As I write this blog post, scuba divers are in the middle of a rescue effort to save twelve young soccer players and their coach from a flooded cave in Thailand. Eight of the boys are out. Four players and the coach remain to be saved. The story has the world’s attention; it is terrifying, thrilling, heart-warming, and heart-breaking, all in turns. One diver has died in the rescue attempt. So many others have risked their lives. By the time you read this, you will know whether the remaining four players and their coach were rescued, and whether anyone else died in the rescue attempt, which is heroic by any standards.
The question I have not seen any asked, and it is almost obscene to do so, is this: “How much is all this costing and what else might we have done with the money?” The question itself sounds unbelievably and nearly inhumanly insensitive to even voice, but I am prompted to raise it by a passage I read yesterday in Hans Rosling’s very popular book, Factfulness: Ten Reasons We’re Wrong About the World—and Why Things are Better Than You Think (2018). The general point of the book is that there are lots of good developments in the world that most of us are not aware of. In general, poverty is being reduced, education is spreading to young women, life spans are lengthening, etc. Life on planet Earth is far from perfect, but it is improving.
I recommend the book not only because of the facts that Rosling shares, but also because of the stories he tells about the amazing life he has led as a physician and public health expert.
In the early 1980s, Rosling was in the Nacala district of Mozambique. The population he alone served would have been served by 50 doctors in Rosling’s native Sweden. The resources at his disposal were few. He admitted around 1,000 children to his hospital each year and approximately one per week died. Once he was visited by a friend who was a pediatrician. The friend accompanied Rosling on an emergency call at the hospital to treat a baby who was so weak with diarrhea that it could not breastfeed. Rosling admitted the child, inserted a feeding tube, and ordered that oral rehydration solution be delivered through the tube. The friend angrily confronted Rosling and accused him of providing substandard treatment by forgoing an intravenous drip. Rosling describes their exchange:
I became angry at his lack of understanding. “This is our standard treatment here,” I explained. “It would take me half an hour to get a drip running for this child and then there would be a high risk that the nurse would mess it up…”
My friend couldn’t accept it. He decided to stay at the hospital struggling for hours to get a needle into a tiny vein.
When my colleague finally joined me back at home, the debate continued. “You must do everything you can for every patient who presents at the hospital,” he urged.
“No, I said. “It is unethical to spend all my time and resources trying to save those who come here. I can save more children if I improve the services outside the hospital. I am responsible for all the child deaths in this district: the deaths I do not see just as much as the deaths in front of my eyes.”
My friend disagreed, as do most doctors and perhaps most members of the public. “Your obligation is to do everything for the patients in your care. Your claim that you can save more children elsewhere is just a cruel theoretical guess.”
This exchange caused Rosling to put the numbers to his theory. It turned out that only about 1.3% of the child deaths occurring in his district were happening in the hospital. The vast majority of children never made it to the hospital. So, Rosling continued to devote as much attention as he could to training health workers, to getting children vaccinated, and to setting up small health facilities around the district which would provide basic treatment to more children. Sometimes those efforts came at the expense of time he might spend on a seriously ill child in his hospital, just down the hall.
It felt almost inhuman to look away from an individual dying child in front of me and toward hundreds of anonymous dying children I could not see.
Paying too much attention to the individual visible victim rather than to the numbers can lead us to spend all our resources on a fraction of the problem, and therefore save many fewer lives….Doing so is often taken for heartlessness. Yet so long as resources are not infinite—and they never are infinite—it is the most compassionate thing to do to use your brain and work out how to do the most good with what you have.
It is possible that the resources used in Thailand to rescue the twelve trapped youths and their coach could, if they’d been poured into a public health program, have saved more than thirteen lives. It is also extremely unlikely that most humans, even presented with firm evidence that this was the case, could have made the call that Rosling did.
Our videos on the tangible and the abstract, both our Ethics Defined video and the longer Concepts Unwrapped video, make it clear that humans are typically much more strongly affected by factors that are tangible (in the here and now) than factors that are more abstract (farther away in time or location).
I am confident that even if presented with the strongest possible statistical evidence, I could never make the call: “Let’s leave the boys in the cave and instead take the $15 million the government has budgeted for their rescue and put it into a vaccination program.” But would my decision to pursue the rescue be the ethical choice? By honoring the tangible at the expense of the abstract, I might be costing more lives than I was saving.
“Chile’s Mine Rescue: Costs and Benefits,” PBS NewsHour, Oct. 14, 2010, available at https://www.pbs.org/newshour/world/cost-of-mine-rescue.
David Grossman, “Ex-DEAL Diver Dies in Thai Cave Rescue Attempt,” Popular Mechanics, July 6, 2018, available at https://www.popularmechanics.com/science/environment/a22072698/ex-seal-diver-dies-in-thai-cave-rescue-attempt/.
Euan McKirdy et al., “Thai Cave Rescue Operation Suspended After Four More Boys Freed,” July 9, 2018, available at https://www.cnn.com/2018/07/09/asia/thai-cave-rescue-intl/index.html.
Hans Rosling, Factfulness: Ten Reasons We’re Wrong About the World—and Why Things are Better Than You Think (2018).