We have argued, then that a division of labour between cost-effectiveness analysis and ‘rescue-reasoning’ already exists in medical decision making. It exists in rescue situations and non-rescue situations. It exists in the emergency room and the local clinic. And we have also suggested that this is a beneficial situation from the point of view of doctor-patient relationships. And it should also be apparent that we regard this as an attractive way to reconcile what appeared to be two, irreconcilable, approaches to medical decision making. Yet there may be a lingering concern that the solution is too stark to be accurate. Is it really true that ‘rescue’ intuitions are absent in the committee room? Or that cost-effectiveness considerations never occur in the emergency room? If it is true that both types of considerations apply in both venues then it seems we are back to where we started: having to worry about how to combine two quite different styles of reasoning into a single decision procedure.
To start with the committee room, is it true that rescue intuitions have some place there too? Although the committee room will rarely have to deal with identified patients in known emergencies, nevertheless they can rationally predict that emergencies will occur and will need to be dealt with. Will considerations of basic humanity mean that cost-effectiveness has to be abandoned, or at least modified, from time to time in the committee room? Here, we suggest that the notion of the rescue adjusted QALY may have some place after all, albeit in different terminology. The key elements of rescue that will arise in the allocation room are those of end of life and of severity of disease. In both cases, we have seen policy proposals that the calculation should be adjusted so that a higher cost per QALY is allowed (NICE 2009; Department of Health 2010). This, we suggest can be seen as moving in the direction of rescue, but doing so in the cold-light of day when such decisions have to made as a matter of routine. The earlier objection—that humanitarian reasoning is debased by reducing it to a formula—still has some purchase, but the fact that the formula is used at a general level for resource allocation and not as a way of mediating a relationship between doctor and patient removes some of its sting. Hence at this level it seems satisfactory.
What, though, can we say about the emergency room. Is it really true that doctors should put considerations of cost completely to one side? This seems unrealistic and, indeed, unwise. There are regular campaigns, for example, to persuade doctors to prescribe generic medicines rather than more expensive branded equivalents. Doctors are often rightly reluctant to send their patients for expensive tests, and may spend a few weeks, or longer, in a state of ‘watchful waiting’ before doing so. The emergency room is rightly suffused with considerations of expense after all.
Yet it is interesting to reflect on how considerations of cost could enter the reasoning of the doctor. Robert Nozick distinguished two theories of rights: one in which a moral agent tries to minimize rights violations—the ‘rights as goals’ theory—and the other in which rights function as ‘side constraints’, setting absolute barriers to action (Nozick 1974). Although we would not want to follow Nozick’s model exactly in the current case, it reminds us that there is more than one way a consideration can function in one’s reasoning. Our suggestion is that the humane but responsible doctor will consider considerations of cost as a type of provisional side-constraint on action. By analogy consider, for example, how one chooses from a menu in a restaurant, when another person is paying. Some people will deliberately choose an expensive option, others a cheap one. But a common experience is simply to choose what you want, but keeping an eye out for cost, avoiding the most expensive dishes. Cost here functions as a background consideration. It is not a firm constraint, perhaps today you will order the lobster after all. Yet cost is something to be taken into account in background reasoning, albeit only when a certain threshold is crossed.
To apply the analogy to rescue cases, we may say that we will save lives at all costs, given the equipment available, yet at the back of our minds there may also be a thought that ‘enough is enough’. When the chances of a successful rescue are falling and the costs of the next step are increasing, the consideration of cost, reluctantly, comes into view. The rescue may be halted on cost-effectiveness grounds. Cost-effectiveness lurks in the background, but it is rarely central to the decision-making process, and it is not always over-riding even when it is relevant.
We suggest here that as an empirical account of moral psychology what is sometimes termed ‘threshold deontology’ is the kind of moral thinking that takes place in the emergency room. That is, one should act in a way consistent with one’s duty until cost reaches some threshold that suggests acting contrary to that particular duty; see Alexander (2000). And indeed, in every case in an emergency room where a life may be lost, some decision is taken as to when to no longer apply resources to saving that life. For example, think of the familiar case in medical dramas where a doctor furiously trying to resuscitate a patient is told ‘Let it go. You’ve done all you can’, and then ‘time of death’ must be declared. Note that death is declared when the efforts to save the patient have stopped, not by some objective indicator of remaining brain or heart activity; this suggests that up to some limit there could always be a bit more done to save that life, but some consequential evaluation must take place when it is felt that the resources could be better used elsewhere than in trying to resuscitate a particular patient. This suggests that there is some small, implicit element of consequentialist concern with costs and benefits in almost every emergency scenario.
Similarly, as we have seen above, the committee room is not devoid of humanity. There will be norms implicit about how much humanitarian reasoning can enter into decisions made at the highest levels of allocation, and it will not necessarily be all ‘cold calculation’. There is an informal rule in environmental economics when eliciting preferences over environmental goods: ‘no fluffy bunnies’. This means that no images meant to prime the subject to over-value a particular good should be allowed in an objective valuation exercise. One can imagine as well that when committees make decisions there must be rules for how much affective priming will be allowed, but it will not be disallowed completely. Indeed, all NICE decisions will have input from patient groups where the issue being decided is intentionally given a human face.
A related idea to what we are suggesting draws on the role morality suggested by F.H. Bradley’s famous “My Station and its Duties” (1927).Footnote 7 We generally want those in the committee room to follow the logic of promoting the best consequences, and we generally want those in the emergency room to act to promote health and life regardless of cost. Therefore, we create and design institutional roles which will allow individuals inhabiting those roles to ‘silence’, or ‘forswear calculation’ of, other types of consideration which might be given voice: in our case, the individual in the emergency room will (almost) silence considerations of cost, and the individual in the committee room will (almost) silence considerations of humanitarian ‘special pleading’.Footnote 8 It is worth noting that the silencing considerations in the emergency room are specifically endorsed in the committee room; as Kamm puts it “...if a policy allocates some money to an institution like an emergency room, this might just be a way of saying that in some areas of life, however small, a different principle than is involved elsewhere governs distribution” (2007: 46, fn. 66).
Our reasoning here suggests that institutions can play an important role in resolving intra-personal value conflicts, as discussed here in the conflict between motives of pursuing the greatest good per pound spent and acting consistently with the rule of rescue. Where there are hard cases in conflicts of values we often create a division of labour between the choices made by individuals (in the emergency room) and the allocation of resources (in the committee room) for those individuals to make their choices. This issue has an obvious basis in normative ethics, but it may well be that different institutions separate moral labour between rationalist utilitarian calculation and non-calculating humanitarian motives, and these may well vary by the type of institution which has evolved to address a particular set of conflicting distributional aims (Elster 1992; Ostrom 2005), and hence this division of moral labour will need to draw on the study of social institutions in order to be properly addressed.