As Few As Possible

All of eco­nomics, ev­ery last bit of it, is about scarcity. About what is scarce and what is not, and about who does and who doesn’t get their needs (and some­times wants) satis­fied.

Much of the de­bate about health­care is in fact a scarcity prob­lem. There aren’t enough prac­ti­tion­ers in prac­tice to han­dle ev­ery pa­tient, so some peo­ple don’t get doc­tors. It’s a com­bi­na­tion of self-se­lec­tion where peo­ple who can’t af­ford to take time off to have an in­grown toe­nail treated pro­fes­sion­ally hack at it with a pock­etknife in­stead, and in­surance se­lec­tion where granny’s in­surance will pay for hos­pice but not a new hip, and ac­tual med­i­cal dis­cre­tion now and then.

But this is about what med­i­cal care does right. Triage.

In times of very acute scarcity when many peo­ple are in­jured and need med­i­cal at­ten­tion to sur­vive, but few doc­tors are available to treat them, medicine does triage. The de­tails can be com­plex, but one of the fea­tures of triage is that if doc­tors are too scarce to save ev­ery­one, they pri­ori­tize sav­ing *as many peo­ple as pos­si­ble*, even though that of­ten means giv­ing spe­cific peo­ple no treat­ment at all. The scarcity is dis­tributed so that *as few peo­ple as pos­si­ble* suffer from scarcity.

This is not about mass trauma triage.

Imag­ine for a mo­ment how ut­terly ab­surd it would be if there was an earth­quake, but there were enough doc­tors to si­mul­ta­neously treat ev­ery­one in­jured in it, but they in­sisted on fol­low­ing triage pro­to­cols and the very worst in­jured were given black tags in­di­cat­ing “do not treat”, even as sur­geons who could save them sat idle, be­cause ev­ery­one else was be­ing treated. No civ­i­lized per­son would defend that kind of thing.

But this is not about hy­po­thet­i­cal earth­quakes with plenty of doc­tors.

The world pro­duces sig­nifi­cantly more food than needed to feed ev­ery­one. Quite a few peo­ple ac­tu­ally are an­gry that much of it is de­stroyed even though many peo­ple starve for lack of food. Many agree that is un­ac­cept­able that, even though there is enough to go around, not enough goes around.

This is not about hunger or food waste, or stores throw­ing bleach in the dump­sters to keep peo­ple from eat­ing stale crack­ers.

This is about scarcity, and who gets it.

By it’s very na­ture as a lack of enough, if scarcity ex­ists then some­one must get it; there’s no ac­count­ing trick to pay Tues­day if there is no ham­burger to­day. Var­i­ous eco­nomic philoso­phies try to dis­tribute scarcity in var­i­ous ways. Some try to give the scarcity to the least pro­duc­tive, some try to split it as evenly as pos­si­ble, still oth­ers just ad­mit that the scarcity goes to the low­est sta­tus or losers at vi­o­lence. Var­i­ous im­ple­men­ta­tions of those philo­soph­i­cal prin­ci­ples han­dle those philoso­phies to vary­ing de­grees of faith­ful­ness and effec­tive­ness.

But this is not about eco­nomics. This is about one of the fun­da­men­tal de­ci­sions of moral­ity: who gets the scarcity?

There is only one an­swer I can pos­si­bly ac­cept:

As few peo­ple as pos­si­ble, and no more.

A nurse in a triage ward who has to mark the pa­tient who will not be treated should not be so sad at what they do as the one who or­ders that food be de­stroyed, lest some bar­gain hunters pilfer from the dump­ster in­stead of buy­ing from the com­mer­cial es­tab­lish­ment. The hy­po­thet­i­cal trol­ley con­trol­ler stand­ing as his hy­po­thet­i­cal lever and won­der­ing if he is a mur­derer would be aghast if he un­der­stood a zon­ing board’s de­ci­sion that causes dozens of non-hy­po­thet­i­cal to die of ex­po­sure so that a hand­ful of high-sta­tus peo­ple, the el­dest sons of the ones who got credit for in­dus­tri­al­iz­ing the land that was cred­ited to the win­ners of vi­o­lence.

Any poli­ti­cal or eco­nomic philos­o­phy or policy that ever wan­tonly de­stroys a scarce thing, or fails to pro­duce a scarce need that could have been pro­duced, is evil. Those who man­u­fac­ture scarcity for their own profit, to ac­cu­mu­late their own po­si­tional goods, have cre­ated a new hell. Not for them­selves, but for their vic­tims, and on Earth.

When there is not enough to go around, it doesn’t go all the way around. The an­swer is the same whether it be food, shelter, text­books, med­i­cal at­ten­tion, love, mosquito nets, or any­thing else that peo­ple need. Who should miss out?

As few as pos­si­ble.