1 00:00:00,000 --> 00:00:03,570 Hello, I'm Katrien Devolder. 2 00:00:03,570 --> 00:00:10,000 This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all. 3 00:00:10,000 --> 00:00:14,000 This is a special edition on ethical questions raised by the Corona pandemic. 4 00:00:14,000 --> 00:00:19,000 This time, I will talk to Moti Gorin, assistant professor at Colorado State University. 5 00:00:19,000 --> 00:00:23,970 He argues that when we can't treat everyone, because medical resources are scarce, 6 00:00:23,970 --> 00:00:28,190 we should sometimes give priority to patients who are parents of dependent children. 7 00:00:28,190 --> 00:00:33,210 I think this view has intuitive appeal, but it is also extremely controversial. 8 00:00:33,210 --> 00:00:37,000 So let's dig a bit deeper into the arguments in support of it. 9 00:00:37,000 --> 00:00:41,260 The question which COVID-19 patients. 10 00:00:41,260 --> 00:00:48,850 We should treat when we can't treat them all because we just don't have enough medical resources is a really difficult question. 11 00:00:48,850 --> 00:00:54,760 And it seems like all proposed approaches have some problems. 12 00:00:54,760 --> 00:01:04,930 But what you propose is even more controversial because you think that we should take into account whether a patient is a parent. 13 00:01:04,930 --> 00:01:08,000 Right. Or a caregiver. Can you just explain your view a little bit? 14 00:01:08,000 --> 00:01:14,000 The view I want to sort of suggest and I think, you know, I would like to see implemented. 15 00:01:14,000 --> 00:01:25,470 I think that one's status as a primary care caregiver to dependent children 16 00:01:25,470 --> 00:01:32,350 It is a moral consideration that ought to be taken into account along with whatever other mix we're already taking into account. 17 00:01:32,350 --> 00:01:35,980 It's not that you prioritise parents above everything else. 18 00:01:35,980 --> 00:01:42,000 How heavily this consideration ought to be weighted. I leave kind of open, I think at its weakest at the weakest level. 19 00:01:42,000 --> 00:01:50,350 It could serve as a sort of tiebreaker. You might give it more weight and let it outweigh, I don't know. 20 00:01:50,350 --> 00:01:53,560 Prognosis or a certain degree of prognosis or something like that. 21 00:01:53,560 --> 00:01:56,440 But I leave that sort of an open question. 22 00:01:56,440 --> 00:02:06,720 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. 23 00:02:06,720 --> 00:02:11,620 It's quite controversial because many people think that medicine should only be concerned with health. 24 00:02:11,620 --> 00:02:17,290 Right. So, yes. What is it about this parental role that makes it so important? 25 00:02:17,290 --> 00:02:20,080 Why should we take that into consideration? 26 00:02:20,080 --> 00:02:26,260 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. 27 00:02:26,260 --> 00:02:31,940 I had a bit of a health scare. I had a melanoma on my arm. And this is a potentially deadly skin cancer. 28 00:02:31,940 --> 00:02:37,210 And I had it removed, but it was early stage. No problem. 29 00:02:37,210 --> 00:02:42,000 But upon getting this news, that's, of course, frightening. And at the time, my children are still young. 30 00:02:42,000 --> 00:02:47,000 They they're very young. And one of my first thought was, well, this isn't going to be good for them. 31 00:02:47,000 --> 00:02:57,000 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 32 00:02:57,000 --> 00:03:05,800 might play in distributive schemes. There are lots of different dimensions along which the death of a parent can be bad for a child, 33 00:03:05,800 --> 00:03:11,000 because I want the argument to work in a pluralistic society. 34 00:03:11,000 --> 00:03:23,290 I had to find an argument that doesn't appeal to some controversial conception of the good, right. 35 00:03:23,290 --> 00:03:28,330 It's not that parents are more socially valuable. It's not that parents are virtuous. 36 00:03:28,330 --> 00:03:33,200 They're choosing a good life like you might get from some religious conservatives, for example, 37 00:03:33,200 --> 00:03:37,650 at least in the United States, believe there's something intrinsically valuable about having children. 38 00:03:37,650 --> 00:03:43,330 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. 39 00:03:43,330 --> 00:03:53,000 Now, as it turns out, there is a fairly good literature or empirical literature on the health effects of parental death on children. 40 00:03:53,000 --> 00:04:01,000 You get kids with higher rates of depression, higher rates of mental health problems up to and including suicide. 41 00:04:01,000 --> 00:04:11,050 Now that you've got a health implication, it seems like doctors can no longer say, oh, we're not concerned about social value. 42 00:04:11,050 --> 00:04:15,000 We're not here to save the banker because they help grease the wheels of the economy. 43 00:04:15,000 --> 00:04:19,540 We're not going to make those judgements. We only care about clinical criteria. 44 00:04:19,540 --> 00:04:27,220 Well, we've got clinical criteria here. And so I appeal just to the health benefits to the child of benefiting the parent. 45 00:04:27,220 --> 00:04:33,970 Just to clarify, so does it matter whether, for example, the parent has more children or whether the children are, 46 00:04:33,970 --> 00:04:40,450 for example, young young children or, for example, children with a disability? 47 00:04:40,450 --> 00:04:48,000 So I would need to look more deeply at the empirical literature or we would need to speak to somebody who studies the stuff. 48 00:04:48,000 --> 00:04:59,290 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. 49 00:04:59,290 --> 00:05:01,030 And let's suppose you're deciding between them. 50 00:05:01,030 --> 00:05:07,930 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. 51 00:05:07,930 --> 00:05:09,000 But after reducing harm amongst. 52 00:05:09,000 --> 00:05:15,000 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 53 00:05:15,000 --> 00:05:21,000 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. 54 00:05:21,000 --> 00:05:28,000 But, yes, you're open to the possibility that we might have to take into account these differences. 55 00:05:28,000 --> 00:05:36,000 If if it turns out that some groups have much worse health effects of the death of a parent. 56 00:05:36,000 --> 00:05:47,060 That's right. The way I've approached this project is I look at the the rationale provided by the bioethicists 57 00:05:47,060 --> 00:05:53,000 and policy makers who have been writing about resource allocation and conditions of scarcity. 58 00:05:53,000 --> 00:06:00,050 And the more recent papers have come out thinking that's been done with respect to the COVID-19 pandemic. 59 00:06:00,050 --> 00:06:07,000 And what you see there, rightly or wrongly, right, is a real emphasis on maximising health outcomes. 60 00:06:07,000 --> 00:06:11,000 So you're trying primarily to save as many lives as you can. 61 00:06:11,000 --> 00:06:17,850 And also to save as many life years as you can with certain constraints grounded in justice. 62 00:06:17,850 --> 00:06:23,600 And so I assume that broad theoretical framework, just because there's only so many fights you can pick at once. 63 00:06:23,600 --> 00:06:27,000 And so I want to introduce parental status as a moral consideration. 64 00:06:27,000 --> 00:06:32,000 And I want to say, given what's we're already committed to 65 00:06:32,000 --> 00:06:37,000 we ought to be committed to this. Then there is, of course, a question about where to draw the line. 66 00:06:37,000 --> 00:06:43,000 So if we should prioritise parents because of the indirect health benefits on others, I mean, 67 00:06:43,000 --> 00:06:51,000 should we prioritise other patients who also have indirect health effects on others, 68 00:06:51,000 --> 00:06:57,000 like health care workers themselves have, definitely have health effects on other people? 69 00:06:57,000 --> 00:07:04,160 Of course, of they die than many other people will die. So do you think we should also prioritise healthcare work? 70 00:07:04,160 --> 00:07:11,830 I, I do think we should. Frontline health care workers have instrumental value when I save you the doctor. 71 00:07:11,830 --> 00:07:15,520 You, the doctor, go on and save other lives. We need doctors to save lives. 72 00:07:15,520 --> 00:07:19,120 There are also some who argue that we owe some kind of. 73 00:07:19,120 --> 00:07:24,880 We have a duty of reciprocity. Health care workers put themselves at risk for the benefit of others. 74 00:07:24,880 --> 00:07:30,550 And so when they themselves become ill society, we should you know, we should we should sort of pay them back in a way. 75 00:07:30,550 --> 00:07:40,020 Health and Human Services some years ago at a policy out for how to prioritise influenza vaccines in the case of a pandemic, 76 00:07:40,020 --> 00:07:48,550 as one of the first groups to be prioritised were pregnant women and mothers or parents or 77 00:07:48,550 --> 00:07:53,290 anybody who was in close proximity to children who were six months of age and younger. 78 00:07:53,290 --> 00:07:58,330 The reason being a child that six months or younger couldn't take the vaccine directly. 79 00:07:58,330 --> 00:08:02,830 And so what you do is you provide a kind of herd immunity around that child. 80 00:08:02,830 --> 00:08:10,090 What's going on there? Why prioritise a parent of a six month old or younger child? 81 00:08:10,090 --> 00:08:18,880 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. 82 00:08:18,880 --> 00:08:26,000 Just one more question about drawing the line. There are several arguments to prioritise health care workers. 83 00:08:26,000 --> 00:08:31,360 But what about like I mean, there are other people who have indirect health effects? 84 00:08:31,360 --> 00:08:36,000 For example, someone who employs many people? I mean. 85 00:08:36,000 --> 00:08:42,000 if all these people lose their jobs. That will definitely have mental and even other health effects. 86 00:08:42,000 --> 00:08:47,000 Here I'm sort of torn. There are one of two ways. One of two routes to go. 87 00:08:47,000 --> 00:08:51,000 And I'll explain what they are. So the first route was to just accept it. 88 00:08:51,000 --> 00:08:54,580 Say sure. It just it's a matter of consistency. Right. 89 00:08:54,580 --> 00:09:01,000 If saving this person what would be instrumentally valuable with respect to maximising health, then we ought to give that person some priority. 90 00:09:01,000 --> 00:09:08,290 Another route is to say, no, there's something that might it might not be unique to parenting. 91 00:09:08,290 --> 00:09:13,780 It might not be unique to being a primary caregiver of dependent children. 92 00:09:13,780 --> 00:09:20,890 But there is something at least unusual and special about that role as it relates to health. 93 00:09:20,890 --> 00:09:26,800 There are certain benefits or sources of benefits that you might call fungible. 94 00:09:26,800 --> 00:09:32,800 I mean, we like to sort of glorify creative, large employers. 95 00:09:32,800 --> 00:09:39,000 But, you know, I don't know. Steve Jobs died and Apple goes on. 96 00:09:39,000 --> 00:09:47,230 So there's important roles that can be filled by maybe not anyone, but more than one person. 97 00:09:47,230 --> 00:09:52,600 But it's not as if a new human individual can come in and they can give you some support and love. 98 00:09:52,600 --> 00:10:00,610 But it's not your parents. There's something very distinctive and idiosyncratic about that particular individual, 99 00:10:00,610 --> 00:10:04,000 and it has to be that individual in order to achieve the full benefit. 100 00:10:04,000 --> 00:10:11,800 And so the other way, I might argue, say, no, it doesn't need to be only parents, 101 00:10:11,800 --> 00:10:16,570 but certainly parents have a special relationship with their children that that's going to affect the health outcomes. 102 00:10:16,570 --> 00:10:19,390 I think the special relationship is quite plausible. 103 00:10:19,390 --> 00:10:24,600 But then, of course, the next question is, I mean, there are other relationships that are very special. 104 00:10:24,600 --> 00:10:31,000 So I can, for example, be that you have dependent parents. Or, for example, are really close friends. 105 00:10:31,000 --> 00:10:34,480 My best friend. Oh, we've been friends since we were three years old. 106 00:10:34,480 --> 00:10:42,910 So that's completely irreplaceable and unique in a way that's like a parent child relationship could be unique. 107 00:10:42,910 --> 00:10:49,180 So what do we do with other sort of relationships? 108 00:10:49,180 --> 00:10:52,480 I mean, one thing I can say here is that sort of ethically speaking, 109 00:10:52,480 --> 00:10:59,110 morally speaking, yes, they should be granted some priority as a practical matter. 110 00:10:59,110 --> 00:11:08,000 There are just too many variables involved in assessing whether this particular friendship meets the bar or 111 00:11:08,000 --> 00:11:17,560 this particular sibling caring relationship would really have an adverse effect on that particular individual. 112 00:11:17,560 --> 00:11:28,480 The practical difficulties seem to me to be insurmountable. Whereas with parenting policy wise, it's a fairly easy, clean cut principle. 113 00:11:28,480 --> 00:11:29,000 And you're going to get it wrong sometimes. 114 00:11:29,000 --> 00:11:36,130 But we get it wrong sometimes, now in the sense that you can prioritise the person with the better prognosis. 115 00:11:36,130 --> 00:11:39,000 It turns out they leave the hospital. They get hit by a bus. And so you wasted that. 116 00:11:39,000 --> 00:11:42,000 You wasted a liver 117 00:11:42,000 --> 00:11:50,790 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. 118 00:11:50,790 --> 00:11:52,000 And maybe for several reasons. 119 00:11:52,000 --> 00:12:01,000 So one reason I thought was, well, some might say people who don't have children already contributes. 120 00:12:01,000 --> 00:12:08,000 via taxes like financially. Quite a lot, yes, to the education of children and so on. 121 00:12:08,000 --> 00:12:12,230 And then they come in this situation and then they have to sacrifice their lives. 122 00:12:12,230 --> 00:12:16,360 So that seems unfair. Yes. So that's one concern. 123 00:12:16,360 --> 00:12:22,160 Yes. Yes. So. So I think this is actually the strongest objection to my view. 124 00:12:22,160 --> 00:12:26,000 And you might frame it in terms of unjust discrimination. 125 00:12:26,000 --> 00:12:29,780 So my response here, and I'd be curious to see what you think. 126 00:12:29,780 --> 00:12:36,470 I think I sort of developed a clever response here, but it's dangerous to think we're too clever. 127 00:12:36,470 --> 00:12:40,380 So what I want to say here is. 128 00:12:40,380 --> 00:12:49,530 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. 129 00:12:49,530 --> 00:12:54,420 But the rationale for doing so is grounded in the well-being of the child. 130 00:12:54,420 --> 00:12:58,620 All of us, whether we're parents or not, we're once dependent children. 131 00:12:58,620 --> 00:13:05,880 So although I as a not hypothetically, if I did not have children, I today can't get the benefits, 132 00:13:05,880 --> 00:13:11,040 but I would have been it would have been open for me to get the benefit. Had one of my parents been ill. 133 00:13:11,040 --> 00:13:16,620 And so in principle, nobody is being excluded because everybody, like it or not, 134 00:13:16,620 --> 00:13:22,570 is born in a particular way and has caretakers or else you wouldn't make it past one day of life. 135 00:13:22,570 --> 00:13:28,000 That sounds quite plausible to me. Yes, the parents find this very plausible. 136 00:13:28,000 --> 00:13:37,170 Some people may think. That's sort of the parents then are sort of used as a mere means, I suppose. 137 00:13:37,170 --> 00:13:47,230 Yes, because we only look at them like in so far as as they are valuable to the health of their children. 138 00:13:47,230 --> 00:13:50,810 And maybe some people might have objections about that. 139 00:13:50,810 --> 00:13:52,300 I don't find it that plausible. 140 00:13:52,300 --> 00:13:59,890 But I can imagine some people finding that a little bit disturbing because normally medicine is really about the health of the patient. 141 00:13:59,890 --> 00:14:10,400 So the one thing I want to say is. The parent also has to quite independently of their parental status. 142 00:14:10,400 --> 00:14:14,000 Achieve a certain score by other metrics. 143 00:14:14,000 --> 00:14:23,290 Prognosis , So if this parent already has stage four cancer, they're not going to get the organ. 144 00:14:23,290 --> 00:14:28,000 Or the ventilator or whatever for that reason. 145 00:14:28,000 --> 00:14:35,380 So you're already recognising, right, this the parent as an independent person, because they have to make, 146 00:14:35,380 --> 00:14:37,600 They have to clear a certain bar. 147 00:14:37,600 --> 00:14:48,310 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, 148 00:14:48,310 --> 00:14:55,090 no, don't give me the ventilator, no, don't give me the organ, no, don't give me the vaccine. 149 00:14:55,090 --> 00:14:56,000 We wouldn't force it upon them. 150 00:14:56,000 --> 00:15:07,000 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. 151 00:15:07,000 --> 00:15:15,830 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. 152 00:15:15,830 --> 00:15:20,000 Just as we say, we don't allow parents to neglect their children when they need cancer therapies. 153 00:15:20,000 --> 00:15:23,000 I think that would be a tough question, really. That's really interesting 154 00:15:23,000 --> 00:15:29,000 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. 155 00:15:29,000 --> 00:15:35,000 Yes, you have to take up your parental responsibility. And this is one way of doing it. 156 00:15:35,000 --> 00:15:44,060 That's right. Yeah. The way you're talking gives me the impression that your proposal not only applies when there's a pandemic, 157 00:15:44,060 --> 00:15:53,960 but that you think parental status should be taken into account, like in normal circumstances when there are scarce medical resources. 158 00:15:53,960 --> 00:16:02,420 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. 159 00:16:02,420 --> 00:16:05,120 Nobody I've read really likes that policy. 160 00:16:05,120 --> 00:16:11,060 But you can imagine why clinicians like it, because once you've got the patients, you have a duty to that patient. 161 00:16:11,060 --> 00:16:14,840 And if you give up first come, first serve, you're kicking somebody out of the bed. 162 00:16:14,840 --> 00:16:21,950 And that's a difficult thing to do. Organ allocation policies don't take into account parental status. 163 00:16:21,950 --> 00:16:25,390 I think they should. That's independent of a pandemic. 164 00:16:25,390 --> 00:16:39,380 Any health care resource allocation mechanism should, I think, take into account parental status when resources are scarce. 165 00:16:39,380 --> 00:16:45,080 Thanks for listening to this thinking out loud interview. 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