Who Do We Treat First When Resources Are Scarce?

An opinion on Tom Walker’s Who Do We Treat First When Resources Are Scarce?

In this paper, Tom Walker explains that healthcare resources are limited, and difficult decisions must be made about who should receive treatment first. A common intuition suggests that we should prioritize those whose illnesses are not self-inflicted. However, Walker argues that if resources are sufficient, everyone should receive care, and his aim is to construct a principle for determining priority when resources are scarce. Initially, he presents a principle stating that if two people require the same resource, but only one is ill due to their own choices—assuming they had reasonable knowledge of the risks and did not take steps to mitigate them—then the other person should be treated first.

However, this principle raises several ethical concerns. It does not account for whether the choice was truly voluntary, whether the individual had full autonomy, or whether they were in a position to fully understand the risks. Walker attempts to refine this principle by introducing the requirement that the person could have reasonably foreseen the consequences of their actions. Yet, even this revision does not fully resolve the issue, as it does not consider whether the individual had viable alternatives. Walker does present a final principle that further specifies that the person must have had reasonable alternatives and could have recognized a safer course of action. Even so, the principle remains problematic in its application. For example, firefighters who knowingly risk their lives in the line of duty could be deprioritized under such a framework, despite the fact that their actions are widely recognized as selfless and honorable. This suggests that the criteria for determining responsibility in healthcare decisions are far more complex than a simple distinction between voluntary and involuntary harm.

Fundamentally, I disagree with any framework that attempts to base medical treatment on judgments about whether a person’s illness is self-inflicted. First, from a practical standpoint, it is exceedingly difficult to determine the degree to which an individual is responsible for their condition. Many diseases and injuries involve complex interactions of genetic, environmental, and social factors, making personal responsibility a murky and often unfair criterion. Second, such a principle risks introducing moral judgments into medical practice, which could lead to a culture of blame and punishment—precisely the opposite of the compassionate, impartial care that medicine should provide. Biases, both conscious and unconscious, could further distort these decisions, leading to inequitable treatment. Moreover, mental health considerations must not be overlooked: many supposedly “self-inflicted” conditions, such as substance use disorders or complications from risky behaviors, are often driven by psychological, social, and economic factors that diminish true autonomy. A system that denies care based on perceived responsibility risks deepening existing disparities and further marginalizing vulnerable populations.

Ultimately, while Walker’s attempt to establish a rational framework is understandable, it fails to account for the deeper moral imperative of medicine: to care for all people with dignity, irrespective of the circumstances that led to their suffering. In triage situations, the primary considerations should be medical urgency and the ability to benefit from treatment, not subjective judgments of merit. If two patients are equally in need, choosing the one closest or using random selection ensures fairness while upholding the fundamental principle that all human lives are of equal worth. Healthcare should not be seen as a privilege reserved for those deemed "deserving" based on past choices but as a basic human right, reflective of the intrinsic dignity of every individual.

So God created mankind in his own image,
   in the image of God he created them;
   male and female he created them.

— Genesis 1:27 (NIV)