like thought experiments cooked up in a first year ethics class, but they are not. Indeed, decision-making of this sort is not uncommon in crisis situations. For example, infamous tales are told about what happened at the Memorial Medical Center in New Orleans during Hurricane Katrina in 2005. With rising flood waters, no electricity and several critically ill patients who could not be evacuated, medical workers at Memorial had to make some tough decisions: abandon patients and leave them die in agony or administer euthanizing drugs to end their suffering more quickly? The suspicion is that many chose the latter course of action.
And medical decisions are just the tip of the iceberg. As we are all now being asked to isolate ourselves for the common good, many of us will find ourselves confronting similar, albeit less high stakes decisions. Which is more important: my duty to care for my elderly parents or my duty to protect them (and others) from potential transmission of disease? My duty to work to ensure that other people have the essential services they need or my duty to myself and my family to protect them from illness? We may not like to ask these questions, but we cannot avoid them.
But what are the answers? What should people do in cases like this? I don't know that I have much in the way of specific guidance to offer, but I do have a point that I think is worth making. It's at times like this that the essentially tragic nature of much moral decision-making reveals itself. This tragedy lurks in the background most of the time, but it is brought into sharp relief at times like this. Once we are aware of this ineluctable tragedy we might be inclined to change some of our common moral practices. We might be less inclined to blame others for the choices they make; and we might be more conscious of the pain of moral regret.
Let me explain what I mean.
1. Do Moral Dilemmas Exist?
One way to get at the point I wish to make is to consider whether or not genuine moral dilemmas exist. This is a topic that Lisa Tessman has addressed at some length in her work. Tessman argues that there is a distinction to be drawn between moral conflicts and moral dilemmas:
Moral Conflict: This is any situation in which two or more moral obligations appear to be in tension with each other in such a way that it is not possible to satisfy both obligations. Nevertheless, it is possible that one of the obligations overrides and cancels out the other.
Moral Dilemmas: These are situations in which two or more moral obligations appear to be in tension with each other in such a way that it is not possible to satisfy both obligations and neither obligation ceases to be an obligation just because you favour one over the other.
Moral dilemmas are, thus, a specific kind of moral conflict. They are a kind of moral conflict that is, in a critical sense, morally unresolvable. You may, as a matter of practical necessity, favour one obligation over the other but in doing so you do not eliminate the other. Your choice is, consequently, tragic because it necessarily entails some moral loss.
That's just to characterise the phenomenon. Do any genuine moral dilemmas exist? Some people argue that they do not. Such people typically fall into two different groups. The first group argue that basic principles of moral logic imply that moral conflicts cannot exist and so dilemmas cannot exist; the second group argue that conflicts do exist but none of them are genuine dilemmas.
The argument made by the first group can be quite complicated but the gist of it is easy to follow. It's best to use a concrete example to ground the discussion. Take the medical triage decisions now facing doctors with more patients than they have ventilators/respirators. Presumably we would ordinarily say that a physician has a duty to save any patient's life. So in the triage case, the following obligations would seem to apply:
Obligation A: You have a duty to save the 80-year-old patient's life.
Obligation B: You have a duty to save the 50-year-old patient's life.
Ordinarily, again, we would say that both obligations can be combined together into a single obligation stating that you have a duty to save both patient's lives. The problem is that, in the triage circumstances in which you find yourself, you cannot save both patient's lives. That's the root of the apparent moral conflict. But proponents of this first argument say that this conflict is not real because there is a general principle of deontic logic that stipulates that 'ought implies can'. In other words, you are only obligated to do that which it is possible for you to do. In the triage circumstances, it is impossible for you save both patient's lives. Therefore, you cannot be obliged to do so. Dilemmas cannot exist.
The second argument against dilemmas is the one favoured by moral consequentialists. They argue that moral conflicts do exist but that the tension between two or more moral obligations can be resolved, decisively, in favour of one obligation in most cases. As Tessman puts it, proponents of this argument believe that all moral obligations are defeasible or negotiable. So, although you might think you have an obligation to save someone's life, in the right circumstances that obligation can be outweighed by another weightier obligation. Take the triage case again. In that case you are weighing two lives against each other. Prima facie, it seems like you have an obligation to save both, but a closer inspection reveals that your obligation to save one life outweighs your obligation to save the other. How so? Well, a simple cost-benefit analysis makes it clear. The 80 year old has had a longish life anyway. They have an underlying chronic condition. Even if you save them from COVID-19 they will probably die in the not too distant future from that condition. The 50 year old has more life left in them. They are unlikely to die in the near future. If you save them, then you save more quality adjusted life years. The obligation to save the younger person's life clearly outweighs the obligation to the older person, at least in the difficult circumstances in which you find yourself.
Of course, it's not that simple. The cost-benefit analysis I just outlined is crass and, arguably, callous (although probably not that dissimilar from the kinds of decisions that doctors are now making in the wake of COVID-19). If we had the time, we might like to revisit some aspects of it. Is it really true that the 50 year old will live much longer? Could they have an underlying condition that has not yet been discovered? What have they done with their lives so far? Are they evil psychopathic killers? Might their death affect fewer people? The answers to these questions might push us in a different direction. Nevertheless, the basic point is clear enough: conflicts can be resolved if we examine the facts and likely consequences of our actions in a bit more detail.
In sum, these two arguments go against the claim I made in the introduction: that much moral decision-making is tragic in nature. They suggest that either (a) no moral decision-making is tragic because moral conflicts cannot (logically speaking) exist or (b) moral conflict is more apparent than real: moral obligations are negotiable and can be overridden in the right circumstances.
2. The Problem of Moral Remainders
It would be nice if those arguments worked. They wouldn't absolve us of the hard work of analysing apparent moral conflicts, but they would provide us with some reason to hope that this exercise is not in vain. They would suggest that it is possible to avoid moral wrongdoing when confronting difficult cases like this.
But it doesn't really feel like this, does it? Many times the conflict seems real and unresolvable. Bernard Williams once wrote an article that examined this problem in some detail. In it, he argued that you have to compare moral conflicts with two other kinds of conflict: conflicts of belief and conflicts of desire.
Suppose I believe that I got married on a Friday and I also believe that I got married on the 18th of November 2017. Suppose now that the 18th of November 2017 wasn't a Friday: it was a Saturday. Clearly, my beliefs conflict. But when I learn of the conflict, and of the underlying facts, one of the beliefs clearly wins out. My belief that I got married on a Friday must be wrong. The knowledge that the 18th November was, in fact, a Saturday cancels out this earlier belief. Nothing of that belief remains after the conflict is resolved.
Contrast that with a conflict of desire. Suppose I would really like to go to Aruba on my summer vacation but I would also really like to spend my summer on a visiting fellowship at New York University. I cannot fulfil both desires at the same time. In the end, I choose to go to Aruba. Does this mean that my desire for New York dissipates or ebbs away? Not at all. It lingers as a regret. I'll always be inclined to ask: What if I had chosen the other path?
As Williams describes it, the point here is that conflicting desires leave 'remainders' no matter how you resolve the conflict. And moral conflicts are much more like conflicts of desire than they are like conflicts of belief. When you are confronted by the triage case, and when you decide to save one life over the other, the sense that you violated your obligation to the life not saved lingers. It is a perpetual source of moral regret. It leaves a moral remainder.
This is an appealing line of thought and certainly resonates with my own experiences. Whenever I have had to resolve a moral conflict, I often find myself plagued by the sense that I violated an obligation. But apart from the intuitive appeal of Williams' comparison is there anything more to be said in favour of the idea that resolving a moral conflict often leaves a moral remainder? There is and Tessman says much of it in her book Moral Failure. Her position is a complex one and I cannot do justice to it here, but there are two facets of morality to which I would draw your attention that support the idea of a persistent moral remainder.
1. Value pluralism: We value many different things. We value freedom and equality; security and privacy; life and well-being; health and happiness; and so on. Although some people argue that these different values are reducible to something else (e.g. pleasure) many people reject that idea. They believe that each of these values is a different thing. They cannot be reduced to one another, nor can they be measure along a single scale of value. They are, to use the technical jargon, incommensurable. If we were asked whether freedom was more important than well-being, we would have a hard time coming up with an answer. If that's right, then any moral conflict involving a clash of different moral values will leave a moral remainder. Why? Because resolving the conflict in one direction doesn't mean that the neglected moral value is unimportant or cancelled out by the weight of the other value. It's just not really possible to make those kinds of comparisons
2. The Uniqueness of Persons: It is a common presupposition of moral thought that each human person is both unique and equally valuable. That is to say, no one person's life takes precedence over another's and all human lives are distinct. This implies that human lives are not fungible or interchangeable. This creates problems for any moral conflict involving competing duties to unique persons. Since every person is unique, you cannot trade your obligation toward them with an obligation toward another person. That obligation lingers, no matter what you do.
But, when you think about it, both of these features of morality are pervasive features of our daily moral lives. We owe obligations to many, distinct people -- our children, our friends, our colleagues, our partners and our fellow citizens -- and we work with competing values all the time. So many moral choices leave remainders, not just the kinds of radical dilemmas beloved by ethics professors.
3. Moral Remainders and COVID-19
This brings me back to my opening point. We are now in the midst of a global health crisis of historic proportions. People are dying on a daily basis because of this rapidly spreading disease. We are forced to make choices we don't want to make; to trade lives and values off against each other. The speed at which we are forced to decide is what makes the tragedy so apparent. Whenever we confront clearly limited resources, both temporal and physical, we can perceive moral conflicts in a starker way. Ordinarily, we live with the illusion that we can postpone hard choices or reverse/correct them if we make a mistake. In the midst of a crisis, this illusion is unsustainable.
What does all this mean? I'm not sure. We have to make choices, and we have to trade lives and values off against each other. I don't know of any way to do this without resorting to something like a consequentialist analysis of the probable outcomes of our choices. But we shouldn't be too confident in the power of that consequentialist analysis. It will sometimes rely on arbitrary and unjustifiable preferences. The people who make such decisions will have to live the moral remainders that result.
Correction: we will all have to live with them.