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Let Us Be Fair to 5-Year-Olds: Priority for the Young in the Allocation of Scarce Health Resources

Let Us Be Fair to 5-Year-Olds: Priority for the Young in the Allocation of Scarce Health Resources Abstract Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. The Problem Life-saving health resources like organs for transplant and experimental medications are persistently scarce. There are not enough of such resources to go around, so rationing of some sort must take place. This leaves us facing the question of how, morally speaking, we ought to allocate persistently scarce medical resources. Who should receive priority for them? Which moral principles should we use to guide our allocation decisions? While there is much disagreement as to what is the morally best allocation scheme, there is widespread agreement on one claim: age is an important consideration in allocation decisions. Many hold that, in any morally acceptable allocation scheme for scarce health resources, the young should to some extent be prioritized over the old (Harris, 1985; Daniels, 1988; Persad et al., 2010; Solberg and Gamlund, 2016). One way to ration scarce health resources is to take a benefit maximizing approach: to maximize health benefit generated per dollar spent. Suppose for the sake of simplicity that it would cost the same to preserve the life of each of several candidates for a scarce, life-saving resource. A benefit maximizer would then calculate the expected health benefit of various allocations and implement the one that brings about the greatest health benefit. One common metric used to measure the expected benefit from particular allocations is the quality-adjusted life year (QALY). QALYs are calculated on the basis of how many life years a particular way of allocating resources would save, adjusted for the health-related quality of those life years. One QALY is equal to a year in full health. The more QALYs a given medical intervention or public health program would produce, the greater the benefit. Benefit maximizing using QALYs would often have the result of giving younger people priority over older people for life-saving interventions. This is because, costs being equal, saving younger individuals will often result in more life years preserved than saving older individuals would. But people have many objections to benefit maximizing. First, we have good reason to be skeptical of a one-principle prioritization scheme, especially one that implies that it is of equal value to save one person for 80 years of full health as it is to save eight people for 10 years of full health each, assuming the costs of saving the one and the eight are the same. Relying solely on one principle to make allocation decisions leaves benefit maximization blind to other important moral considerations, like the importance of number of lives saved. Second, costs of intervention being the same, benefit maximizing would give equal priority to saving a 75-year-old who would live for an additional 15 years in full health as it would give to saving a 5-year-old who would live for an additional 15 years in full health. While benefit maximization will often favor the younger over the older, in particular cases it will be insensitive to the importance of considerations like fairness. Fairness considerations lead us to think that, even when the benefit accrued from a particular allocation will be the same, 5-year-olds deserve additional life years more than 75-year-olds. Straightforward benefit maximization thus seems unable to accommodate our intuitions regarding who ought to be prioritized in a medical resource allocation scheme, especially regarding fairness and the importance of number of lives saved. Allocation based solely on maximizing health benefit per dollar spent neglects important moral considerations. Advocates of multi-principle prioritization schemes try to remedy this neglect by suggesting principles inspired by various moral considerations, such as the intrinsic value of lives or life years, or the great instrumental value to others of people with special skills. Such a scheme might thus include a principle directing us to save lives, another prescribing us to preserve life years, and yet another specifying that health professionals should get priority under certain circumstances, and so forth. These various principles would somehow need to be ordered or weighted against one another. Many hold that we ought to incorporate into whichever scheme we accept a principle that, at least to an extent, privileges younger people over older people. There is surely an intuitive appeal to taking age into account when making allocation decisions. But why is this? First, we have a general fairness concern. As we just noted, given the choice of giving a life-saving medical resource to either a 75-year-old who would then live for 15 more years or a 5-year-old who would then live for 15 more years, it seems that it would, other things being equal, be unfair to opt for the 75-year-old. This is presumably because the 75-year-old has had the opportunity to do many more things than the 5-year-old, opportunities that the 5-year-old would never have, if she were to die. Therefore, we have moral reason to favor saving the 5-year-old over the 75-year-old. Second, there is the more specific notion of fair innings. The idea here is that there is an age threshold at which a person can be taken to have had a fair shot at living a complete or full life. If one’s life ends before this threshold, then one has not received one’s fair innings (Harris, 1985: 87–102; Bognar, 2008: 167–189; Bognar and Hirose, 2014: 88–95). Thus, we have moral reason to prioritize those who have not yet reached this threshold over those who have. This means that, for instance, we have moral grounds for prioritizing the young who are just beginning their lives over the elderly who have already had a chance to live a full life. Finally, there may be prioritarian considerations to take into account. Prioritarianism is predicated on the claim that benefitting people matters more morally the worse off these people are (Parfit, 1997). Younger people are worse off, as a class, than older people because they have had less of a precious resource: life years. To rectify this inequality, we have reason to give younger individuals priority for scarce life-saving resources. Considerations of fairness, fair innings and prioritarianism, taken separately or together, provide us with moral grounds for thinking that there should be a principle favoring the young over the old in whatever health resource allocation scheme we ultimately accept. This leaves us with the question of how exactly we ought to incorporate priority to the younger into a prioritization scheme. One option might be to prioritize the younger over the older, perhaps up to a certain threshold age. This would mean prioritizing infants over 13-year-olds. But some have argued that the death of an adolescent is worse than the death of an infant (Dworkin, 1994; McMahan, 2002; Solberg and Gamlund, 2016). Should the intuition that adolescents’ deaths are worse than young childrens’ deaths lead us to a principle privileging the saving of adolescents over the saving of young children, other things being equal? Modified Youngest-First Arguments Govind Persad, Alan Wetheimer and Ezekiel Emanuel propose a multi-principle allocation scheme for scarce life-saving health resources called the Complete Lives System, which reflects this intuition and explicitly prioritizes adolescents over young children. Persad, Wertheimer and Emanuel have embraced a principle according to which persons roughly between 15 and 40 years old get priority for scarce life-saving health resources over younger children and older adults, other things being equal (Persad et al., 2009). They defend this ‘modified youngest first’ principle in part by an appeal to a social investment argument.1 Adolescents, as opposed, for example, to very young children, ‘have received substantial education and parental care, investments that will be wasted without a complete life’ (Persad et al., 2009: 428, Note 2). However, some find this social investment argument inadequate. As Kerstein and Bognar note, it seems arbitrary to understand investment solely in terms of education and parental care when there are other forms of social investment such as advanced career training that people undertake well into their 40s (Kerstein and Bognar, 2010: 40, 41). According to Persad, Wertheimer and Emanuel’s reasoning, should not these 40-year-olds (e.g. diplomats or business leaders) get priority over younger people, other things being equal, contrary to what modified youngest first implies? Further, some might be uncomfortable with an appeal to social investment simply because it seems to reduce the importance of individuals to the resources that we, as a society, have put into them. Recently, Ruth Tallman has proposed a distinctive defense of modified youngest first, a defense that, she underscores, rests not at all on this social investment argument (Tallman, 2014: 207–213; 209, 210). This defense of modified youngest first is our focus. Since Tallman defends a principle developed by Persad, Wertheimer and Emanuel as part of the complete lives approach to the allocation of scarce, life-saving resources, we need to have in view a brief outline of this approach. Constitutive of it is a set of principles, including modified youngest first and four others: prognosis, save the most lives, lottery and instrumental value (Persad et al., 2009: 427, Note 2, Table 2). A youngest-first principle would consistently prescribe prioritizing younger people over older people, for example, 5-year-olds over adolescents. But Persad and colleagues embrace modified youngest first, which, again, prioritizes persons roughly between 15 and 40 years old over younger children and older adults (Persad et al., 2009: 428). For example, the modified youngest-first principle prioritizes 17-year-olds over 5-year-olds and 30-year-olds over 10-year-olds. According to a second principle, namely, prognosis, we ought to ‘save the most life-years’ (Persad et al., 2009: 425). This principle would give priority for a kidney transplant to a patient who would live an additional 20 years over a patient who would live an additional 10 years with the transplant. Persad and colleagues suggest that lotteries might be used to choose between ‘roughly equal’ candidates for a life-saving intervention (Persad et al., 2009: 428). Finally, an instrumental value principle ‘prioritizes specific individuals to enable or encourage future usefulness’ (Persad et al., 2009: 426). Limited in application by Persad and colleagues to ‘some public health emergencies’, this principle might imply that during a flu pandemic, medical staff needed to disperse vaccine should be vaccinated before others (Persad et al., 2009: 424; 429, Table 1). Persad and colleagues offer no priority ranking among the principles but suggest that the principles should be balanced against one another (Persad et al., 2009: 429). Focusing on modified youngest first, Tallman argues for two main claims. The first is the following: The overall goal of the complete lives approach warrants its including modified youngest first rather than youngest first, assuming that it must include one or the other. Tallman’s second, more ambitious, claim is simply that: Modified youngest first is justified as a principle for the allocation of persistently scarce, life-saving resources. Tallman fails to defend adequately either of these claims, we contend. In her argument for the first claim she attributes an overall aim to the complete lives approach that it does not and, given the aim’s implications for priority-setting, ought not to have (Section 2). Moreover, her argument that modified youngest first is justified tout court falls short of grounding central features of this principle, for example, the priority it gives 30-year-olds over 5-year-olds, other things being equal (Section 3). And, as we explain (Section 4), there is at least some, if not necessarily overriding, moral reason to reject modified youngest first on the basis that it is unfair to young children. Why should kindergartners get less priority for life-saving interventions than young adults when the adults have already had far more life? Tallman is aware of this concern and tries to address it, apparently in the course of arguing for her two main claims. But, as we try to show, she does not diminish the concern’s force.2 The Implausibility of Allocating to Maximize Complete Lives One of Tallman’s main aims is to defend Persad and colleagues’ choice to embrace as a constituent of the complete lives system the modified youngest-first principle rather than a straightforward youngest-first principle (Tallman, 2014: 207, Note 5). Her attempt to realize this aim invokes two key concepts: that of a complete life and that of people in the midst of a complete life. According to Tallman, a ‘complete life is one that lasts long enough for its owner to have the opportunity for the range of experiences normal for a human being’ (Tallman, 2014: 208). Tallman associates a complete life with ‘the holistic experience of a full life lived’ (Tallman, 2014: 208, Note 3). Such a life involves embarking on life projects and having the opportunity to see them to fruition around ‘retirement age’ (Tallman, 2014: 210, Note 13). According to Tallman, to be in the midst of a complete life, an individual must fulfill several conditions. First, the person must not have already had a complete life. Many elderly people presumably thus fail to meet this condition. Moreover, to be in the midst of a complete life, she says, one must be able to understand the concept of a complete life, have adopted attainable goals and projects and be able to understand what it would look like to realize those goals and projects (Tallman, 2014: 210). If, as Tallman holds, infants fail to fulfill all of these conditions, then they do not count as being in the midst of a complete life. Although Tallman writes in terms of a person’s being in the midst of a complete life, what she means is that the person is in the midst of a life that might, practically speaking, be complete. Not all of us who are in the midst of a complete life in her sense will complete our lives: we might fail to complete them, for example, as a result of not getting some scarce, life-saving resource before we reach old age (Tallman, 2014: 210). To mirror Tallman’s usage, we will continue to write in terms of someone being in the midst of a complete life, but it is important to keep in mind that in her view people can be in the midst of a complete life even if they will not go on to complete their lives. Tallman’s first argument unfolds against the background of the assumption that the complete lives approach needs to include either the youngest-first principle or the modified youngest-first principle. Consider people in the midst of a complete life. According to the argument’s first premise, the complete lives approach aims to allocate scarce life-saving resources in a way that maximizes the number of these people who actually end up having complete lives (Tallman, 2014: 208, Note 5; 210; 213). The approach should embrace whichever of the two principles better promotes this aim, continues the argument. Modified youngest first obviously better promotes it than youngest first. Modified youngest first prioritizes individuals who are in the midst of a complete life (e.g. typical 30-year-olds) over individuals who are not (e.g. infants), while youngest first does the inverse. Therefore, the complete lives approach should embrace modified youngest first rather than youngest first. We find untenable the first premise of Tallman’s argument. Persad, Wertheimer and Emanuel do at one point say in passing that the complete lives system’s ‘aim is to achieve complete lives’ (Persad et al., 2009: 428, Note 2). However, if we assume that the complete lives approach gets realized solely in the five principles just enumerated, it obviously does not maximize the number of those in the midst of complete lives who end up having such lives. So it is implausible to suggest, as does Tallman in her first premise, that maximizing in this way is, on Persad, Wertheimer and Emanuel’s considered view, the goal of the complete lives approach. By way of illustration, suppose we must choose between saving a 50-year-old for 15 years, thus enabling her to have a complete life, or two 17-year-olds for 20 years each, leaving each of them short of a complete life. Lottery and instrumental value do not apply in this case, let us assume. That leaves prognosis, save the most lives and modified youngest first. Each one of these principles would favor saving the two 17-year-olds: two lives is more than one, 40 years is more than 15 and 17-year-olds get priority over 50-year-olds according to modified youngest first. However, to maximize complete lives, we would have to save the 50-year-old; for she is the only person concerned who would be capable of having such a life, and one complete life is greater than none. So Tallman in effect attributes to the complete lives approach a goal that the system supposedly designed to realize it cannot attain. Moreover, Tallman’s attribution of this goal to the complete lives approach is uncharitable, to say the least. To save one 50-year-old who would be able to have a complete life with the extra 15 years, we could give her instead of saving two 17-year-olds who would live 20 years each but fall short of attaining complete lives would be to allocate in a morally questionable manner. This allocation would not save the most lives or preserve the most life years, and it would seem to be unfair to the 17-year-olds. What is so important, they might legitimately ask, about getting one 50-year-old over the threshold of a complete life such that it justifies not saving the two of us for 40 years combined? Finally, promoting the goal Tallman attributes to the complete lives system (i.e. that of maximizing complete lives) would actually involve saving one such 50-year-old over any number of such 17-year-olds! That is unacceptable. In sum, Tallman tries to support Persad, Wertheimer and Emanuel’s adoption of modified youngest first over youngest first by appealing to what she takes to be the overall goal of their complete lives approach to the allocation of scarce, life-saving resources. But charity demands that we reject her interpretation of their approach. Their allocation principles do not (and clearly do not) realize this goal, and allocation principles that did realize it would in some contexts prescribe wildly implausible allocations. A Flawed Justification for Modified Youngest First Tallman’s second argument in support of modified youngest first runs as follows: Premise 1. In the allocation of scarce, life-saving resources we should give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. Premise 2. Modified youngest first prioritizes in just this way. Therefore, modified youngest first is justified as a principle for the allocation of scarce, life-saving resources (Tallman, 2014: 211, Note 5; 213). Tallman’s first premise is controversial, to say the least. It is far from obvious, for example, that if someone subjectively values her life, but, as a result of a longevity-limiting genetic predisposition, is not in midst of a complete life, then this person should get lower priority for a scarce, life-saving resource than someone who both subjectively values her life and is in the midst of a complete life. But for the sake of argument, let us accept this first premise. Here we try to show that Tallman’s second premise is false. Tallman asserts that we should give distributive priority to those who are in the midst of a complete life and who subjectively value their lives. But modified youngest first does far more than give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. Modified youngest first gives priority to 15-year-olds over 10-year-olds, for example. But, as we will now argue, children as young as 5 years old typically are both in the midst of a complete life and subjectively value their own lives. So, even assuming as we are that Tallman’s first premise is warranted, her argument leaves priority for those from age 15–40 years over people younger than 15 years undefended and thus modified youngest first unjustified as a principle for the allocation of scarce, life-saving resources. Being in the Midst of a Complete Life According to Tallman, a complete life for a person is a characteristically human life, one in which she has the opportunity for the range of experiences normal for a human being. To be in the midst of a complete life, she says, one must be able to understand the concept of a complete life, have (possibly attainable) goals and projects in place and be able to understand what it would look like for those goals and projects to come to fruition (Tallman, 2014: 210, Note 5). Tallman’s first criterion states that the capacity to understand the concept of a complete life is required in order for one to be in the midst of a complete life (Tallman, 2014: 210). One need not ever have actually reflected on such a concept; it is solely the capacity to understand it that matters. Tallman leaves unspecified how well one must be able to understand the concept of a complete life to meet this criterion. But the concept of a complete life, as a life that lasts at least a certain amount of time and contains certain defining features, is simple enough that it is plausible to think that children would be able to understand this concept well in advance of age 15. Simply understanding the concept of a complete life is no complex or intellectually demanding endeavor. Even very young children may understand that people characteristically grow up, get jobs, get married, pursue hobbies, raise children and eventually die. Further, from an early age, children are exposed to arc-of-life narratives, both in real life and in fiction. Once children can converse coherently about these narratives, they can plausibly be taken to understand the notion of a complete life. It is reasonable to think that most children who are able to carry on a complex conversation would be able to answer questions about life narratives as well as their own their life plans, formulate new life plans and flesh out these plans, especially with the aid of conversational prompting. So, if understanding a complete life amounts to understanding what a characteristic human life looks like, it seems that children should be able to do this far in advance of age 15. Tallman’s remaining two criteria state that to be in the midst of a complete life, an individual must have goals and projects in place and ‘those goals and projects must be the type of thing that, given a reasonable amount of time, could be seen to completion, such that the individual can imagine what it would be for those goals to be met, and thus to have achieved a complete life’ (Tallman, 2014: 210). The very young—at least as young as age 5—can typically make plans for the future (even if it is something as simple as aiming to go to the park after lunch) and may feel distress at the prospect of their plans being thwarted (‘What if it rains after lunch? Then we wouldn’t be able to go to the park! Oh no! I’d better eat quickly’) (Carlson et al., 2004; Atance and Jackson, 2009; Russell et al., 2010). With some prompting one can discuss with such a child her life goals and projects, for example, being a firefighter, having a family, and so on. What is it then that the plans of adults are meant to possess but which those of young children—who can at least speak in terms of such plans—lack? In light of her third criterion, Tallman seems to hold that children are ruled out from the sort of plan-making relevant to being in the midst of a complete life because they can have neither an understanding of what is necessary to accomplish their goals nor of what life after having accomplished them might look like. Of course, many adults actually lack such an understanding regarding their life goals. An adult who, for example, plans to have a child to save his failing marriage may have a view of the future that is not fully grounded in reality. This adult may have no idea of what it means to emotionally support a spouse through pregnancy and recovery. And he would likely have little to no real understanding of the consuming and sometimes draining commitment of caring for an infant. If this adult thinks that mutual love for a child can override the toll that sleep deprivation will take on an already failing marriage, he may well be sorely mistaken. Yet we do not say that this possibility precludes him from setting life goals or projects. In any case, Tallman’s assertion is that while adults, presumably including this prospective father, have the capacity to understand what it takes to accomplish their goals and what their lives might be like afterward, children under 15 do not. We do not find this assertion compelling. The case of the prospective father is not so different from that of a kindergartner who says she wants to be a firefighter when she grows up with images in her mind of constantly sliding down a pole to the sound of blaring sirens, saving kittens from burning buildings and being hailed for heroism. This child does not realize that she would in reality be performing chores around the fire station and responding to markedly unglamorous emergency situations. But this does not mean that she is incapable of understanding what it would look like for her to accomplish this life goal. Through discussion with an adult, she could grasp that her job as a firefighter would be to help people, for example, by putting out fires, but that it would also involve staying at the firehouse and doing the kind of chores she sometimes helps out with around the house. Moreover, with the help of an adult, the child could learn that getting to be a firefighter requires hard work, both in class (e.g. through learning to read) and outside of class (e.g. by training her body on the jungle gym). Granted, we are here invoking some of the best reasoning available to children and some of the worst practiced by adults. But our doing this helps to underscore just how low the bar is set by Tallman’s appeal to a capacity to set life goals. Tallman says that ‘these goals and projects need not have progressed very far, they might change or fall through, and they might fail to conform to someone else’s standard of goodness or worth’ (Tallman, 2014: 210). Tallman purposefully refrains from characterizing in any sort of substantive detail the sort of goals and projects that are required in order for one to be in the midst of a complete life. It seems to us that children as young as 5 can typically meet all three of her stated criteria for being in the midst of a such a life. They not only have attainable projects in place but can also understand the concept of a complete life and what it would look like for those goals and projects to come to fruition. But Tallman appears to suggest one addition to her three stated criteria for being in the midst of a complete life. She characterizes the goals that an individual must have as ones ‘that are important to the individual, that he cares about seeing through, so that he would feel a particular kind of pain at the prospect of his life being cut off in the midst of those projects’ (Tallman, 2014: 210). She seems here to be embracing the idea that to be in the midst of a complete life, a person must have projects that she is seriously committed to realize. That she would experience pain if her project was thwarted appears to be an indicator of such commitment. If we consider the ways in which one might demonstrate a serious resolve to carry out one’s life projects, we must acknowledge that an average 5-year-old fails to do so. A typical 5-year-old presumably does not, in pursuing a long-term life goal like competing in the Olympics or becoming a firefighter, have the self-motivation to wake up early every morning to train. Her pursuit of her goal would likely be less marked by the sort of self-regulating, daily commitment needed to consistently overcome the temptations of short term rewards (such as sleeping in or watching morning cartoons) than that of a seriously resolved adult. But if this is what separates the life aspirations of very young children from adults, this still would not be enough to raise the bar to 15-year-olds as a class. Even 10- and 12-year-olds are capable of this sort of self-regulated, willful pursuit of long-term goals and life aspirations. If the ability to demonstrate serious resolve in the pursuit of a goal is necessary for being in the midst of a complete life, then perhaps it is 10-year-olds rather than 5-year-olds whom modified youngest first unreasonably fails to prioritize over younger children. Either way, we are given no reason to think that demonstrating serious resolve toward accomplishing a life goal is something that emerges first at age 15, and so this is not the way we ought to differentiate the goal-setting of those to whom modified youngest first gives top priority for scarce, life-saving resources over those to whom it does not. In sum, we find it difficult to see what exactly Tallman has in mind when she talks of the goal-setting necessary in order for one to be in the midst of a complete life. If it just amounts to setting goals and adopting life projects, it seems that 5-year-olds are capable of doing so. And, if it amounts instead to adopting and seriously resolving to carry out life projects, then it seems that 10-year-olds are capable of doing so. Depending on what standards are set for life planning, the bar could be met by 5-year-olds or 10-year-olds, but it is not clear what unique capacity fitting this description would arise first around age 15. Our own judgment is that if we grant Tallman’s premise that those in the midst of a complete life should be given distributive priority over those who are not, then this should track the weak notion of formulating life projects, which applies to children as young as 5 years of age. Even if a ‘particular sort of pain’ is unavailable to them at the prospect of their projects being lost, this does not preclude them from setting projects and committing to the extent possible at their age. A kindergartener who is fixated on becoming a firefighter when she grows up, trains on the jungle gym to be a skilled ladder-climber, repeatedly watches the fire station episode of Mr. Rogers’ Neighborhood and bombards firefighters with questions when her class visits the local fire station seems to be pursuing this life plan to the best of her ability, despite potential limitations in willpower and long-term perspective. If this pursuit ultimately leads to her becoming a firefighter or entering some related profession, it is clear that we would trace back the origination of her career plan to the goal she set at age 5. And it would be no accident that she ended up becoming a firefighter, EMT or police officer. We should designate the age at which individuals are capable of life planning by considering what the earliest age might be at which we could reasonably take a life project to originate. In the case of our firefighter, this would be the age to which she might trace back the beginnings of her life story in terms of her career choice. Subjectively Valuing One’s Own Life We have argued that children as young as 5 may be in the midst of a complete life, according to Tallman’s criteria. Now we will address Tallman’s claim that the very young cannot assign subjective value to their own lives (Tallman, 2014: 212, Note 5). According to her, very young children cannot ‘reflect on their experiences’, normatively evaluate their lives, or ‘determine whether or not they would prefer that their lives continue’ (Tallman, 2014: 213). Since beings who do not fulfill these three criteria cannot subjectively value their own lives, asserts Tallman, such children cannot subjectively value their own lives. She concludes that ‘the fact that the very young cannot apply first person value to their lives is sufficient to establish priority in favor of those who are able to make such judgments’ (Tallman, 2014: 213). In responding to this argument, we will show that children younger than 15 can in fact meet all three of these criteria for subjective valuing. Before evaluating Tallman’s argument, we ought first to specify who the ‘very young’ here are meant to be. It is of course clear that infants, for example, cannot reflect on and assign first person value to their lives. But remember that modified youngest first not only prioritizes 15-year-olds over infants but over 10-year-olds and 5-year-olds as well. So if Tallman is making a claim about distributive priority which is meant to be consistent with the system of priority set in place by modified youngest first, the ‘very young’ should here consist in children younger than age 15, as a class. And it is far from clear that children of these ages are unable to subjectively value their lives in this way. Similar to what we have argued regarding the ability to form plans for what one wants to do in life, simply valuing one’s own life is no complicated or intellectually demanding endeavor. Children younger than 15 are in fact capable of meeting Tallman’s first two criteria for subjective valuing: they can reflect on their experiences and evaluate how well things are going for them. You may ask a typical 5-year-old what he did yesterday, whether it was good or bad, what he wants to do tomorrow and so on, and you will receive answers (Busby and Suddendorf, 2005; Wang and Koh, 2015). They may not be the most sophisticated answers, and they may change from day to day, but the fact that the very young are not yet very skilled at reflection and prospection in no way shows that they cannot do it. Now the question remains as to whether such children can also prefer that their lives continue, thus fulfilling Tallman’s third criterion for subjective valuing. Perhaps Tallman thinks that young children cannot prefer that their lives continue because they do not understand what it would be for them not to continue, that is, they do not understand what it would be to die. But we do not find that move plausible. To begin with, to say that children, even very young children, are incapable of preferring that their lives continue runs directly counter to common sense. Children often react poorly to separation from their loved ones as well as the prospect of an enjoyable time coming to an end. Imagine, for instance, the pouting of a child being dropped off at day care or a tantrum thrown at the prospect of a play date drawing to a close. If a child can understand death as the sort of thing that permanently separates her from her loved ones or permanently prevents her from doing things that she likes, then she will be able to establish a preference to refrain from dying. A child faced with the prospect of a permanent (or even very long) separation from loved ones and cessation of all experience (including, especially, fun experiences) would clearly seem to prefer this not happen. This is at least prima facie evidence that children younger than 15 can prefer that their lives continue. However, Tallman may hold that a more sophisticated understanding of death is required in order for a child to be able to form a preference to go on living rather than to die. While the empirical research on children’s death concepts is far from definitive, what it seems to show is that a fully fleshed out death concept is constructed out of multiple components and does not reliably emerge in human beings until age 10.3 If Tallman’s account of subjective valuing entails that the valuer possess a complete and sophisticated death concept to prefer to continue living, this would not be present until age 10 which, it is worth noting, is still significantly in advance of age 15. However, we hold that one need not have a particularly sophisticated or fully fleshed-out death concept to prefer that one’s life continue. All that is required for one to be able to establish a preference that one’s life continue is a very basic understanding of the fact that death entails an end to all of one’s activities and is not the sort of thing that can be undone. At this stage, it seems that children should be able to understand that death is a loss and prefer that they themselves not undergo that loss. The full understanding of death that arises by age 10 involves proficiency in understanding these five central death concepts: universality (‘death is inevitable to living things and … all living things die’), irreversibility (‘death is final and, once dead, a person cannot become alive again’), personal mortality (‘understanding […] that “I will die.”’), non-functionality (‘all life sustaining functions cease with death’) and causality (‘understanding what causes death’—e.g. non-natural causes like accidents, natural causes like illnesses or spiritual causes like the will of god) (Kenyon, 2001: 65). There are three elements that are relevant to establishing whether someone is able to have the preference that his life continues: irreversibility, personal mortality and non-functionality. We do not believe that possessing a solid understanding of causality or universality is necessary to establishing a preference that one’s life continue. In the case of causality, it is unnecessary to understand what leads to death in realistic terms to prefer that one’s life continue, and in the case of universality, it seems largely irrelevant to understand that everyone else will someday die to understand that you yourself will die and to prefer not to do so. An understanding of universality is understood to emerge before or around the same time as personal mortality, so if a child understands personal mortality, she will most likely understand universality (Kenyon, 2001: 69; 70). While, again, the empirical research is far from conclusive on this topic, there is evidence that a basic understanding of all three of the relevant elements of death emerges by age 5 (Speece and Brent, 1992, 1984; Kenyon, 2001; Barrett and Behne, 2005). Our contention is that in order for a person to subjectively value her own life in the way important to Tallman, two things need to be the case: a person needs to have a concept of death and she needs to want to go on living. The understanding of death available to children by age 5 is sufficient to establish that such children are capable of preferring to continue on living rather than to die. Whether any particular child actually does prefer that her life continue is a further question, but so long as she has the capacity to do so, a child should be able to meet Tallman’s third criterion for subjective valuing. After all, individual adults may not prefer to go on living, and adults as a class clearly possess the capacity to subjectively value their own lives. By age 5, most children understand death to at least some significant extent in terms of irreversibility, personal mortality and non-functionality. This is evidence that those children can in fact form a preference to go on living, which is enough to reasonably conclude that children as young as 5 can meet Tallman’s third criterion for being able to subjectively value one’s own life. We have argued that children much younger than 15 are typically both able to be in the midst of a complete life and to subjectively value their own lives. Depending on how one defines these criteria, this may be true of children as young as 5 years of age, and definitely seems to be true of children from age 10 onward. In light of this, neither the criterion of being in the midst of a complete life nor that of subjectively valuing one’s own life provide the support for modified youngest first that Tallman takes them to. Appeal to these criteria fails to support the idea, inherent in modified youngest first, that teenagers and 30-year-olds should get priority over 5-year-olds and 10-year-olds in the distribution of scarce, life-saving resources. The Unfairness of Modified Youngest First Modified youngest first gives priority for scarce, life-saving resources to adolescents and young adults over children. For example, it gives priority to a 30 year-old over a 10 year-old, even when no other principle in the complete lives system favors one candidate over the other—even when, for instance, both the 10 year-old and the 30 year-old would, if treated, go on to live an additional 60 years, thus having a complete life (Persad et al., 2009: 428, note 2). This priority seems unfair to the 10 year-old.4 While the 30-year-old has had an opportunity to have romantic relationships, learn a trade or profession and even have children, the 10-year-old has not. She has had far less chance to have experiences and engage in activities that are normal for a human being. She has had two-thirds less time alive. This type of unfairness, which is endemic to modified youngest first, gives us some significant reason to reject the principle (Kerstein and Bognar, 2010: 40, Note 3). As Tallman seems to acknowledge, one cannot rebut this charge of unfairness in the same way that one might rebut a charge of unfairness in giving priority for scarce, life-saving resources to a 30-year-old over an 80-year-old (Tallman, 2014: 209). In that case, one can argue that had the 80-year-old needed the resource when he was 30, he would have received priority for it over an 80-year-old with whom he was in competition for it, according to modified youngest first. In effect, he had a fair opportunity to get it if he needed it. (For a basis for this sort of point, see Daniels, 1988.) But one cannot say the same regarding the 10-year-old in our example; at no point in her life would she be given priority over a 30-year-old for a scarce, life-saving resource, according to modified youngest first. Tallman is aware of this concern. In response, she invokes the idea that the complete lives approach does not aim to give each individual his fair share of life years but has a different aim, familiar to us from discussion above, namely, to enable a maximum number of those in the midst of a complete life to actually complete their lives (Tallman, 2014: 209, Note 5). Her view is apparently that any unfairness inherent in modified youngest first would be outweighed by the moral importance of securing complete lives. This response fails. First, as we have noted, children much younger than 10 count as being in the midst of a complete life. So fulfilling the (supposed) aim of the complete lives system would simply not require or even license saving the 30-year-old rather than the 10-year-old. Since one complete life will be secured no matter whom we choose, there is no way that unfairness, assuming there is some, in choosing the 30-year-old, would be outweighed by the importance of securing a complete life for someone. Of course, Tallman might contend that there would be absolutely no unfairness in saving the 30-year-old. But she does not defend this stance, and we find it untenable. Second, Tallman’s response is predicated on the idea that the complete lives approach aims to maximize complete lives. We have already highlighted that it is problematic to attribute this aim to the approach, both because it seems not to square with Persad, Wertheimer and Emanuel’s intentions, and because a system with this aim is morally unacceptable. Third, let us assume for the sake of argument that the complete lives approach does aim to maximize complete lives. Tallman leaves unexplained (and, we think, rather mysterious) the idea that attaining this aim is so morally important as to outweigh fairness considerations. Take the case of choosing between saving one 10-year-old for 40 years, leaving her short of a complete life or one 60-year-old for 10 years, thereby allowing him to have a complete life. Why is allowing the 60-year-old to have the opportunity for the range of experiences normal for a human being, presumably including a taste of old age, so important that it outweighs the unfairness to the 10-year-old of her never getting a chance to have a much greater range of such experiences, including, for example, those of falling in love, developing a career or raising a child? Perhaps the unfairness inherent in modified youngest first fails to give us sufficient grounds to abandon it. We will not here argue against the possibility that some consideration, such as the principle’s promotion of social utility, outweighs its unfairness. But we insist that Tallman provides no such outweighing consideration. Concluding Remarks Before closing, it is worth considering briefly the plausibility of a straightforward youngest-first approach. If we are correct that modified youngest first unjustly discriminates against children as young as 5 and that there are important fairness objections to a prioritization scheme that incorporates modified youngest first, then it makes sense to wonder whether the best way to take age into account in an allocation scheme might be, other things being equal, to privilege the younger over the older. On such a youngest-first principle, the younger the person, the higher she will be prioritized for receiving scarce, life-saving medical resources. So, for instance, an infant would be prioritized over a 10-year-old, who would in turn be prioritized over a 50-year-old. A youngest-first approach would thus commit us to prioritizing infants over older children and adults, which is an entailment many find unacceptable. There are several grounds for rejecting the prioritization of infants, some of which we describe briefly, though we do not endorse any of them here. First, one might think that death is not as bad for infants as it would be for those who are older (McMahan, 2002). This could be because infants do not have the same sort of connection to their lives as individuals with a greater capacity for understanding and investing in their lives. If the badness of death is a legitimate consideration in medical resource allocation decisions, then it seems that this gives us reason to prioritize adolescents and older children over infants for scarce, life-saving resources. Solberg and Gamlund (2016) have advocated such a view. Based on work by Jeff McMahan, they claim that from 10 years old on, people typically possess the psychological capacities necessary to have ‘complete ownership’ of their futures, which makes death bad for them in a way it would not be for the younger who do not possess such a psychological connection to their futures. On this view, 10-year-olds should have priority for life-saving health resources over infants. But 10-year-olds would also get priority over 5-year-olds, which runs contrary to what, we have argued, Tallman ought to hold. Second, recall the first premise in Tallman’s argument for modified youngest first: in allocating scarce, life-saving resources we should give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. If this premise were true, it would, we acknowledge, support the idea that adolescents and young adults ought to get priority over some younger children, for example, infants. Infants are presumably neither in the midst of complete lives nor able to subjectively value their lives, at least if we construe these notions as Tallman does. The implications of Tallman’s premise regarding prioritization might, however, parallel that of a principle that favored persons, defined as beings who have a certain set of psychological capacities, including, for example, those of self-consciousness and instrumental rationality, over non-persons. One might argue, third, that infants do not possess the capacities necessary for personhood, and so should get lower priority than those who do possess such capacities. Indeed, capacities sometimes thought of as constitutive of personhood are ones necessary to set ends and construct plans; they enable one to be in the midst of a complete life. A rhetorical advantage might accrue to saying ‘Infants are ruled out from equal consideration because they are not yet in the midst of complete lives’, over saying ‘Infants are ruled out from equal consideration because they are not yet persons’. But that does not change the fact that personhood and being in the midst of a complete life seem to invoke several of the same psychological capacities. Appeals to personhood in resource priority debates are controversial, to say the least. And we will here take no stance on their overall plausibility. But it is worth pointing out that justifying the prioritization of adolescents over infants on the basis that adolescents have but infants lack the status of persons has at least one advantage over the justification contained in Tallman’s premise. The personhood justification is free of an implication of her premise that some of us find highly implausible. The implication is that an older person, say a 55-year-old, who is in the midst of a complete life should get priority for a scarce life-saving treatment over a much younger person whose lifespan is limited, and so is not in the midst of such a life, say a 20-year-old with a cystic fibrosis, even when with the resource each would live 15 (and only 15) more years. Let us close by summarizing our main findings. Tallman attempts to bolster Persad, Wertheimer and Emanuel’s modified youngest-first principle. We have argued that she fails to do so. She does not establish that if we accept Persad and colleagues’ complete lives approach to the fair apportionment of scarce, life-saving resources we ought to embrace modified youngest first over a straightforward youngest-first principle. Nor does she succeed in her more ambitious project of showing, without appeal to a social investment argument, that modified youngest first is justified in its own right. Finally, Tallman does not dispel what we take to be a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. Footnotes 1. ‘Modified youngest first’ is a label introduced by Kerstein and Bognar (2010). 2. For a recent critique of Tallman which focuses instead on accounting for the badness of death, see Gamlund, 2016. 3. ‘The age at which children understand various aspects of the death concept continues to be unclear. However, it appears that children understand that death is a changed state by about four years of age, and most children understand most components by about five years of age. Full understanding of all components is not generally seen before about nine or ten years of age’ (Kenyon, 2001, 68). 4. Greg Bognar has recently noted that to many it seems unfair, other things being equal, not to prefer to save a 30-year-old for 10 years over a 40-year-old for 10 years when one cannot save both (Bognar 2015, 255). 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Consciousness and Cognition , 36 , 131 – 138 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Let Us Be Fair to 5-Year-Olds: Priority for the Young in the Allocation of Scarce Health Resources

Kelsey, Gipe,; J, Kerstein, Samuel
Public Health Ethics , Volume 11 (3) – Nov 1, 2018
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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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1754-9981
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10.1093/phe/phy007
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Abstract

Abstract Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. The Problem Life-saving health resources like organs for transplant and experimental medications are persistently scarce. There are not enough of such resources to go around, so rationing of some sort must take place. This leaves us facing the question of how, morally speaking, we ought to allocate persistently scarce medical resources. Who should receive priority for them? Which moral principles should we use to guide our allocation decisions? While there is much disagreement as to what is the morally best allocation scheme, there is widespread agreement on one claim: age is an important consideration in allocation decisions. Many hold that, in any morally acceptable allocation scheme for scarce health resources, the young should to some extent be prioritized over the old (Harris, 1985; Daniels, 1988; Persad et al., 2010; Solberg and Gamlund, 2016). One way to ration scarce health resources is to take a benefit maximizing approach: to maximize health benefit generated per dollar spent. Suppose for the sake of simplicity that it would cost the same to preserve the life of each of several candidates for a scarce, life-saving resource. A benefit maximizer would then calculate the expected health benefit of various allocations and implement the one that brings about the greatest health benefit. One common metric used to measure the expected benefit from particular allocations is the quality-adjusted life year (QALY). QALYs are calculated on the basis of how many life years a particular way of allocating resources would save, adjusted for the health-related quality of those life years. One QALY is equal to a year in full health. The more QALYs a given medical intervention or public health program would produce, the greater the benefit. Benefit maximizing using QALYs would often have the result of giving younger people priority over older people for life-saving interventions. This is because, costs being equal, saving younger individuals will often result in more life years preserved than saving older individuals would. But people have many objections to benefit maximizing. First, we have good reason to be skeptical of a one-principle prioritization scheme, especially one that implies that it is of equal value to save one person for 80 years of full health as it is to save eight people for 10 years of full health each, assuming the costs of saving the one and the eight are the same. Relying solely on one principle to make allocation decisions leaves benefit maximization blind to other important moral considerations, like the importance of number of lives saved. Second, costs of intervention being the same, benefit maximizing would give equal priority to saving a 75-year-old who would live for an additional 15 years in full health as it would give to saving a 5-year-old who would live for an additional 15 years in full health. While benefit maximization will often favor the younger over the older, in particular cases it will be insensitive to the importance of considerations like fairness. Fairness considerations lead us to think that, even when the benefit accrued from a particular allocation will be the same, 5-year-olds deserve additional life years more than 75-year-olds. Straightforward benefit maximization thus seems unable to accommodate our intuitions regarding who ought to be prioritized in a medical resource allocation scheme, especially regarding fairness and the importance of number of lives saved. Allocation based solely on maximizing health benefit per dollar spent neglects important moral considerations. Advocates of multi-principle prioritization schemes try to remedy this neglect by suggesting principles inspired by various moral considerations, such as the intrinsic value of lives or life years, or the great instrumental value to others of people with special skills. Such a scheme might thus include a principle directing us to save lives, another prescribing us to preserve life years, and yet another specifying that health professionals should get priority under certain circumstances, and so forth. These various principles would somehow need to be ordered or weighted against one another. Many hold that we ought to incorporate into whichever scheme we accept a principle that, at least to an extent, privileges younger people over older people. There is surely an intuitive appeal to taking age into account when making allocation decisions. But why is this? First, we have a general fairness concern. As we just noted, given the choice of giving a life-saving medical resource to either a 75-year-old who would then live for 15 more years or a 5-year-old who would then live for 15 more years, it seems that it would, other things being equal, be unfair to opt for the 75-year-old. This is presumably because the 75-year-old has had the opportunity to do many more things than the 5-year-old, opportunities that the 5-year-old would never have, if she were to die. Therefore, we have moral reason to favor saving the 5-year-old over the 75-year-old. Second, there is the more specific notion of fair innings. The idea here is that there is an age threshold at which a person can be taken to have had a fair shot at living a complete or full life. If one’s life ends before this threshold, then one has not received one’s fair innings (Harris, 1985: 87–102; Bognar, 2008: 167–189; Bognar and Hirose, 2014: 88–95). Thus, we have moral reason to prioritize those who have not yet reached this threshold over those who have. This means that, for instance, we have moral grounds for prioritizing the young who are just beginning their lives over the elderly who have already had a chance to live a full life. Finally, there may be prioritarian considerations to take into account. Prioritarianism is predicated on the claim that benefitting people matters more morally the worse off these people are (Parfit, 1997). Younger people are worse off, as a class, than older people because they have had less of a precious resource: life years. To rectify this inequality, we have reason to give younger individuals priority for scarce life-saving resources. Considerations of fairness, fair innings and prioritarianism, taken separately or together, provide us with moral grounds for thinking that there should be a principle favoring the young over the old in whatever health resource allocation scheme we ultimately accept. This leaves us with the question of how exactly we ought to incorporate priority to the younger into a prioritization scheme. One option might be to prioritize the younger over the older, perhaps up to a certain threshold age. This would mean prioritizing infants over 13-year-olds. But some have argued that the death of an adolescent is worse than the death of an infant (Dworkin, 1994; McMahan, 2002; Solberg and Gamlund, 2016). Should the intuition that adolescents’ deaths are worse than young childrens’ deaths lead us to a principle privileging the saving of adolescents over the saving of young children, other things being equal? Modified Youngest-First Arguments Govind Persad, Alan Wetheimer and Ezekiel Emanuel propose a multi-principle allocation scheme for scarce life-saving health resources called the Complete Lives System, which reflects this intuition and explicitly prioritizes adolescents over young children. Persad, Wertheimer and Emanuel have embraced a principle according to which persons roughly between 15 and 40 years old get priority for scarce life-saving health resources over younger children and older adults, other things being equal (Persad et al., 2009). They defend this ‘modified youngest first’ principle in part by an appeal to a social investment argument.1 Adolescents, as opposed, for example, to very young children, ‘have received substantial education and parental care, investments that will be wasted without a complete life’ (Persad et al., 2009: 428, Note 2). However, some find this social investment argument inadequate. As Kerstein and Bognar note, it seems arbitrary to understand investment solely in terms of education and parental care when there are other forms of social investment such as advanced career training that people undertake well into their 40s (Kerstein and Bognar, 2010: 40, 41). According to Persad, Wertheimer and Emanuel’s reasoning, should not these 40-year-olds (e.g. diplomats or business leaders) get priority over younger people, other things being equal, contrary to what modified youngest first implies? Further, some might be uncomfortable with an appeal to social investment simply because it seems to reduce the importance of individuals to the resources that we, as a society, have put into them. Recently, Ruth Tallman has proposed a distinctive defense of modified youngest first, a defense that, she underscores, rests not at all on this social investment argument (Tallman, 2014: 207–213; 209, 210). This defense of modified youngest first is our focus. Since Tallman defends a principle developed by Persad, Wertheimer and Emanuel as part of the complete lives approach to the allocation of scarce, life-saving resources, we need to have in view a brief outline of this approach. Constitutive of it is a set of principles, including modified youngest first and four others: prognosis, save the most lives, lottery and instrumental value (Persad et al., 2009: 427, Note 2, Table 2). A youngest-first principle would consistently prescribe prioritizing younger people over older people, for example, 5-year-olds over adolescents. But Persad and colleagues embrace modified youngest first, which, again, prioritizes persons roughly between 15 and 40 years old over younger children and older adults (Persad et al., 2009: 428). For example, the modified youngest-first principle prioritizes 17-year-olds over 5-year-olds and 30-year-olds over 10-year-olds. According to a second principle, namely, prognosis, we ought to ‘save the most life-years’ (Persad et al., 2009: 425). This principle would give priority for a kidney transplant to a patient who would live an additional 20 years over a patient who would live an additional 10 years with the transplant. Persad and colleagues suggest that lotteries might be used to choose between ‘roughly equal’ candidates for a life-saving intervention (Persad et al., 2009: 428). Finally, an instrumental value principle ‘prioritizes specific individuals to enable or encourage future usefulness’ (Persad et al., 2009: 426). Limited in application by Persad and colleagues to ‘some public health emergencies’, this principle might imply that during a flu pandemic, medical staff needed to disperse vaccine should be vaccinated before others (Persad et al., 2009: 424; 429, Table 1). Persad and colleagues offer no priority ranking among the principles but suggest that the principles should be balanced against one another (Persad et al., 2009: 429). Focusing on modified youngest first, Tallman argues for two main claims. The first is the following: The overall goal of the complete lives approach warrants its including modified youngest first rather than youngest first, assuming that it must include one or the other. Tallman’s second, more ambitious, claim is simply that: Modified youngest first is justified as a principle for the allocation of persistently scarce, life-saving resources. Tallman fails to defend adequately either of these claims, we contend. In her argument for the first claim she attributes an overall aim to the complete lives approach that it does not and, given the aim’s implications for priority-setting, ought not to have (Section 2). Moreover, her argument that modified youngest first is justified tout court falls short of grounding central features of this principle, for example, the priority it gives 30-year-olds over 5-year-olds, other things being equal (Section 3). And, as we explain (Section 4), there is at least some, if not necessarily overriding, moral reason to reject modified youngest first on the basis that it is unfair to young children. Why should kindergartners get less priority for life-saving interventions than young adults when the adults have already had far more life? Tallman is aware of this concern and tries to address it, apparently in the course of arguing for her two main claims. But, as we try to show, she does not diminish the concern’s force.2 The Implausibility of Allocating to Maximize Complete Lives One of Tallman’s main aims is to defend Persad and colleagues’ choice to embrace as a constituent of the complete lives system the modified youngest-first principle rather than a straightforward youngest-first principle (Tallman, 2014: 207, Note 5). Her attempt to realize this aim invokes two key concepts: that of a complete life and that of people in the midst of a complete life. According to Tallman, a ‘complete life is one that lasts long enough for its owner to have the opportunity for the range of experiences normal for a human being’ (Tallman, 2014: 208). Tallman associates a complete life with ‘the holistic experience of a full life lived’ (Tallman, 2014: 208, Note 3). Such a life involves embarking on life projects and having the opportunity to see them to fruition around ‘retirement age’ (Tallman, 2014: 210, Note 13). According to Tallman, to be in the midst of a complete life, an individual must fulfill several conditions. First, the person must not have already had a complete life. Many elderly people presumably thus fail to meet this condition. Moreover, to be in the midst of a complete life, she says, one must be able to understand the concept of a complete life, have adopted attainable goals and projects and be able to understand what it would look like to realize those goals and projects (Tallman, 2014: 210). If, as Tallman holds, infants fail to fulfill all of these conditions, then they do not count as being in the midst of a complete life. Although Tallman writes in terms of a person’s being in the midst of a complete life, what she means is that the person is in the midst of a life that might, practically speaking, be complete. Not all of us who are in the midst of a complete life in her sense will complete our lives: we might fail to complete them, for example, as a result of not getting some scarce, life-saving resource before we reach old age (Tallman, 2014: 210). To mirror Tallman’s usage, we will continue to write in terms of someone being in the midst of a complete life, but it is important to keep in mind that in her view people can be in the midst of a complete life even if they will not go on to complete their lives. Tallman’s first argument unfolds against the background of the assumption that the complete lives approach needs to include either the youngest-first principle or the modified youngest-first principle. Consider people in the midst of a complete life. According to the argument’s first premise, the complete lives approach aims to allocate scarce life-saving resources in a way that maximizes the number of these people who actually end up having complete lives (Tallman, 2014: 208, Note 5; 210; 213). The approach should embrace whichever of the two principles better promotes this aim, continues the argument. Modified youngest first obviously better promotes it than youngest first. Modified youngest first prioritizes individuals who are in the midst of a complete life (e.g. typical 30-year-olds) over individuals who are not (e.g. infants), while youngest first does the inverse. Therefore, the complete lives approach should embrace modified youngest first rather than youngest first. We find untenable the first premise of Tallman’s argument. Persad, Wertheimer and Emanuel do at one point say in passing that the complete lives system’s ‘aim is to achieve complete lives’ (Persad et al., 2009: 428, Note 2). However, if we assume that the complete lives approach gets realized solely in the five principles just enumerated, it obviously does not maximize the number of those in the midst of complete lives who end up having such lives. So it is implausible to suggest, as does Tallman in her first premise, that maximizing in this way is, on Persad, Wertheimer and Emanuel’s considered view, the goal of the complete lives approach. By way of illustration, suppose we must choose between saving a 50-year-old for 15 years, thus enabling her to have a complete life, or two 17-year-olds for 20 years each, leaving each of them short of a complete life. Lottery and instrumental value do not apply in this case, let us assume. That leaves prognosis, save the most lives and modified youngest first. Each one of these principles would favor saving the two 17-year-olds: two lives is more than one, 40 years is more than 15 and 17-year-olds get priority over 50-year-olds according to modified youngest first. However, to maximize complete lives, we would have to save the 50-year-old; for she is the only person concerned who would be capable of having such a life, and one complete life is greater than none. So Tallman in effect attributes to the complete lives approach a goal that the system supposedly designed to realize it cannot attain. Moreover, Tallman’s attribution of this goal to the complete lives approach is uncharitable, to say the least. To save one 50-year-old who would be able to have a complete life with the extra 15 years, we could give her instead of saving two 17-year-olds who would live 20 years each but fall short of attaining complete lives would be to allocate in a morally questionable manner. This allocation would not save the most lives or preserve the most life years, and it would seem to be unfair to the 17-year-olds. What is so important, they might legitimately ask, about getting one 50-year-old over the threshold of a complete life such that it justifies not saving the two of us for 40 years combined? Finally, promoting the goal Tallman attributes to the complete lives system (i.e. that of maximizing complete lives) would actually involve saving one such 50-year-old over any number of such 17-year-olds! That is unacceptable. In sum, Tallman tries to support Persad, Wertheimer and Emanuel’s adoption of modified youngest first over youngest first by appealing to what she takes to be the overall goal of their complete lives approach to the allocation of scarce, life-saving resources. But charity demands that we reject her interpretation of their approach. Their allocation principles do not (and clearly do not) realize this goal, and allocation principles that did realize it would in some contexts prescribe wildly implausible allocations. A Flawed Justification for Modified Youngest First Tallman’s second argument in support of modified youngest first runs as follows: Premise 1. In the allocation of scarce, life-saving resources we should give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. Premise 2. Modified youngest first prioritizes in just this way. Therefore, modified youngest first is justified as a principle for the allocation of scarce, life-saving resources (Tallman, 2014: 211, Note 5; 213). Tallman’s first premise is controversial, to say the least. It is far from obvious, for example, that if someone subjectively values her life, but, as a result of a longevity-limiting genetic predisposition, is not in midst of a complete life, then this person should get lower priority for a scarce, life-saving resource than someone who both subjectively values her life and is in the midst of a complete life. But for the sake of argument, let us accept this first premise. Here we try to show that Tallman’s second premise is false. Tallman asserts that we should give distributive priority to those who are in the midst of a complete life and who subjectively value their lives. But modified youngest first does far more than give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. Modified youngest first gives priority to 15-year-olds over 10-year-olds, for example. But, as we will now argue, children as young as 5 years old typically are both in the midst of a complete life and subjectively value their own lives. So, even assuming as we are that Tallman’s first premise is warranted, her argument leaves priority for those from age 15–40 years over people younger than 15 years undefended and thus modified youngest first unjustified as a principle for the allocation of scarce, life-saving resources. Being in the Midst of a Complete Life According to Tallman, a complete life for a person is a characteristically human life, one in which she has the opportunity for the range of experiences normal for a human being. To be in the midst of a complete life, she says, one must be able to understand the concept of a complete life, have (possibly attainable) goals and projects in place and be able to understand what it would look like for those goals and projects to come to fruition (Tallman, 2014: 210, Note 5). Tallman’s first criterion states that the capacity to understand the concept of a complete life is required in order for one to be in the midst of a complete life (Tallman, 2014: 210). One need not ever have actually reflected on such a concept; it is solely the capacity to understand it that matters. Tallman leaves unspecified how well one must be able to understand the concept of a complete life to meet this criterion. But the concept of a complete life, as a life that lasts at least a certain amount of time and contains certain defining features, is simple enough that it is plausible to think that children would be able to understand this concept well in advance of age 15. Simply understanding the concept of a complete life is no complex or intellectually demanding endeavor. Even very young children may understand that people characteristically grow up, get jobs, get married, pursue hobbies, raise children and eventually die. Further, from an early age, children are exposed to arc-of-life narratives, both in real life and in fiction. Once children can converse coherently about these narratives, they can plausibly be taken to understand the notion of a complete life. It is reasonable to think that most children who are able to carry on a complex conversation would be able to answer questions about life narratives as well as their own their life plans, formulate new life plans and flesh out these plans, especially with the aid of conversational prompting. So, if understanding a complete life amounts to understanding what a characteristic human life looks like, it seems that children should be able to do this far in advance of age 15. Tallman’s remaining two criteria state that to be in the midst of a complete life, an individual must have goals and projects in place and ‘those goals and projects must be the type of thing that, given a reasonable amount of time, could be seen to completion, such that the individual can imagine what it would be for those goals to be met, and thus to have achieved a complete life’ (Tallman, 2014: 210). The very young—at least as young as age 5—can typically make plans for the future (even if it is something as simple as aiming to go to the park after lunch) and may feel distress at the prospect of their plans being thwarted (‘What if it rains after lunch? Then we wouldn’t be able to go to the park! Oh no! I’d better eat quickly’) (Carlson et al., 2004; Atance and Jackson, 2009; Russell et al., 2010). With some prompting one can discuss with such a child her life goals and projects, for example, being a firefighter, having a family, and so on. What is it then that the plans of adults are meant to possess but which those of young children—who can at least speak in terms of such plans—lack? In light of her third criterion, Tallman seems to hold that children are ruled out from the sort of plan-making relevant to being in the midst of a complete life because they can have neither an understanding of what is necessary to accomplish their goals nor of what life after having accomplished them might look like. Of course, many adults actually lack such an understanding regarding their life goals. An adult who, for example, plans to have a child to save his failing marriage may have a view of the future that is not fully grounded in reality. This adult may have no idea of what it means to emotionally support a spouse through pregnancy and recovery. And he would likely have little to no real understanding of the consuming and sometimes draining commitment of caring for an infant. If this adult thinks that mutual love for a child can override the toll that sleep deprivation will take on an already failing marriage, he may well be sorely mistaken. Yet we do not say that this possibility precludes him from setting life goals or projects. In any case, Tallman’s assertion is that while adults, presumably including this prospective father, have the capacity to understand what it takes to accomplish their goals and what their lives might be like afterward, children under 15 do not. We do not find this assertion compelling. The case of the prospective father is not so different from that of a kindergartner who says she wants to be a firefighter when she grows up with images in her mind of constantly sliding down a pole to the sound of blaring sirens, saving kittens from burning buildings and being hailed for heroism. This child does not realize that she would in reality be performing chores around the fire station and responding to markedly unglamorous emergency situations. But this does not mean that she is incapable of understanding what it would look like for her to accomplish this life goal. Through discussion with an adult, she could grasp that her job as a firefighter would be to help people, for example, by putting out fires, but that it would also involve staying at the firehouse and doing the kind of chores she sometimes helps out with around the house. Moreover, with the help of an adult, the child could learn that getting to be a firefighter requires hard work, both in class (e.g. through learning to read) and outside of class (e.g. by training her body on the jungle gym). Granted, we are here invoking some of the best reasoning available to children and some of the worst practiced by adults. But our doing this helps to underscore just how low the bar is set by Tallman’s appeal to a capacity to set life goals. Tallman says that ‘these goals and projects need not have progressed very far, they might change or fall through, and they might fail to conform to someone else’s standard of goodness or worth’ (Tallman, 2014: 210). Tallman purposefully refrains from characterizing in any sort of substantive detail the sort of goals and projects that are required in order for one to be in the midst of a complete life. It seems to us that children as young as 5 can typically meet all three of her stated criteria for being in the midst of a such a life. They not only have attainable projects in place but can also understand the concept of a complete life and what it would look like for those goals and projects to come to fruition. But Tallman appears to suggest one addition to her three stated criteria for being in the midst of a complete life. She characterizes the goals that an individual must have as ones ‘that are important to the individual, that he cares about seeing through, so that he would feel a particular kind of pain at the prospect of his life being cut off in the midst of those projects’ (Tallman, 2014: 210). She seems here to be embracing the idea that to be in the midst of a complete life, a person must have projects that she is seriously committed to realize. That she would experience pain if her project was thwarted appears to be an indicator of such commitment. If we consider the ways in which one might demonstrate a serious resolve to carry out one’s life projects, we must acknowledge that an average 5-year-old fails to do so. A typical 5-year-old presumably does not, in pursuing a long-term life goal like competing in the Olympics or becoming a firefighter, have the self-motivation to wake up early every morning to train. Her pursuit of her goal would likely be less marked by the sort of self-regulating, daily commitment needed to consistently overcome the temptations of short term rewards (such as sleeping in or watching morning cartoons) than that of a seriously resolved adult. But if this is what separates the life aspirations of very young children from adults, this still would not be enough to raise the bar to 15-year-olds as a class. Even 10- and 12-year-olds are capable of this sort of self-regulated, willful pursuit of long-term goals and life aspirations. If the ability to demonstrate serious resolve in the pursuit of a goal is necessary for being in the midst of a complete life, then perhaps it is 10-year-olds rather than 5-year-olds whom modified youngest first unreasonably fails to prioritize over younger children. Either way, we are given no reason to think that demonstrating serious resolve toward accomplishing a life goal is something that emerges first at age 15, and so this is not the way we ought to differentiate the goal-setting of those to whom modified youngest first gives top priority for scarce, life-saving resources over those to whom it does not. In sum, we find it difficult to see what exactly Tallman has in mind when she talks of the goal-setting necessary in order for one to be in the midst of a complete life. If it just amounts to setting goals and adopting life projects, it seems that 5-year-olds are capable of doing so. And, if it amounts instead to adopting and seriously resolving to carry out life projects, then it seems that 10-year-olds are capable of doing so. Depending on what standards are set for life planning, the bar could be met by 5-year-olds or 10-year-olds, but it is not clear what unique capacity fitting this description would arise first around age 15. Our own judgment is that if we grant Tallman’s premise that those in the midst of a complete life should be given distributive priority over those who are not, then this should track the weak notion of formulating life projects, which applies to children as young as 5 years of age. Even if a ‘particular sort of pain’ is unavailable to them at the prospect of their projects being lost, this does not preclude them from setting projects and committing to the extent possible at their age. A kindergartener who is fixated on becoming a firefighter when she grows up, trains on the jungle gym to be a skilled ladder-climber, repeatedly watches the fire station episode of Mr. Rogers’ Neighborhood and bombards firefighters with questions when her class visits the local fire station seems to be pursuing this life plan to the best of her ability, despite potential limitations in willpower and long-term perspective. If this pursuit ultimately leads to her becoming a firefighter or entering some related profession, it is clear that we would trace back the origination of her career plan to the goal she set at age 5. And it would be no accident that she ended up becoming a firefighter, EMT or police officer. We should designate the age at which individuals are capable of life planning by considering what the earliest age might be at which we could reasonably take a life project to originate. In the case of our firefighter, this would be the age to which she might trace back the beginnings of her life story in terms of her career choice. Subjectively Valuing One’s Own Life We have argued that children as young as 5 may be in the midst of a complete life, according to Tallman’s criteria. Now we will address Tallman’s claim that the very young cannot assign subjective value to their own lives (Tallman, 2014: 212, Note 5). According to her, very young children cannot ‘reflect on their experiences’, normatively evaluate their lives, or ‘determine whether or not they would prefer that their lives continue’ (Tallman, 2014: 213). Since beings who do not fulfill these three criteria cannot subjectively value their own lives, asserts Tallman, such children cannot subjectively value their own lives. She concludes that ‘the fact that the very young cannot apply first person value to their lives is sufficient to establish priority in favor of those who are able to make such judgments’ (Tallman, 2014: 213). In responding to this argument, we will show that children younger than 15 can in fact meet all three of these criteria for subjective valuing. Before evaluating Tallman’s argument, we ought first to specify who the ‘very young’ here are meant to be. It is of course clear that infants, for example, cannot reflect on and assign first person value to their lives. But remember that modified youngest first not only prioritizes 15-year-olds over infants but over 10-year-olds and 5-year-olds as well. So if Tallman is making a claim about distributive priority which is meant to be consistent with the system of priority set in place by modified youngest first, the ‘very young’ should here consist in children younger than age 15, as a class. And it is far from clear that children of these ages are unable to subjectively value their lives in this way. Similar to what we have argued regarding the ability to form plans for what one wants to do in life, simply valuing one’s own life is no complicated or intellectually demanding endeavor. Children younger than 15 are in fact capable of meeting Tallman’s first two criteria for subjective valuing: they can reflect on their experiences and evaluate how well things are going for them. You may ask a typical 5-year-old what he did yesterday, whether it was good or bad, what he wants to do tomorrow and so on, and you will receive answers (Busby and Suddendorf, 2005; Wang and Koh, 2015). They may not be the most sophisticated answers, and they may change from day to day, but the fact that the very young are not yet very skilled at reflection and prospection in no way shows that they cannot do it. Now the question remains as to whether such children can also prefer that their lives continue, thus fulfilling Tallman’s third criterion for subjective valuing. Perhaps Tallman thinks that young children cannot prefer that their lives continue because they do not understand what it would be for them not to continue, that is, they do not understand what it would be to die. But we do not find that move plausible. To begin with, to say that children, even very young children, are incapable of preferring that their lives continue runs directly counter to common sense. Children often react poorly to separation from their loved ones as well as the prospect of an enjoyable time coming to an end. Imagine, for instance, the pouting of a child being dropped off at day care or a tantrum thrown at the prospect of a play date drawing to a close. If a child can understand death as the sort of thing that permanently separates her from her loved ones or permanently prevents her from doing things that she likes, then she will be able to establish a preference to refrain from dying. A child faced with the prospect of a permanent (or even very long) separation from loved ones and cessation of all experience (including, especially, fun experiences) would clearly seem to prefer this not happen. This is at least prima facie evidence that children younger than 15 can prefer that their lives continue. However, Tallman may hold that a more sophisticated understanding of death is required in order for a child to be able to form a preference to go on living rather than to die. While the empirical research on children’s death concepts is far from definitive, what it seems to show is that a fully fleshed out death concept is constructed out of multiple components and does not reliably emerge in human beings until age 10.3 If Tallman’s account of subjective valuing entails that the valuer possess a complete and sophisticated death concept to prefer to continue living, this would not be present until age 10 which, it is worth noting, is still significantly in advance of age 15. However, we hold that one need not have a particularly sophisticated or fully fleshed-out death concept to prefer that one’s life continue. All that is required for one to be able to establish a preference that one’s life continue is a very basic understanding of the fact that death entails an end to all of one’s activities and is not the sort of thing that can be undone. At this stage, it seems that children should be able to understand that death is a loss and prefer that they themselves not undergo that loss. The full understanding of death that arises by age 10 involves proficiency in understanding these five central death concepts: universality (‘death is inevitable to living things and … all living things die’), irreversibility (‘death is final and, once dead, a person cannot become alive again’), personal mortality (‘understanding […] that “I will die.”’), non-functionality (‘all life sustaining functions cease with death’) and causality (‘understanding what causes death’—e.g. non-natural causes like accidents, natural causes like illnesses or spiritual causes like the will of god) (Kenyon, 2001: 65). There are three elements that are relevant to establishing whether someone is able to have the preference that his life continues: irreversibility, personal mortality and non-functionality. We do not believe that possessing a solid understanding of causality or universality is necessary to establishing a preference that one’s life continue. In the case of causality, it is unnecessary to understand what leads to death in realistic terms to prefer that one’s life continue, and in the case of universality, it seems largely irrelevant to understand that everyone else will someday die to understand that you yourself will die and to prefer not to do so. An understanding of universality is understood to emerge before or around the same time as personal mortality, so if a child understands personal mortality, she will most likely understand universality (Kenyon, 2001: 69; 70). While, again, the empirical research is far from conclusive on this topic, there is evidence that a basic understanding of all three of the relevant elements of death emerges by age 5 (Speece and Brent, 1992, 1984; Kenyon, 2001; Barrett and Behne, 2005). Our contention is that in order for a person to subjectively value her own life in the way important to Tallman, two things need to be the case: a person needs to have a concept of death and she needs to want to go on living. The understanding of death available to children by age 5 is sufficient to establish that such children are capable of preferring to continue on living rather than to die. Whether any particular child actually does prefer that her life continue is a further question, but so long as she has the capacity to do so, a child should be able to meet Tallman’s third criterion for subjective valuing. After all, individual adults may not prefer to go on living, and adults as a class clearly possess the capacity to subjectively value their own lives. By age 5, most children understand death to at least some significant extent in terms of irreversibility, personal mortality and non-functionality. This is evidence that those children can in fact form a preference to go on living, which is enough to reasonably conclude that children as young as 5 can meet Tallman’s third criterion for being able to subjectively value one’s own life. We have argued that children much younger than 15 are typically both able to be in the midst of a complete life and to subjectively value their own lives. Depending on how one defines these criteria, this may be true of children as young as 5 years of age, and definitely seems to be true of children from age 10 onward. In light of this, neither the criterion of being in the midst of a complete life nor that of subjectively valuing one’s own life provide the support for modified youngest first that Tallman takes them to. Appeal to these criteria fails to support the idea, inherent in modified youngest first, that teenagers and 30-year-olds should get priority over 5-year-olds and 10-year-olds in the distribution of scarce, life-saving resources. The Unfairness of Modified Youngest First Modified youngest first gives priority for scarce, life-saving resources to adolescents and young adults over children. For example, it gives priority to a 30 year-old over a 10 year-old, even when no other principle in the complete lives system favors one candidate over the other—even when, for instance, both the 10 year-old and the 30 year-old would, if treated, go on to live an additional 60 years, thus having a complete life (Persad et al., 2009: 428, note 2). This priority seems unfair to the 10 year-old.4 While the 30-year-old has had an opportunity to have romantic relationships, learn a trade or profession and even have children, the 10-year-old has not. She has had far less chance to have experiences and engage in activities that are normal for a human being. She has had two-thirds less time alive. This type of unfairness, which is endemic to modified youngest first, gives us some significant reason to reject the principle (Kerstein and Bognar, 2010: 40, Note 3). As Tallman seems to acknowledge, one cannot rebut this charge of unfairness in the same way that one might rebut a charge of unfairness in giving priority for scarce, life-saving resources to a 30-year-old over an 80-year-old (Tallman, 2014: 209). In that case, one can argue that had the 80-year-old needed the resource when he was 30, he would have received priority for it over an 80-year-old with whom he was in competition for it, according to modified youngest first. In effect, he had a fair opportunity to get it if he needed it. (For a basis for this sort of point, see Daniels, 1988.) But one cannot say the same regarding the 10-year-old in our example; at no point in her life would she be given priority over a 30-year-old for a scarce, life-saving resource, according to modified youngest first. Tallman is aware of this concern. In response, she invokes the idea that the complete lives approach does not aim to give each individual his fair share of life years but has a different aim, familiar to us from discussion above, namely, to enable a maximum number of those in the midst of a complete life to actually complete their lives (Tallman, 2014: 209, Note 5). Her view is apparently that any unfairness inherent in modified youngest first would be outweighed by the moral importance of securing complete lives. This response fails. First, as we have noted, children much younger than 10 count as being in the midst of a complete life. So fulfilling the (supposed) aim of the complete lives system would simply not require or even license saving the 30-year-old rather than the 10-year-old. Since one complete life will be secured no matter whom we choose, there is no way that unfairness, assuming there is some, in choosing the 30-year-old, would be outweighed by the importance of securing a complete life for someone. Of course, Tallman might contend that there would be absolutely no unfairness in saving the 30-year-old. But she does not defend this stance, and we find it untenable. Second, Tallman’s response is predicated on the idea that the complete lives approach aims to maximize complete lives. We have already highlighted that it is problematic to attribute this aim to the approach, both because it seems not to square with Persad, Wertheimer and Emanuel’s intentions, and because a system with this aim is morally unacceptable. Third, let us assume for the sake of argument that the complete lives approach does aim to maximize complete lives. Tallman leaves unexplained (and, we think, rather mysterious) the idea that attaining this aim is so morally important as to outweigh fairness considerations. Take the case of choosing between saving one 10-year-old for 40 years, leaving her short of a complete life or one 60-year-old for 10 years, thereby allowing him to have a complete life. Why is allowing the 60-year-old to have the opportunity for the range of experiences normal for a human being, presumably including a taste of old age, so important that it outweighs the unfairness to the 10-year-old of her never getting a chance to have a much greater range of such experiences, including, for example, those of falling in love, developing a career or raising a child? Perhaps the unfairness inherent in modified youngest first fails to give us sufficient grounds to abandon it. We will not here argue against the possibility that some consideration, such as the principle’s promotion of social utility, outweighs its unfairness. But we insist that Tallman provides no such outweighing consideration. Concluding Remarks Before closing, it is worth considering briefly the plausibility of a straightforward youngest-first approach. If we are correct that modified youngest first unjustly discriminates against children as young as 5 and that there are important fairness objections to a prioritization scheme that incorporates modified youngest first, then it makes sense to wonder whether the best way to take age into account in an allocation scheme might be, other things being equal, to privilege the younger over the older. On such a youngest-first principle, the younger the person, the higher she will be prioritized for receiving scarce, life-saving medical resources. So, for instance, an infant would be prioritized over a 10-year-old, who would in turn be prioritized over a 50-year-old. A youngest-first approach would thus commit us to prioritizing infants over older children and adults, which is an entailment many find unacceptable. There are several grounds for rejecting the prioritization of infants, some of which we describe briefly, though we do not endorse any of them here. First, one might think that death is not as bad for infants as it would be for those who are older (McMahan, 2002). This could be because infants do not have the same sort of connection to their lives as individuals with a greater capacity for understanding and investing in their lives. If the badness of death is a legitimate consideration in medical resource allocation decisions, then it seems that this gives us reason to prioritize adolescents and older children over infants for scarce, life-saving resources. Solberg and Gamlund (2016) have advocated such a view. Based on work by Jeff McMahan, they claim that from 10 years old on, people typically possess the psychological capacities necessary to have ‘complete ownership’ of their futures, which makes death bad for them in a way it would not be for the younger who do not possess such a psychological connection to their futures. On this view, 10-year-olds should have priority for life-saving health resources over infants. But 10-year-olds would also get priority over 5-year-olds, which runs contrary to what, we have argued, Tallman ought to hold. Second, recall the first premise in Tallman’s argument for modified youngest first: in allocating scarce, life-saving resources we should give priority to those who are in the midst of a complete life and who subjectively value their lives over those who are either not in the midst of a complete life or who do not subjectively value their lives. If this premise were true, it would, we acknowledge, support the idea that adolescents and young adults ought to get priority over some younger children, for example, infants. Infants are presumably neither in the midst of complete lives nor able to subjectively value their lives, at least if we construe these notions as Tallman does. The implications of Tallman’s premise regarding prioritization might, however, parallel that of a principle that favored persons, defined as beings who have a certain set of psychological capacities, including, for example, those of self-consciousness and instrumental rationality, over non-persons. One might argue, third, that infants do not possess the capacities necessary for personhood, and so should get lower priority than those who do possess such capacities. Indeed, capacities sometimes thought of as constitutive of personhood are ones necessary to set ends and construct plans; they enable one to be in the midst of a complete life. A rhetorical advantage might accrue to saying ‘Infants are ruled out from equal consideration because they are not yet in the midst of complete lives’, over saying ‘Infants are ruled out from equal consideration because they are not yet persons’. But that does not change the fact that personhood and being in the midst of a complete life seem to invoke several of the same psychological capacities. Appeals to personhood in resource priority debates are controversial, to say the least. And we will here take no stance on their overall plausibility. But it is worth pointing out that justifying the prioritization of adolescents over infants on the basis that adolescents have but infants lack the status of persons has at least one advantage over the justification contained in Tallman’s premise. The personhood justification is free of an implication of her premise that some of us find highly implausible. The implication is that an older person, say a 55-year-old, who is in the midst of a complete life should get priority for a scarce life-saving treatment over a much younger person whose lifespan is limited, and so is not in the midst of such a life, say a 20-year-old with a cystic fibrosis, even when with the resource each would live 15 (and only 15) more years. Let us close by summarizing our main findings. Tallman attempts to bolster Persad, Wertheimer and Emanuel’s modified youngest-first principle. We have argued that she fails to do so. She does not establish that if we accept Persad and colleagues’ complete lives approach to the fair apportionment of scarce, life-saving resources we ought to embrace modified youngest first over a straightforward youngest-first principle. Nor does she succeed in her more ambitious project of showing, without appeal to a social investment argument, that modified youngest first is justified in its own right. Finally, Tallman does not dispel what we take to be a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. Footnotes 1. ‘Modified youngest first’ is a label introduced by Kerstein and Bognar (2010). 2. For a recent critique of Tallman which focuses instead on accounting for the badness of death, see Gamlund, 2016. 3. ‘The age at which children understand various aspects of the death concept continues to be unclear. However, it appears that children understand that death is a changed state by about four years of age, and most children understand most components by about five years of age. Full understanding of all components is not generally seen before about nine or ten years of age’ (Kenyon, 2001, 68). 4. Greg Bognar has recently noted that to many it seems unfair, other things being equal, not to prefer to save a 30-year-old for 10 years over a 40-year-old for 10 years when one cannot save both (Bognar 2015, 255). 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Journal

Public Health Ethics – Oxford University Press

Published: Nov 1, 2018

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