Distributive justice and the importance of context

I have always wondered why there were not enough lifeboats on the Titanic. Not only were many lifeboats removed to allow first-class passengers an unobstructed view from the ship’s deck, but few steerage passengers had the opportunity to vie for one after the ship struck an iceberg during its fatal maiden voyage in April 1912.¹

What keeps us fascinated with the Titanic tragedy is that it is a window to the context of the times, and as Tom Koch wrote, the “lifeboat ethic”² that was normal in pre-war Europe points to both hubris and a deeply ingrained inequity in society. The ethic, which posits that some must die due to resource restrictions, was justified in part by the broader context of shipowners cutting corners and running vessels at ever-higher speeds to extract ever-higher profits.² Thankfully, the Titanic tragedy led to much stricter safety standards for the transport industry, and—we can interpolate—to the health care industry.

Over 100 years later, we have an opportunity to step back and assess the ethic that guides us now, as a report from the College of Family Physicians of Canada Ethics Committee (page 209)³ invites us to do in this issue of Canadian Family Physician. Over a series of 3 articles in the journal’s March, April, and May 2026 issues, the committee presents a framework to address important choices facing health care today: How do we distribute resources? Do increasingly expensive treatments offer incremental benefit with diminishing return? Who benefits the most from the ethic of our time?

These questions around distributive justice are the most critical in our time of expansive technology in a finite system. In the end, we must once again accept that our lives are also finite. In their article, the committee quotes Dr Iona Heath:

Nowadays, doctors are driven by a sense of guilt and discomfort at fighting more and more for the prolongation of life, often at the expense of its quality. Once again, the hubris and ambition of biomedical science are largely responsible for the dangerous and damaging denial of death in contemporary society.⁴

When I discuss ethics with World Organization of Family Doctors past president Dr Anna Stavdal, who writes about the importance of context in her instalment (page 164)⁵ of the Foundations for tomorrow series, she points out history is less circular and more like a spiral. We are making progress, but through a series of mistakes, growing smaller with time, around the same issues.

Canada is at a turning point in how we address distributive justice in our health care system. Some decry the lack of lifeboats. Others see the rise of for-profit solutions as launching lifeboats too early, as occurred far too often in 1912.¹ We must also examine the broader context.

As Stavdal and Senstad write about integrating context into our approach to medicine,

[s]uch a commitment requires intent, and certainly some courage. It becomes far less daunting when we and our colleagues support one another in continually updating our insights [into] deeply embedded institutional and cultural forces that promote fragmentation and specialization.⁵

Norwegians, like Stavdal, understand something about our northern context. There are the commonalities of expansive geography, how people value freedom of choice, and how certain people in the far north face disadvantages. Perhaps it is the Nordic winters that contribute to communal values and a welfare state.

There were 5 mail workers on the Titanic, tasked with sorting transatlantic mail as well as heaps of postcards being sent from the ship’s first journey, when it sank. When disaster struck, the mail workers connected with some higher calling: They started fighting the hordes, not to reach the deck, but to go down into the galleys. They all died in service, trying to drag the bags of mail up to the surface.

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