Empathy ethics: How to get a lung for your child

By Julian Savulescu & Brian D. Earp

[updated version – as of 17 April 2016]

Sarah Murnaghan is a 10-year-old from Pennsylvania. Suffering from cystic fibrosis, she was likely to die without a lung transplant. Her situation was deteriorating. But because of a rule that says that children under the age of 12 have the lowest priority for adult donor lungs, Sarah would have to wait for another child’s lungs to become available, a much rarer occurrence.

Sarah’s parents sprang into action. They got the attention of members of congress and the media. They shared Sarah’s story on social networking sites, showing pictures of their daughter in the hospital bed. They said that the “Under 12” rule was discriminatory against children, and got a federal judge to agree. So, with the help of a court order temporarily preventing the enforcement of the Under 12 rule, Sarah got a second chance at life. An adult lung match became available, and Sarah is now recovering from transplant surgery.

It’s a story with a happy ending—depending upon how you tell it. Certainly the news is good for Sarah. Yet as Sarah’s mother acknowledged in a post on Facebook, “We … know our good news is another family’s tragedy.”

But who are those families? What are their stories? What are the names of those who will die—or who have already died—without a lung transplant of their own?

What this case illustrates is something we might call “empathy ethics” – pushing one’s own story, or that of one’s family member, into the moral spotlight in order to trigger an empathic response. Since ordinary human beings—from news anchors to congressmen to federal judges—are more likely to feel empathy for known individuals with compelling narratives of suffering, they can become motivated to bend the rules in favor of those specific individuals whose stories best capture their attention.

The basic psychology involved is well-known. As Peter Singer famously argued with his case about a child drowning in a pond, no decent person could fail to rescue someone who was close at hand—whose need was evident, and whose suffering could be relieved by a minimum of well-directed effort. But we’re much less likely to take actions that could save the life of a child far away, even if the cost of doing so would be minimal—such as by donating a small amount of money to an effective charity—because that child’s suffering is not as salient to our emotions. We didn’t evolve in an environment in which our actions could bring benefit over long distances (or stretches of time) and so our intrinsic moral motivations are constricted. By the same token, anonymous people pull at our heartstrings much less powerfully than do named individuals.

(In fact, one way that charities have learned to increase donations from the public is to accompany their requests with photographs of specific children who are suffering from, e.g., malnutrition. This is different from empathy ethics, however, in that it’s not done to advantage any particular child, but rather all of the children who might be helped by an increase in charitable donations.)

But is there anything wrong with engaging in empathy ethics? Wouldn’t anyone with a dying loved one want to shout that person’s story from the rooftops, doing anything they could to secure help? And aren’t the friends and parents of those “anonymous” people just as free to harness public empathy to their side?

The ethics of this kind of approach comes down to a couple of key factors. First, there is nothing wrong per se with reaching out to the news media, or to congress, or to Facebook and Twitter to bring attention to the suffering of someone you love. And if some injustice—some discriminatory rule—is standing between your child and a life-saving operation, then to fail to challenge this rule would be condemnable. But what if the rule is fair? The problem with empathy ethics, when all is said and done, is that it unfairly disadvantages someone else who is equally in need. The problem is with zero-sum games.

As Kathleen Sebelius, the U.S. Secretary for Health and Human Services, stated at a congressional hearing on the Under 12 rule: “Unfortunately there are about 40 very seriously ill Pennsylvanians over the age of 12 also waiting for a lung transplant.” If an adult set of lungs goes to a 10-year old child, then it can’t go to an older patient who would have been a more secure match.

Of course, it may be that the Under 12 rule places too much weight on maximizing prognosis. It may be also be too arbitrary, needlessly precluding case-by-case analysis. And, as Sarah’s parents argued in court, the rule may indeed be unfair to children. This sort of debate needs to happen. If the rule does turn out to be faulty, however, it needs to be replaced with a fair procedure that will determine who will live and who will die—no special pleading. There are, sadly, not enough organs to keep everyone alive. A fair procedure will mitigate the force of empathy ethics—allocation according to attention, priority to the emotionally endearing or the better-known.

Another problem with empathy ethics is that it doesn’t cure the underlying disease—in this case, the basic shortage of organs. We consistently fail to fix this problem because we don’t personally see the people in need actually dying before our noses. So we choose to burn or bury our life-saving organs (after our own or our children’s death) because it is too painful, too time consuming, or too bothersome to think about the suffering of anonymous people—even as they gasp for breath, or slowly turn blue and then black.

Unless we see them on the TV.

If it weren’t for our profound moral and psychological limitations—the ones that generate as well as react to the deceptive allure of empathy ethics—there would be no need for a fair allocation procedure. For this reason, we need ethical policy. People should donate their organs. Burying them in the ground or burning them up—when they could save a person’s life—is not only unconscionable, it is as good as murder.