Beyond Moral Regret Asymmetric Altruism and the Problem of Tragic Dilemmas

Abstract

Photo ID 11672535 © Cammeraydave | Dreamstime.com

Abstract

Tragic dilemmas, situations in which available courses of action result in inevitable harm or loss of life, impose a psychological burden of moral regret. Moral regret persists despite an agent’s reasoned deliberation, yet, paradoxically, it exists because of human agency. Empirical studies in clinical psychology, neuroscience, and behavioral economics show that agent-centric and calculative models of decision-making amplify rather than alleviate moral regret. Conventional coping strategies, namely, denying the reality of tragic dilemmas (illusionism), deferring choice to others (delegation), and embracing total accountability (responsibilisation), each prove inadequate in isolation. This article addresses a fundamental question: How should moral agents cope with moral regret arising from tragic dilemmas? This paper argues that asymmetric altruism offers a viable framework for mitigating moral regret while preserving accountability. By re-centering ethics on the pre-cognitive and non-reciprocal responsibility for the Other, Levinasian thought displaces the self-referential and procedural rationality that exacerbates regret. This paper claims that asymmetric altruism provides a more adequate response to tragic dilemmas than conventional coping strategies. 

Introduction

Moral dilemmas pervade human experience in varying degrees. They present the moral agent with competing duties, obligations, and values that are on a par, necessitating moral deliberation. The moral agent can weigh, compare, and justify a decision based on principles, anticipated consequences, and virtues. Despite making a difficult choice, a moral agent does not always experience lingering regret, especially when confident he or she made the right choice.

However, tragic dilemmas are a different type of moral dilemma. In tragic dilemmas, the agent cannot avoid wrongdoing: both options require compromising a moral position and lead to tragic consequences. The agent can decide only which obligation to break or which harm to condone. The last bed dilemma, where a physician must decide who among his critically ill patients receives the sole remaining intensive care unit bed, exemplifies this condition with tragic clarity. During the COVID-19 pandemic, these dilemmas became common across healthcare systems globally, especially in low-income countries where resources were already scarce. A global study of intensive care management during the COVID-19 pandemic found inequitable access to ICUs since large numbers of patients required critical care, resources were limited, and non-COVID cases were severely compromised.^[1]

The fundamental question that this article addresses is both philosophical and practical. How should moral agents cope with the inevitable moral regret arising from tragic dilemmas without succumbing to self-deception, relinquishing responsibility, or experiencing psychological exhaustion?

Recognizing that altruism is asymmetric and grounded in non-reciprocal responsibility provides a framework for coping with moral regret. First, the paper argues that agent-centric and calculative models of decision-making amplify moral regret rather than reducing it. Second, the paper demonstrates that conventional coping mechanisms, such as denying regret, delegating accountability, and assuming total responsibility, are individually inadequate because moral agency remains inescapable and accountability alone cannot resolve moral regret. Third, the paper reconstructs Levinas’ ethics of the face-to-face encounter, emphasizing the concepts of being different, or “otherness,” vulnerability, and asymmetrical and infinite responsibility. Fourth, the paper recommends a model of asymmetric altruism grounded in vulnerability, proximity, and the concept of going beyond one’s duties. The paper demonstrates how these principles diffuse the psychological impact of moral regret. The conclusion considers the broader philosophical question of how to live with the choices we cannot avoid making.

The Nature of Tragic Dilemmas and the Inevitability of Moral Regret

When facing a moral dilemma, the moral agent does not know what he ought to do because he must compromise a moral position. In tragic dilemmas, every available choice has a bad consequence.^[2]

The last bed dilemma is an example of a tragic dilemma. It occurs when resources are scarce, and circumstances demand a decision that cannot escape tragedy.^[3] This tragic dilemma has three features. First, options are on a par because no decision-making procedure can establish that saving patient A is objectively superior to saving patient B. Second, an unquantifiable good, namely human life, is at stake. Third, treating both patients simultaneously is impossible. The dilemma is simply a constraint of reality.

However, several philosophers argue that the last bed dilemma is a fallacy. The objection rests on two claims. First, triage exists precisely to avoid such dilemmas because it provides an objective criterion for prioritization; second, no two patients ever present with identical levels of criticality.^[4] However, triage systems do not eliminate tragic choices; rather, they relocate decision-making to physicians.^[5] In effect, physicians’ personal preferences and biases influence decision-making. While no two patients have exactly the same level of severity, the influx of COVID-19 infections overwhelmed healthcare systems, leaving them unable to meet patients' medical needs.^[6]

Moral Regret as Constitutive of Tragic Choice

In tragic dilemmas, the moral agent cannot divest himself of conflicting obligations. The physician, who decides to leave a patient in the hospital corridor because no beds remain, continues to have a moral obligation to the patient but cannot meet it due to scarcity. For many physicians who faced this dilemma during the pandemic, moral regret ensued.

Furthermore, moral regret persists even within utilitarian and deontological frameworks. On the one hand, utilitarianism, at least in its simplest form, treats any form of regret as irrational, especially when the agent has maximized expected utility. It dismisses the reason for regret when the physician has saved the patient with a greater chance of survival. On the other hand, deontologists do not blame the agent because he fulfilled a moral duty despite compromising the competing moral duty. However, regret persists despite doing the right thing according to those philosophies. In other words, the moral agent understands what was at stake and regrets being unable to do both.

There are documented cases of “agent-regret” among clinicians whose faultless actions nevertheless result in harm or death.^[7] Surgical operations go awry despite foolproof techniques; life-saving interventions and correct triage decisions leave physicians guilt-stricken. It should be clear that regret is not tantamount to guilt, for guilt presupposes fault. In this case, the physician is faultless, yet he cannot escape the burden of regret following the patient’s death. Even when moral agents acknowledge that they could not have acted otherwise, persistent feelings of regret impact their well-being.^[8]

Amplification of Regret in Agent-Centric Decision-Making

The intensity and persistence of regret depend on both what is at stake and the mode of decision-making. Empirical research nevertheless reveals a counterintuitive result: more extensive deliberation tends to intensify regret rather than alleviate it.^[9]

Neuroscientific studies link regret to the orbitofrontal cortex, a brain region associated with counterfactual thinking and comparative evaluation.^[10] Regret arises when agents imagine better outcomes that might have followed from alternative choices. Deliberation increases the range and vividness of these counterfactuals and strengthens agent responsibility for both chosen and unchosen options. Consequently, deliberation can heighten regret.

Studies further show that forced choices, common in tragic dilemmas, amplify regret regardless of the outcome.^[11] The suppression of moral agency may appear to relieve the agent of regret, but really it intensifies regret and perceived responsibility, especially under uncertain outcomes. Studies show that regret increases as agents identify themselves with decisions whose outcomes they neither intended nor controlled.^[12] Both agentic decision-making and enforced choices amplify regret because they heighten the sense of ownership over the decision without assuring moral correctness.

These studies have profound implications for the standard view of moral deliberation in relation to regret. If the weighing of reasons, comparative evaluation of outcomes, and acceptance of responsibility amplify regret, then increased deliberation cannot resolve it. Paradoxically, deliberative processes may even intensify regret rather than mitigate it.

The Inadequacy of Conventional Coping Strategies

      (i) Illusionism: Denial as a Defense

One strategy for avoiding moral regret is to deny the existence of tragic dilemmas. Illusionism treats the appearance of a genuine moral dilemma as a cognitive illusion that rational deliberation can dispel.^[13] If no situation requires wrongdoing regardless of choice, then an agent who reasons correctly has nothing to regret. The feeling of regret is an effect of a flawed and incomplete analysis. The fallacy argument against the last bed dilemma exemplifies illusionism. In insisting that proper triage protocols be applied, illusionists transform a tragic dilemma into a technical problem requiring a determinate technical solution. The regret that physicians felt in this strategy is a failure to apply established procedures correctly. Illusionism promises relief from regret without requiring any change in how decisions are made.

However, the promise comes at the cost of self-deception. Cognitive dissonance theory explains how individuals confronted with conflicting beliefs reduce discomfort by denying the evidence and preserving the illusion of coherence.^[14] Here, the tension between the reality of a tragic dilemma and the conviction that none exists produces cognitive dissonance, where the denial of the evidence can preserve an illusion of internal harmony. Such denial is not only epistemically dishonest but morally troubling because it leaves the moral agent unprepared to confront genuine tragic dilemmas when they arise. Denial of tragic dilemmas does not eliminate moral regret. They are only repressed and later surface in more harmful forms. Illusionism, then, offers denial rather than a genuine strategy for coping with moral regret.

      (ii) Delegation: Passing the Buck

If illusionism fails, a moral agent may defer responsibility to another.^[15] Delegation, which is the transfer of decision-making authority to another person, committee, or system, offers relief from moral responsibility and regret. Such “passing the buck,” particularly in complex, high-stakes, and blame-laden decisions, is well documented.^[16] While the delegating agent may regret the outcome, he may not regret the decision itself because it was not his choice.

Choice deferral illustrates the psychology of delegation. It involves refusing or postponing decision-making by delaying or avoiding judgment altogether.^[17] For example, a physician may defer to a triage system to avoid the burden of choice and accept the system’s calculative judgment in deciding critical cases. In this example, delegation insulates the physician from external blame and internal guilt.

Delegation, however, has the same problem as illusionism. It undermines moral agency. The physician who delegates the decision to allocate the last bed does not cease to be responsible for the patient who dies. He obscures this responsibility from himself. When delegation becomes the sole response, responsibility shifts downward through the organizational hierarchy. Lower-level authorities experience the brunt of moral accountability and regret. Delegation, therefore, does not solve the problem of moral regret. It redistributes responsibility and moral regret to others while preserving the delegator’s presumed innocence. Delegation is not a genuine coping strategy for moral regret but a mechanism for shifting moral responsibility onto others.

      (iii) The Burden of Taking Total Responsibility

The third conventional strategy is responsibilisation, which unconditionally affirms moral responsibility.^[18] Rather than denying or deflecting responsibility, the agent claims ownership of both choices and the corresponding moral regret. Rooted in the Western moral tradition, responsibilisation preserves moral seriousness more faithfully than either illusionism or delegation.

However, responsibilisation risks collapsing into pathological hyperagency. Agents cannot coherently be held responsible for everything that falls within the causal ambit of their choices, particularly outcomes that were unforeseeable or unpreventable.^[19] The physician becomes vulnerable to pathological hyperagency when assuming total responsibility for a patient who could not be saved, exemplifying not moral excellence but failure to recognize the limits of agency. A hyperagentic disposition amplifies rather than mitigates regret, though it may not be the cause of one’s regret.^[20] Responsibilisation, when pursued as an exclusive strategy, becomes a source of moral stress, burnout, and diminished capacity to care.

The shortcomings of each strategy do not negate their usefulness. First, illusionism recognizes that some dilemmas are resolved through better reasoning. Second, delegation acknowledges the value of collective decision-making and institutional protocols. Lastly, responsibilisation correctly rejects the denial of accountability. However, all three strategies share an agent-centric conception of moral experience that fails to account for the richness of ethical experience. While differing in their approach toward tragic dilemmas, they leave the assumption that the moral agent must remain the center of ethical reflection unexamined.

Levinas and the Decentering of the Ethical Subject

      (i) The Priority of the Other

Emmanuel Levinas tried to displace the self as the primary ground of ethics in favor of the Other; he focused on the Other rather than on the self’s logic, rationality, and self-interest. According to his philosophy, the Other is absolutely other: transcendent, infinite, irreducible to any category of the self, and vulnerable.^[21] Ethics, therefore, emerges from the encounter between the self and the Other rather than from the application of moral values and principles.

This inversion reshapes the understanding of moral regret. If ethical subjectivity is grounded in responsibility for the Other through the immediate encounter, then moral experience should not be reduced to deliberation and evaluation of choices. Immediate ethical responsiveness precedes reflection. In effect, the self finds itself already responsible. Moral regret, on this view, reflects the unwavering obligation that persists even when it could not be fulfilled rather than a failure of a decision or outcome. This account shifts moral regret from the domain of moral agency to moral encounter.             

The encounter is immediate and pre-reflective, calling for response rather than recognition or deliberation of the Other. Ethical responsibility establishes the priority of direct responsiveness over moral justification.

      (ii) Asymmetry and Infinite Responsibility

Responsibility that arises is asymmetrical because it is non-reciprocal.²² The self is responsible for the Other regardless of whether that responsibility is returned. While reciprocity may arise in social or institutional contexts, Levinasian ethical responsibility is fundamentally one-directional and constitutive of subjectivity.

Moral responsibility for the Other is also infinite. It cannot be discharged completely or one cannot claim to have done enough. Each encounter renews the ethical obligation.

Levinasian Asymmetric Altruism: Three Principles for Coping with Moral Regret

      (i) The Vulnerability Principle

Vulnerability is the fundamental condition of human existence and the primary state in which the Other makes an ethical claim.²³The vulnerability principle reframes tragic dilemmas. Standard utilitarian or deontological theories begin by asking what the agent ought to do and seek resolution through a decision procedure. The vulnerability principle, by contrast, begins from the recognition that all patients are vulnerable and therefore morally significant. Vulnerability cannot be ranked or reduced to any measurable metric. A less critically ill patient is no less real or morally commanding than one in greater danger.

This perspective clarifies the ethical status of triage as an institutional mechanism that seeks justice for all patients under conditions of severity or scarcity. Triage is a tragic necessity rather than a technical and moral solution. When a physician follows triage protocols, the inability to treat a patient reflects limited capacity rather than the termination of his responsibility. The vulnerability principle consequently shifts the source of regret. It relieves the physician of the burden of proving that a decision was objectively correct or optimal. Moral regret, thus, is a mark of fidelity to the person who cannot be saved rather than a moral failure. This shift from an ethics of agency to an ethics of relationality transforms regret from accusation into a testimony of infinite responsibility to the Other.

      (ii) Proximity Principle

Proximity denotes the condition of being immediately present to the Other.²⁴ Ethical responsibility emerges from exposure to the Other and not from deliberate and rational selection of whom to care for.

The proximity principle offers guidance when vulnerability alone underdetermines choice or triage criteria remain indeterminate. Medical realities resist clear ranking, and small differences often fail to justify the moral weight placed on life-and-death decisions. On such occasions, proximity demands that the physician’s primary responsibility is to the patient encountered most immediately. However, this claim requires careful qualification in relation to the general rule of “first come, first served.” Proximity is a description of an ethical relation and not a procedural standard. The patient who confronts the physician face-to-face is proximate in the ethical sense, while other patients remain proximate through institutional mediation. Proximity complements rather than replaces triage systems in guiding actions when protocols are indeterminate.

Proximity also reframes moral regret. Instead of attaching moral regret to the choice, proximity locates regret within the tragic situation. What is regretted is not the decision but the limiting conditions that prevent care for all. Moral regret, therefore, reflects the tragedy of the one’s finitude and situation rather than a defect in moral agency.

In addition, proximity addresses the problem of cognitive depletion, which leads decision makers to become progressively less capable of sound judgment.²⁵ A physician who must repeatedly decide who gets to live and who does not is at risk of such depletion, with dire consequences for patient care and well-being. In such circumstances, attentive and intuitive responsiveness may be ethically preferable to exhaustive calculation. Proximity legitimizes immediate responses as adequate moral approaches under extreme conditions.

      (iii) The Supererogation Principle

Levinas’s account of responsibility as non-reciprocal and infinite aligns with supererogatory actions, or acts performed freely for the benefit of others, often at the cost of the agent, that go beyond a duty.²⁶ Supererogatory actions are not required, but they express deep ethical commitment. When moral regret persists despite correct decision-making, supererogatory action can diminish the force of regret without denying its legitimacy.²⁷ Examples involve staying with the patient, being physically present, administering palliative care, or ensuring the patient does not die alone.

Such prosocial actions do mitigate negative feelings.²⁸ Further studies establish a positive correlation between prosocial behavior and psychological well-being.²⁹ These findings affirm that supererogatory actions actively counteract the psychological burden of unavoidable harm and promote the psychological resilience needed to remain present to the vulnerable Other.

Together, the three principles form a coherent ethical response to tragic dilemmas and moral regret. Vulnerability affirms that every other person commands a personal response; proximity guides actions when protocols underdetermine the right action; supererogation sustains responsibility beyond duty. Rather than denying tragedy, delegating responsibility, or embracing absolute culpability, Levinasian asymmetric altruism offers a relational ethics capable of coping with moral regret without collapsing under it.

Counterarguments

Many would argue that many philosophers, e.g., Kant’s duty-based ethics strongly require caring for the vulnerable/recognizing vulnerability. An abstract Other is not necessarily going to make a physician less regretful. Many healthcare workers were deeply moved by the vulnerability they witnessed.

Moral regret could continue alongside vulnerability, proximity, and supererogation, which is consistent with many philosophies, and, in practice, many healthcare workers did this – they helped facetime relatives, etc. Proximity and vulnerability are built-in to triage.

Conclusion

Particularly in clinical settings, tragic dilemmas generate forms of moral regret that cannot be eliminated with better rules or clearer decision-making processes. Levinasian asymmetric altruism offers a more adequate response to tragic dilemmas than the conventional strategies of illusionism, delegation, and responsibilisation. By shifting ethics from agency to responsibility for the Other, it reframes moral regret as evidence of the self’s infinite and irreplaceable responsibility rather than as a failure of moral agency.

This reframing of moral regret is given practical shape through the principles of vulnerability, proximity, and supererogation. Together, they direct ethical life away from rule-following and toward sustained responsiveness even under conditions of constraint. Such a perspective transforms moral regret as a sign of moral fidelity rather than moral culpability.

Although the experience of moral regret in tragic dilemmas is undesirable and ineliminable, it need not be corrosive and debilitating. Through Levinasian asymmetric altruism, moral regret becomes more bearable by affirming human finitude and plenitude, and enduring responsibility to the Other that persists beyond what one was able to do.

-

^[[1]^] Arabi, Yaseen M., Myatra, S. N., & Lobo, S. (2022).  Surging ICU during COVID-19 pandemic: an overview. Current opinion in critical care vol. 28 (6): 638-644. doi:10.1097/MCC.0000000000001001.

^[[2]] Ives, J. (2020, March 14). Coronavirus may force UK doctors to decide who they will save. The Guardian. https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-older-people-doctors-treatment-ethics.

^[[3]]  Teres, D. (1993). Civilian Triage in the Intensive Care Unit: The Ritual of the Last Bed. Critical Care Medicine 21 (4): 598-606. DOI: 10.1097/00003246-199304000-00022.

^[[4]^]  Valera, L., Castro, R., & Carrasco, M. (2022). Fallacy of the Last Bed Dilemma. Journal of Medical Ethics 48 (11): 915-921. DOI: 10.1136/medethics-2021-107333.

^[[5]]  Smith, E., Kulasegaran, N., Cairns, W. et al. (2024). Physician experiences of critical care triage during the COVID-19 pandemic: a scoping review. Discover Health Systems 3 (30). https://doi.org/10.1007/s44250-024-00086-6  

^[[6]]  Jiaoling, H., Ying, Q., Yuge, Y., Hong, L., & Laijun Z. (2024). Addressing Hospital Overwhelm During the COVID-19 Pandemic by Using a Primary Health Care-Based Integrated Health System: Modeling Study. JMIR Medical Informatics 12. https://doi.org/10.2196/54355   

^[[7]] Enck, G., & Condley, B. (2023). Agent-Regret in Healthcare. The American Journal of Bioethics, 25(2), 6–20. https://doi.org/10.1080/15265161.2023.2276166

^[[8]^] de Snoo-Trimp, J., Van Den Hoven, M., & Molewijk, B. (2025). Agent-Regret in Healthcare: Toward a More Precise and Empirical-Based Look into the Dynamics of Agent-Regret Experiences. American Journal of Bioethics 25 (2):29-31. https://doi.org/10.1080/15265161.2024.2441744

^[[9]] Vickers, A. J. (2017). Decisional Conflict, Regret, and the Burden of Rational Decision Making. Medical Decision Making: An International Journal of the Society for Medical Decision Making, 37(1): 3–5. https://doi.org/10.1177/0272989X16657544

^[[10]] Turin, M. (2023). The Neuroscience of Regret: Why it Haunts us. Science News Today. https://www.sciencenewstoday.org/the-neuroscience-of-regret-why-it-haunts-us

^[[11]^] Matarazzo, O., Abbamonte, L., Greco, C., Pizzini, B., & Nigro, G. (2021). Regret and Other Emotions Related to Decision-Making: Antecedents, Appraisals, and Phenomenological Aspects. Front. Psychol.,12, sec. cognition. https://doi.org/10.3389/fpsyg.2021.783248

^[[12]] Connolly, T., Ordóñez, L. D., & Coughlan, R. (1997). Regret and responsibility in the evaluation of decision outcomes. Organ. Behav. Hum. Decis. Process. 70, 73–85. doi: 10.1006/obhd.1997.2695

^[[13]] Danaher, J. (2022). Tragic Choices and the Virtue of Techno-Responsibility Gaps. Philosophy and Technology 35 (2):1-26. doi:10.1007/s13347-022-00519-1  

^[[14]] Festinger, L. (1957). A Theory of Cognitive Dissonance. Stanford University Press.

^[[15]] Danaher, 2022.

^[[16]] Steffel M., Williams, E., & Perrmann-Graham, J. (2016). Passing the buck: Delegating choices to others to avoid responsibility and blame. Organizational Behavior and Human Decision Processes, 135: 32-44. doi.org/10.1016/j.obhdp.2016.04.006.

^[[17]] Bhatia, S., & Mullett, T.L. (2016). The Dynamics of Deferred Decision. Cognitive Psychology, 86, 112-151. https://doi.org/10/1016/j.cogspych.2016.02.002

^[[18]^] Danaher, 2022.

^[[19]^] Levy, N. (2011). Hard Luck. Oxford University Press; Levy, N. (2014). Consciousness and Moral Responsibility. Oxford University Press.

^[[20]^] Matarazzo et al., 2021.

^[[21]^] Levinas, 1979. p. 194 (alterity).

[22] Levinas, 1979. p. 216.

[23] Levinas, 1979. p.199.

[24] Bernasconi, R. (2018). When Alterity Becomes Proximity: Levinas' Path. In The Oxford Handbook of History of Phenomenology.  (Dan Zahavi, Ed.) Oxford University Press.

[25] Ariely, D. (2012). The Honest Truth about Dishonesty. Harper Collins Publishers.

[27] Schwind, P. (2019). “Do Psychological Defeaters Undermine Foundationalism in Moral Epistemology? - a Critique of Sinnott-Armstrong’s Argument against Ethical Intuitionism.” Ethical Theory and Moral Practice. 22 (4):941-945. https://www.jstor.org/stable/45237961.

[28] Espinosa JC, Antón C and Grueso Hinestroza MP (2022). Helping Others Helps Me: Prosocial Behavior and Satisfaction With Life During the COVID-19 Pandemic. Front. Psychol. 13:762445. doi: 10.3389/fpsyg.2022.762445   

[29] Kakulte, A., & Shaikh, S. (2023). Prosocial Behavior, Psychological Well-Being, Positive and Negative Affect Among Young Adults: A Cross-Sectional Study. Industrial Psychiatry Journal. 32 (1):127-130. https://doi.org/10.4103/ipj.ipj_214_23