Conclusion

Even if according to all plausible theories of distributive justice, spending more on the care and cure of patients suffering from mental illness should be a priority rather than on marginal life extension, this will not happen. The reason has to do with fear of death and human irrationality. Does the fact that we will not abide by any one of the theories, even if we are convinced that it is true, mean that there is something wrong with it? Does our reluctance to act on the theories mean that they must be false? I think not. Here I avail myself in my argument of moral realism. If there is a truth in the matter, there is no reason to believe that the correct moral theory must be such that we abide by it, once we accept it (theoretically speaking) as true. This means that our unwillingness to live according to the theories does not show that they are unreasonable. The problem lies not with the theories themselves but rather with our unwillingness to abide by them. We are to blame, not abstract moral theory.

The Maximin/Leximin Theory

The maximin/leximin theory is applied in real medical life. The general result, in relation to any welfare state assuming its global obligations, is that more resources ought to be directed to the care and cure of people suffering from mental illness; less should be spent on marginal life extension (especially among elderly patients).The urgency of mental health, when the matter is assessed from the point of view of the maximin/leximin theory, has to do with the fact that people often suffer for very long time from mental disease rendering it plausible to assume that many people in this category garner throughout their lives a net deficit in terms of happiness. Hence they are the patients who are worst off. The problem with marginal life extension among elderly patients has to do with the fact that many among them have throughout their long lives already garnered a lot of happiness. Now these people have to stand back when there is fierce competition for available medical resources.

Egalitarianism

The idea that it is bad for a person when someone else is better off is presented. If taken seriously, this means that one should maximize not the sum total of happiness but a weighed sum where the weights for each person are given with reference to a position in relation to others with regard to happiness. This is egalitarianism. The egalitarian idea presupposes that interpersonal comparisons of happiness are possible and it takes for granted the distinction between persons. Yet, while it acknowledges that compensation within lives is morally unproblematic, and accepts some compensation between lives, the latter kind of compensation comes with a moral price whenever it means that increments fall on those who are better off rather on those who are worse off (comparatively speaking). Since compensation within lives is considered morally acceptable it is maintained that when we assess how badly off a person is, in relation to others, we focus on their entire lives rather than on time-slice of them.

Utilitarianism

Utilitarianism is the idea that we ought to maximize the sum total of happiness. The notion of happiness is clarified. Happiness is taken in a subjective and empirical sense, as a kind of mood. Affirmative answers to the following questions are provided: What is happiness? Can it be measured? Can we compare it between persons? Can it function as a common currency when the different theories of distributive justice are compared? What about the heterogeneity objection? Can very different kinds of happiness be measured on a single scale? In the answers to these questions the idea of a least noticeable difference with respect to happiness plays a crucial role. It is conjectured that, if a person is in a certain mood (momentarily), then there exists an exact number of just noticeable changes for the worse or the better to the point where life is just worth living. Many different conditions can contribute to cause a person to be at the state where she is. A distinction of the utmost importance between physical and subjective time is introduced and a claim is made that what matters, from the point of view of moral theory, is subjective time.

Introduction

Three theories of distributive justice are introduced: the maximin/leximin theory, egalitarianism, and utilitarianism (with or without a prioritarian amendment). A methodology for assessing their plausibility is adumbrated: applied ethics turned upside down. This means arranging with crucial thought experiments where we reach conflicting verdicts from the theories. We confront the verdicts with the content of our considered intuitions. Roughly speaking, an intuition is taken to be ‘considered’ if it has survived cognitive psychotherapy, where we have learnt all we can about its causal origin. The theory that provides the best explanation of the content of our considered intuition gains support from the experiment. A nice aspect of thought experiments, it is noted, is that we are all capable of repeating them for ourselves.

Utilitarianism

Utilitarianism and prioritarianism are compared. It may seem that only prioritarianism takes suffering seriously enough. Even if utilitarianism is more sensitive to suffering than is the maximin/theory or egalitarianism, it does not take suffering seriously enough. According to prioritarianism, we should help a person in deep distress rather than improving the situation of a very happy person, even if this means some waste of happiness (the person in distress gains fewer hedons that the happy person would do if instead we tended to her needs). The prioritarian needs to tell us exactly how much weight should be given to momentary suffering and happiness, however. They need to specify the relevant function. This has been shown to be a difficult task to undertake. Moreover, according to prioritarianism a life with a net surplus of happiness may be worth not living. Some may give up on prioritarianism because of this implication of the theory. Others may stick to the rationale behind it, bite the bullet, and amend utilitarianism with prioritarianism. Both moves are considered justifiable.

Triage in Situations of Mass Casualty

In situations of mass casualty there is a need to tend to the medical supply side. We must contemplate whether, by saving one person rather than another, we affect the medical resources available to us. Should medical personnel be tended to first if this means that those who are saved first can go on to save other lives? When resources are scare, should younger patients be treated rather than old ones? The unexpectedly similar implications of the three theories of distributive justice in situations of mass casualty are presented. Here a discussion is also undertaken about equity and the idea that we should save as many lives as possible. Does it make sense to flip a coin when you decide about priority setting in a triage situation? Could saving as many lives as possible work as a proxy for utilitarian thinking? Both the equity view and the idea that one should save as many lives as possible are rejected. It is argued that we should rely on our favoured theories: utilitarianism (with or without a prioritarian amendment), the maximin/leximin theory, and egalitarianism.

Some Controversial Implications of the Three Theories

Utilitarianism, the maximin/leximin theory, egalitarianism, and prioritarianism all come with, on the face of it, plausible rationales. However, these theories are inconsistent with one another, so they cannot all be true. It is of note, also, that each of them comes with some problematic implications. In particular, according to utilitarianism there are fewer reasons to extend the life of an unhappy person than the life of a happy person. Hence it has been thought to discriminate against disability. On the maximin/leximin theory, on the other hand, those who are worst off may seem to have a morally legitimate claim on all the good things in life (they become what is here nicknamed as ‘utility thieves’). Egalitarianism implies that levelling down to a situation where everyone is on the same low level of happiness means, at least in one respect, an improvement. Moreover, egalitarianism is insensitive in relation to momentary suffering. Prioritarianism does take suffering seriously, but apart from this it shares the standard problems with utilitarianism, which is only to be expected, since it is here seen as a mere amendment to utilitarianism.

Prioritarianism

The rationale behind prioritarianism is the idea that suffering has a special moral importance. This means that a person who momentarily suffers has a special moral claim for improvement of her hedonic situation. It is the other way around with happiness. Prioritarianism is seen as a possible amendment to utilitarianism. Since suffering takes place at a definite time, momentary suffering, not suffering within an entire life, is what matters, according to prioritarianism. While the maximin/leximin theory gives absolute priority to those who are worst off prioritarinism presents a more nuanced view. Some special weight is given to an amount of happiness/unhappiness depending on where it falls, on a happy or on a miserable moment. There are many ideas, however, about how to specify the exact weight which should be given to an instant of happiness/unhappiness depending on where it appears on the hedonistic scale. This means that prioritarianism presents us with a family of theories rather than with one theory in particular. They all agree on the claim, however, that what should be maximized is a weighted sum of happiness rather than the sum total of happiness.

The Maximin/Leximin Theory

Presented in this chapter is the Rawlsian idea that one should take seriously the distinction between (and integrity of) persons. This distinction between, and integrity of, persons, is the metaphysical rationale behind the normative idea here discussed to the effect that absolute priority should be given to the person who is worst off. This is the maximin idea. Once the needs of those who are worst off have been catered to, we ought to tend to the needs of those who come next in line. This is the leximin idea. In the defence of these normative ideas it is taken for granted that interpersonal comparisons of happiness are possible and that compensation within lives but not between lives is permissible. This idea is contrasted with the utilitarian maxim that we ought to maximize the sum total of happiness. It is argued that the metaphysical rationale behind the maximin/leximin idea is consistent with utilitarianism so the choice between the maximin/leximin and utilitarianism relies in the final analysis on normative, not metaphysical, considerations.