Focus on institutions

First, bioethicists should consider the duty to rescue as it applies to institutions, not just individuals. By institutions we mean collectively shared social schemes responsible for the distribution of benefits and burdens across members in the collective, and primarily, we have in mind government institutions. Oftentimes, bioethicists speak of the duty to rescue that a clinician or researcher has in virtue of being a moral agent. But, more accurately, this agent would use institutional resources to enact a rescue at an opportunity cost to healthcare elsewhere. Focusing on institutions over individuals brings this wider context into focus.

The institutional duty to rescue differs from the individual duty to rescue in two important ways. First, it is held by an institution or institutional actor to populations rather than to individuals. Second, institutional obligations are not general, they are held to a specific population. As such, the institutional focus can provide guidance on the scope of a duty to rescue. Where with the individual duty to rescue it was unclear why an agent would have a duty to rescue some specific person rather than another in similar need, an institutional focus prioritises individuals for which an institution is responsible. Despite the great amount of need in the world, institutions have primary responsibility to address the needs of their own constituents.

The institutional nature of the duty can also assuage concerns about its force. Giving absolute priority to people in need of rescue over people with lesser needs would be unfair. Institutions have obligations to all of their members, and so there is some threshold at which an institution should forgo providing a costly rescue to some individual so that it can provide lesser benefits to a larger number of people. A plausible institutional duty of rescue, then, will be limited to cost-effective ‘easy’ rescues. Though we cannot specify the threshold for easy rescues here, a limited institutional duty of easy rescue can be motivated in a way that a limited individual duty of rescue cannot. In the latter case, the motivation for limiting the demands is the agent's personal interests. As noted above, it is controversial whether and when personal interests should defeat a duty to rescue. In the institutional case, the motivation is fairness to other institutional members who also have a claim on institutional resources. Costs to members to whom the institution has obligations to benefit provide solid grounding for limiting the institution's duty to rescue to easy cases.

Thus, the institutional duty of easy rescue differs from the rule of rescue by implying a cost threshold and a feasibility requirement for rescues that receive priority: it applies to those rescues that can be met at relatively low cost. Further, it does not unjustly select beneficiaries in virtue of their salience; it prioritises them based on need. Need is a morally relevant consideration reflected in a popular strand of thinking about justice, which requires that institutions give some priority to those people who are worst off (prioritarianism).ⁱⁱⁱ

There is yet another way in which an institutional focus can address concerns about the force of rescue duties, that is, how demanding they are. Substantial institutions can respond to very demanding rescues without any one person incurring a large unredressed burden because the burdens can be spread across individuals. For instance, taxpayers fund the fire department to conduct rescue operations, sharing the burden of rescue communally. Though firefighters do incur great burdens, they are also compensated for the risk. One could also imagine an institutional scheme whereby individuals who incur great costs to enact rescue—recall the man who must sacrifice his sports car to save a child on the railroad tracks—could be compensated for their personal loss. By spreading the demands of rescue among individuals, institutions can better coordinate rescues and collectively shoulder its burdens. The demands of individual rescue are less burdensome when addressed by institutions.23

Focusing on institutions provides a response to, and a diagnosis of, the demandingness concern. A primary reason why the demands of rescue can be so great is because poorly functioning or absent institutions cause rescue cases to proliferate. For example, wide inequalities in rates of childhood vaccinations within and between Indian states suggest that many children do not receive life-saving vaccinations because their state institutions are not just.24 If institutions were just and properly functioning, a great number of rescue cases would likely disappear.

In the absence of just institutions, the ethical challenge for individual potential rescuers remains. Recall the case of the Malian research subject with a cardiac defect. The cost to an individual researcher of airlifting her to a hospital for heart surgery would be very high. Assuming that the researcher is not wealthy, paying for the rescue himself might be praiseworthy, but not obligatory. Likewise, if the resources available to the research team are limited, it may not be obligatory for them to pay for the airlift. Moreover, if the opportunity costs to other needy patients is too large, a duty to rescue may be overridden.

But the story does not end there. Mali's lack of capacity to treat patients needing complex heart surgery is, plausibly, not an accident, but the result of systemic failures intranationally and internationally. If the researchers are not going to engage in costly rescues themselves, they can still work towards, and advocate for, improvements in Mali's healthcare system. Together with the efforts of others, and without any individual incurring excessive costs, it may be possible to expand the country's institutional capacity to respond to urgent needs. Recognising that an institutional response to predictable rescue needs may be appropriate can help concerned agents to focus on what should be changed without becoming paralysed or overwhelmed. We need not choose between doing nothing and sacrificing everything.

Professional duties to rescue

It is widely assumed that the individual duty to rescue just applies to moral agents as such.25 But, in fact, professionals frequently have additional (or more demanding) duties to rescue in virtue of their roles.26 For example, police and firefighters have a duty to rescue even at great risk to their own lives. Physicians must offer emergency medical assistance when not on the job.27 This explains and justifies the pull that urgent medical needs often have on healthcare professionals. The exact requirements of the professional duty to rescue will vary by profession: for example, firefighters may be required to risk their lives, though not their own personal resources, whereas doctors are rarely required to risk their lives, but may be required to devote their own time and resources. What these professions share, despite differences in the details, is a more demanding duty to rescue than the general, individual duty to rescue.

The existence of these more stringent professional duties to rescue is uncontroversial: they are grounded in the profession's history, an implicit contract with society, and voluntary assumption of the role by the individual professionals.28 ,29 The professional context thereby explains the demanding force of the professional's duty to rescue. The professional context is also relevant to the duty's scope. For example, doctors have special obligations to their patients that justify partiality to these patients over others. More generally, professionals must take on greater costs to perform rescues within their area of expertise than outside it. Doctors have more demanding duties to rescue the sick and injured than people who are drowning. Lifeguards have an increased duty to rescue swimmers, though they don't have an increased duty to rescue people trapped in burning buildings; the latter is the professional domain of firefighters. All these agents have the same individual duties of easy rescue as other moral agents, but their responsibility increases when the rescue involves people who are the standard beneficiaries of their professional role.

In locating the scope of the professional duty to rescue, this conception provides a middle ground between two extremes: the rule of rescue unjustifiably advocates rescuing those with the most salient need, even at great opportunity cost. On the other side, consequentialism advocates always acting to bring about the optimific result. On the latter view, a heart surgeon should refuse to do a heart transplant when the resources for this costly surgery could save more lives if spent on, say, improving sanitation. A professional duty to rescue explains why the professional may and should favour rescuing a person to whom she is responsible at the opportunity cost of rescuing others (up to some threshold). Since the duty is generated from the professional role, it does not extend to rescues outside that role.^iv

We noted earlier that individuals, particularly professionals, are often faced with rescue situations in which they are allocating institutional resources. Institutional duties to rescue and professional duties to rescue are therefore closely tied. An ideal society^v would assign responsibilities to rescue to individuals in conformity with the requirements of justice. However, this does not imply that individual professionals should always take an institutional view of the rescue cases they confront. Our institutions coordinate rescues, in part, by delegating them to professionals. But our professionals are not merely or even always institutional actors. The duties of a professional have a rich grounding in historical tradition, as well as social contract. Doctors will feel compelled to provide medical rescues to patients in their care regardless of whether this is the most efficient use of resources from the institutional standpoint. Indeed, this is at least partly desirable even from the institutional standpoint, for we wouldn't want our professionals on the ground worrying about allocation at each rescue. Firefighters shouldn't have to check a budget before responding to each call. That allocation decision happens at a societal or institutional level, not at the professional level.

Returning to the case of Oregon's Medicaid spending, the state might have been justified in refusing to pay for bone marrow transplants, on the grounds that providing alternative, more cost-effective services would be more fair to the population it served; however, the doctor of a patient like Coby Howard might still be justified in advocating for his treatment. In practice, the duties of professionals can come apart from those of institutions. The relationship between institutional and professional duties to rescue is a rich area for future study by bioethicists.