Looking at the consequences is one of the ingredients of every medical calculation.

Every medical decision (including omission) is an action that must be justifiable in terms of an impact assessment.

The heart specialist, researcher and author Bernard Lown, who only died at the beginning of the year, set the standard: patients should feel a little better after every visit to the doctor.

Even if it is just a hint of mental calm.

Is medicine and its ethical challenges an Eldorado for consequentialists?

The impression arises after reading Annette Dufner's analysis on how to deal with scarce resources in medicine.

The general public has also become aware of the problems due to the threat of the health system being overwhelmed by the Covid 19 pandemic.

However, the triage in the distribution of ventilators is only dealt with as an appendix at Dufner.

The text was drafted with a view to an often overlooked distribution conflict that has existed for years, namely the allocation of donor organs in transplant medicine in view of long waiting lists.

But both areas of conflict have a lot in common.

Morals and math formulas

At the center of Dufner's argument is the justification of what is termed “moral aggregation”. In the event of a conflict, can the larger number of possible life-saving options be decisive? Is it permissible to weigh life against life? Is it morally justifiable to sacrifice one life in order to save two or more lives? Does aggregate well-being outweigh the larger number? Is there therefore the perspective of a good that is independent of individual persons and that is able to outperform the individual good?

Discussions about these questions very quickly wag the constitution: The dignity of the person forbids the offsetting of life in favor of others.

It is forgotten that medical aid conflicts are not about instrumentalizing people, but simply lacking resources.

In the case of transplant medicine, it cannot be increased with more money either.

Therefore, the judgment of the Federal Constitutional Court on the Aviation Act, which is often quoted in such debates, is not relevant, which Dufner rightly points out.

In it, the court forbade the shooting down of a hijacked airliner that had been hijacked and destroyed and perhaps killed a thousand times over, with a view to the ban on instrumentalization.

Ultimate reasons are not to be expected here

The search for a principle to resolve medical auxiliary conflicts makes up the main part of the text. Annette Dufner guides the reader in a kind of parforce ride through the current analytical literature on the consequentialist justification of norms. The apology of moral aggregation sought by Dufner requires extremely fine-grained justification if one wants to include not only the number of possible people to be rescued, but also the degree of benefit and the level of need in each case. In her argumentation, Dufner also takes into account aspects of decision theory. Its representatives often want to express the moral calculation in the form of mathematical formulas. But this only shifts the ethical challenge into the definition of the elements of the equations,or the ethical problem is thrown away completely. For, as Leszek Kolakowski rightly remarked, a value ceases to be such when it is explained causally.

Dufner's remarks, which are not kept free from the jargon of consequentialist milieus, lead to the formulation of a principle that she considers suitable for resolving auxiliary medical conflicts and which is provided with the abbreviation ARP: "Promote the aggregated good in conflict cases between relevant interests in a prioritarian way . "That means that the rescue of as many as possible should always be attempted, whereby their interests (emergencies) must be relevant and the most needy people are to be preferred.

Ultimate reasons are not to be expected here, Dufner describes ARP as a middle principle. Medical ethics is not reluctant to revert to these. Years ago Tom Beauchamp and James Childress presented their influential ethics, which require the observance of four central principles: respect for the autonomy of the patient, duty to avoid harm as well as to care and respect justice. It is not easy to see what profit ARP should have in comparison.

The ARP may not have caught a big fish, but the bycatch is remarkable. As Dufner's analysis in the second part of her book, devoted to the application of ARP, shows, when deciding on the allocation of limited resources - such as scarce space in intensive care units or never enough donor organs - it is inevitable in medicine, and to a limited extent also judgments about Quality of life. A fact that is not infrequently overlooked. Generally and rightly the principle applies that doctors should make decisions about the allocation of scarce medical resources irrespective of the person and should therefore refrain from making a judgment about the quality of life of those affected whenever possible. Dufner does not want to abolish the principle, it only refers to its limits.

Annette Dufner: “Which lives should one save?” An ethic for medical aid conflicts.

Suhrkamp Verlag, Berlin 2021. 261 pp., Br., € 24.