What Is a Fair Share of Life?
The Fair Innings Argument in bioethics

11 minutes read - 2328 words

What is a fair share of life? Do the young deserve life more? Has someone who dies young been wronged in any way?

Is it more tragic when people die young? If you have two patients and only one ventilator, who should be treated and who should die? Has the elderly patient “already lived their life?” And what is a “fair share” of life anyway?

The “Fair Innings Argument” assumes that there is such a thing as a fair share of life. If someone has lived that much, then any additional lifetime is considered a bonus. While if someone still has to reach the limits of their fair share, then they seem to have a stronger claim to additional lifetime. The problem with the argument is that it assumes that the two lives being compared are equal in every other respect. And this is never the case.

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Dying young

It’s an old problem, but the coronavirus crisis has yanked it out of the philosophers’ drawers and into the news: should we let elderly patients die in order to benefit the young?

So you have this doctor standing there in his hospital ward, and he has two patients in front of him, but only one ventilator. The one patient is, say, 80 years old, the other 20. How can he make sense of this situation? How can he decide?

There is an argument called the Fair Innings Argument, and the idea is that some people have already had their fair share of life. So you’d assume that there is such as thing as a fair share of a human life, let’s say seventy years. If you get more than seventy years, that’s good for you, but since you’ve already had your fair share, everything beyond that is valuable and good and you should enjoy it, but it is not something you are entitled to. While other people might not yet have had their fair share. So that 20-year-old is missing 50 years to complete his fair share of life, and because these 50 years are missing, he would somehow suffer an injustice if he died right now. Something would have been denied him that the other patient already had.

So if you believe that argument, you’d say, I prefer to give my limited resource, my medicine, my ventilator, my nurse time to the younger patient, just because they still haven’t enjoyed their fair share of life. So it becomes a matter of justice. It seems more just to give these resources to the younger patient. But is this true? And is the Fair Innings Argument really a good argument?

We’ll use ideas from a paper by Michael Rivlin (Why the fair innings argument is not persuasive. BMC medical ethics. 1(1):E1, 2000).

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So the question is: is there something like a fair share of life?

The first thing we can do to answer that is to ask: What does it even mean to have a fair share of something? Where does this concept of a “fair share” come from? We might think of a cake or a pizza when we picture a fair share. I have a number of people who are interested in the cake, or the pizza, and now I can cut it up so that every person gets a fair share. Easy.

But now try to apply this to a life, and you’ll see that it’s not immediately obvious how you’d go about defining what a fair share of a life even means. With the cake, I can take my fair share and give it to someone else, if I like. I cannot do the same with a share of my life. I cannot give two years of my life to my daughter. Perhaps I’d desperately wanted to do that, but it’s not possible. We can use our lives in particular ways, but that’s a different thing. We cannot actually give shares of our lives away in the same way as we may give away a piece of cake.

And then: a cake is divisible. I can easily cut a cake into eight equal pieces. But how to divide a life into eight equal pieces? Or even into eight somewhat equivalent pieces? Is one year of my childhood worth the same as one year of old age? Or is middle time worth more? Which one? My twenties, in which my body worked flawlessly and I could stay up with friends all night, but I didn’t have a house or money to spend; or my late middle age, in which my bones start creaking and my knees hurting, but where I can afford a place to live that I like, and where I don’t need to be up with people all night, but I can instead enjoy a beautiful Sunday on the sofa with a book? Are these two experiences of life comparable in any meaningful way?

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Another interesting question is whether there’s such a thing as a “fair share” of medical resources. You could perhaps argue that everyone should get the same amount of medical care. But then, this doesn’t seem to work. Not every person in the country needs a ventilator, or eight hours of care from a nurse, or chemotherapy. If you had, say, an hour’s worth of care from a nurse, and two people: one who’s ill and a hospital patient, and one who’s healthy and just visiting the other one. Should both get half an hour of the nurse’s time?

With medical resources, we seem to accept the fact that a fair share is measured according to one’s needs. So if someone needs the nurse right now, he should get the whole hour. The healthy visitor shouldn’t get any of her time, and that’s also fair. It’s even more just, we would think.

But it’s not only the need that’s the basis for fairness. We could also look at how much each of two patients has contributed to the existence of the resources that they both claim. If I’m the one who’s always buying the coffee that is shared around the office, then perhaps I have a stronger claim to a cup when the coffee supplies run low. Seen that way, the younger of two patients has probably contributed less towards the existence of these ventilators. At twenty, a person has not yet contributed much to society, either financially, through taxes, or in any other way. Twenty-year-old people mainly consume resources – which is fine, because this is the way we’ve set up our society. But when we talk about access to scarce medical resources, then probably an elderly citizen has a stronger claim. He has contributed to society, perhaps paying taxes for forty years, and much of that ventilator that he claims has been financed from his taxes (and those of his generation). It has not been paid for by the twenty-year-old. So this is another reason why we should consider that perhaps a “fair” distribution is not necessarily a distribution favouring the young.

But let’s go back from the question of resources to what we were talking about previously: what is a fair share of life? What is a fair length of life? Why is it considered “fair” to live 70 years rather than 20?

Have you lived your life yet?

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Utilitarianism is the moral theory that says that the morally good action is one that maximises happiness for all.

From a utilitarian point of view, one could perhaps say that there is some minimum amount of happiness that each person should be able to get out of their lives; some amount of happiness every human being is expected to gain, or perhaps even entitled to. This happiness might include things like having children, having grandchildren, having a fulfilling job, a loving partner and so on. And somebody who is 80 has had most of these things in his life, so he has “consumed” these sources of happiness. He has enjoyed these things that make a human life worthwhile; while someone who is 20 has not. So this would be an argument why we should save the younger patient first: so that he can enjoy the happiness that he (and everyone else) is entitled to, but has not yet enjoyed.

But why would we think that the actual enjoyment of one’s life is proportional to age?

You can think of a 20-year-old who’s had a lot of fun in his short life, and actually many 20-year-olds do have quite a bit of fun, at least in our wealthy societies: that’s the age for partying, for going out, for having all sorts of pleasant and exciting friendships, the time for love affairs, for travelling the world.

On the other hand, one can equally easy imagine an 80-year-old who didn’t have such a great life. Somebody who’s now 80 or 90 has probably lived through the Second World War as a child, perhaps lost family members in the war, experienced post-war shortages and poverty, and maybe became a steelworker or coal miner and lived in social housing all his life. The fact that somebody is 80 doesn’t mean that they necessarily had a ton of enjoyment in their lives. They might have lost their partner when they were 50 and never remarried, and now they’re 90 and they’ve had ten years of war and another ten of post-war depression, 50 years of backbreaking work, and 40 living alone as a widower. So one can ask, has this really been such a great life? Are we justified in withholding the ventilator and terminating his life because this old man has completed his allotted amount of life enjoyment, his fair share of fun and games?

This whole Fair Innings Argument assumes that there is such a thing as “equal enjoyment of life,” but that doesn’t seem to be the case.

One doesn’t have a bigger share of life’s spoils just because they’re older. This might be the case if, as philosophers are fond of saying, “all other things were equal.” But they never are.

People are different. What if the young person is handsome and beautiful, humorous, a gifted painter, sporty, and their piano play can make you cry? And the older guy is ugly and an introvert, someone who never had the opportunity to discover and cultivate their talents. They had a boring life, spent all their long evenings of a life on the sofa watching TV, early to bed and early to rise, until they ended up in the same hospital room as the young prodigy?

Lives are not “equal in other respects.” And so the argument that we should give the medical resources to the young rather than the old seems to be based on many misconceptions: it is unfair when we think about their respective contributions to the resources that they claim; it’s not clear what is being shared there at all; and the idea that life’s enjoyment accumulates over the years in the same way across individuals is plainly wrong.

So what can utilitarians do?

If we really want to go this way of measuring a life’s happiness over another’s, we cannot do so by using age as a proxy for enjoyment. We might try to estimate the actual happiness of a life lived, though, by looking at who the two patients really are and what cards life has handed them.

But we might also refuse to go that way entirely.

Are all lives equal?

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We could reject this whole idea that people have different claims to life, and that one life is more valuable than another. And we could argue instead that every life should have the same value, no matter whether the person is young or old, a criminal, a politician, a shopkeeper, or an environmental activist.

This is perhaps what Christians would say: every life is made in the image of God, and is worth the same, demands the same respect, deserves the same protection.

Immanuel Kant (1724-1804) would agree. He thought that what makes human life valuable is human autonomy: the ability to decide how to live one’s life according to one’s own moral code, one’s own preferences and values, guided by one’s own reason. There’s no difference between the autonomy of a person at 20 and one at 80, and so their essential human value, their dignity, is equal. And therefore we’re not allowed to prioritise one over the other.

So a Christian, or a Kantian, should say, I refuse to make this decision. I cannot calculate the relative worth of two people and then go and play God. If one believes that every human life is infinitely valuable, then we can never choose to kill one life in order to save another, no matter what specific properties, achievements, abilities and history the two patients have.

Now, although this is the easiest and least controversial approach, it doesn’t actually solve the problem. We’re still stuck with two patients and one ventilator for the two of them, and we still have to decide who’s going to get the resource and who will die. If we refuse to make a rational decision between the two, then we’re only left with the option of randomly giving the ventilator to one of the two. But would this really make things better? Is a random decision more moral than a carefully considered one?

As often in philosophy, there are no easy answers to this problem. But sometimes, realising that the answer is hard is already an important step forward.

Thanks for reading! What do you think? Let me know in the comments!

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