Ah, good old utilitarianism is back, not that it ever left. Hate it hate it hate it. Why? Not because we aren’t forced into the situation sometimes of asking how to maximize utility, because of course we are. I hate it because as soon as we think of that as the operative ethical calculus, we stop asking how we got into a situation in the first place. We stop asking what parameters of the calculus might changed, or be changed, in order to suggest a different outcome.
So now we’re asking how to make the decision about who gets care and who doesn’t, in an environment of scarcity of both personnel to give that care and the requisite tools like ventilators to use, and in an environment of risk of further infection. This is the time when our capitalist for-profit health care system was supposed to shine. After all, it’s supposed to be nimble (not centrally planned, not bogged down by bureaucracy); it’s supposed to be properly incentivized (no underpaid health care people on state salaries); it’s supposed to be able to unleash innovation (entrepreneurs will fill needs since they can respond to them faster than some centrally planned system); it’s supposed to be apolitical (a need is a need, and there’s profit to be made no matter what someone’s beliefs might be).
It has failed on every one of these measures. Why? Because health isn’t a market like other markets. There are no do-overs if you die from this virus – you don’t get to go back to the store and return what you bought because you don’t like it. This system tends towards just-in-time delivery, which limits and discourages central stockpiles of things needed in a crisis. Innovation is discouraged by medical device manufacturers having captured large portions of a market, and the technological ecosystem around those portions, so that it is difficult for any new innovator to break in. Yes, some of that is also government approval, but that’s a process that can be streamlined in the case of disaster, whereas the legal barriers to innovation cannot easily be streamlined. And of course, this whole thing is highly politicized by a federal government that sees it as an opportunity to punish enemies, confuse public discourse, ignore experts, and press for the resumption of economic activity even though that would exacerbate the situation.
So, in all of this, how is it possible to be a utilitarian? You take the given circumstances as given, and then decide what to do. Life is a series of trolley problems, and ethics amounts to simply being a calculation.
But to back all this up and ask how we got here, and to ask what parameters of the calculation might be changed in order to change the range of options available, those are the things that are lost. When George W. Bush said, after 9/11, that “you’re either with us or you’re with the terrorists”, he exhibited a lack of moral imagination. What got us to that point? Well, in part, a lot of US activity in foreign countries. A lot of oil colonialism and resource colonialism. And, a lot of inept foreign policy that did little or nothing to find other options. Does that mean that the terrorists are off the hook, that their actions are justified? Of course not. They had decisions to make too.
This might seem a long way from decisions about who gets health care in the coronavirus crisis. I don’t think it is all that far. Now, we’re in a position to have to make hard decisions, at least some of the time. But the parameters of these decisions are as much political as they are real, by which I mean that we still have a federal government unwilling to do what it needs to, to provide the tools and supplies that medical people need at a time like this. They think the market will rise to the occasion – no it won’t. Sorry. It just won’t. The market environment is too captured and controlled by big corporate players. Their interest, and their inertia, is in profitability, not in saving lives. Their interest is private, whereas this crisis is public. Their ethic, as Milton Friedman eloquently put it, is to maximize shareholder profit, not to help solve social problems. And, the market will have a view which is as short-term as it possibly can, whereas a crisis like this (and all the ones yet to come) necessitates longer term thinking.
Some other countries have been hit hard through this crisis. Others, not so much. Why? In part because many of those others have not assumed that the market and its actors will save us. Obviously, it’s more complicated than that, because every society is a mix of market logic and public good logic. And yet, some countries had quick and decisive action, whereas in the US the federal government has to be dragged kicking and whining into partial, inadequate action, all the while both politicizing everything and trying to pivot back to business as usual as quickly as possible.
We knew this was coming, if not now then next year or the year after. We knew, and we weren’t prepared. There’s the ethical failure, and the shame and grief that health care people will have to bear as they make those last-minute utilitarian decisions about who to help and who not to help. They bear the pain, but a morally corrupt government and a system that makes working for the public good almost impossible bear the blame.