by J.S. Blumenthal-Barby, Ph.D.
Partiality is a common phenomenon. We are partial to our significant others, children, friends, employers, colleagues, neighbors, fellow citizens, etc. In the health care setting, clinicians are partial to their patients (as opposed to non-patients or others’ patients), and even to certain patients (as opposed to other ones). This partiality can manifest itself in a variety of ways. Clinicians may order tests or procedures that their patients would benefit from or desire as opposed to being centrally concerned with stewardship of health care goods and costs. They may prioritize a particular patient for a scarce resource such as an organ (or an experimental drug…). Or, they may provide a particular patient with special treatment regarding discounts on hospital bills, flexible scheduling, extra time, etc.
Is such partiality justified, and if so, why?
Philosopher Simon Keller develops an answer to this question in his recently published book, Partiality. Keller aims to “present a theory of the reasons supporting special treatment within special relationships and explores the vexing problem of how we might reconcile the moral value of these relationships with competing claims of impartial morality.”
Keller’s presents three different accounts of partiality: the projects view, the relationships view, and the individuals view (Keller argues in favor of the individuals view).
The Projects View: On the projects view, reasons of partiality are explained by facts about you. Specifically, your (in the words of Bernard Williams) “ground projects.” Each of us has projects that are essential parts of ourselves, and those projects give us special reasons for various things, including reasons of partiality (prioritizing some people or things over others). Clinicians may view caring for her patients, or even caring for a particular patient, as a ground project, giving rise to reasons of partiality.
The Relationships View: On the relationships view, relationships hold a special kind of value, and reasons (and perhaps even duties) of partiality derive from that value. The fact that I have a relationship with someone can on its own give me a reason for giving that person special treatment (either because relationships are valuable, or simply because it [the relationship] is a fundamental [reason-giving] fact).
The Individuals View: On the individuals view, reasons of partiality are explained by the value of the individuals with whom we have a special relationship. Other individuals might have the same (or more) value, but the fact that we have a relationship with that particular person allows us to “see” it more in them. Moreover, your partiality (as their loved one, etc.) is good for them—it is a “special good.” And, “In seeing that it would be valuable for a person to receive special goods, we can see why the person’s value generates reasons for some other people, but not all other people, to act.” (107).
As Keller succinctly puts it, imagine two houses on fire side by side, one of which contains two strangers and one of which contains your parents. There is only time to intervene and save one. When pressed why you believe it is ethically justified to choose your parents, the Projects View would say “Because they are MY parents,” the Relationships View would say, “Because they are my PARENTS,” and the individuals view would say because they are MIKE AND JEAN.”
Which account provides us with the best justification for partiality, in life, and in medicine?
Perhaps the go to answer in medicine would be the Relationships View, since so much emphasis is put on the moral importance of the physician-patient relationship, but as Keller argues, the Relationships View gets something phenomenologically wrong. He returns to Bernard Williams’ famous example of the drowning wife and asks us to imagine that the husband justifies saving her over another drowning person by exclaiming, “That’s my MARRIAGE.” There would be something odd about this response.
Perhaps, as Keller argues, the Individuals View has the advantage of providing an account of reasons of partiality that is also in line with the phenomenology of partiality. Partiality towards particular patients lies in the value of those patients—value that becomes apparent to clinicians as they enter into the world of the patient and begin to care for him or her. And that partiality is further driven by the fact that this patient begins to need his/her clinician to be partial to him/her (in the same way that I need my significant other to be partial to me); an important good that only this particular clinician can provide.