Tuesday, March 20, 2018

Cost-Benefit Analysis And Informed Consent Both Seem Neutral But They're Totally Different

Because I'm interested in value pluralism, I spend a certain amount of time thinking about two seeming alternative approaches to complex ethical situations, namely efficiency and informed consent.

As I see it, in contexts of value pluralism, making ethically complex decisions often requires making trade offs among values and figuring out what to do in cases of moral conflict. For example, we might value autonomy, benevolence, justice, honesty, and fidelity -- and these might recommend different actions in different circumstances. If you have to lie to keep a secret that you've promised to keep, honesty might entail telling the truth, while fidelity and keeping commitments might entail lying. We might make different judgments about which value matters more in a given case, and those decisions might be highly context-sensitive. Crucially, those judgments require judgment: someone has to make a decision about what they think matters and why.

One of the knocks on this kind of pluralism is that because it relies on ethical judgments, it is arbitrary and subjective. Someone has to make a moral judgment. How? And based on what? If you want to see why I think that these criticisms are misplaced, you can read my book. The point of this post has to do with the potential alternatives. Very broadly speaking, two alternative ways to approach decision-making are through cost-benefit-analysis and informed consent. Those aren't ethical theories, but they are informal descriptions of methods people use. What's interesting to me is that while these are often simultaneously treated as impartial, objective, and commonsensical, they're also really deeply different.

As everyone probably knows, cost-benefit analysis means adding up the costs and benefits and generally choosing the action that maximizes the benefits at the least cost. Costs and benefits can refer to money, or they can refer very generally to well-being and preference satisfaction, or to something else. If you're trying to decide where to build a new road, you might add up the costs and benefits and see which proposal looks best.

Informed consent may be most familiar to us from medical ethics, but it is in play in any system in which rights and voluntary exchange are seen as the relevant ethical components. When we round up people for testing a new medical treatment, we don't use cost-benefit analysis and then choose the best people and make them do it; we recruit people and ask them to give their informed consent. Presumably, that's because we think people have a right to control what happens to an in their bodies.

These two ways of approaching issues are really different. One focuses on what's best for the group, and doesn't pay much attention to individual rights. The other focuses entirely on individual rights, and doesn't pay much attention to what's best for the group.

In regular life, I expect most of us shift smoothly from one to the other as seems appropriate. If you're thinking about the social norms around deciding whether or not to have sex, it would be strange to use cost-benefit analysis. What if person A really really wanted it and person B mostly didn't? Could CBA could yield the conclusion that B had to go along with it? Typically, we use the autonomy-decision-consent framework there. If you're thinking institutionally, though, about questions like where and how a university should build new gym or dorm space, then cost benefit analysis may be just what you want. Would you really want to give each person a veto?

How do we know when to use the one and when to use the other? It's complicated, but roughly something like this: some areas of life concern basic rights and you have to use the autonomy/consent framework; others involve presumed cooperation and you expect to use the CBA framework. When? It's based on institutional structures and also background judgment.

Sometimes, we use a mix of the two approaches. This CBC story describes a situation where a provincial government is deciding to close a small town because it is too expensive to supply the town with resources. The way the system works, communities must volunteer to close and in a vote, at least 90 per cent of residents must be in favour of relocating; then if they do relocate, each resident receives between $250,000 and $270,000 to move to another town.

It's not CBA, since there's a consent requirement. It's not the consent-autonomy framework, because you might be in that 10 percent who doesn't want to move; also, I'm guessing CBA of some kind was used in arriving at the dollar range specified. It's a mix. Where did that "90 percent" come from? I imagine it's a number that seemed about right to someone, based on all the factors involved. It's a judgment.

So: if we use our judgment in deciding when to use the various frameworks, and if sometimes we use a mix of the two approaches that incorporates some group thinking and some individual thinking ... well, doesn't that mean we're always using the same kind of judgment calls that value pluralism makes use of?

These two ways of looking at things might seem objective or neutral, but the fact that they're so different ethically shows they're not really objective or neutral. They're value systems. That is not bad -- it's good! But as long as you're using a value system anyway .. why not use one that reflects the full multiplicity of values and represents accurately the complexity of ethical decisions? It sometimes seems uncomfortable for decision-processes to rely on judgment and values, because then we have to ask, "Whose judgment and values"? But I think any way of making complex choices relies on judgment and values. So that question is, in some sense, always with us, even when we can't see it clearly. 

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