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Open Research Online The Open University’s repository of research publications and other research outputs Moral Luck in Medical Ethics and Practical Politics Thesis How to cite: Dickenson, Donna (1989). Moral Luck in Medical Ethics and Practical Politics. PhD thesis. The Open University. For guidance on citations see FAQs. c 1989 The Author Version: Version of Record Copyright and Moral Rights for the articles on this site are retained by the individual authors and/or other copyright owners. For more information on Open Research Online’s data policy on reuse of materials please consult the policies page. oro.open.ac.uk Luri Î umvtKbff y DX88774 11NRESTR\CTEB Moral Luck in Medical Ethics and Practical Politics Donna Dickenson, B.A., M.Sc. (Econ.) Submitted for the Degree of Doctor of Philosophy Department of Philosophy Faculty of Arts June 1989 No part of this material has previously been submitted for a degree or other qualification at the Open University or any other institution. l^at(L oj SLibmis^ioA *. 2A bh J iin€/ I1S4 J^aké. û|. a w a ri ; L(-bH Ockûbe.P ProQ uest Number: 27758699 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent on the quality of the copy submitted. in the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 27758699 Published by ProQuest LLC (2019). Copyright of the Dissertation is held by the Author. Ail Rights Reserved. This work is protected against unauthorized copying under Title 17, United States Code Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106 - 1346 Moral Luck in Medical Ethics and Practical Politics Abstract . : v; Typically we maintain two incompatible standards towards right action and good character, and the tension between these polarities creates the paradox of moral luck. In practice we regard actions as right or wrong, and character as good or bad, partly according to what happens as a result of the agent's decision. Yet we also think that people should not be held responsible for matters beyond their control. This split underpins Kant's assertion that only the good will is securely good, that its goodness is impervious to outcome ill-luck. Some commentators, such as Martha Nussbaum and to some extent Bernard Williams, think that this simply writes off the paradox. Williams asserts that the paradox is insoluble, and that its inescapability threatens the notion of agent responsibility. In contrast Thomas Nagel argues that agents' most cherished projects may be indeed be subject to luck, but that does not mean that their deepest motivations are moral. This, I suggest, is one of several means whereby we might limit the effect of the paradox without denying that the tension exists. But I also argue that it is wrong to accuse Kant of ignoring the paradox. Ethical consequentialists, on the other hand, appear to have no problem with moral luck, because the paradox depends on a dichotomy between the outside world and the locus of moral worth in the individual agent. But this turns out not to be true. The problem of moral luck is not some strange Kantian fixation, but a general dilemma: a variant on what Nagel terms "the problem of excess objectivity" which cuts across all of ethics and metaphysics. Retaining a broadly Kantian notion of agent-responsibility, but limiting \diat agents are responsible for, requires us to delineate the realm of ethics more narrowly than has been done by those who believe that the rational and/or prudential are coterminous with the ethical. This strategy for minimising the paradox's impact is explored in two areas from medical ethics, the allocation of scarce medical resources and informed consent, and two from public policy, secrecy and nuclear deterrence. Throughout, the analysis seeks to test Nagel's maxim that the best we can hope for is to act in such a manner that we would not have to revise our opinion of how we should have acted once the consequences of our actions become apparent. ; TABLE OF CONTENTS 1. Ethics versus Luck? 1 2. Risk and Kant 27 3. Probability and Utilitarianism 58 4. Rationality and Prudence 85 5. Moral Luck and the Allocation of Scarce Medical Goods 116 6. Secrecy and Moral Luck 145 7. Responsibility, Risk, Rationality and Consent 175 8. The Illest Chance? Luck, Moral Mathematics and 204 Nuclear Deterrence Bibliography 242 Chapter One Ethics : versus Luck? Is "moral" incompatible with "luck"? The attempt to shore up the ethically right against the tidal waves of ill chance is generally thought central to the Kantian moral enterprise. But if that effort is hopelessly quixotic, or even misguided, is Kantianism in danger? More broadly, is ethics, as a idiole somehow at risk? Typically, we maintain two incompatible standards towards right actions . and good character, and the tension between these polarities creates the paradox of moral luck. In practice we regard actions as right or wrong, and moral character as good or bad, partly according to what happens as a result of the. agent's decision. That is, we make responsibility hinge to some extent on things outside the agent's control. Yet at the same time we think that people should not be held responsible for matters beyond their control. This tension underpins Kant's famous assertion that only the good will is securely good, and that its goodness is impervious to ill-luck in how things actually turn out. Even if it should happen that by a particularly unfortunate fate or by the niggardly provision of a stepmotherly nature, this will should be vÆiolly lacking in power to accomplish its purpose, if even the greatest effort should not avail it to achieve anything of its end, and if there remained only the good will (notas a mere wish, but as the summoning of all the means in our power), it would sparkle like a Moral Luck in Medical Ethics and Practical Politics Page 1 Ethics versus Luck?/Chapter 1 jewel in its own right, as something that had its full worth in itself.1 But is moral luck only a problem for a .Kantian? Martha Graven Nussbaum has claimed that not only Kant but also Plato was motivated by a concern to minimise the effects of chance on moral character and the rightness of ethical choices.*^ And though ethical consequentialism appears not to have a problem with moral luck, in fact it does so, as I shall argue in chapter three. But most particularly, I want to see whether the concept of moral luck can cast any light on problems in medical ethics and practical politics— and conversely, how grounding the concept in practical ethics might help us to better understand and perhaps resolve the paradox. This moral luck debate, begun by Bernard Williams and Thomas Nagel in 1976,^ has become reasonably familiar to many ethicists. And its application has been extended to theories outside the original scope of the debate, most notably in Nussbaum* s work— vhich stretches the concept to fit classical tragedy as well as philosophy. But it has not yet been applied to practical ethics, and this is what I intend to do in chapters five through eight. The areas which I discuss— the allocation of scarce medical resources, informed consent, secrecy in politics, and nuclear deterrence— can be fruitfully explored, I argue, in terms of the simple question arising from a concern with moral luck; \diat happens if things go wrong? This practical ethics section occupies slightly more than half of the dissertation. In it I conclude that a modified Kantian approach can handle the moral luck problem as it surfaces in these areas of medical ethics and practical politics. Page 2 Moral Luck in Medical Ethics and Practical Politics Ethics versus Luck?/Chapter 1 In the first four chapters I erect the theoretical framework for \diat I hope will be a more sophisticated discussion than might be suggested by the basic question of what happens when things beyond an agent’s control go wrong. I begin in this chapter with a systematic exposition of the moral luck debate between Williams and Nagel, considering also the ramifications of the debate in further articles on the same subject by other writers^. (It has also surfaced in such unexpected areas as feminism.^) I end with Williams’s own further reflections on the significant debate which he set in train.^ The second chapter analyses the Kantian sources of the claim that ethics cannot allow itself to be undermined by chance, and deals at some length with Nussbaum’s stimulating critique of what she presents as Kant’s view as well as Plato’s.^ It asks vdiether Kant’s approach to the moral luck paradox is essentially sound, despite Nussbaum’s criticisms, and concludes in part that Nussbaum has misrepresented Kant’s solution, which is closer to her own than she acknowledges. In chapter three I turn from deontology to consequentialism, and particularly to utilitarianism. Here I explore the threat from moral luck, which I argue a threat even to consequentialists, in terms of actual and potential consequences, with the associated concept of probability also entering in. In the course of chapter three I suggest that the best way to resolve the paradox turns out to be retaining a broadly Kantian conception of agency, with considerable strictness about responsibility, but limiting severely what agents are responsible for. This requires an equally strict delineation of \diere the ethical ends and the merely prudential begins, and this I attempt to do in Moral Luck in Medical Ethics and Practical Politics Page 3 Ethics versus Luck?/Ghapter 1 chapter four, which also considers rationality.

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