The American Journal of Bioethics, 15(2): 12–29, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.990169

Open Peer Commentaries

Rethinking Rescue Medicine Nancy S. Jecker, School of Medicine, University of Washington The prospect of rescuing a person in immediate peril seems at first glance to be an unqualified good. Take, for example, the events of April 15, 2013, at the 117th Boston Marathon. Two consecutive explosions killed three spectators, including an 8-year-old boy, and injured 264 others, one of whom was as young as 2. The explosions, caused by bombs, occurred on the sidewalk near the finish line, leaving 17 people with critical injuries, including 14 who required amputations. Media reports describe the response of physicians, nurses, and paramedics: Rescue workers rushed in to care for the dozens of maimed and injured, some of whom lost legs in the blast, witnesses said. (Eligon and Cooper 2013) [Rescue workers] were running . . . to treat exhausted runners. . . . When [Dr. Vivek] Shah reached the wounded, he was not alone. “By the time I got there, there were so many first responders and volunteer physicians . . . I’ve never seen anything like it in terms of the quickness of the response to that tragedy.” . . . Within the first 15 minutes, 15 patients were at Brigham and Women’s Hospital, a Level I trauma center. . . . Seven operating rooms were immediately cleared for the nine patients needing surgery, he said. (Duke 2013) After running the Boston Marathon on a broken foot, Dr. Natalie Stavas raced to save as many lives as possible. . . . The 32-year-old physician, who’s a pediatric resident at Boston Medical Center, jumped over the barricades and started tending to the most severe cases. Stavas provided life-saving treatment to a number of seriously injured victims. She pumped oxygen into a woman whose thigh had been blown open and then worked on another woman who had a hole in her groin. She also wrapped a tourniquet on a man with a mangled foot, according to the Los Angeles Times. (Goldberg 2013) Dr. David King, a physician who’s worked in Iraq and Afghanistan, completed the marathon and then ran to Boston Medical to perform surgery, ABC reports. (Goldberg 2013)

In tragic situations, rescue medicine rekindles hope, and in the context of terrorist bombings it has the power to restore our faith in human beings. A Huffington Post blog offering guidance to parents trying to give comfort to children in the aftermath of the Boston Marathon bombing

captures this point poignantly. Quoting from The Mister Rogers Parenting Book, the blogger writes: “When I was a boy and I would see scary things in the news, my mother would say to me, ’Look for the helpers. You will always find people who are helping’” (“Look for the helpers” 2013). Yet despite the strong positive emotions rescue efforts elicit, rescue can also run amok. There are many plausible reasons for this claim. First, the mere fact that a person is in dire straits does not suffice to show that it is morally heroic, or even permissible, to attempt rescue (Jecker 2013). Under different circumstances, attempted rescue may be pointless, offering an exceedingly poor chance of helping the victim. Second, yielding to an impulse to rescue in each and every case of apparent need would lead to an impossibly expensive system. Thus, the value of rescue in a particular case must be considered not as an isolated event, but rather in the broader context of limited resources and opportunity costs forgone. A third and related point is that rescue efforts may help a relatively small number of individuals at the expense of helping a much larger group of people. In other words, rescue may not do the greatest good, even if it benefits particular individuals. Finally, rescue may fall short of justice standards by misallocating health care resources. It may create a bias in favor of acute medical interventions at the expense of other health priorities, such as prevention or caring for patients with ongoing chronic health problems. In contrast to the situation of the Boston Marathon, one can imagine a set of circumstances where attempted rescue would be morally egregious. For example, it would be ethically indefensible to attempt to rescue a patient with multiple-organ failure who suffers cardiac arrest by performing in-hospital cardiopulmonary resuscitation (CPR) despite good evidence that CPR would be futile and would prolong the patient’s misery without giving the patient a reasonable chance of surviving to hospital discharge (Schneiderman and Jecker 2011; Schneiderman, Jecker, and Jonsen 1990). To even call such efforts “rescue” is farcical; a more honest telling might be: harming the patient, wasting resources, feeding false hope, disregarding professional standards, failing to show courage,

Address correspondence to Professor Nancy S. Jecker, PhD, University of Washington, Bioethics and Humanities, Box 357120, School of Medicine, Seattle, WA 98195-7120, USA. E-mail: [email protected]

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being seduced by technology, neglecting to focus on palliative care, being coopted by the family, refusing to acknowledge medicine’s limits, denying a patient’s impending death. (Jecker 2013, 8)

Yet if rescue is not an ethical absolute, what are the ethics of rescue? When should providers attempt rescue and when should they refrain? Surprisingly little attention has been paid to addressing this question. Instead, the tendency has been to assume that rescue is a moral absolute, and that it takes ethical priority regardless of the consequences. Yet our unqualified endorsement of rescue medicine has contributed greatly to the high cost of medical care, to the misallocation of scarce health care resources, and to overtreatment. It has also contributed to moral distress and “burnout” among health care professionals. To address these concerns, public deliberation about health care priorities is needed. Setting priorities is not the responsibility of physicians, nurses, or other health care professionals who find themselves in rescue situations, but is instead a collective obligation of all citizens.

THE HIGH COST OF MEDICAL CARE In the United States, health care costs are far higher than in other developed countries, yet our results are no better based on standard measures, such as life expectancy and infant mortality. One side effect of the high cost of health care is that the United States has the dubious distinction of being the only industrialized nation that does not guarantee universal health insurance to all citizens. We claim we cannot afford it (Berwick, Nolan, and Whittington 2008). The list of factors allegedly contributing to the relatively high cost of health care in the United States is well known. It includes considerations such as an aging society, advancing technologies, greater supply of hospitals and doctors, higher incomes, fear of legal liability, and insulation of consumers from the true costs of care. A recent study by the Commonwealth Foundation identifies higher prices, more readily accessible technology, and greater obesity as primary drivers of U.S. health care costs compared with other countries (Squires 2012). Yet as Morreim notes, the standard explanations overlook an important factor, namely, the psychological imperative we feel to aid the stranded individual. Conforming to this psychological imperative, we find ourselves sparing no expense to help the desperate soul on the evening news who needs but cannot afford the latest lifesaving medical technology. However, we also find that the cost of extending the same extravagant rescue for everyone in similar situation is ferocious and that those situations are ubiquitous (Morreim 1994). The moral dilemma rescue poses arises from the requirements of formal justice, which instruct us to treat like cases alike. Thus, once we rescue one individual, we cannot fairly deny rescue to someone else who is similarly

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situated. In this way, a single case of rescue is never an isolated event, because it always creates a justice obligation to care for others when they have similar health care needs.

THE MISALLOCATION OF HEALTH CARE When rescue medicine thwarts other values we hold, such as prevention, long-term care for the elderly, or universal access to basic care, it becomes an unjust and irrational system for allocating health care. To address the challenge of more fairly allocating health care, and better balancing health care priorities, various solutions have been offered. One of the best known attempts to develop a fair system is cost-effectiveness analysis, which balances the benefits gained by a medical intervention against the costs associated with it. Eddy, for example, has long been an advocate of considering costs on equal footing with benefits when defining what constitutes “essential care” (Eddy 1991). He notes that medical decision making has finally made a welcome shift away from clinicians’ subjective judgments toward a more formal analysis of evidence related to benefits and costs (Eddy 2011). Despite its rational appeal, however, one difficulty that cost-effectiveness analysis encounters is that it requires policies whereby providers refrain from helping identifiable patients. Hadorn, for example, underscores this point when he notes that rational approaches, such as cost-effectiveness analysis, collide with the “rule of rescue,” referring to a term coined by Jonsen to describe our psychological impulse to rescue endangered human life (Hadorn 1991; Jonsen 1986). Jonsen rightly cautions that the impulse to rescue can become a “compulsion” that is “more instinctive than rational.” Yet others who recognize a “rule of rescue” have subsequently turned this rule into a normative requirement, representing “a moral rule prescribing the rescue of identifiable people at immediate risk of serious harm” (Hughes and Walker 2009). When rescue becomes a moral requirement or, even worse, a moral absolute, it runs amok. This is because extending rescue indiscriminately results in an irrational system for allocating health care. We saw this occur in the early days of kidney dialysis, when the U.S. Congress rescued patients with end-stage renal disease (ESRD) by deciding to fund all care for patients with this condition. The result has been that patients with ESRD consume a vastly disproportionate amount of resources. According to the U.S. Renal Data System Annual Data Report, the total costs of ESRD in 2011 was $45.5 billion, and it represented 18% of total Medicare expenditures (U.S. Renal Data System 2013). The deeper problem is that this uneasiness about enforcing limits has been not just irrational, but unjust. It has deterred us from allocating health care fairly. Creating a more just system of health care allocation requires countering our psychological proclivity to rescue endangered human life under any and all circumstances. It requires

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denying at least some rescue benefits, to some people, some of the time. For example, relatively high-cost benefits with relatively low yield merit a lower priority than lowcost benefits with a high yield. Moderately good chances of rescue with very high costs must be balanced against other health priorities, such as investing the same health care dollars in preventive measures that stand to benefit a much larger number of people. One way to accomplish limits on rescue and begin to frame rescue decisions in comparative terms is to require patients to have an economic stake in their care, for example, by charging high emergency department deductibles and co-pays. Another way is to ask patients to choose a package of benefits they are willing to pay for, and then require them to live within those limits, rather than rescuing them with interventions beyond that health care package. Although it may be “very sad to deny someone his small glimmer of hope . . . it is not unfair. What is unfair is to permit health care access to lapse into an uncontrolled explosion of expenses engendered by willy-nilly rescue” (Morreim 1994, 466). Of course, requirements of justice do call for rescuing some people some of the time. But justice also requires meeting the medical needs of people in nonrescue situations. For example, justice requires a fair allocation of health care to healthy individuals who need preventive services like cancer screening, prenatal care, vaccinations, or well child checkups to stay well. Likewise, justice requires providing resources to people who suffer the daily indignity of needing assistance with activities of daily living, such as toileting, feeding, and bathing as a result of progressive chronic diseases like cancer, stroke, heart disease, and dementia. A fair system for allocating health care sets priorities among the various health care goods by framing medical decisions broadly, that is, by considering the full range of health care services and setting priorities among them. The task of setting priorities should not fall on the shoulders of first responders, that is, the doctors, nurses, and paramedics who arrive on the scene of a disaster with mass casualties. Their job is to do their best for individual patients with the resources at their disposal. Instead, priority setting must be agreed to in advance, and determined by public deliberation at a societal level. One example of a process of public deliberation about how to use limited resources to protect fairly the health of a population with varied needs requires that four conditions be met: (1) publicity condition: decisions regarding health care priorities and their rationale are publicly accessible; (2) relevance condition: the rationales give a reasonable account of how society will meet the varied health needs of a defined population under reasonable resource constraints, i.e., the rationales appeal to reasons and principles that are accepted; (3) appeals condition: there is a mechanism for challenge and dispute resolution; and (4) enforcement condition: there is a voluntary or public regulation of the process ensuring conditions 1 through 3 are met (Daniels 2001).

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OVERTREATMENT In rescue situations, the obligation of health care professionals is to help. If a particular intervention does not hold out a reasonable chance of helping the patient, there is no obligation to use it (Schneiderman and Jecker 2011; Schneiderman et al. 1990). When the likelihood of benefitting the patient is exceedingly poor, less than 1 chance in 100, rescue would be quantitatively futile and should not be attempted. Quantitative futility draws on the idea that in the statistical analysis of controlled clinical trials, when there is less than 1 chance in 100 that an intervention has produced an effect, this is not considered to be statistically significant, because it is just as likely that the effect is due to chance as to the intervention. Likewise, in the case of rescue medicine, 1 chance in 100 of helping the patient does not rise to the level of statistical significance (Schneiderman et al. 1996). Medical futility is also at stake when the quality of outcome associated with rescue is exceedingly poor. For example, if attempting to rescue a particular patient were known to have an outcome in which a patient will survive but never regain consciousness, rescue would be qualitatively futile and should not be attempted. Even if resources are abundant, rescuers have no obligation to use interventions simply because they can. Nor is it heroic to do so. Instead, what makes medical rescue heroic is that it helps people. It is not the wielding of technology that makes doctors and nurses true heroes, nor is it the fact that they can produce physiological effects on patient’s bodies. Instead, it is their commitment to helping people. Rescue becomes irrational when it involves fighting at all costs to save a victim who is beyond help.

MORAL DISTRESS AMONG HEALTH CARE PROVIDERS Related to overtreatment is the phenomenon of moral distress among health care professionals, particularly nurses. “Moral distress” refers to the suffering that occurs when the right course of action is known but is not carried out (Silen et al. 2008). The most common ethical dilemmas leading to moral distress involve decision making to initiate or withdraw treatment. For example, an attempt to resuscitate a patient who is beyond help creates moral distress for members of the medical team if it runs contrary to their own professional standards of good medical care. Such an attempt may be based on a patient’s or family’s request that everything possible be done, on fear of legal liability, or on the broader culture of medicine, which tends to emphasize actively fighting disease. In the early 1900s, Solomon et al. (1993) were among the first to report that overtreatment was endemic in medical practice. They studied 687 physicians and 759 nurses in five U.S. hospitals looking at attitudes toward care of hospital patients near the end of life, and found that almost half (47%) of those surveyed reported having acted against their conscience in providing care. Of those, 55% reported

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feeling that sometimes the treatments offered were overly burdensome, compared with only 12% overall concerned about undertreatment of patients. More recent findings show that overtreatment continues to be a major concern among health care professionals. In 2011 Sirovich and colleagues surveyed 627 U.S. primary care physicians and found that nearly half (42%) believed that patients within their own practice were receiving too much medical care, compared with just 6% who believed that their patients were receiving too little care (Sirovich et al. 2011). More than one-quarter (28%) said they themselves were practicing medicine too aggressively. This kind of moral distress is not just a “bad feeling.” It has been demonstrated to be seriously detrimental to the provider’s family relationships and professional performance. It affects physical well-being, self-image, and job satisfaction, often culminating in a loss of focus, reduced patience, and burnout (Silen et al. 2008).

THE UNDERLYING ISSUES How did we arrive at this state of affairs? One factor is that considered from the perspective of rescuers on the scene, that is, physicians, nurses, and other health care professionals, the primary obligation is individual beneficence, that is, doing good for a particular patient. When health professionals face rescue situations, what is at the forefront in their minds is helping a needy individual. For providers, rescue medicine is about doing one’s best for an individual patient. Yet for society, rescue decisions represent more than the choices of individual providers and patients. They occur in the broader context of social, economic, cultural, legal, and other contextual features. When an attempt to rescue is made, it is the wider society’s job to notice that even if the focus is on the individual, we are at the same time allocating finite health care resources toward a rescue effort. While allocating resources to rescue may be ethically supported in a particular situation, this claim stands in need of justification. We cannot simply assume at the outset that the fact that a person is in imminent peril means that we should do everything possible to try to help. After all, societies do not possess unlimited resources, or unlimited amounts of money to pay for health care. Thus, to prioritize rescuing patients in imminent peril may result in fewer resources being available for nonrescue health priorities.

ALLOCATING HEALTH CARE BY DEFAULT When a decision to rescue is made without being part of an explicitly stated policy or plan for allocating health care resources, and without any attempt to justify it by appealing to ethical standards of justice and fairness, it represents an unplanned allocation of health care. The problem with an unplanned approach is that it is not thought through, not applied consistently, not accountable to the public, not decided democratically, and not insulated from arbitrary and unfair manipulation. In short, de facto allocation lacks

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integrity and violates the requirements of formal justice. Formal justice requires that when different individuals or groups are treated differently, there must be an ethically defensible basis for differential treatment. One of the underlying tensions is that in the short term, it is often easier to make hard choices by default, that is, by living with the consequences of “not deciding.” IDENTIFIABLE VERSUS STATISTICAL LIVES This last point leads to an obvious question: Is there an ethically justified basis for giving priority to rescue over, for example, preventive services? One distinguishing feature of rescue situations is that we are faced with identifiable individuals, rather than hypothetical or “statistical lives.” Thus, a rescue operation aimed at specific people whose lives might be saved differs from a preventive measure, which is aimed at reducing morbidity or mortality risk in a population. In the latter case, the lives that might be improved or saved are “statistical lives,” as opposed to identified lives. Are we justified in giving priority to identifiable individuals over statistical lives, or is doing so morally arbitrary? As Menzel notes, “The statistical perspective typical of prevention makes setting limits on . . . particular preventive services easier to swallow than setting limits on treatment” (Menzel 2015, 239). Yet the observation that it is psychologically easier to say no to prevention than to treatment leaves open the question of whether saying no to prevention is ethically supported. The distinction between identifiable lives and statistical lives reveals a deeper tension within moral reasoning, a tension between consequentialist and nonconsequentialist approaches. Consequentialist reasoning focuses exclusively on producing the best consequences overall. By contrast, deontological moral reasoning emphasizes duties that hold irrespective of whether abiding by such duties produces the greatest good. Giving priority to identifiable individuals reflects a deontological approach to moral reasoning; it suggests that whatever the consequences, there is an absolute duty to rescue an individual in peril. By contrast, those who endorse prioritizing public health measures and preventing harm to persons who might become sick support their position by appealing to consequentialist considerations and the idea of producing the best consequences for the population as a whole. The ethical problem with saying no to effective preventive medicine is that it represents what Shklar calls “passive injustice” (Shklar 1990). Passive injustice consists of our collective refusal to prevent harms from occurring when we could have. It occurs not only when we neglect preventive medicine by focusing excessively on rescue, but also when we refuse to take necessary steps to address the myriad social factors that so profoundly impact the health of populations. As Daniels notes: Health is produced not merely by having access to medical prevention and treatment, but also—to a measurably greater extent—by the cumulative experience of social conditions

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over the course of one’s life. By the time a sixty-year-old heart attack victim arrives at the emergency room, bodily insults have accumulated over a lifetime. For such a person, medical care is, figuratively speaking, “the ambulance waiting at the bottom of the cliff.” (Daniels 2001, 6)

Thus, even if all we cared about was health, that is, the health of the identifiable 60-year-old heart attack victim, we would not be wise to invest all of society’s resources in health care. We would, instead, be wise to think more broadly about social conditions that place people at increased risk of disease, injury, and early death. In other words, in order to do our very best for the 60-year-old victim, we would be wise to think about upstream factors that led to the heart attack victim’s emergency room visit (Jecker 2008). We would be smart to ask how we could prevent the need for rescue altogether. Identifiable people have histories, rather than arriving on the planet de novo at the time of a medical crisis; we can change the trajectory of a disease and, indeed, of a person’s life by intervening earlier. When statistical lives become identifiable, medical care is already, as Daniels says, “the ambulance at the bottom of the cliff” (6).

MEDICAL VERSUS SOCIETAL JUSTICE When health care professionals are called to the scene of a disaster, their job is to do everything possible to help the injured. If the victims requiring medical attention overwhelm the capacity of the medical system, priorities are set on the basis of medical criteria. Disaster triage, for example, appeals to medical criteria to prioritize patients in mass casualty situations. It calls for helping first those whose injuries can be improved with relatively simple procedures and will not otherwise improve. Other groups include those who are unlikely to benefit regardless of what we do, and those who do not have an urgent medical need and can delay medical assistance without significant risk (Kipinis 2004). Notice that disaster triage decisions do not appeal to nonmedical considerations, but focus exclusively on producing the greatest medical benefit. This approach to allocation has been called “medical justice,” because it guides health care professionals to make benefitting patients their primary duty, and allows denying care to patients only in extreme situations where demand overwhelms the capacity of providers to meet it (Schneiderman and Jecker 1996). “Medical justice” identifies the primary responsibility of health care professionals to be acting in the best interests of their patients. Thus, physicians owe the ideal of service to anyone in need who can benefit from medical treatment. While medical justice works well at the level of individual patients and providers, it does not work well at a societal level. This is because society must take a broader view, considering not only the needs of identifiable individuals in emergent situations, but also the broader health of populations, the so-called “statistical lives” of those whose are now healthy but will be at risk of injury or early

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death if services such as primary and preventive care are not provided (Jecker 2008). Unlike physicians and other health professionals, society is forced to set priorities, either by default or by means of fair processes and explicit policies. In contrast to medical justice, societal justice is comparative. It draws distinctions among individuals and groups and allocates scarce resources on both medical and nonmedical grounds (Feinberg 1974). Garrett (2015) gets it right when he argues that we need “a social institutional view” that “engages proactively with the rescue landscape” in order to arrive at allocation decisions (5). The failure to do so is not a failing of health professionals, but of us as citizens. Society decides, either deliberately or by default, (1) the priority of health care versus other goods; (2) within health care, the priority of different type of health care services; and (3) within a particular type of health care service, the criteria for prioritizing individual patients (Calabersi and Bobbitt 1978). Thus, while we recognize a collective obligation to contribute to rescue efforts—for example, first responders, including fire, police, ambulance services, are supported by tax dollars— at the same time, we recognize limits to our collective obligation. This becomes clear once we imagine a world where all available resources were invested in rescue. There would be scant resources left for other medical priorities, and the system would soon destroy itself. Thus, although society invests in rescuing needy patients, it also rejects giving full priority to rescue, because the opportunity cost of doing so would be too great. If we are ethically required to give some weight to statistical as well as identifiable lives, how much weight should we give? A utilitarian perspective instructs us to give the greatest weight to producing the best outcome with our limited resources. Thus, it would place a high priority on helping many people, even if the benefits accruing to them were relatively minor. It would reject investing large amounts of resources in helping a relatively small number of people, even if they were in dire need. Yet this perspective must be balanced against a competing view, which reasons along deontological lines. For example, a Rawlsian perspective might argue that utilitarian principles should be rejected because we would not accept them upon reflection. After all, individuals would not agree to make large sacrifices to produce the greatest good for others. Determining the proper balance between these competing moral perspectives requires a fair process for choosing principles of justice. For example, a Rawlsian approach defines a fair process for choosing justice principles as requiring that we place ourselves behind a veil of ignorance, which is a heuristic device that asks us to imagine that we are deprived of important information about ourselves, such as our socioeconomic class, sex, race, health, age, or facts such as where in the country we live or what our job or plan of life is. Behind the veil, we are prevented from tailoring distributive principles to our own benefit. Instead, we imagine that we might be any member of society, and try to make the situation of those who are least

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well off as good as possible, remembering that we could be among the least well off. Daniels has argued persuasively that from such a vantage point we would give greater priority to protecting opportunity by prioritizing health care that prevents, cures, or compensates for deficiencies in the normal range of opportunities open to individuals. With an emphasis on safeguarding opportunity, the highest priority would be given to modifiable risk factors that carry the potential to profoundly curtail normal opportunity— for example, preventive medicine and public health measures that effectively reduce the incidence of conditions such as cardiovascular disease and cancer in a healthy population. Moderate rescue attempts, those that hold out a reasonable chance of benefitting individuals at a reasonable cost, would fall somewhere in the middle. Finally, rescue of individuals where the likelihood or quality of outcome associated with rescue interventions is poor, but not futile, would be ranked last; within this category, more costly interventions would come after less costly ones.

but rather: Is a person in imminent peril more needy than a healthy pregnant woman who needs prenatal care? How should we think about the neediness of a person with an acute condition versus a child who requires vaccination to prevent disease or mental health counseling to cope with chronic mental illness? What is the comparative need of a rescue victim compared with a frail elderly person with dementia who needs assistance with toileting and bathing? All of these individuals display need, yet whose need is greatest? As soon as we frame rescue choices more broadly, they become more difficult. Yet if we aspire to live as reflective individuals, we cannot shirk priority setting. Nor can we resort to making such important decisions only by default. Instead, we must embrace the complexities of living moral lives by exercising moral agency. &

REFERENCES CONCLUSION: A BROADER VIEW The ethical question rescue situations raise is, when should we attempt to rescue and when should we not? The example of the terrorist attack at the 2013 Boston Marathon is the kind of paradigm case that we tend to think of when we envision rescue. The case involves a high probability of benefit, a low or reasonable cost to the rescuer, and a rescuer who is uniquely situated to help because he or she happens to be present. The event was random, isolated, and no amount of preventive medicine could have stopped the injuries. Yet many cases depart from this paradigm. They may carry relatively low odds of success; come at a high cost, not only to the rescuer but to others who need finite health care resources; and other options, perhaps less visible, may be possible upstream that could have prevented a medical problem from developing, thereby avoiding rescue altogether. When we depart from the rescue paradigm of the 2013 Boston Marathon, we see that the burdens of rescue may be great, and the benefits modest. We see that justice may require that we refrain from rescue. I have argued that a major factor that should be taken into account in rescue situations is the probability of medical success. Another central consideration is the opportunity cost of rescue: specifically, what alternative health care services are foregone by investing in rescue? When considering how to prioritize different categories of health care, I have proposed that we follow Daniels’s approach of considering the impact that setting different health priorities is likely to have on the normal opportunities open to individuals. An additional ethical concern is the deontological duty to help the most needy and vulnerable individuals. Yet this duty is determined not on the basis of whether someone is identifiable, but on the basis of needs themselves, and the impact of unmet needs on a person’s normal opportunities. Finally, I have proposed framing questions about whether to rescue in comparative terms, asking not just whether we should rescue an individual,

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Berwick, D. M., T. W. Nolan, and J. Whittington. 2008. The triple aim: Care, health, and cost. Health Affairs 27(3): 759–769. Available at: http://dx.doi.org/10.1377/hlthaff.27.3.759 Calabresi, G., and P. Bobbitt. 1978. Tragic choices. New York, NY: W. W. Norton and Company. Daniels, N. 2001. Justice, health, and healthcare. American Journal of Bioethics 1(2): 2–16. Available at: http://dx.doi.org/10.1162/ 152651601300168834 Duke, A. 2013. Boston Marathon bombing heroes: Running to help. CNN US. Available at: http://www.cnn.com/2013/04/16/ us/boston-heroes/ Eddy, D. M. 1991. What care is ‘essential’? What services are ‘basic’? Journal of the American Medical Association 265: 786–788. Eddy, D. M. 2011. The origins of evidence-based medicine—A personal perspective. Virtual Mentor: American Medical Association Journal of Ethics 13(1): 55–60. Available at: http://dx.doi.org/ 10.1001/virtualmentor.2011.13.1.mhst1-1101 Eligon, J., and M. Cooper. 2013. Blasts at Boston Marathon kill 3 and injure 100. New York Times. Available at: http://www. nytimes.com /2013/04/16 /us/ explosions-reported-at-site-of-bos ton-marathon.html?pagewantedDall&smidDnytcore-ipad-share& smprodDnytcore-ipad&_rD0 (accessed November 7, 2014). Feinberg, J. 1974. Noncomparative justice. Philosophical Review 83 (30): 297–338. Available at: http://dx.doi.org/10.2307/2183696 Garrett, J. R. 2015. Collectivizing rescue obligations in bioethics. American Journal of Bioethics 15(2): 3–11. Goldberg, E. 2013. Natalie Stavas, Boston doctor, ran marathon on broken foot and then helped bombing victims. Huffington Post. Available at: http://www.huffingtonpost.com/2013/04/22/ natalie-stavas-saved-marathon-victims_n_3133896.html (accessed November 7, 2014). Hadorn, D. C. 1991. Setting health care priorities in Oregon: Costeffectiveness meets the rule of rescue. Journal of the American Medical Association 265(782): 2216–2225.

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Seeking Context for the Duty to Rescue: Contractualism and Trust in Research Institutions Karen M. Meagher, Presidential Commission for the Study of Bioethical Issues, U.S. Department of Health and Human Services Garrett’s (2015) “collective approach” offers a helpful redirect of contemporary research ethics discourse regarding research results. In response, I provide a brief sketch of the research terrain and then offer two points for further consideration.

To cover areas of general agreement, there are some cases in which research results bear on a participant’s wellbeing, and disclosure seems to be the best course of action (Illes et al. 2008). However, general handling of research findings is far more complex than the intuitive appeal of

This commentary is not subject to U.S. Copyright Law. Address correspondence to Karen M. Meagher, U.S. Department of Health & Human Services, Presidential Commission for the Study of Bioethical Issues, 1425 New York Avenue NW, Suite C-100, Washington, DC 20005, USA. E-mail: [email protected]

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February, Volume 15, Number 2, 2015

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Rethinking rescue medicine.

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