by George R. Lucas, Jr.
Mr. Lucas is research associate at the Peace Institute, Garrett-Evangelical Theological Seminary, Evanston, Illinois.
This article appeared in The Christian Century, September 3-10, 1975, pp. 753-758. Copyright by The Christian Century Foundation; used by permission. Current articles and subscription information can be found at www.christiancentury.org. This material was prepared for Religion Online by Ted and Winnie Brock.
An interview with social ethicist Joseph Flecher which delves into the ethical issues of the “triage/lifeboat” approach to world hunger relief.
Social ethicist Joseph Fletcher -- author of Situation Ethics, Morals and Medicine and The Ethics of Genetic Control -- is a visiting professor of medical ethics at the University of Virginia Medical School and at the Texas Medical Center’s Institute of Religion and Human Development.
Q.: CALIFORNIA biologist Garrett Hardin has been the most recent exponent of a selective famine-relief procedure he calls "lifeboat ethics." Other writers have compared "lifeboat ethics" to "triage" -- a process of selective allocation in medicine. As a medical ethicist, how do you regard the use of triage in wartime and in emergency medical procedures?
A.: Triage is an entirely justifiable procedure based on the principles of distributive justice. When lifesaving medical resources are scarce or in short supply, they must be allocated with some regard to optimal benefit. From the standpoint of utilitarian ethics, triage is the most moral option for making such medical selections.
Q.: What criteria are employed in selecting recipients for scarce medical supplies?
A.: Several factors must be considered. In selecting between two patients requiring a kidney transplant from one live donor, for example, the patient who exhibits the lower immunosuppressive reaction to the donor tissue might be judged the more suitable for the transplant. This criterion of "medical suitability," objectively determined by the attending physician, constitutes one rather straightforward basis for making a selection.
The classical triage criterion, developed during wartime, is that of "maximum benefit." Wounded soldiers were divided into three groups: those who would survive without treatment, those who would die regardless of treatment and, finally, those who would die unless treated immediately. Maximum medical benefit was attained by treating members of that third group as priority cases.
Finally, in a more disturbing vein, faced with the choice of allocating personnel and resources toward a mode of medicine benefiting only a few, and allocating those same personnel and resources toward a mode of medicine which would benefit many, one should opt for the greater good for the greater number -- although this would be a very agonizing choice for any triage officer to face.
Q.: William and Paul Paddock, in their book Famine -- 1975, maintain that the problem of allocating scarce medical supplies during emergencies and the problem of allocating scarce food supplies during a time of world famine are similar. Do you regard this analogy as a valid one?
A.: Not really. There is a significant difference in the dimensions of the respective situations, for one thing. Clinical triage officers deal with specific, limited and immediate problems of allocating scarce resources in lifesaving and medical care programs. The consequences of their allocations -- that is, who shall live and who shall die -- are readily predictable with reasonable certainty; in fact, the predictions dictate to a major extent the methods of allocation.
When one begins to apply this procedure to the problems of allocating scarce food resources on a global scale, the size differential -- and accordingly, the lack of control of the situation) the unpredictability of the results, and the resulting uncertainty of the final outcome -- render inaccurate any comparisons of this with the medical situation. Both situations represent problems of distributive justice, to be sure. But the difference in scope between the immediate consequences of medical triage and the vast, unforeseeable consequences of a global food triage would seem to invalidate any further analogy between the two.
Q.: It strikes me that the global context for triage in the case of famine might admit to ulterior motives for making a selection among potential recipients of aid. Would you agree?
A.: Yes, that is a good point. For example, discrete or discriminating considerations of political power could very easily -- and, I should think, obviously -- enter into the allocation of economic resources on a global scale.
Q.: Does the existence of such alternate criteria distinguish "social triage" from the rather straightforward medical triage situations?
A.: Political considerations do not necessarily discredit the allocation implied by the term "social triage," but it is significantly true that such considerations do not enter into the medical situation.
Q.: Might the existence of a possible "hidden agenda" of motives for social triage, however, constitute a reason for being very cautious about the use of this procedure?
A.: Undoubtedly. The ethicist must scrutinize all the motives influencing social allocation. Quite commonly, it seems to me, political motives for this type of allocation, regardless of their legitimacy or illegitimacy, do remain unexpressed, and do therefore constitute what you refer to as a "hidden agenda" influencing social triage decisions.
Q.: You imply that medical triage is fairly straightforward and justifiable in ethical perspective. Might the use of the term "triage" to describe proposals for food allocation represent an attempt to extrapolate the sense of moral justification from the medical context into the more complex global-resources context?
A.: This may be the case, though I tend to discount the possibility of such a conscious predication in the minds of the proponents of social triage. Rather, I believe that the current popularity of this term is due almost solely to a superficial resemblance between the medical and global situations -- one which very quickly will be exposed as false.
Q.: Garrett Hardin himself has not employed the term "triage," but he has compared the current status of the existing nation-states to a hypothetical collection of lifeboats cast adrift at sea. Is Hardin’s "lifeboat" simile more appropriate to the global situation than the triage analogy?
A.: Yes, Hardin’s illustration is unquestionably a more fruitful and accurate description of our current situation. His simile takes into account the problem of finiteness and the harsh realities of selfishness, isolationism and separatism, as well as the sense of competition for survival and supremacy arising in the lack of a unified, governing consensus.
This simile is not without its detractors, however. Daniel Callahan of the Hastings Institute, for example, has complained that in terms of Hardin’s analogy the United States should be characterized as a "luxury yacht" rather than a lifeboat, because of its great affluence in comparison with most other nations. Hardin immediately accepted that opinion -- as I do also -- because, in terms of his argument, this factor is morally irrelevant.
Q.: How is American affluence irrelevant to the moral issues surrounding world famine?
A.: Hardin’s moral concern is that the more famine relief we provide for some countries, the more people will die in the long run of disease and starvation, as a direct consequence of our sharing. That is, indiscriminate sharing is not always good -- indeed, it may never be good. In this regard, considerations of donor affluence -- and of consequent ability to give aid -- are irrelevant to the moral question of whether potential recipients of that aid will benefit or will be harmed by it. If aid will ultimately harm rather than help, then the prospective donors should withhold such aid, regardless of their ability to provide it.
Q.: Every illustration or comparison has its limits. You have described the strengths of Hardin’s analogy. Does it have any weaknesses? Does it break down at any point?
A.: At the level of logic and biological reasoning, I cannot see that it breaks down at any important point whatever. I am nonetheless not altogether happy about the analogy or receptive to it. I believe that Hardin’s reasoning needs to be reinforced with extensive, empirical data -- that is, information about resources, numbers of consumers and the costs of sharing in a physical, economic and moral sense.
Q.: Are you implying that demographic data which would verify or refute Hardin’s thesis are not now available in any extensive or convincing form?
A.: That is correct. Lester Brown, formerly with the Overseas Development Council and currently president of the Worldwatch Institute in Washington, D.C., is probably the most knowledgeable person in the country on the subject. I was therefore impressed to learn from a conversation between Brown and Hardin on the "David Susskind Show" that Brown shares my opinion that there are insufficient data to support Hardin’s conclusions.
Q.: Biologist Jack Christian has reportedly made extensive studies of animal populations. He reports a "cyclic effect" -- a sustained increase, followed by abrupt "crashes" in these populations. Hardin contends that human populations have similar cycles and that when we "interfere" in the cycle with indiscriminate famine relief and medical assistance, we sustain the increase and artificially postpone the "crash," making it larger and more tragic in the end -- a process which Hardin terms the "ratchet effect." Would Christian’s animal studies constitute the kind of data you are seeking?
A.: I am not familiar with Christian’s work, but it sounds as if it would constitute an effort to amass the kinds of data which I contend are necessary to permit a reasoned consideration of Hardin’s thesis.
Q.: Other critics of lifeboat imagery have questioned the legitimacy of shortages, have attacked the injustice inherent in current practices of distribution of food and resources, and have argued that it is possible to feed from 38 to 45 billion people on this planet. It is possible from these observations to conclude that triage and lifeboat ethics represent a "cop-out" -- a cover-up to avoid dealing with over-consumption and waste in affluent countries. Do you find any merit in the substance of these criticisms?
A.: Roger Reville, a senior research fellow at the Harvard Center for Population Studies, has indeed produced figures and estimates to argue that planet earth could support some 40 billion persons, and that these could be adequately sustained -- that is, fed, clothed and housed -- at that population level. Long before we reached such population densities, however, we would in all probability have been wiped out by "effluence" -- that is, pollution and similar secondary problems of overpopulation. In my opinion, then, talk of "maximum" or optimal populations in the face of present famine conditions is simplistic and misleading.
Paul Ehrlich, Lester Brown and others advocate allocation of one form or another -- not as a copout" or "cover-up" but because they truly believe that this policy will optimize benefits. The whole affair hangs, then, on an empirical verification of their logic. My own demand, consistent with Hardin’s logic but less radical in its conclusions, is that we compute available donor aid as a percentage of total food production, and then determine quantitatively the points at which it hurts to help, endangers to help, and finally becomes suicidal to help. Such data would immeasurably aid the development of a responsible famine relief policy -- one in which we would be enabled to give until it hurts, or even endangers us to do so, without violating Hardin ‘s premise that we must not give when it would be ultimately tragic to recipients and suicidal for donors to do so.
Q.: It is assumed in all this that triage and lifeboat ethics currently have the status of policy guidelines and recommendations; the proposals were discussed with a great deal of pessimism at the 1974 World Food Conference in Rome. But aren’t the selective "lifeboat" procedures in fact being practiced even now by the United States, and by other governments and international agencies?
A.: I would reply, without wishing to be tendentious, that responsible governments always practice a selective form of aid and allocation, both internally and externally. Our Bureau of the Budget, for example, exists precisely to allocate finite resources, measured economically as tax revenue -- though it often fails to calculate and compare values as thoroughly and responsibly as it does economic figures. On the international scene, Latin American countries have been the beneficiaries of our so-called "Food for Peace" program for many years, in order to ensure that they will vote with the U.S. in United Nations assemblies on many questions of global importance. Quite transparently, such actions imply that there is less food aid available for countries which cannot or will not provide such political assistance or benefits to this country.
Q.: Some would regard our Latin American food policies as a legitimate, political use of excess resources -- a wise stewardship of our products. Others might term these practices bribery or international blackmail. How do you view the situation?
A.: Obviously those who approve of American foreign policy will tend to regard such use of resources as valid political realism. Those who oppose our foreign policy will condemn it in the terms you have suggested. The downfall of Chile’s Salvador Allende and the rise to power through violence of a military junta in his place immediately come to mind. Our State Department policy had been to oppose Allende unequivocally -- for example, the "Food for Peace" administration had refused to sell him wheat, despite his offer to pay cash. Following his overthrow by the military junta, however, the State Department provided millions of dollars of aid and food to the Chilean dictatorship.
My personal political bias is to hate and despise military juntas and dictators, and I admired Allende’s courage and vision. Therefore I would use all the pejorative language which you suggested to denounce our government’s intervention in that nation’s internal political affairs -- an intervention which depended substantially upon the selective allocation and sales of excess food resources.
Other cases of triage practices in food aid have been cited. For example, there were rumors of a case in 1974 involving the Agency for International Development. Faced with choosing one of three potential recipients of assistance -- Bangladesh, Ethiopia and Syria -- it opted for Syria on the basis of potential political benefits for the U.S. in the Middle East. In terms of classical triage reasoning, however, Ethiopia would have received the assistance, simply because it was the only one of the three nations which couldn’t survive without help but which also would definitely benefit from receiving it.
Another example involved our efforts in South Vietnam and Cambodia: prior to the conclusion of their respective revolutions, the former governments of these nations received the lion’s share of our excess food resources, while Bangladesh and other needy countries were left to go "nature’s way."
It is unrealistic to suppose that allocative reasoning will take place without some thought by those in charge as to the political benefits to be gained. So long as national sovereignty is "where the buck stops" in regard to global policy, then every nation-state will consciously and deliberately take its own interest into account, and that will always skew or bias the final distribution of benefits.
Q.: Is it fair, then, to say that these are the "harsh realities" of the present situation?
A.: Certainly the situations which I have described are not what the ideal moral observer would like to see. But, for the present, this is the situation with which we are faced. I would count it far more consistent and helpful for social ethicists and others concerned with the negative undertones of this present condition to work toward a political and pragmatic solution for just allocation that admits and allows at least enlightened self-interest and political realism to play a part, thereby acknowledging and incorporating the role of national sovereignty in this process rather than defying it or simply wishing that it did not exist. In this sense, one of the greatest present dangers to responsible moral discourse in social ethics is, I think, "moralism" and unrestrained idealism, which frequently operate to overcome these harsh realities I have described by attacking them -- or worse, by simply ignoring them.
Q.: Still other critics of triage and lifeboat ethics have decried as "mere calculated justice" -- or even as the lack of justice -- the formula for justice by mathematics alone in the lifeboat procedures. And some have maintained that lifeboat or triage procedures, though they may be just, abandon love and mercy as reasoned considerations. How would you react to these charges?
A.: Those who decry "mere" calculated justice are loading their phrase with the modifier "mere." I reply that I cannot imagine any problem in distributive justice being morally reasoned without the most careful and sensitive calculations possible. Part of the love-justice problem is the question of how love is to distribute its favors fairly among many neighbors, since there are always many neighbors involved. I contend that a perceptive and humane utilitarian calculus must be employed. Insofar as "lifeboat ethics" takes this problem into account, I find it to be a just and often justifiable procedure. As to the suggestion or contention that allocating resources in a deliberate and self-conscious fashion abandons important values like love and mercy, that would depend upon how the persons responsible for the distribution had calculated the foreseeable consequences of their assistance. In the case of Hardin’s argument, if the calculations revealed that giving aid to certain countries would result in more rather than less disease and death, it would follow then that to do so would be an offense against love and mercy.
Q.: According to your position, then, not only is "calculated justice" not a negative or undesirable factor, but it is in fact the most loving, sensitive and responsible method for making these decisions.
A.: That is correct. Any practicing situationist would agree that judgments must be situationally realistic. Accomplishing this aim requires as much objective knowledge of the facts as possible. In this matter of famine relief, one of the most vital facts to be considered is not the resources available in the affluent donor countries, but rather the foreseeable consequences of indiscriminate sharing.
Q.: According to your formulation of situation ethics, love in the end must dictate the measure of any decision made, and is therefore the principle by which one calculates and determines final results, and hence discerns appropriate moral action. Might it be fair to argue that, if allocative lifeboat or triage decisions must be made, that it is this principle of love, rather than any other consideration, which should guide such decisions?
A.: I would answer only that any Christian situationist would agree with that position. In this framework, it is indeed agape -- selfless, loving concern -- which is the ultimate and indeed the only imperative to be served in this or any situation. I add also that, as love and justice are perceived in situation ethics, they are one and the same thing. Thus, to act lovingly toward the victims of famine in Bangladesh, for example, is to distribute one’s loving concern as wisely and responsibly as one can.
Finally, your question implicitly demands that a distinction be made between disinterested love and enlightened self-interest. The great majority of the world’s people make their decisions about these problems of allocation in terms of enlightened self-interest rather than in terms of disinterested love. Either basis could (though not necessarily or invariably) result in the same decisions being made, particularly if the self-interest involved is indeed enlightened, rather than narrowly selfish. For the great majority of people, it is enlighted self-interest, rather than agape, which is the value of final appeal.
Q.: Proponents of triage and lifeboat ethics have responded to criticisms by advancing several formulations of an argument based upon biological need. In the extreme, such defenses hold that ethics, love and justice are luxuries in which we indulge only after our basic needs have been met. Therefore, in the pinch of critical shortages, individuals will fight if necessary to protect their own, their family’s, or their nation’s needs in lieu of sharing. This contention is reminiscent of the "bomb shelter" logic advanced by many persons in the late 1950s. Do you regard this argument as defensible?
A.: I would say, without wanting to endorse this position, that as to its adequacy or fairness as a statement about the normal human condition and about the behavior of most human beings, it is unquestionably accurate.
Q.: Theologian James Sellers has countered this claim by arguing further that "needs" also include a need for community interaction, which in turn requires giving and sharing as well as getting. How does this response strike you in terms of the present human condition?
A.: It strikes me as being entirely correct. I would agree with Sellers that an important part of what we are and what we do as human beings involves a sense of community and its attendant relationships, as well as a sense of belonging and a need for interaction. But to say this still does not, in my opinion, get at the most searching question at stake here -- namely, what does one do when one must choose between that value and the value of survival? Hans Jonas has argued -- and I agree with him -- that survival is the highest good, the summum bonum, for the simple reason that, without survival, all other values have no meaning. I am quite certain that the great majority of people would, if need be, choose survival even at the expense of isolation and loneliness.
Q.: Another objection frequently raised to "lifeboat ethics" involves the probable negative and destructive effects of such life-and-death decisions on the individual and collective American conscience. Garrett Hardin agreed, in a recent New York Times interview, that this well may be the most salient and disturbing obstacle to his position. Would you venture to anticipate or predict the possible ramifications of such triage decisions on the individual or collective lives of A men cans?
A.: I suppose that the thrust of this objection is a fear that refusing to help starving people would constitute a self-brutalization, and would contribute to the development of a terrible moral callousness. It could be so. It has been so. It need not be so. I think, in fact, that it is not so. If we ever determined that we ought not to give aid to starving people in some situations, that decision would certainly be a cause for regret or sorrow. It is sad to witness a person dying for lack of food or clothing. But it should not be cause for remorse or grounds for self-accusation if, in so acting, one was convinced that he was optimizing total human well-being.
Q.: Americans have always perceived their culture as very moral, idealistic, humanitarian. If it came to light that decisions of the triage/lifeboat variety were being made in the distribution of our excess food resources, not for the sake of long-range survival and well-being of the greatest number based upon utilitarian calculation, but rather for the rawest, most crass and most selfish political reasons, would this not indeed have a devastating effect on the American moral consciousness?
A.: Such practices and the full impact of their revelation and realization would indeed be a very great blow to our character and our quality as a people. Such possibilities, in addition, present a real and present danger to our community and national life.
I take some comfort, therefore, in an impression that most Americans could be won to the position that assistance to famine-suffering countries must be given internationally. The only guard against a "parade of horrors" -- that is, the corruption, morally speaking, of famine efforts by hidden, alternative and immoral objectives -- is for famine relief to be undertaken as a multilateral, globally communal effort involving the U.S., the U.S.S.R., the Peoples’ Republic of China, the petroleum-rich countries in the Middle East, and many of the richer western European countries.
After all these dire and gloomy predictions and conversations, I am wont to hope that there would be, in fact, very few instances in which famine relief would actually increase rather than decrease human misery. And I would therefore want to see this relief come from a global consciousness and a sense of community, involving international responsibility.
Q.: One final question: coincident with the expanding frontiers in science, medicine and technology in the past decade, there also has been a great deal of discussion about a theology of hope. What about religious hope? And what about the hope and optimism still embodied in the areas of human creativity -- science and its attendant technologies? Some persons have advocated that we should "hold out," despite Hardin’s logic, and try to give aid and comfort to all people, wherever we can, in the hope that a "breakthrough" may occur, or that, an alternative will manifest itself and we will be spared the horrendous consequences which Hardin and others predict as the outcome of indiscriminate sharing.
Is it both reasonable and moral to wait for the "cavalry to come over the hill," so to speak, or must we face and make these agonizing decisions -- these triage decisions -- right now, as Hardin advocates?
A.: It is reasonable to hope that science and technology, along with other expressions of human imagination and creativity, will find progressively better solutions to our problems as time goes on. However, we are still obligated to deal rationally, realistically and morally with the present problems that confront us. When faced, for example, with the decision of whether or not to let a seriously ill or irreversible patient succumb voluntarily in terminal situations, we might avoid making the decision now, arguing for the possibility -- maybe next week -- that a new cure for the patient’s condition will be discovered. That is, in my opinion, a convenient escape from moral responsibility and from the discomfort of facing and making moral decisions. Such an evasion is not a valid exercise in religious or theological hope; it is moral cowardice.
To hope, while facing the allocative problems inherent in feeding starving people, that the "cavalry will come over the hill" and solve the problem for us is really to run from the problem. We must face and make these decisions. To move ahead with present, ill-considered famine relief policies, salving our moral consciences regardless of the foreseeable consequences, in the hope of some unforeseen future rescue, is to deny the imperatives of moral responsibility, and therefore is itself an immoral act.