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23. Overpopulation and the Ethics of Triage

XXIII. If I donate to UNICEF, I'll just help create a situation, in the further future, when there'll be disastrously more children painfully dying. So, it's actually better to throw away the envelope. At the very least, it's not wrong.

When thinking about cases like the Envelope, many often have some thought of the disastrous further future: "If I help prevent some of these young children from dying soon, then, years from now, they'll produce yet more children, worsening the population explosion that, more than anywhere else, goes on precisely where there are so many imperilled children.

But is this just another excuse not to give or is there substance to this concern? Doesn't it require us to know much, much more about population explosion, overpopulation, population control, and so on, to begin to even think about this concern fully? And if it were true, that saving thirty children from dying now will only make for more pressure on the population of the planet, albeit quite miniscule, is this a way of distinguishing between the two cases, between John's saving the child from drowning and my sending money to UNICEF?

Say John notices (he has a very keen eye) that the child who has fallen into the shallow pond is from Bangladesh. Say he knows this because a couple and their five children from the porest regions of Bangladesh are visiting Brandeis to talk with students about the food crisis there. They plan to return shortly top their country and the region from which they have come. UNICEF has made arrangements for them to visit so that students might have the opportunity to speak directly to a family that is experiencing the hardships talked about in the Final Paper Topic in the Human Rights class as part of a newly sponsored UNICEF Program: "Operation Wake-Up." Imagine, too, that John is one of those persons in the Human Rights class who has expressed concern about the long-term consequences of saving children through UNICEF's ORT Project on the future population of countries like Bangladesh.

So there's John at the edge of the pond in his brand new Gucci shoes and he's overcome his worry about the damage his shoes will suffer if he comes to this child's aid. But now just as he's about to wade into the pond and pull the child to safety, the following thoughts flood his mind: "If I save this child from drowning, her parents will take her back to Bangladesh and she'll probably grow up to be a very attractive person and give birth to many little Bangladeshi's. But if I do not save her from drowning and head straight for the Human Rights class to the hospital, then, she won't be able to contribute to any further population explosion further down the road and to a disastrous dying of Bangladeshi's many years hence. So a quick calculation of the future effects upon world population of my being a Good Samaritan in this particular instance, it's best for all concerned that get myself to the Human Rights class and leave this child to drown. In any event, if someone were to ask me what I did, I shall at least be able to say I did what was best in the long run, and if anyone has any difficulty accepting that analysis, I won't have behaved badly."

If John were to act in this way with the accompanying rationale above for his having acted as he did, would you think anymore leniently of his behavior than your judgment of his behavior in the "original" case of the Shallow Pond?

Does this variant of the Shallow Pond case suggest that the effects of sending money to UNICEF on the world population or future generations are not morally relevant? What do yout think? Since Garret Hardin in the reading for the Human Rights class makes a case for population control through famine and starvation, what is the evidence on the other side? Some believe and argue that, contrary to Hardin, the available evidence strongly supports the thought that decreasing childhood mortality stabilizes population. To be sure, the increasingly widespread availability of modern contraceptives is partly responsible for the recent big decreases in how fast the world's population is growing, as many studies show. If you are concerned about population control, this is one reason, even if perhaps not the most important reason, to support the International Planned Parenthood Federation, or IPPF. With maternal mortality still standing at about 500,000 women a year, IPPF is also cutting down the number and, so, lessening the number of children, still in the millions, who each year become motherless, although if you are concerned with over-population this may make support of the IPPF more complicated for you. Also in IPPF clinics, many in the developing countries receive the basic health care they need. Perhaps the greatest of all IPPF affiliates, Colombia's PROFAMILIA supports some clinics for men only. Owing to that, the terribly macho attitudes of many Colombian men have become much less macho, a big benefit to many Colombian women. At all events, in Colombia there's occurring a population success story. The IPPF's most relevant address is:

International Planned Parenthood Federation
International Planned Parenthood Federation
Western Hemisphere Region, Inc.
902 Broadway - 10th Floor
New York, NY 10010

IPPF Affiliate Organizations and Programs:

Danish Family Planning Association

Family Planning Association of India

Federation of Family Planning Associations of Malaysia (FFPAM)

FFPAM Youth Centre

Fundación Mexicana para la Planificación Familiar (MEXFAM)

IPPF Western Hemisphere Regional Office, New York

Latvian Family Planning and Sexual Health Association

Ottawa Family Planning Association

Planned Parenthood Association of Edmonton

Planned Parenthood Association of South Africa (PPASA)

Planned Parenthood Federation of America

Planned Parenthood Federation of Canada (PPFC)

Pro Familia: German Association for Family Planning, Sex Education and Sexual Counselling

RFSU Sweden

Rutgers Stichting (Netherlands)

Türkiye Aile Planlamasi Dernegi (FPAT)

Vaestoliitto: Family Federation of Finland

Association of Reproductive Health Professionals (ARHP)

Alan Guttmacher Institute

AVSC International

Demographic and Health Surveys

Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ)

Earth Times newspaper

Family Care International

Family Health International

German Foundation for World Population (Deutsche Stiftung Weltbevoelkerung)

Global Reproductive Health Forum at Harvard


JHPIEGO Corporation

Johns Hopkins University Center for Communication Programs

Johns Hopkins University Population Center

JOICFP (Japanese Organization for International Cooperation in Family Planning)

Management Sciences for Health

Margaret Sanger Papers Project

Marie Stopes International

Pathfinder International

Population Action International

Population Communications International

Population Council

Population Institute

Population Reference Bureau

Path (Program for Appropriate Technology in Health)

Program for International Training in Health (INTRAH)

ReproLine: Reproductive Health Online (maintained by JHPIEGO Corp.)

World Population Federation (WPF)

UNAIDS: The Joint United Nations Programme on HIV/AIDS

United Nations

United Nations Children's Fund (UNICEF)

United Nations Development Programme

United Nations Office in Geneva

United Nations Population Fund

United Nations Population Information Network (POPIN)

World Bank

World Health Organization

Canadian International Development Agency (CIDA)

United Kingdom Department for International Development (DfID)

United States Agency for International Development (USAID)

Still, for population to stabilize, much more is needed than what the IPPF is able to provide. What's also needed can be seen from many perspectives. Take the Indian state of Kerala, highlighted in the film "The Politics of Food," for an example: Since the Total Fertility Rate's already down to 1.9, or even lower, population won't just stabilize there; it will decline. Beyond widespread availability of contraceptive means, there are other reasons that fully 80% of Keralan couples actually use family planning measures: Because they know the childhood mortality rate there is very low, Keralans can be confident that, without having many kids, they'll have some surviving children. And, since they know the community will make sure their basic needs are met, Keralans know that, even without children to rely on, their life expectancy is high. And, since the female literacy rate is very high, marking much respect for women's interests, it's no surprise that in Kerala there's a population success story. (Adapted from Unger)

Here is Peter Singer's on "Population and the Ethics of Triage":

"Perhaps the most serious objection to the argument that we have an obligation to assist is that since the major cause of absolute poverty is overpopulation, helping those now in poverty will only ensure that yet more people are bom to live in poverty in the future. In its most extreme form, this objection is taken to show that we should adopt a policy of 'triage'. The term comes from medical policies adopted in wartime. With too few doctors to cope with all the casualties, the wounded were divided into three categories: those who would probably survive without medical assistance, those who might survive if they received assistance, but otherwise probably would not, and those who even with medical assistance probably would not survive. Only those in the middle category were given medical assistance. The idea, of course, was to use limited medical resources as effectively as possible. For those in the first category, medical treatment was not strictly necessary; for those in the third category, it was likely to be useless.

"It has been suggested that we should apply the same policies to countries, according to their prospects of becoming self-sustaining. We would not aid countries that even without our help will soon be able to feed their populations. We would not aid countries that, even with our help, will not be able to limit their population to a level they can feed. We would aid those countries where our help might make the difference between success and failure in bringing food and population into balance. Advocates of this theory are understandably reluctant to give a complete list of the countries they would place into the 'hopeless' category; Bangladesh has been cited as an example, and so have some of the countries of the Sahel region of Africa.

"Adopting the policy of triage would, then, mean cutting off assistance to these countries and allowing famine, disease, and natural disasters to reduce the population of those countries to the level at which they can provide adequately for all. In support of this view Garrett Hardin has offered a metaphor: we in the rich nations are like the occupants of a crowded lifeboat adrift in a sea full of drowning people. If we try to save the drowning by bringing them aboard, our boat will be overloaded and we shall all drown. Since it is better that some survive than none, we should leave the others to drown. in the world today, according to Hardin, 'lifeboat ethics' apply. The rich should leave the poor to starve, for otherwise the poor will drag the rich down with them.

"Against this view, some writers have argued that overpopulation is a myth. The world produces ample food to feed its population, and could, according to some estimates, feed ten times as many. People are hungry not because there are too many but because of inequitable land distribution, the manipulation of third world economies by the developed nations, wastage of food in the West, and so on.

"Putting aside the controversial issue of the extent to which food production might one day be increased, it is true, as we have already seen, that the world now produces enough to feed its inhabitants-the amount lost by being fed to animals itself being enough to meet existing grain shortages. Nevertheless population growth cannot be ignored. Bangladesh could, with land reform and using better techniques, feed its present population of 115 million; but by the year 2000, according to the United Nations Population Division estimates, its population will be 150 million. The enormous effort that will have to go into feeding an extra 35 million people, all added to the population within a decade, means that Bangladesh must develop at full speed to stay where it is. Other low-income countries are in similar situations. By the end of the century, Ethiopia's population is expected to rise from 49 to 66 million; Somalia's from 7 to 9 million, India's from 853 to 1041 million, Zaire's from 35 to 49 million. What will happen if the world population continues to grow? It cannot do so indefinitely.

"It will be checked by a decline in birth rates or a rise in death rates. Those who advocate triage are proposing that we allow the population growth of some countries to be checked by a rise in death rates that is, by increased malnutrition, and related diseases;,by widespread famines; by increased infant mortality; and by epidemics of infectious diseases. The consequences of triage on this scale are so horrible that we are inclined to reject it without further argument. How could we sit by our television sets, watching million starve while we do nothing? Would not that be the end of all notions of human equality and respect for human life? ... Don't people have a right to our assistance, irrespective of the consequences?

"Anyone whose ,~initial reaction to triage was not one of repugnance would be an unpleasant sort of person. Yet initial reactions based on strong feelings are not always reliable guides. Advocates of triage are rightly concerned with the long-term consequences of our actions. They say that helping the poor and starving now merely ensures more poor and starving in the future. When our capacity to help is finally unable to cope - as one day it must be - the suffering will be greater than it would be if we stopped helping now.

"If this is correct, there is nothing we can do to prevent absolute starvation and poverty, in the long run, and so we have no obligation to assist. Nor does it seem reasonable to hold that under these circumstances people have a right to our assistance. If we do accept such a right, irrespective of the consequences, we are saying that, in Hardin's metaphor, we should continue to haul the drowning into our lifeboat until the boat sinks and we all drown. If triage is to be rejected it must be tackled on its own ground, within the framework ,of consequentialist ethics. Here it is vulnerable. Any consequentialist ethics must take probability of outcome into account. A course of action that will certainly produce some benefit is to be preferred to an alternative course that may lead to a slightly larger benefit, but is equally likely to result in no benefit at all. Only if the greater magnitude of the uncertain benefit outweighs its uncertainty should we choose it. Better one certain unit of benefit than a 10 per cent chance of five units; but better a 50 per cent chance of three units than a single certain unit. The same principle applies when we are trying to avoid evils.

"The policy of triage involves a certain, very great evil: population control by famine and disease. Tens of millions would die slowly. Hundreds of millions would continue to live in absolute poverty, at the very margin of existence. Against this prospect, advocates of the policy place a possible evil that is greater still: the same process of famine and disease, taking place in, say, fifty years' time, when the world's population may be three times its present level, and the number who will die from famine, or struggle on in absolute poverty, will be that much greater. The question is: how probable is this forecast that continued assistance now will lead to greater disasters in the future? Forecasts of population growth are notoriously fallible, and theories about the factors that affect it remain speculative.

"One theory, at least as plausible as any other, is that countries pass through a 'demographic transition' as their standard of living rises. When people are very poor and have no access to modern medicine their fertility is high, but population is kept in check by high death rates. The introduction of sanitation, modern medical techniques, and other improvements reduces the death rate, but initially has little effect on the birth rate. Then population grows rapidly. Some poor countries, especially in sub-Saharan Africa, are now in this phase. If standards of living continue to rise, however, couples begin to realise that to have the same number of children surviving to maturity as in the past, they do not need to give birth to as many children as their parents did. The need for children to provide economic support in old age diminishes. Improved education and the emancipation and employment of women also reduce the birth-rate, and so population growth begins to level off. Most rich nations have reached this stage, and their populations are growing only very slowly, if at all.

"If this theory is right, there is an alternative to the disasters accepted as inevitable by supporters of triage. We can assist poor countries to raise the living standards of the poorest members of their population. We can encourage governments of these countries to enact land reform measures, improve education, and liberate women from a purely child-bearing role. We can also help other countries to make contraception and sterilisation widely available. There is a fair chance that these measures will hasten the onset of the demographic transition and bring population growth down to a manageable level.

"According to United Nations estimates, in 1965 the average woman in the third world gave birth to six children, and only 8 per cent were using some form of contraception; by 1991 the average number of children had dropped to just below four, and more than half the women in the third world were taking contraceptive measures. Notable successes in encouraging the use of contraception had occurred in Thailand, Indonesia, Mexico, Colombia, Brazil, and Bangladesh. This achievement reflected a relatively low expenditure in developing countries - considering the size and significance of the problem - of $3 billion annually, with only 20 per cent of this sum coming from developed nations. So expenditure in this area seems likely to be highly cost- effective. Success cannot be guaranteed; but the evidence suggests that we can reduce population growth by improving economic security and education, and making contraceptives amorc widely. available.

"This prospect makes triage ethically unacceptable. We cannot allow millions to die from starvation and disease when there is a reasonable probability that population can be brought under control without such horrors. Population growth is therefore not a reason against giving overseas aid, although it should make us think about the kind of aid to give. Instead of food handouts, it may be better to give aid that leads to a slowing of population growth. This may mean agricultural assistance for the rural poor, or assistance with education, or the provision of contraceptive services. Whatever kind of aid proves most effective in specific circumstances, the obligation to assist is not reduced.

"One awkward question remains. What should we do about a poor and already overpopulated country that, for religious or nationalistic reasons, restricts the use of contraceptives and refuses to slow its population growth? Should we nevertheless offer development assistance? Or should we make our offer conditional on effective steps being taken to reduce the birth-rate? To the latter course, some would object that putting conditions on aid is an attempt to impose our own ideas on independent sovereign nations. So it is- but is this imposition unjustifiable?

"If the argument for an obligation to assist is sound, we have an obligation to reduce absolute poverty; but we have no obligation to make sacrifices that, to the best of our knowledge, have no prospect of reducing poverty in the long run. Hence we have no obligation to assist countries whose governments have policies that will make our aid ineffective. This could be very harsh on poor citizens of these countries-for they may have no say in the government's policies-but we will help more people in the long run by using our resources where they are most effective. The same principles may apply, incidentally, to countries that refuse to take other steps that could make assistance effective-like refusing to reform systems of land holding that impose intolerable burdens on poor tenant farmers." - Peter Singer, Practical Ethics.

Some useful links:

   United Nations Population Information Network (POPIN). Latest 1998 information on population trends.

   Zero Population Growth. In their own words, " Zero Population Growth, Inc. (ZPG) is a national non-profit organization working to slow population growth and achieve a sustainable balance of people, resources, and the environment."

   The United Nations Commission on Sustainable Development.

   The United Nations International Conference on Population and Development (ICPD), September 5-13, 1994 in Cairo, Egypt

   The Cairo Conference Home Page

   Bill McKibben, "Reaching the Limit," New York Review of Books, May 29, 1997. Reviews of How Many People Can the Earth Support? by Joel E. Cohen and The Carrying Capacity Briefing Book by the Carrying Capacity Network.

   Do We Consume Too Much?," Atlantic Monthly, June 1997. Reviews of Do We Consume Too Much? by Mark Sagoff and Discussions of the future of the planet are dominated by those who believe that an expanding world economy will use up natural resources and those who see no reasons, environmental or otherwise, to limit economic growth. Neither side has it right

   The Non-Trivial POP- ulation Quiz How much do you know about the population of this planet? Here is an opportunity for you to test your "POP I.Q."

The world population will reach six billion at the beginning of the next academic year. Are you ready for this important milestone in human history?

In October 1999, the United Nations will announce this global demographic event. It will mark the first time in human history that any generation has witnessed the tripling of world population, which was a mere two billion in 1930 (up from 1 billion in the early 1800's).

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February 14, 1998
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