The Rule of Rescue
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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