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• In Defense of Instrumental Value
  Angela Wentz Faulconer
  Published on: 12 July 2021

• Published on: 12 July 2021

  In Defense of Instrumental Value

  • Angela Wentz Faulconer, Visiting Assistant Professor Brigham Young University

  The authors argue that when we prioritize healthcare workers for ventilators because of their instrumental value as healthcare workers, we fail to value human lives equally. While they suggest that “it may be ethically justifiable for healthcare workers to receive priority for some scarce healthcare resources” and argue that healthcare workers should have sufficient personal protective equipment (PPE), they do little to explain why granting priority for these resources isn’t also, as they argue with ventilators, a case of failing to attribute equal value to human lives. Indeed, it is not clear that they think prioritizing healthcare workers for vaccines was the right thing to do: “. . . our social fabric has shown signs of unravelling as vaccine roll-outs have pulled on loose threads” and prioritizing vaccines has resulted “in unanticipated frustration, mistrust and strife.” The authors are right in their conclusion about ventilators, but we should reject the concerns their article raises about vaccines and PPE. If saving the most lives is the goal, it is consistent with valuing each person’s life equally to prioritize healthcare workers for preventive measures, particularly at the outset of a pandemic.
  The authors mention three reasons ventilators are different from preventive measures like PPE and vaccines: 1) Efficacy: Those who require a ventilator will not return to work quickly. 2) Lifesaving: While ventilators rescue endangered lives, preventive measures only...

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  The authors argue that when we prioritize healthcare workers for ventilators because of their instrumental value as healthcare workers, we fail to value human lives equally. While they suggest that “it may be ethically justifiable for healthcare workers to receive priority for some scarce healthcare resources” and argue that healthcare workers should have sufficient personal protective equipment (PPE), they do little to explain why granting priority for these resources isn’t also, as they argue with ventilators, a case of failing to attribute equal value to human lives. Indeed, it is not clear that they think prioritizing healthcare workers for vaccines was the right thing to do: “. . . our social fabric has shown signs of unravelling as vaccine roll-outs have pulled on loose threads” and prioritizing vaccines has resulted “in unanticipated frustration, mistrust and strife.” The authors are right in their conclusion about ventilators, but we should reject the concerns their article raises about vaccines and PPE. If saving the most lives is the goal, it is consistent with valuing each person’s life equally to prioritize healthcare workers for preventive measures, particularly at the outset of a pandemic.
  The authors mention three reasons ventilators are different from preventive measures like PPE and vaccines: 1) Efficacy: Those who require a ventilator will not return to work quickly. 2) Lifesaving: While ventilators rescue endangered lives, preventive measures only reduce risk. 3) Urgency: Not being prioritized for preventive measures likely means waiting until they become available, while not being prioritized for a ventilator means not receiving one at all. The point about efficacy should be acknowledged as an important difference between ventilators and preventive measures. If healthcare workers qualify for priority for scarce life-saving resources due to their instrumental value in their roles as care providers, and the need for a ventilator indicates an inability to fulfill this role, then healthcare workers requiring ventilators shouldn’t receive priority for those resources over others.
  The authors’ commitment to community solidarity leads them to concern about the results of assigning (or worse, reassigning) the last ventilator to a healthcare worker as opposed to someone in equal medical need. However, if prioritizing ventilators for healthcare workers weakens our social fabric, we must ask whether this also applies to preventive measures. Contra the authors’ last two points about differences between ventilators and preventive care: a) preventive care is lifesaving: The life of a nurse forced to face Covid patients without adequate PPE is endangered. b) preventive measures are urgent: If hospitals are overwhelmed and death rates are spiking, those aware of the virus’s danger and the vaccine’s efficacy in January will find only limited comfort in knowing that they might be able to receive the vaccine if they are healthy by May.
  Preventive measures are like ventilators in that they are scarce lifesaving medical resources and their use is urgent. Can prioritizing them be justified? The authors follow James Childress in supposing that any justification for their use on the basis of instrumental value carries a “heavy burden of proof.” Childress made his comments in 1970, while grappling with how to approach extremely limited dialysis or organ transplant opportunities. He argued that the burden for straying from randomness or chance as a basis for allocation demands showing not that someone has positive contributions to make, but that they are literally irreplaceable, that disaster would likely result from that person’s loss. However, in the context of a pandemic, this burden of proof is too heavy. It is possible to be instrumental in saving many lives yet still fall short of Childress’ standard.
  The most straightforward justification for prioritizing those who save more lives is the multiplier effect, an instance of instrumental value. If we save the life of a life-saver, more total lives are saved. This is evidence not that we value lives unequally—the life-saver’s life isn’t valued more highly—but that we value saving more lives above saving fewer lives. The authors make the point that many workers, not just healthcare workers, have instrumental value. It is true that healthcare workers aren’t alone in having instrumental value (many are instrumental in keeping the economy running or society functioning, for example) and in fact, aren’t the only ones in roles that might save lives. My argument is that if saving the most lives is our primary objective, then prioritizing those we believe will make that possible is consistent with valuing each life equally.
  These judgments are context dependent. Decisions must be judged by the information available at the time. At the outset of a pandemic, we are information poor. No one knows whether the infectious agent in question is as contagious as measles or Ebola, how it spreads, or which groups are most at risk. This is difficult because PPE must be stockpiled in advance, and successful planning for mass vaccine allocation/distribution, although it happens later, isn’t last minute either. We must act on our best predictions. For pandemic disease, it is reasonable to assume that healthcare workers will be particularly vulnerable to death and that more lives will be saved if healthcare worker lives are saved. If we later come to have solid evidence that prioritizing housekeepers for vaccines instead of healthcare workers would actually save more lives (not the same as concluding that housekeepers are dying at higher rates, as mentioned in the article), we should adjust our priorities accordingly.
  The authors’ account of unravelling social fabric is overblown. Scarcity brings sorrow; there aren’t enough lifesaving resources to go around. However, this is more a reflection of the pandemic’s toll than our decision to save the most lives by prioritizing healthcare workers. The goal is to save the most lives, not a perfect distribution process. Inevitably an imperfect distribution system will lead to the frustration the authors reference. Many will disagree with which goals are primary or how to achieve them. But frustration isn’t failure. When we come to know more, we can do better. Meanwhile, we save the most lives we can.

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  Conflict of Interest:
  None declared.

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