By Nathaniel Counts
[Part I is here.]
First, let us consider whether opting for end of life care is morally problematic on its own, without reference to its resource costs. Certainly wanting to live longer on its own is not morally problematic in our society – we do not consider exercise or healthy eating wrong and many tout it as a social good. On the other hand, wanting to die early, for example through suicide, has traditionally been viewed as a moral wrong and is illegal in many areas. It similarly seems that there is nothing problematic with wanting even a short amount of additional time, even with arguably compromised quality. If end of life care involved only pressing a button for an additional day of life, even in severe pain, it is unlikely that anyone would consider the pressing of the button good or bad morally.
It may be that opting for intensive curative end of life care is irrational, even if it is were cost-free. If palliative and hospice care would have led to greater overall life enjoyment for that time period, regardless of its length, then opting for the intensive treatments would not have been the right choice, even for that individual. This does not make it immoral however – individuals are generally allowed to make choices that are worse for themselves as long as they do not violate norms, and the pervasiveness of these intensive treatments at end of life may indicate that they are in fact the norm.
It could be that what an individual expresses by opting for heroic treatments that offer minimal benefits is bad for society. The type of fear that others may interpret into these choices may make these individuals less comfortable with their own mortality, enhance their sense of trepidation with aging, and depreciate their quality of life. If one believes that individuals have a duty to guard the fears they may express to society and to minimize this externality, then intensive end of life care could have moral implications.
Second, there is the possibility that it is immoral because of its extensive resource expenditure for little social utility when there is a limited total pool of resources. In this example, the drowning man is pulling others under by both depleting the resources needed to offer meaningful healthcare to others and failing to save herself (although of course no one can be truly “saved”). This individual is also taking advantage of the identified victim bias in resource allocation – we have a person in front of us in the most dire need, while all the others that could possibly benefit from these same resources are out in the world, unknown to us, so we do not consider them in decision-making. There may be something to this in theory, but in reality, the individual making the decisions is ill, potentially heavily medicated, and she, along with her family, is under enormous stress. It is troubling to impute blameworthiness on these most vulnerable individuals, especially when the option is freely presented to them and their individual resource usage compared to the total pool is slight – it is only truly a problem when a lot of individuals make these same decisions. If individuals were given the option to opt into heroic end of life care when they are young and healthy in contemplation of wanting to extend life a short amount of time at such a cost that others will fare worse, then perhaps this would be more morally problematic.
Third, if one does not believe either of the two possibilities above for moral fault in selecting resource intensive end of life care, then it is not a moral issue at all. It is only being unfairly framed as one because one option would be better for resource allocation than the other (intensive care v. palliative/hospice care), although the selection between them is neutral.
