In the last two chapters we looked at harms that affect more than one group. Those harms, if they occur, will affect the Have-nots, but they will also affect the Haves and the Will-nots. In this chapter we will look at possible harms that are unique to the Have-nots.1
The problem starts here: If you die at 90 in a world where no one lives much past 100, your death is not so bad. Death is always a great loss, but you lived about as long as it’s possible to live, and you had a good run. If, however, you live in a world where life extension is available to the rich but you must age normally and die at 90, your death seems worse. Ninety years no longer seems like enough time when others get a lot more time, even though you get just as much time as you would in a world without life extension. Dying at 90 under those conditions seems much worse than dying at 90 in a world where no one lives much past a century.
If it’s worse to die at 90 in a world where some people can afford life extension but you can’t, then introducing life extension into the world seems to make the Have-nots worse off in just that way. In other words, introducing life extension into the world seems to make billions of people worse off even if their lives are no shorter. However, it’s not immediately obvious why they are worse off. After all, their lives are no shorter. We don’t usually think that we become worse off just because someone else becomes better off: if my neighbor wins the lottery, I do not thereby become poor. What, exactly, is the harm here?
One obvious answer is that many or most Have-nots will suffer feelings we’d all rather avoid: horror, despair, depression, anger, resentment, and other feelings so unpleasant that experiencing them counts as a harm in its own right. Let’s refer to the entire set of these feelings as “distress.” Introducing life extension without making it available to everyone seems to harm billions of people by making them seriously distressed.
It can be hard to disentangle distress from questions of justice: the Have-nots may feel distressed because it seems unfair that others get life extension and they don’t, and they may be right that it’s unfair. We’ll discuss justice in the next three chapters, but in this chapter, I want to focus on distress by itself. To distinguish distress questions from justice questions, let’s imagine a case that leaves justice out of this: Imagine that it’s impossible to provide life extension for a portion of the human race because those people are physiologically unable to benefit from the treatment. Life extension works only for those who have the right genes; these people have the wrong genes, and there’s no genetic intervention that affects those genes. They are genetic Have-nots. Because it’s impossible to provide them with life extension, the fact that they don’t get it is not evidence of injustice—just bad luck.2 Justice aside, what is true about the distress felt by genetic Have-nots should be true of the distress felt by those who are Have-nots because they lack the money to buy life extension. In other words, these imaginary genetic Have-nots will help us think about distress in a context where issues of justice do not arise, so we can isolate questions of distress from questions of justice.
If we set aside issues of justice, what else do the Have-nots in our case have to be distressed about? What about the potential Malthusian consequences and other possible bad social consequences we talked about in the last two chapters? Those harms may be significant, but it’s still worth asking whether distress alone counts as a morally significant harm in its own right, even leaving those possible harms aside. For one thing, the Malthusian harms and other bad social consequences might be avoided or turn out to be insignificant. For another, Malthusian and other bad social consequences won’t happen right away; some of them may take generations to fully materialize. However, Have-nots will probably suffer serious distress as soon as they hear about the first Silicon Valley billionaires who get life extension.
Perhaps the Have-nots are distressed because the Haves get extended life and the Have-nots don’t. The mere fact that the Haves are better off leaves the Have-nots comparatively worse off, even if they are not worse off in an absolute sense. If, for example, your income remains the same but other people get raises, you’re worse off compared to them but not worse off in any other way. But is being comparatively worse off a harm? We almost never call it a harm. If your neighbor wins the lottery, you’re now comparatively worse off than he is, but we don’t say you were harmed by this. If your house was burglarized and you lost property, you are worse off than your neighbor who was not burglarized, but we don’t think the mere fact that he now has more property than you is a harm to you apart from what the burglar did.
Refusing to count being comparatively worse off (without being absolutely worse off) as a harm not only fits our moral judgments but also makes sense. Recognizing every instance of being worse off than other people as a harm would expand the right against harm so massively that no one could do much of anything without running the risk that they are harming someone else. A set of moral rules that contained such a right would not promote human flourishing. Moreover, prohibiting anything that makes some people better off than other people would amount to an extremely radical kind of egalitarianism—something no egalitarian would support.3
If there are no purely comparative harms, then we’re talking about distress in the absence of harm (at least before Malthusian and other collective harms materialize). Distress without corresponding harm is psychologically plausible, of course, but it’s morally puzzling. If the Have-nots are distressed but not otherwise harmed, what, if anything, should we do about their distress? Can distress without a harm to be distressed about count as a harm all by itself?
Let’s address those questions by considering this case: A homeowner feels very distressed when he learns that the couple who bought the house next door is gay. He’s beside himself over the fact that the two women living next door sleep together and have sex. Should we take that distress as seriously as we would if the homeowner felt that amount of distress because the couple next door held loud parties and kept him up every night? Being kept awake every night is a real harm to the homeowner, and he would be justified in feeling distressed about it. He’s not justified in feeling distressed because the people next door are gay. Therefore, his distress at their behavior does not have the moral weight it would if they did some real harm to him.
Of course, the homeowner may be unable to control his reaction. In that case his distress might have some moral weight. We might then take his distress seriously in certain ways: We would avoid goading him about his neighbors, try to be patient and diplomatic when we talk to him about his neighbors, recognize that he can’t help this, and so on. Moreover, if we could help him eradicate his distress by coming to see that his neighbors are good people who are harming no one, we should do so—not just because his neighbors deserve this but also because the homeowner himself will be better off without that distress. His distress is not devoid of moral significance. Nonetheless, we would still give his distress less moral weight. His neighbors have a moral duty to end their parties by ten o’clock, but they don’t have a duty to sleep separately.
Now transfer this analysis to life extension. Although the Have-nots will eventually suffer other harms, let’s stipulate for purposes of discussion that at least early on, the Have-nots are not suffering any harm apart from the distress, just to isolate that issue. Should we do anything about their distress as a harm in its own right? We may have a moral duty to be compassionate, to try to ease their distress in some ways, and so on, especially if they can’t help feeling distressed and their distress is severe. Nonetheless, their distress is not as strong a reason to inhibit or prohibit life extension, all else being equal, as it would be if they suffered a harm apart from their distress.
Let me sharpen this a bit. I don’t simply mean that their distress is a reason of X weight, and the other harm is a reason of Y weight and that X + Y is a greater total weight of reasons to inhibit life extension than the moral weight of X alone. Anyone would agree with that. What I mean is, if there is no other harm of Y weight, then their distress does not have X weight in the first place—it has less than X weight: X − n. That’s not to say that their distress has no moral weight at all or that Haves can disregard the Have-nots’ distress entirely. Even if the moral weight of their distress is X − n, X − n weighs something. The Haves have a duty to be sympathetic, to avoid rubbing it in, and perhaps even a duty to compensate the Have-nots to some extent for that distress. If, however, the Have-nots had another harm to be distressed about, then the moral weight of the Have-not distress would be X, not X − n.
Whether their distress, whether it has moral weight X − n or moral weight X, is a sufficient reason to inhibit or prohibit life extension is another question. Nothing I’ve said so far implies that distress without another harm could not, by itself, be a sufficiently large harm to make it wrong to develop life extension—I leave that question open for now. (I’ll later argue that life extension should not be inhibited or prohibited at all, even when we consider all the possible harms, so you know where I’m going to come down on this.) My conclusion here is simply that their distress by itself has less moral weight than it would have if it were accompanied by some other harm for them to be distressed about.
However, even before Malthusian consequences or other harms have a chance to materialize, and even apart from issues of equality and justice, there is a separate harm the Have-nots will suffer, and this other harm will arrive as soon as life extension itself arrives. I call it the death burden.
Some deaths are worse than others. Dying at 9 seems far worse than dying at 90. All else being equal, the younger you are when you die, the worse your death is, for the number of years you might have lived is larger. This intuition is, I suspect, so universal and so strong that we can propose it as a partial account of how bad it is to die. It’s a counterfactual account, for it turns on what would have happened if (counter to the facts) you had not died then. When we talk about how bad a particular death is for the one who dies, let’s call that the severity of death. When we talk about how bad it is to die at a particular age (all else being equal), let’s call that the temporal death burden, or death burden for short. I propose a counterfactual measure of the severity of death: your death is worse, all else being equal, the more years you would have lived had you not died when you did, and the number of potential years you missed out on is your death burden. (I’m not the first to offer such an account. Many philosophers have done so, particularly Jeff McMahan, who explores the counterfactual account of the severity of death in greater depth and detail than anyone else, though he doesn’t call it that.4)
The severity of death is not what philosophers call the harm of death. The problem of the harm of death concerns this question: If you no longer exist once you die, how can death harm you? (The problem is that it’s hard to see how anything can happen to you—including harm—if you no longer exist.) The severity issue is a different problem. It concerns how bad death is, while the harm issue concerns how it can be bad at all. They sound similar, for I’m proposing a counterfactual measure of the severity of death, and the most popular account of death’s harm is that death harms us by depriving us of potential years of life—roughly the same counterfactual. However, it’s possible to hold a counterfactual view of the severity of death while denying the deprivation account, for we can distinguish between using the number of years you would have lived as an index of harm and using them in an explanation of harm. This is important because not everyone accepts the deprivation account of the harm of death. Stephen Blatti, for example, is a nondeprivationist who argues that part of death’s harm consists in the fact that death constrains our autonomy; in plain English, death stops you from accomplishing certain things.5 The harm is not that you are deprived of time, the harm is that your autonomy is constrained by lack of time, so being deprived of those years is not part of the explanation of the harm. However, this is consistent with a deprivation account of the severity of death, for those years are an index of how badly you were harmed by dying at 9 rather than 90, even if we can’t say you were deprived of those years (because you can’t be deprived of anything when you don’t exist).
Now let’s think about the death burden in a world where life extension is available. Does introducing life extension into a world where not everyone can get it increase the death burden for the Have-nots, who can’t get life extension? Here is an argument that it does. If they had life extension, they might live for centuries. They cannot get life extension. Therefore, when they die, they miss out on centuries of life—a gigantic death burden. This would not be true if life extension were never developed. Therefore, introducing life extension into a world where not everyone can afford it makes the death burden immensely worse for the Have-nots. It increases the severity of their deaths. (Note that this argument works also for the kind of life extension that consists of slowing aging but not halting it, for the more we slow aging, the greater the life expectancy of those who get life extension and the greater the death burden for those who do not.) This isn’t simply a matter of distress, for how a Have-not feels about a given harm is a separate, different harm. Rather, this may be part of what Have-nots are distressed about.
You might question the death burden argument. Instead of comparing death at 90 to how long a Have-not would have lived with life extension, why not compare it to how long he would have lived without life extension? After all, he couldn’t get it, so why is it relevant? Right now it’s medically impossible to provide life extension; in the future it will be fiscally impossible to provide it to everyone, at least for a while. Why does it matter whether you couldn’t get it because it’s not medically possible (the situation now) or because it’s not fiscally possible (the situation in the future)?6
This objection rests on the fact that there is more than one counterfactual we might use to measure your death burden if you’re a Have-not in a world where life extension exists:
The death burden argument uses counterfactual A (how long you would have lived with life extension), and the impossibility objection uses counterfactual B (how long you would have lived without it). Counterfactual C is a blend of the two. If A is the correct counterfactual, then introducing life extension into the world harms billions of people by increasing their death burdens, and if counterfactual B is the correct counterfactual, then introducing life extension into the world does not do this. (It may harm them in other ways, but right now, I’m focused solely on whether it harms Have-nots by increasing their death burdens.)
The argument for counterfactual A is that we’re really asking what should happen instead, not what’s most likely to happen instead. For example, when we ask how long a patient would have lived, we might ask what would have happened in the cut-rate medical facility he could actually afford or we might ask what would have happened in the far superior medical facility that society should have paid for. Both counterfactuals are correct for different questions; the second counterfactual is correct for questions about justice in the distribution of healthcare. Similarly, counterfactual A is relevant in situations where we want to know what the world should be like—that is, what justice requires. The argument for counterfactual A is that we want to know whether introducing life extension into the world will be harmful to the Have-nots and hence unjust.
But this argument begs the question. Suppose we say that counterfactual A is the right counterfactual because the world should not be one where life extension is available only to the rich. Why should the world not be like this? Because making it available to some people but not to everyone harms those who don’t get it, even if their lives are no shorter. Why does it harm them? Because that state of affairs is unjust; therefore, counterfactual A is correct. Why is that state of affairs unjust? Because it harms them, and around we go again. The justice argument for counterfactual A is circular unless we can find some reason other than the death burden for why unequal access to life extension is unjust.
Suppose it is unjust for some reason other than imposing a death burden on the Have-nots. Suppose, for example, that those who lack extended life have fewer opportunities and therefore failure to fund life extension for them violates their right to equal opportunity. Does that get us past the circularity? The idea is that if making life extension available is unjust to the Have-nots for some reason other than an increased death burden, then (and only then) counterfactual A becomes the correct measure for the death burden Have-nots suffer when life extension becomes available to the Haves. In effect, counterfactual A would piggy-back onto some other injustice.
I doubt that this works. Counterfactual A was introduced as a measure of how much death harms the Have-nots when life extension is available to the Haves, and it doesn’t qualify as a measure of that harm just because, when we think about equal opportunity, we note that Have-nots would live far longer if they had life extension too. The harm that consists of being denied equal opportunity and the harm that consists of increased death burdens are two distinct and different harms, and establishing that one of those harms exists does not thereby establish that the other one exists any more than a criminal defendant acting alone becomes guilty of conspiracy to commit murder because he’s also guilty of murder itself.
So the argument for counterfactual A seems faulty. What about counterfactual B? When we inquire into what might have been, we usually focus on what was most likely to happen: If you had taken that job, would you have made more money than you make now? No; that company went bankrupt in the recession, and you would have been forced back into the job market at a bad time. The argument for counterfactual B, then, is twofold. First, counterfactual B is the kind of counterfactual we usually take an interest in. When we want to know what might have been, it makes more sense to be interested in the alternatives that are most likely. Second, the argument for counterfactual A faced serious problems that counterfactual B does not face.
If counterfactual B is the right measure, then introducing life extension into a world where not everyone can get it doesn’t increase the death burden for the Have-nots, for the Have-nots weren’t likely to get life extension in that world. Because they weren’t likely to get it, we can say, for example, that a Have-not who died at 85 didn’t lose very many years, for she probably would have died by age 90 anyway.
However, counterfactual B suggests that life extension is simply impossible for the Have-nots, and that’s not quite correct. Life extension would not be completely impossible for Have-nots to obtain. If you’re a Have-not, you might win the lottery, or make a fortune in business, or manage to emigrate to a country rich enough to provide life extension for all its citizens, and thereby obtain life extension. There is a chance for you to get life extension; it’s just a remote chance. For this reason, we should not use counterfactual B. We should use counterfactual C, where the death burden is measured by the years you would have had if you obtained life extension but discounted by the odds of your getting it. If, for example, your odds of getting life extension were 1 in 100 and life extension completely halts aging, then your death burden would be 1 percent of the estimated 1,000-year life expectancy for people who never age—a death burden equivalent to 10 lost years of life. You didn’t lose that many years, but you lost something, and this is how to quantify it.
This needs some refinement. What are we calibrating the harm to? Your odds of getting life extension when society has done all it’s morally required to do to make it possible for you to get it, or your odds of getting life extension when society has not done all it’s required to do? It makes a difference. We don’t want to say that the harm is less simply because you are unlikely to get life extension due to serious injustice in your society. That lets your society off the hook far too easily (the harm is one reason why this is unjust). The first answer, then: how hard it is for you to get it under conditions where your society has fulfilled its moral obligations to make it possible for you to get life extension. This does not mean we must assume your society can actually provide it, only that your society has done all it can to fulfill whatever obligation it has to make it possible for you to get it. That might include, among many other things, having a legal framework that provides equal opportunity to succeed in business so that you can make the money to afford life extension. For now, we can leave open the question of what obligations, if any, a society has in this direction. The point is that if we’re going to use a counterfactual measure to decide whether people are harmed, we don’t want to say there is no harm just because a society is unjust.
So the Have-nots do have a harm to be distressed about even before Malthusian consequences and other social ills arrive. However, the death burden is complex, subtle, and a good deal more abstract than most people are used to dealing with. How many Have-nots will have anything like this in mind when they express distress? They might say things like, “It sucks that the rich get this,” “This is outrageous,” or “I feel like my life means nothing now,” but they’re not likely to talk about counterfactual measures of the severity of death. In short, there is another harm here, but are Have-nots really aware of it? I’m inclined to say yes, at least for many of them. Many of them, I suspect, will feel as if their life spans are now less satisfactory, that their deaths are tragic in a way they were not before. They will feel that they’re missing out on something that they wouldn’t miss out on if life extension didn’t exist. That, I think, is sufficient for us to conclude that their distress is about the death burden even if few of them ever see the arguments about the severity of death in the previous section.
You may think that all this can be avoided if society simply refrains from developing life extension in the first place. You may even think that imposing larger death burdens on the Have-nots is a good reason to stop researching and developing life extension. We then face questions about whether there are moral arguments in favor of developing life extension that might outweigh that reason against it, but right now, I want to address a narrow question: Can the death burden be avoided by not developing life extension?
Unfortunately, this won’t work—or at least not very well. The problem is that if life extension would eventually be developed if society did not prevent it, then life extension is possible even if society succeeds in preventing it. The possibility is more remote if society prevents it from being developed—to get it would require a lot of research and development and expense. However, it is still possible.
To see the problem from another angle, consider a range of cases:
Until very recently, everyone in human history lived in Case 1 (if they were lucky enough to die of old age). Though most of us don’t realize it yet, we are beginning to find ourselves in Case 2, where life extension is foreseeable but not available to anyone. As the time when life extension is a practical possibility comes closer, the tragedy of missing out on life extension will become greater. It was not so bad to miss out on life extension a hundred years ago, but it’s somewhat worse now, and it will be even worse as more and more potential life-extending drugs are in clinical trials.
This means that you—the reader—may already be suffering an increased death burden. In effect, you and I are temporal Have-nots (we were born too soon). We are living in a time when life extension is increasingly possible, and our death burden is increasing along with it. It is still heavily discounted, but as life extension becomes more possible, that burden will be discounted less and less. We are a sort of lost generation, for living closer to the time when life extension is developed makes our death burden worse than those of earlier generations, for whom life extension was a medical impossibility. Life extension is still a remote possibility for us, so our death burden is not yet very large, but it will grow larger the closer we get to developing life extension.
Even if society does nothing to develop life extension, it’s still true that life extension is possible in our time, for it’s possible for society to fund and pursue life extension research even if we don’t do so. In other words, even if we do nothing, we may be lost. We can reduce our death burden by putting on the brakes and making life extension less possible, but we can’t completely prevent our death burdens from increasing to some extent.
This means that those who get life extension in the future will do so at the cost of making death worse for others. In the long run, it’s likely that a rising tide of prosperity and a falling cost of treatment will make life extension available to all who want it, but between now and then, humanity will contain some lost generations. The generations who live through the period when life extension slowly becomes a more and more imminent possibility will suffer, for their deaths will be worse than those of previous generations. Then again, even if we do nothing, it is still true that life extension is possible in our time, for it is possible for us to fund and pursue life extension research even if we do not do so.
Even if we do nothing, we are lost.