Two ICU Beds, Three Patients
The intensive care unit at a city hospital has two free beds and three patients who need ventilation within the next two hours. Patient A is 34, a primary school teacher, with a 70% predicted survival and no major comorbidities. Patient B is 68, a retired nurse with mild dementia, predicted 55% survival. Patient C is 45, a father of three, with obesity and a 40% predicted survival. The hospital's triage policy says to 'save the most lives' but does not specify whether age or life-years may be used. One nurse argues for a lottery because all lives are equal. Another argues for first-come, first-served. A third says the father should be prioritised because his children depend on him. The team must decide in 90 minutes and document reasons. A fourth patient may arrive by ambulance.
1. How would an act-utilitarian and a Kantian deontologist decide? Which gives the more defensible answer here?
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An act-utilitarian would compare expected outcomes. On a simple 'save the most lives' rule, A (0.70) and B (0.55) together give 1.25 expected lives, while A and C give 1.10 and B and C give 0.95; so A and B are chosen. If the policy is interpreted as maximising life-years, the calculation changes: A is young and has a high survival probability, C is younger than B but has a lower probability, and B has fewer remaining years. A and C might then produce more expected life-years. The utilitarian must also consider rule-utilitarian effects: a policy that uses age or social worth may erode trust and produce worse outcomes overall. A Kantian deontologist would reject using the father's dependents as a reason to treat him as a means to others' welfare, and would reject age alone as a proxy for worth. But Kantians can use medical prognosis because it is a relevant difference in the likelihood of benefiting from treatment. If A and B have the best prognoses, treating them is universalisable; if prognoses were equal, a lottery would respect equal moral worth. The most defensible decision is therefore A and B on prognosis, with a public rationale that rejects social worth and explains why age is not being used as a tie-breaker.
2. How would virtue ethics reframe the decision, and what would a virtuous triage team do?
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Virtue ethics would ask what a phronimos - a person of practical wisdom - would notice and do. Such a person would notice the nurse's moral distress, the father's dependents, the retired nurse's mild dementia, and the possibility of a fourth patient. They would not reduce the decision to a score sheet. The virtues of compassion and justice pull in different directions: compassion may favour the father, justice favours a rule that does not value people by social role. Practical wisdom would seek a decision that is transparent, revisable, and humane. A virtuous team would deliberate openly, allow dissent, and avoid pretending that the decision is cost-free. It would also prepare to support the patient who is not ventilated and the staff who must implement the decision. Virtue ethics does not yield a unique rule, but it does rule out certain attitudes: contempt for the lottery nurse, sentimental prioritisation of the father, or cold satisfaction with the arithmetic. The team should ask not only 'Which two patients?' but 'How should we decide, and who will we become in deciding this way?'
3. What should the team do about the nurse who argues for a lottery?
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The nurse who argues for a lottery is making a serious claim about equal moral worth. The team should not silence her or treat her as naive. A lottery is a procedural device that expresses the idea that each patient's life counts equally when no morally relevant difference justifies prioritisation. If the team rejects the lottery because prognosis is a relevant difference, it should say so explicitly and show why prognosis is not merely a way of ranking social worth. The team should record the dissent in its documentation. After the decision, it should hold a debrief for staff, because moral residue is likely: even a justified decision can leave the team feeling responsible for the patient who is not treated. The nurse's argument should also inform future policy: the hospital should clarify in advance whether life-years, prognosis, or lottery will be used, so that staff are not forced to improvise under pressure. Taking the dissent seriously is both an ethical and an epistemic duty: it tests the team's reasons and protects against self-serving certainty.