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About a week ago, at the onset of the COVID-19 epidemic in Bulgaria, a Bulgarian entrepreneur (Ivaylo Penchev, founder of Walltopia), offered a conditional donation of medical ventilators to a state-owned hospital. The donation was conditional upon employees of his company, as well as their family members, receiving preferential treatment, should the need arise. When asked what 'preferential treatment' means, and specifically whether he expects a person who is being ventilated using one of the donated machines to be disconnected to free up a machine for a Walltopia employee who needs ventilation, he said "That's exactly what I expect". The hospital initially accepted but then (after media attention) declined the donation, quoting conflict with the Hippocratic Oath.

Is this kind of donation morally permissible?

Was the hospital right to reject it, given that the net result may be loss of life?

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    – J D
    Mar 24 '20 at 17:14
  • Does Bulgaria have a universal health care system? If it does, then universal means that everyone receives the same treatment - there are no exceptions. A state owned hospital would not be able to accept such conditions.
    – NWR
    Mar 24 '20 at 18:01
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    You may find the discussion of the doctrine of double effect relevant, and this case seems to land on the wrong side of it. According to the doctrine, it is permissible to advance a good end while foreseeing harmful consequences of doing that and minimizing them, but not permissible to do so by harmful means. Although the distinction is vague, most people would probably judge the suggested disconnection as harmful means that put one life above another. And "first, do no harm" oath will definitely have to be violated.
    – Conifold
    Mar 24 '20 at 19:19
  • @Nick Formally that's probably true, but I'm more interested in the moral aspect. Also, I think moral considerations should take precedence over legal ones i.e. if it is morally permissible, laws should be changed to allow it. Mar 25 '20 at 6:32
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    @Conifold in this particular case one could question whether there is a harmful effect, as without this donation the disconnected patients would not have had a chance at all. Mar 25 '20 at 6:35
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If giving preference to a certain group of people (in this case, employees of a given company) does not come at the expense of people outside that group, it is ok.

However, in this case the question is trickier, since ventilators don't operate by themselves, i.e. they need the attention of highly qualified medical personnel. Disconnecting a person to transfer the ventilator to someone else is equivalent to wasting all the effort and resources spent on the former's recovery. As resources are limited, this is likely to harm the unprivileged group. In effect, Penchev is renting the hospital staff and other resources in exchange for his donation.

Thus, in its original form, the donation is probably not acceptable ethically.

A modified version might however be acceptable, e.g. giving preference to a certain group without disconnecting anyone that is already connected to a ventilator.

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It is not a donation, it is business proposition. Looked at that way, it is ethical. The company is purchasing a given right for a given sum-in-kind.

As a business proposition, the hospital would have to arrange for it to be tractable within the requirements of their business process. That includes working around the fact it employs doctors, who swear the Hippocratic Oath. So it would have to plan to hold enough of these ventilators in abeyance to serve the priviledged employees, since it cannot disconnect life support once it is deployed, without being guilty of attempting manslaughter.

That could prevent others who could be treated from being treated. This is not explicitly forbidden, but it is an edge case. It would be hard to enforce, and could be damaging to the relationship between the hospital and the doctors. That could easily cause more lost life in the future.

So the hospital probably chose wisely. But there was nothing unethical in making the offer, other than possibly misrepresenting a deal as a gift.

Again, since this is a business proposition, not a gift, it need not be taken as given. The hospital might have negotiated clearer terms, say that the company providing this help chooses how these get deployed, under the condition that there is no risk anyone might have to be murdered. It would then be on the hands of the employer to withhold his help or extend it, on a case-by-case basis. It would come down to the employer looking at the statistics and the risk his own people might suffer, or that he might be increasing the suffering of others.

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