A few years ago, a colleague was diagnosed with cancer. He was young, fit, and lived what many would consider an exemplary lifestyle: He was a vegetarian, a non-smoker, abstained from alcohol and other substances, and consistently maintained a positive, stress-free demeanor. He was well-liked, always smiling, and seemed to epitomize the qualities we associate with good health and well-being.
When he was diagnosed with cancer, it felt profoundly unjust. No one deserves cancer, but I thought he really didn’t deserve it. This personal experience brought into sharp focus the arbitrary nature of illness and suffering and led me to reflect on the broader concepts of fairness, moral luck, and the role these ideas play in our perceptions and treatment of patients.
Physicians as Moral Agents
As healthcare providers, we are trained to treat all patients equally, striving to uphold the ideals of healthcare equity and equality. We often assume the role of moral agents, dispensing care without judgment, believing ourselves noble in our impartiality. At least that is what we aspire to — or how we wish to be perceived.
This approach aligns closely with Immanuel Kant’s philosophy that one should act according to maxims that could be universally applied, ensuring consistent ethical standards across all cases. Kant argued that moral actions should be judged by the intentions behind them rather than by their outcomes, which could be influenced by factors beyond an individual’s control — what philosophers Thomas Nagel and Bernard Williams later termed “moral luck.”
As human beings, however, we inevitably harbor judgments about our patients and their circumstances. These judgments can subtly influence our medical decision-making, sometimes in ways that challenge our commitment to impartiality.
For example, consider two patients admitted to a trauma center. The first is a motorcyclist involved in a high-speed accident. He was not wearing a helmet and was driving recklessly in adverse weather conditions. The second is a pedestrian who was struck by that same motorcyclist while obeying all traffic signals.
While it is easy to attribute the motorcyclist’s injuries to his or her poor decisions, we may feel a deeper sense of compassion for the pedestrian, who appears to be a victim of sheer bad luck. This instinctive response reveals a tension between our professional obligation to treat all patients equally and our human inclination to judge individuals based on the perceived morality of their actions.
Healthcare, Moral Values, and Judgment
These biases, though often unconscious, can have significant implications for how we care for our patients. We may unconsciously categorize patients, assigning them to different mental “pigeonholes” based on their circumstances, lifestyle choices, or perceived moral worth.
For example, we might judge one group of patients as less likely to adhere to their treatment plans or be more skeptical of their reports of pain or suffering. These judgments, rooted in moral values and influenced by our own biases, can lead to disparities in care and undermine the very principles of equality and fairness that we strive to uphold.
Kant’s philosophy teaches us that moral worth is linked to rationality and that the only thing with intrinsic moral value is a “good will” — the intention to act according to moral duty, regardless of the consequences. Kant said an action has moral value only if it is done out of a sense of duty, not because of any inclination or potential outcomes, which could be subject to luck.
However, the concept of moral luck challenges this view by suggesting that our ability to make good decisions is itself a product of luck. This idea, developed by Nagel and Williams, posits that individuals can be morally judged based on factors beyond their control, such as their circumstances, upbringing, or even the outcomes of their actions.
This concept of moral luck complicates our understanding of morality and challenges the notion that we can consistently apply ethical standards in healthcare. If our moral worth is influenced by factors beyond our control, how can we fairly judge others or hold them accountable for their actions? Moreover, if our ability to make good decisions is itself a matter of luck, what does this mean for our professional responsibilities as healthcare providers?
The discussion of moral luck can be extended to the concept of “social determinants of health” (SDOH), which refers to the conditions in which people are born, grow, live, work, and age. These determinants include factors such as socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and access to healthcare.
SDOH significantly impact health outcomes, often in ways that individuals cannot control. For instance, a person born into poverty or living in a neighborhood with limited access to healthcare might experience poorer health outcomes, not because of any personal failings, but because of the circumstances of their birth — circumstances beyond their control.
Extrinsic and Intrinsic Moral Luck
Connecting moral luck to social determinants of health, one can argue that people’s health outcomes, much like their moral outcomes in the concept of moral luck, are often determined by factors beyond their control. Just as it seems unfair to morally judge someone for circumstances they cannot control, it also seems unjust to hold people accountable for health outcomes shaped by social determinants.
This connection underscores the ethical responsibility of society and healthcare providers to address these determinants, recognizing that health outcomes are not purely the result of personal choices but are heavily influenced by external factors that can be categorized as luck. This is “extrinsic moral luck.”
To understand patients’ lifestyle choices and adoption of healthy practices more deeply, we must consider “intrinsic moral luck.” Kant argued that morality is independent of luck. But circumstances and constitution contribute to the ability and inclination of a person to make choices that would seem to be in their best interest.
To illustrate the former (circumstantial), a person born in Germany in 1920 may have gone on to lead a life worthy of moral blame, but if raised elsewhere would have led a much different life. Regarding the latter (constitution), education, upbringing, and genetics all shape personality and the resulting rationality and morality.
This perspective can challenge one of the foundational principles of medical ethics: respect for autonomy. If morality itself is subject to luck, how can we reconcile this with the principle of respecting patient autonomy?
Healthcare professionals are obligated to respect patients’ rights to make informed decisions about their own bodies and treatment, even if those decisions might lead to negative outcomes. However, if patients’ abilities to make good decisions are influenced by factors beyond their control, such as their socioeconomic status, education level, or access to healthcare, how do we balance this respect for autonomy with our duty to ensure equitable care for all patients?
Moreover, the concept of moral luck also challenges our understanding of responsibility and accountability in healthcare, particularly in the context of medical errors. In healthcare, practitioners are often judged by the outcomes of their actions, even when those outcomes are influenced by factors beyond their control, such as a patient’s unknown allergy or an unpredictable reaction to treatment. This mirrors the idea of moral luck, where individuals are held responsible for outcomes influenced by luck, rather than solely by their actions or intentions.
For example, consider a healthcare provider who administers a treatment based on the best available evidence and the patient’s known medical history. If the patient experiences a severe adverse reaction, the provider might be judged harshly, even if they acted reasonably based on the information available at the time.
This judgment often does not account for the luck involved in whether an adverse outcome occurs. Thus, moral luck can complicate the fairness of holding healthcare providers accountable for outcomes that may be influenced by factors beyond their control.
This dilemma is further complicated by healthcare errors that frequently arise not just from individual actions but from systemic issues such as understaffing, inadequate resources, or flawed protocols. These systemic factors are often beyond the control of any single healthcare provider, yet the provider may still be held accountable, reflecting the role of moral luck in assigning blame or responsibility.
Adopting a Just Culture
In this context, the concept of moral luck highlights the importance of adopting a “just culture” in healthcare — one that focuses on understanding errors in context and addressing systemic issues rather than unfairly punishing individuals for outcomes influenced by factors beyond their control.
In a just culture, the focus is on learning from errors and improving systems to prevent future harm, recognizing that not all outcomes are within the provider’s control. This approach contrasts with a “blame culture,” where providers might be punished for bad outcomes without considering the external factors that contributed to those outcomes.
By acknowledging the role of moral luck, healthcare systems can promote a more balanced approach to accountability, ensuring that providers are not judged unfairly for outcomes influenced by factors beyond their control.
The connection between moral luck and social determinants of health also has implications for public health and healthcare policy. If health outcomes are influenced by factors beyond an individual’s control, such as their socioeconomic status or access to healthcare, then addressing these social determinants becomes an ethical imperative. By addressing these inequalities, healthcare providers and policymakers can help mitigate the effects of moral luck in health outcomes, promoting a more equitable and just healthcare system.
For example, initiatives aimed at improving access to healthcare, education, and social support for underserved populations can help reduce health disparities and improve outcomes for individuals who are otherwise disadvantaged by their circumstances. Similarly, efforts to address systemic issues within healthcare, such as ensuring adequate staffing, resources, and training for providers, can help reduce the likelihood of medical errors and improve the overall quality of care.
Toward a More Compassion Approach
The concept of moral luck challenges our traditional understanding of morality, responsibility, and accountability in healthcare. It forces us to confront the reality that many factors influencing health outcomes and medical decisions are beyond our control.
By recognizing the role of luck in both moral and health outcomes, we can promote a more compassionate, equitable approach to healthcare, one that acknowledges the complex interplay of factors that shape our lives and our decisions.
This perspective not only aligns with the principles of healthcare equity and justice, but also encourages a more humane and understanding approach to patient care and professional responsibility in the face of uncertainty.