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December 29, 2010


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I think you raise an interesting aspect of this debate here, but I fear I am not convinced that any appeal to moral sentiment does the work that you hope of it.

Many things rouse the imagination or our sentiments and, indeed, many of these may have a moral dimension to them. However, it is not clear, as the phrase 'moral sentiment' seems to convey, that these, and their resulting consequences, are in fact moral in the sense of being morally good or desirable.

Your example of the Chilean miners is a great example of one where we might think that our moral sentiments have run amok. The line of argument you present seems to be something along the lines of 'thank goodness we have some semblance or moral sentiment/are human that can win the day over those with a cold-hearted economic approach'. However, it is not just about a calculation that results in a 'let them suffer' attitude, we also have to consider the things that can no longer be done once resources are used and the other people who will suffer or be disadvantaged as a result of this.

I have argued elsewhere in 'Personal or Public Health' (with my colleague John Harris) that when it comes to rescue situations (of which many health care scenarios can be construed as such) that they are not paradigm cases of easy rescue where there are no opportunity costs or risks to other people. For that reason, while each individual can decide whether or not they are willing to undertake a rescue (saving the drowning child/performing CPR in the hospital corridor/donating a kidney) and might accept the associated risks/opportunity cost, what we cannot/ought not to do is to force people to take on those risks and put their own lives or health in danger. Yet this is exactly what we do in situations where we expend extraordinary amounts of resources on rescue type situations in the health care setting. In doing so we ignore the fact that there may not be enough left to save the lives of others in the future or, worse, to actually prevent others from ending up in similar situations.

In such situations it might be that we have to awaken our 'passive feelings' regarding the consequences of resource expenditure so that they are not completely overshadowed by our current 'active principles'.


Thank you for your comment. I don’t think we disagree. Many outcomes result from what I’ll call “moral sentiments run amuck”! Better outcomes can often be achieved by cost-benefit analysis. So I’ll repeat: moral sentiments may produce both inefficiency and injustice in any particular instance. That is why Adam Smith insisted upon using moral rules (not moral sentiments). Rules are determined by the intersection of many different peoples’ moral sentiments over many years, not simply the passions of an individual at the moment.

A normative moral theory has to be compatible with human nature. It is pointless to say “Use moral theory X” when people are incapable of using it. Human biology is not likely to change much over the next 1,000 years. Moral sentiments are part of the hardwire architecture of human biology. It can explain why many people would argue that health care is different than iPods, because the former involves the externality of shared pain.

So, arguing that we should ignore moral sentiments and focus on cost-benefit alone is likely to backfire. People will instinctively want to rescue the miners. Forcing people to ignore their moral sentiments sounds pretty draconian--and would likely result in politicians getting kicked out of office. Amartya Sen has pointed out that famines have not occurred in democracies, because moral sentiments are aroused, and politicians have listened.

Thanks Jonathan - you are definitely correct to point out that any normative moral theory does have to be compatible with our (human/better/worse?) natures in order to function. Great thought-provoking posts. However, I'm not convinced that ignoring moral sentiments/intuitions is that draconian. Instead it requires people to subject their thoughts and actions to some sort of analysis (I want to insert the word rational in front of that, but since I currently think our notions of rationality need to be revised a little I won't!).

I still worry that certain activities (and here read use of resources) only masquerade as being morally right. Within democracies, for example, we might not have to worry about overt famine, but we do still have to worry about the very poor and the distribution of goods such as health care. My bug bear example to my students is tertiary health care services (cardiac bypass/oncology drugs/specialist transplant services). If we have limited health care budgets and we spend it on tertiary health care services when we could have spent it on preventative or public health measures then something that appears moral (immediate life-saving) could end up worse for more further down the line.

(I guess I should add the caveat that I am talking mostly about public rather than private systems of health care)


Your passion is rightly aroused for the “bug bear" example. But "why" is your passion aroused in this situation? You ultimately have to appeal to “something” outside the model, right?

Using your example of tertiary care versus primary care, presumably you will make the point that more life years can be extended by focusing on preventive care rather than tertiary care. Many babies are untreated and die from easily prevented infections of dirty water, while rich old people spend $1m surviving another month or two comatose in the hospital.

But anyone can respond to you, “so what”? Your next response will to appeal to the idea that children’s life years extended somehow “matters.” Why why does it matter?

Eventually—when all is said and done about costs and benefits—you will need to make a final appeal to something that is intrinsically worthy. I’m arguing that for Adam Smith that final appeal is to the moral sentiments: We can imagine the needless suffering of those children and feel their pain, and imagine the potential joys of them living long and fruitful lives. That is the active principle that makes us want to do something to help them.

Without the moral imagination there would be little reason to act. We would all be like the European who slept soundly after hearing of the death of 100,000 Chinese in an earthquake.

Yes I see your point, but I fear your children example is the wrong one (or at least it is as far as my own moral sentiments are concerned).

I would rather stick to examples of those who are clear moral persons or moral agents and children, or at least the very young ones, don't make it into that category for me. As such, if I am attributing intrinsic worth on the basis of certain characteristics required for moral agency/personhood then I'm not convinced that any argument I make has to end in an appeal to moral sentiments. I'll have to think about it a little more though just to make sure. ;)

I guess you bigger point is that without the ability to imagine, emapthise, etc, then we would have no motivation to act even if we have good reason to. I'll have to think about the connection between these, but I am initially inclined to say that although connected they are separable to the extent that sentiment still has to be subjected to some sort of reason. If all of our reasoning simply comes down to moral sentiment in the end then whose moral sentiments ought to win out?

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