Medicine, Health Care and Philosophy 7: 163–173, 2004. © 2004 Kluwer Academic Publishers. Printed in the Netherlands. Scientific Contribution Towards a dialogue between utilitarianism and medicine Y. Michael Barilan Department of Internal Medicine B, Meir Hospital, Kfar Saba and Department of Behavioral Sciences, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Abstract. Utilitarianism focuses on the optimization of personal well being in ways that seems to make the practice of medicine irrelevant to the well being of the practitioners, unless given external incentives such as money or honor. Care based on indirect incentives is considered inferior to care motivated internally. This leads to the paradox of utilitarian care. Following Nozick’s conceptual Pleasure Machine it is argued that in addition to the promotion of personal well being, people care about fulfilling their well being in a world which is real, just, good, and beautiful. Complete mechanization of social and personal life in accordance with a strict utilitarian regime is also incompatible with the kind of world people desire, even if it promises more fulfillments in terms of personal well being. This explains the so-called Taurek-Parfit paradox, according to which sometimes ethics seems “to count the numbers” and sometimes not. The very pursuit of utilitarianism does not contribute to any personal life plan. The helping professions make the world a better place for us to live in, even though they do not necessarily bear directly on the well being of any individual other than the recipients of care. This resolves the paradox of utilitarian care. Key words: allocation of scarce resources in healthcare, medicine, motivation, utilitarianism, well being 1. The paradox of utilitarian care and the Taurek-Parfit paradox Utilitarianism is one of the dominant schools of ethics nowadays. It is solely committed to maximizing the good, as it is evaluated from a non-partial point of view. Utilitarianism is consequentialist, welfarist, aggregative, optimific and impersonal in attitude (Frey, 2000). Being aggregative and maximizing, utilitarianism is also monistic. Being monistic and consequentialist, utilitarianism comes close to monist teleological ethics in which every action aims at the ultimate value, the good (Plato, Meno, 356a–7b, Aristotle, Nichomachean Ethics, Thomas Aquinas, Summa Theologica I, II, Q94 a2, Sidgwick, 1901, p. 406; see Rawls, 1971, pp. 24–25). Utilitarianism broke ground in two significant ways. First, utilitarianism is committed to a specific perception of the one and ultimate good (summum bonum). According to utilitarianism this is the well being of persons or sentient creatures (welfarism, the substantive claim). Second, utilitarianism relies on mathematics, or mathematical-like modes of thinking in ethical reasoning (the formal claim). Smart (1973, p. 41-1) explains, What utilitarianism badly needs in order to make its theoretical foundations secure, is some method according to which numerical probabilities, even approximate ones, could in theory, though not always in practice, be assigned to any imagined future event. The mathematization of ethics presupposes the canoni- zation of ethically relevant concepts. Canonization of a term means that the term is assigned unambiguous and fixed meaning and value. The morally relevant terms are substituted with variables that are amenable to algorithmic permutations and processing. Utilitarian values are mutable. Every mathematical calculation is reducible to an algorithm. An algorithm is a mechan- ical process which is (1) impersonal and value neutral, (2) reducible to a sequence of simple but absolutely clear and reproducible steps and (3) consequently generates guaranteed and reproducible results. Hence, every algorithm may be carried out by a machine, even a simple one (Dennett, 1995, pp. 50–51). Utilitarianism, therefore, presupposes the transfer- ability of ethical deliberation from the humane sphere to the technological one. 1 In sum, the thrust of utilitarianism is the algo- rithmic approach to personal welfare, as the one and ultimate good.