post by Paul Kelleher
I'd bet a tidy sum that the most cited thought experiment in contemporary moral and political philosophy--aside from Rawls's Original Position, perhaps--is T.M. Scanlon's Pious Aid Recipient example. Google Scholar says the source paper has only 310 citations, which I believe raises pressing questions about the reliability of Google Scholar. In any case, here it is:
The strength of a stranger's claim on us for aid in the fulfillment of some interest depends upon what that interest is and need not be proportional to the importance he attaches to it. The fact that someone would be willing to forego a decent diet in order to build a monument to his god does not mean that his claim on others for aid in his project has the same strength as a claim for aid in obtaining enough to eat (even assuming that the sacrifices required of others would be the same).
Scanlon states his point succinctly, but let me repeat it: to determine which duties we have to others, we should look at the claims they have on us, and not merely at the strengths of their preferences. Someone may want help building their religious monument more than they want to be adequately nourished, but my main duty is to respond to their claims, not to their preferences. This does not mean that there are no claims to have one's preferences satisfied, but note that this would still give priority to the underlying claims and not to the preference themselves.
Scanlon's thought experiment came to mind when reading this post by Leo Katz. Katz asks us to imagine Al, a pianist, who has a finger badly injured in a traffic accident. The only doctor around must choose between helping Al, or helping Bea, who faces paralysis in one of her legs if not helped immediately. Many would say that Bea should receive priority, since losing the use of a leg is in general worse than losing the use of a finger. Of course, to Al, this isn't so. But the doctor's question is who has the stronger claim on the doctor's help, and many would say that Bea does. (If you doubt this, ask yourself: should the doctor interrogate Bea to determine whether her leg is as important to her as Al's finger is to him?)
But there is one more piece to Katz's story. Just before making his decision about whom to help, the doctor sees that Al has another injury that will lead to paralysis in both his legs if not addressed immediately. Now the doctor must choose between three courses of action: (1) save Al's finger; (2) save Al's legs; or (3) save Bea's leg. Here is Katz:
How can he [the doctor] treat Al’s finger when Bea’s more serious leg injury needs attention? How can he treat Bea’s leg injury when Al’s far more serious leg injury isn’t getting treated? How can he treat Al’s leg injury when Al clamors to have his finger treated instead? We are in a sort of cycle.
How is it to be broken? At least one plausible way of breaking it, my own guess is that it is the most plausible, is to not let Al opt for getting his finger treated. He retains his priority over Bea only if he has is leg injury treated, not otherwise. But that means that we are rejecting a win-win transaction. For that is what the doctor’s treating Al’s finger rather than his legs surely is...The reason, in brief, is that Al has a strong claim on the doctor’s attention for his serious injury and a much weaker claim for his less serious injury.
I think Katz is correct to invoke the Scanlonian notion of claims here. I am less sure, however, that treating Al's finger really should be considered a "win-win" that creates the problematic "cycle" Katz describes. Fixing Al's finger is a win-win only if Bea is no longer in the picture. For if Al is the only relevant patient, then it might well be true that the doctor should help Al in whatever way Al prefers (unless fixing his finger is much more costly than fixing his legs). But Bea is never "out of the picture." It is Al's legs, and not Al or Al's preferences, that generate the claim that overrides Bea's claim. If Al's legs-based claim is ignored, then Bea's leg-based claim is the strongest claim remaining. Within the Scanlonian framework of claims, fixing Al's finger while Bea suffers paralysis in her legs is in no sense a "win-win."
The morality of claims and claims-adjudication is essential to the morality of priority-setting in the health care setting. And things can get philosophically hairy very quickly. I will be posting a good deal on these issues in the coming weeks.