In my introductory ethics classes, I present my students with a scenario: You’re a doctor with dwindling supplies of lifesaving medical treatments. How do you decide who lives and who dies? Before the COVID-19 pandemic, our discussions were hypothetical. None of us could foresee a time when the health-care system would be overrun. Back then, I just wanted my students to think through what might drive this decision. As a classically trained philosopher, I’m supposed to be able to resolve dilemmas such as this one rationally, and I often can—in theory. Real life turns out to be a lot more complicated. Under the philosophical principles I taught, no one would choose my husband to live in a triage decision.
My students were accustomed to evaluating acts by their outcomes. I encouraged them to figure out the highest value that is at stake in a particular dilemma, look at the options, and then choose the act or the policy that is likely to produce the greatest amount of good. In triage decisions, the highest value is life; saving people is the whole purpose of medical care. Life is good. Maximize that outcome. Give the treatment to those who are most likely to live as a result, and for the longest period of time. Most often that means the youngest and healthiest patients. My students came to that conclusion in every class I taught. I recommended that conclusion too, which, from a moral perspective, is straightforward.
And then the pandemic hit. And I realized that if my husband gets the coronavirus when care is in critically short supply, he will not survive such a decision. The criteria are against him. He’s 75. He has a blood cancer that weakens his immune system. Regardless of the virus, doctors give him only about three more years to live. No ventilator for him; off he would go to palliative care, where he would die.
Panicked, I find myself defaulting to the philosopher’s go-to response when the implications don’t serve her interests: Surely there are other ways to think about this. Other values—beyond life-years—are important too. Wisdom, for example. If the triage decision were to maximize wisdom, my husband would survive, and so would all he knows about birds and salamanders and scientific reasoning and making a grandkid laugh. Every day, I ask him to tell me about something he knows that I don’t. What is that bird calling in the hedge? How does a meadowlark learn to sing? How does soap kill a virus? Where does courage come from? The only question he hasn’t been able to answer is: How will I live without you?
When doctors let the wise ones die and when the virus takes older people at an accelerated rate, society loses the grace and experience that comes with advancing age. I am not saying that the young ones aren’t magnificent and worthy. They are. I’m just pointing out that it will be painful to learn all over again what their elders have come to know. I’m just saying that the choices are maybe more complicated than what I teach. I’m just saying that the choices are sad.
Another value beyond both life and wisdom is love. I love this man. Love is good. Maximize it. Do not let it die. But maybe love doesn’t die, the way sick old men tend to do. Which is why, along with bleach and peanut butter, I am stocking up on memories. What does it feel like to hug this man, straight and strong as a ponderosa pine? What does it feel like to wriggle closer to his warmth on the couch? What flashes exactly, when he flashes a smile and I light up? What sort of pleasure is it precisely to climb into bed beside his protective bulk?
Maybe to save the life of the person who has the most years remaining makes moral sense—but surely only if each life-year counts as one. Do the ethicists know how much sweeter and deeper the years become the moment your husband is told “You probably have about three years left”? Never has morning light been more beautiful, washed green by the fir trees and huckleberries. Never has rain fallen so softly or a neighbor’s child bounced a basketball with such grace. Never does a touch feel so warm on the skin. The smell of a newly mown lawn is a miracle. Done with striving, done with competing, these are years of gratitude and giving back.
I admit that everything I write sounds a lot like special pleading for my husband’s case, finding reasons to exempt him from the rules that govern everybody else. I warned against this fallacy each semester in logic class. But these days, it’s difficult for me to tell the difference between special pleading and prayer. The truth is that I’m both pleading and praying, and I’ll do whatever else it takes to hold on to those last three years.
Here’s the larger point: Deciding who lives or dies is a false dichotomy. There’s a third path: a proper health-care system that doesn’t require these terrible choices. In class many years ago, a student got tired of all the philosophical wrangling to find a moral way out of a fundamentally immoral situation. He threw up his hands and said, “C’mon, guys, shit happens.” We all laughed then, because it was true. But if I heard that now, I would respond with a fury inappropriate for a philosopher. Yes, shit happens. But sometimes people or governments deliberately create the conditions under which shit is more likely to occur. When that happens, they own that pile of excrement.
No matter how fair or careful a triage decision is, it is still tragic. Something irreplaceable is always lost—a life, of course, but wisdom and laughter and love. The critical question, then, isn’t so much whether the triage committees are making moral or immoral decisions. The moral duty comes before that, and it falls on every one of us, to resolve never to sicken someone else by careless risks, swaggering self-interest, misguided priorities, or arrogantly incompetent leadership. We are smart enough, and good enough, to design an economy and a health-care system in which no one needs to decide who dies.
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