Hello, I'm Katrien Devolder.
This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all.
This is a special edition on ethical questions raised by the Corona pandemic.
This time, I will talk to Moti Gorin, assistant professor at Colorado State University.
He argues that when we can't treat everyone, because medical resources are scarce,
we should sometimes give priority to patients who are parents of dependent children.
I think this view has intuitive appeal, but it is also extremely controversial.
So let's dig a bit deeper into the arguments in support of it.
The question which COVID-19 patients.
We should treat when we can't treat them all because we just don't have enough medical resources is a really difficult question.
And it seems like all proposed approaches have some problems.
But what you propose is even more controversial because you think that we should take into account whether a patient is a parent.
Right. Or a caregiver. Can you just explain your view a little bit?
The view I want to sort of suggest and I think, you know, I would like to see implemented.
I think that one's status as a primary care caregiver to dependent children
It is a moral consideration that ought to be taken into account along with whatever other mix we're already taking into account.
It's not that you prioritise parents above everything else.
How heavily this consideration ought to be weighted. I leave kind of open, I think at its weakest at the weakest level.
It could serve as a sort of tiebreaker. You might give it more weight and let it outweigh, I don't know.
Prognosis or a certain degree of prognosis or something like that.
But I leave that sort of an open question.
What I want to sort of establish is that we're missing something of moral importance when we fail to take parental status into consideration.
It's quite controversial because many people think that medicine should only be concerned with health.
Right. So, yes. What is it about this parental role that makes it so important?
Why should we take that into consideration?
Well, I can tell you, just the way I started thinking about this sort of anecdotally is sort of autobiographically, as I had several years ago.
I had a bit of a health scare. I had a melanoma on my arm. And this is a potentially deadly skin cancer.
And I had it removed, but it was early stage. No problem.
But upon getting this news, that's, of course, frightening. And at the time, my children are still young.
They they're very young. And one of my first thought was, well, this isn't going to be good for them.
And thinking about the ways in which it's bad for children to lose a parent got me thinking about how that, what role that might play that badness
might play in distributive schemes. There are lots of different dimensions along which the death of a parent can be bad for a child,
because I want the argument to work in a pluralistic society.
I had to find an argument that doesn't appeal to some controversial conception of the good, right.
It's not that parents are more socially valuable. It's not that parents are virtuous.
They're choosing a good life like you might get from some religious conservatives, for example,
at least in the United States, believe there's something intrinsically valuable about having children.
And this kind of thing, there's something wrong with you if you don't can appeal to those sort of controversial conceptions of the good.
Now, as it turns out, there is a fairly good literature or empirical literature on the health effects of parental death on children.
You get kids with higher rates of depression, higher rates of mental health problems up to and including suicide.
Now that you've got a health implication, it seems like doctors can no longer say, oh, we're not concerned about social value.
We're not here to save the banker because they help grease the wheels of the economy.
We're not going to make those judgements. We only care about clinical criteria.
Well, we've got clinical criteria here. And so I appeal just to the health benefits to the child of benefiting the parent.
Just to clarify, so does it matter whether, for example, the parent has more children or whether the children are,
for example, young young children or, for example, children with a disability?
So I would need to look more deeply at the empirical literature or we would need to speak to somebody who studies the stuff.
On the one hand, you might think, well, look, so here's let's just say a mother of one child and here's a mother of five children.
And let's suppose you're deciding between them.
You might think on the one hand, you should save the mother of five children because you're going to reduce harm amongst five people.
But after reducing harm amongst.
But you also might think, well, maybe there is some kind of an insulating effect against the loss of a parent by having a number of siblings
Yes. And I don't I don't know the answer to that, it's empirical question, but I don't know whether it's yet.
But, yes, you're open to the possibility that we might have to take into account these differences.
If if it turns out that some groups have much worse health effects of the death of a parent.
That's right. The way I've approached this project is I look at the the rationale provided by the bioethicists
and policy makers who have been writing about resource allocation and conditions of scarcity.
And the more recent papers have come out thinking that's been done with respect to the COVID-19 pandemic.
And what you see there, rightly or wrongly, right, is a real emphasis on maximising health outcomes.
So you're trying primarily to save as many lives as you can.
And also to save as many life years as you can with certain constraints grounded in justice.
And so I assume that broad theoretical framework, just because there's only so many fights you can pick at once.
And so I want to introduce parental status as a moral consideration.
And I want to say, given what's we're already committed to
we ought to be committed to this. Then there is, of course, a question about where to draw the line.
So if we should prioritise parents because of the indirect health benefits on others, I mean,
should we prioritise other patients who also have indirect health effects on others,
like health care workers themselves have, definitely have health effects on other people?
Of course, of they die than many other people will die. So do you think we should also prioritise healthcare work?
I, I do think we should. Frontline health care workers have instrumental value when I save you the doctor.
You, the doctor, go on and save other lives. We need doctors to save lives.
There are also some who argue that we owe some kind of.
We have a duty of reciprocity. Health care workers put themselves at risk for the benefit of others.
And so when they themselves become ill society, we should you know, we should we should sort of pay them back in a way.
Health and Human Services some years ago at a policy out for how to prioritise influenza vaccines in the case of a pandemic,
as one of the first groups to be prioritised were pregnant women and mothers or parents or
anybody who was in close proximity to children who were six months of age and younger.
The reason being a child that six months or younger couldn't take the vaccine directly.
And so what you do is you provide a kind of herd immunity around that child.
What's going on there? Why prioritise a parent of a six month old or younger child?
Well, because when you do that, you might save two lives rather than one. And I think my proposal sort of follows this very similar line of argument.
Just one more question about drawing the line. There are several arguments to prioritise health care workers.
But what about like I mean, there are other people who have indirect health effects?
For example, someone who employs many people? I mean.
if all these people lose their jobs. That will definitely have mental and even other health effects.
Here I'm sort of torn. There are one of two ways. One of two routes to go.
And I'll explain what they are. So the first route was to just accept it.
Say sure. It just it's a matter of consistency. Right.
If saving this person what would be instrumentally valuable with respect to maximising health, then we ought to give that person some priority.
Another route is to say, no, there's something that might it might not be unique to parenting.
It might not be unique to being a primary caregiver of dependent children.
But there is something at least unusual and special about that role as it relates to health.
There are certain benefits or sources of benefits that you might call fungible.
I mean, we like to sort of glorify creative, large employers.
But, you know, I don't know. Steve Jobs died and Apple goes on.
So there's important roles that can be filled by maybe not anyone, but more than one person.
But it's not as if a new human individual can come in and they can give you some support and love.
But it's not your parents. There's something very distinctive and idiosyncratic about that particular individual,
and it has to be that individual in order to achieve the full benefit.
And so the other way, I might argue, say, no, it doesn't need to be only parents,
but certainly parents have a special relationship with their children that that's going to affect the health outcomes.
I think the special relationship is quite plausible.
But then, of course, the next question is, I mean, there are other relationships that are very special.
So I can, for example, be that you have dependent parents. Or, for example, are really close friends.
My best friend. Oh, we've been friends since we were three years old.
So that's completely irreplaceable and unique in a way that's like a parent child relationship could be unique.
So what do we do with other sort of relationships?
I mean, one thing I can say here is that sort of ethically speaking,
morally speaking, yes, they should be granted some priority as a practical matter.
There are just too many variables involved in assessing whether this particular friendship meets the bar or
this particular sibling caring relationship would really have an adverse effect on that particular individual.
The practical difficulties seem to me to be insurmountable. Whereas with parenting policy wise, it's a fairly easy, clean cut principle.
And you're going to get it wrong sometimes.
But we get it wrong sometimes, now in the sense that you can prioritise the person with the better prognosis.
It turns out they leave the hospital. They get hit by a bus. And so you wasted that.
You wasted a liver
But, you know, the obvious concern some people may have is that your proposal would be quite unfair for people who don't have children.
And maybe for several reasons.
So one reason I thought was, well, some might say people who don't have children already contributes.
via taxes like financially. Quite a lot, yes, to the education of children and so on.
And then they come in this situation and then they have to sacrifice their lives.
So that seems unfair. Yes. So that's one concern.
Yes. Yes. So. So I think this is actually the strongest objection to my view.
And you might frame it in terms of unjust discrimination.
So my response here, and I'd be curious to see what you think.
I think I sort of developed a clever response here, but it's dangerous to think we're too clever.
So what I want to say here is.
It's true that the parent gets an advantage relative to the non parents, and it's not as if it's either trivial or that their lives are being saved.
But the rationale for doing so is grounded in the well-being of the child.
All of us, whether we're parents or not, we're once dependent children.
So although I as a not hypothetically, if I did not have children, I today can't get the benefits,
but I would have been it would have been open for me to get the benefit. Had one of my parents been ill.
And so in principle, nobody is being excluded because everybody, like it or not,
is born in a particular way and has caretakers or else you wouldn't make it past one day of life.
That sounds quite plausible to me. Yes, the parents find this very plausible.
Some people may think. That's sort of the parents then are sort of used as a mere means, I suppose.
Yes, because we only look at them like in so far as as they are valuable to the health of their children.
And maybe some people might have objections about that.
I don't find it that plausible.
But I can imagine some people finding that a little bit disturbing because normally medicine is really about the health of the patient.
So the one thing I want to say is. The parent also has to quite independently of their parental status.
Achieve a certain score by other metrics.
Prognosis , So if this parent already has stage four cancer, they're not going to get the organ.
Or the ventilator or whatever for that reason.
So you're already recognising, right, this the parent as an independent person, because they have to make,
They have to clear a certain bar.
And secondly, I'm assuming here that the standard process of getting people's informed consent is at play and that if a parent were to say,
no, don't give me the ventilator, no, don't give me the organ, no, don't give me the vaccine.
We wouldn't force it upon them.
And so we couldn't use them as a mere means so long as we insist, as, of course, we would on adequate informed consent mechanisms.
I think the more difficult question is whether we can force parents who says no? To undergo the medical intervention in order to benefit the child.
Just as we say, we don't allow parents to neglect their children when they need cancer therapies.
I think that would be a tough question, really. That's really interesting
We're going to force you to get the liver, because if we don't save your life, your child is at increased risk of suicide.
Yes, you have to take up your parental responsibility. And this is one way of doing it.
That's right. Yeah. The way you're talking gives me the impression that your proposal not only applies when there's a pandemic,
but that you think parental status should be taken into account, like in normal circumstances when there are scarce medical resources.
I do. So right now, the way we distribute in the United States, the way we distribute to intensive care unit beds is first come, first serve.
Nobody I've read really likes that policy.
But you can imagine why clinicians like it, because once you've got the patients, you have a duty to that patient.
And if you give up first come, first serve, you're kicking somebody out of the bed.
And that's a difficult thing to do. Organ allocation policies don't take into account parental status.
I think they should. That's independent of a pandemic.
Any health care resource allocation mechanism should, I think, take into account parental status when resources are scarce.
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