In an ingenious article John Harris has proposed a 'survival lottery' which would minimize the total number of deaths in a community by sacrificing randomly chosen individuals so that their organs could be transplanted to other people, each of whom needs to have an organ replaced. Since, assuming the perfection of transplant technology, the parts of one 'donor' (if that is the right word) could save the lives of four or five others, the proposal appears to be a rational one. If we had the option of joining such a scheme it seems, at first glance anyway, that we would be imprudent to refuse to join. More lives will be saved by the transplants than will be lost by the sacrifices required; hence our prospects of living to a ripe old age are better if we join.
. . .
The major drawback to the survival lottery seems to be . . . not that it infringes some justifiable moral prohibition against killing; rather, I shall suggest, it is a problem of a utilitarian kind. This is surprising, for the scheme looks like an example of utilitarian planning carried to a new extreme. Harris himself says that utilitarians ought to favour it, and devotes most of his article to meeting absolutist objections. But the survival lottery faces a problem that is faced—though in a milder form—by a wide range of social welfare schemes: by transferring the consequences of imprudent action from the imprudent individual to society at large, the scheme removes the natural disincentive to imprudent action. Thus if I like rich food, and am a member of the survival lottery, I can eat what I like without worrying about growing obese and straining my heart; when it fails, I can always get a new one from a healthier person. My obesity does not increase my chances of being selected by the lottery, and so does not decrease my expected life-span; nor does another person's sensible diet and regular exercise increase his expected life-span. There may even be a tendency toward the reverse, since unhealthy people whose organs have already deteriorated to some extent will be of little use as donors and so presumably would be eliminated from the draw, leaving the healthy to bear the burden of providing organs when required.
. . .
If I am right in believing that it is impossible to sort out those who have brought their need for a new organ upon themselves from those who have not, it seems we must choose between allowing the imprudent to benefit at the cost of the prudent, or [sic] enacting stringent regulations governing almost every aspect of the lives of those admitted to the scheme. The former, quite apart from questions of justice, would lead to a progressive deterioration in the health of the community, and thus in the long run to the very opposite of what the scheme was intended to ensure, namely the saving of lives; while the latter would be a new and greatly extended form of the Prohibition experiment, and conjures up visions of illicit cake-shops providing huge revenues for the Mafia.
(Peter Singer, "Utility and the Survival Lottery," Philosophy 52 [April 1977]: 218-22, at 218, 219, 221 [footnote omitted])
Note from KBJ: Although Singer didn't have nationalized health care in mind when he wrote this short essay, what he says bears on that issue. If we as a nation decide to confer a legal right to health care on everyone, then wealth will be transferred from those who eat and exercise properly to those who don't. This wouldn't be a problem if we could deny treatment to those who are irresponsible, but, as Singer says, this is impracticable (he says "impossible," but that's an exaggeration unless he means "practically impossible"). So we have two choices. We can refuse to make a distinction between the responsible and the irresponsible or we can micromanage people's lives in order to force them into being responsible. If we choose the first option, the overall level of health will decrease. People will know that, no matter how irresponsible they are with their health, they will get the treatment they need. If we choose the second option, we have gone over to totalitarianism. People will be forced to exercise (on pain of punishment?) or prohibited from eating certain foods. (There go alcohol and nicotine, both of which generate staggering health-care [and other] costs.) Perhaps people such as cyclists, mountain climbers, hunters, and race-car drivers will be prohibited from engaging in their activities, since these activities increase the risk of injury, which will require publicly funded health care. Perhaps it will be illegal to have unprotected sex, since that increases the risk of contracting or spreading disease. Singer's essay was published 32 years ago, but the issues he raises are not being discussed. Why? Is it because we no longer believe in personal responsibility? Does the idea that people will be held responsible for their dietary and other choices no longer resonate?
Keith Burgess-Jackson, J.D., Ph.D. 