The Rule of Rescue

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Abstract

Jonsen coined the term “Rule of Rescue”(RR) to describe the imperative people feel to rescue identifiable individuals facing avoidable death. In this paper we attempt to draw a more detailed picture of the RR, identifying its conflict with cost-effectiveness analysis, the preference it entails for identifiable over statistical lives, the shock–horror response it elicits, the preference it entails for lifesaving over non-lifesaving measures, its extension to non-life-threatening conditions, and whether it is motivated by duty or sympathy. We also consider the measurement problems it raises, and argue that quantifying the RR would probably require a two-stage procedure. In the first stage the size of the individual utility gain from a health intervention would be assessed using a technique such as the Standard Gamble or the Time Trade-Off, and in the second the social benefits arising from the RR would be quantified employing the Person Trade-Off. We also consider the normative status of the RR. We argue that it can be defended from a utilitarian point of view, on the ground that rescues increase well-being by reinforcing people's belief that they live in a community that places great value upon life. However, utilitarianism has long been criticised for failing to take sufficient account of fairness, and the case is no different here: fairness requires that we do not discriminate between individuals on morally irrelevant grounds, whereas being “identifiable” does not seem to be a morally relevant ground for discrimination.

Introduction

Why do we mount expensive searches—for sailors lost at sea, for example—when there is little chance of finding those who are missing? (Creadon, 1997). If searching is expensive, and the chance of success is negligible, surely the money would be better spent in other ways? Why do we offer critically ill patients intensive care, when prognosis is terrible? (Osborne & Evans, 1994, p. 779). Surely these policies divert resources from other activities where the benefits would be greater? Why do some patients receive a second or third heart or liver transplant, when first-time recipients have a higher 1-year survival rate? (Ubel, Arnold, & Caplan, 1998, pp. 276–279). When organs are in short supply why not give priority to first-time transplants if they have a better chance of survival? These practices manifest a psychological imperative that is hard to resist: namely, the imperative to rescue identifiable individuals facing avoidable death, without giving too much thought to the opportunity cost of doing so. Jonsen dubbed this the “Rule of Rescue” (RR) (Jonsen, 1986, pp. 172–174). In this paper we address three main questions: (1) What is the nature of this imperative? (2) How might we go about measuring it? (3) Is it ethically defensible?

Section snippets

Opportunity costs

In the health sector it has become common to use “Quality-Adjusted Life Years” or QALYs as the unit of effectiveness in cost-effectiveness analysis (CEA). In its simplest form the QALY represents a year of life that has been weighted, or discounted, by an index of the quality of life. By convention, full health has a weighting of 1 and death has a weighting of 0. So, for example, if a year of life on hospital dialysis is considered to be worth only 57 per cent as much as a year of normal health

Measuring the RR

Since the maximisation of QALYs also maximises health-related utility, and since the RR is at odds with the straightforward maximisation of QALYs, the RR appears to violate the presumption that utility should be maximised. It is therefore an interesting question whether the RR can be justified from a utilitarian point of view. In this respect it is important to note the different possible sources of utility arising from a health intervention. In general terms there are four such sources:

  • (1)

    The

The normative status of the RR

We turn now to the question of whether the RR is ethically defensible. We noted that underlying the RR is the desire to help an identifiable individual. This is contrary to conventional CEA, which does not distinguish between “identified” and “unidentified” individuals, but simply aims to maximise health (measured in QALYs). However, it does not automatically follow that the RR is morally indefensible. First, from a psychological point of view, the RR response is understandable. To abandon an

Discussion

The arguments above provide an ethical rationale for the RR, especially from a utilitarian perspective. However, they must be weighted against the argument that the RR discriminates on morally dubious grounds. Of course, it is sometimes justifiable to discriminate between individuals and groups if the grounds for discrimination are morally relevant.14

Conclusion

Utilitarians are guided by the goal of maximising quality and quantity of life in the allocation of limited health care resources, as is enshrined—at least in principle—in conventional CEA. There will, however, be occasions—and probably numerous occasions—when total utility can be maximised by abandoning the logic of conventional CEA in favour of “the powerful human proclivity to rescue a single identified endangered life, regardless of cost, at the expense of many nameless faces who will

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