Wednesday, May 09, 2007

Moral and Ethical Choices

Dr. Richard Schloss posed the following conundrum recently:
The following 2 vignettes are sometimes used to illustrate that there
are universal moral standards that transcend religion, culture, and
ethnicity, because everyone, regardless of background or belief system,
always gives the same answers. See what you think.

Suppose there is a runaway trolley car that is about to mow down and
kill 5 people. Now suppose that there is one observer standing next to
the track watching this, and he realizes that, by throwing a switch, he
can divert the car onto a different track so that it will kill only one
person, but spare the other 5. Virtually everyone says that the morally
correct thing to do is to throw the switch and sacrifice one person to
save 5; most even go so far as to say that it would be morally
reprehensible for him just to stand there and do nothing, once he
realizes that throwing the switch is an option.

Now, a different scenario: there is a hospital with 5 patients who will
die very soon if they do not receive organ transplants, and there are no
donors immediately available. (They all need different organs.) Now,
suppose someone is brought into the emergency department of that
hospital after having suffered a life-threatening, but easily
repairable, injury -- and he has and organ donor card in his wallet.
Would it be ethical for the ER staff to deliberately withhold treatment
and let him die so that his organs can be used to save the other 5
patients? Everyone says "no" to this question. Why? How is it different
from the trolley car scenario? Aren't they both cases of sacrificing one
to save 5? Why is it right to do so in the first case, but wrong in the
second? And why does everyone, regardless of background, give the same
answers to these two illustrations?

Just for fun, I'd like to throw a few qualifiers into the second
scenario. Would your answer change if the potential organ donor who can
be easily saved, but will die without treatment, had been driving drunk?
Would it change if he were a paroled murderer? What about if he had been
speeding at the time of his accident and had killed a family in another


Anonymous said...

Going back a second to the trolley car, who would throw the switch to divert the car to save the 5 people and sacrifice the life of that one person if that person was their mother/father/son/daughter/best friend? Substitute anyone you like.

A relative of mine is a doc and this doc once told me that, at least in their medical system, an alcoholic is never placed on the list for a liver transplant. There are obvious issues of supply but then again, I thought the medical establishment had declared alcoholism a disease as opposed to a personality defect. No, I am not an alcoholic, it's just a thought. Maybe it wasn't the medical establishment after all. Maybe it was AA?? Still, we do value some lives over others, while people are living them and after they are dead. I don't believe in god so I can't say I believe that all lives are inherently valuable simply because all people are created in god's image. Who knows whether some people might not be more valuable than others, and not just in a free market capitalist society kind of way? No, I am not a socialist either. It's more a question of who has the power to decide the answer to that, and on what basis. Hitler tried, and wiped out all sorts of people. He even had doctors to help him. There are plenty of more current examples but we don't see as much about them because we don't seem to value the lives of people over there in Africa quite so much as we should.

Anonymous said...

I guess I fall outside the group of "virtually everyone" in the trolley car scenario. If I were in that situation, I don't know that I would flip the switch. It's one thing for random chance to kill five people; it's an entirely different thing for me, personally, to actively decide to kill an individual.

Besides that, if I had enough time to look at the situation, see my two choices, and judge what the moral course of action is, then I certainly have enough time to scream and warn all six people about their approaching doom. Screaming out and warning them, seems like the more practical thing to do because it requires a great deal less thought and is, therefore, the quicker action.

Besides, what are all these people doing lounging around on top of a trolley track? Why aren't they paying attention to their surroundings? Are they all blind or deaf or mentally disabled in some way? How do I know that they won't be able to jump out of the way on their own before the trolley reaches them?

What if the five people saw the trolley coming and would have been able to jump out of the way in time, but, instead, I flipped the switch and sent it onto the other track toward the solitairy person. And what if that person, unlike the 5, was not expecting the trolley to come toward him, so he wasn't prepared, and he didn't jump out of the way in time? In that case, my action would have resulted in one death, when my inaction would have resulted in no deaths.

There are so many variables involved.

As far as the second scenario goes, I would not withhold treatment from the man, no matter what the qualifiers were. It is one thing for an individual to choose on their own to sacrifice themselves for someone else or for a group of people. But I don't think I have a right to force someone to sacrifice themselves for other people. I am not god; I am only a fellow human.

It might be easy for me to chose to sacrifice someone else; after all, I'm not the one being sacrificed. In fact, I don't suffer any pain at all.

How would I feel if *I* were the person being sacrificed, and I had no choice in the matter? How would it feel if my life, my personhood, my individuality, my will, my desires, my choice in the matter were of no concern to the person chosing to sacrifice me? Instead, it was just a numbers game to them; all that mattered was that I was 1 person whose death could save 5 people. How would that feel?

If we're making up qualifiers, what if the 1 person was someone like Shakespeare or Einstein, and the 5 people were all average people? What if the 5 people were homeless, or criminals, or disabled mentally or physically? What if all 6 people were just normal people, but the 1 person, if they lived, would have a child who was brilliant? What if the 1 person was brilliant, and 4 of the 5 people were average and 1 of the 5 people was brilliant? What if the 1 person was an absolute genius, and the 5 people were really smart and offered a lot to society but were not quite as great as the 1 person?

Again, there are so many variables involved.

AlisonHymes said...

I am on the transplant list for a kidney and I think it would be completely immoral to withhold treatment from anyone in order to harvest their organs for those of us waiting for one.

Tim McCormack said...

For me, the difference between the two scenarios is the narrowness of the constraints.

The trolley car question has enough qualifiers and constraints that I am forced to accept that 1) there are really only two possible actions, and 2) the consequences of either action are clear-cut and immutable. Thus, it is reduced to a simple numbers question.

The hospital question is less constrained. Were the same situation to occur in a constrained environment (space ship on its way to found a colony), I would feel that it was a numbers question. As it is, there are too many loose variables, so I don't feel that there is a simple, binary dilemma with obvious results. (Human bodies are less deterministic than trolley cars -- the recipients might die anyway, for example.)

Roy said...

It is a pretty narrow and contrived set of circumstances. Tim's comment reminded me of a recent news story about difficult ethical dilemmas in 20 years when we send a team to Mars (story here).

For example, if an astronaut is critically ill without hope of survival, do they terminate his life to prevent using up precious resources, like oxygen?

Anonymous said...

All these scenarios fall into "Survival of the Fittest". The trolley people are all in the wrong place at the wrong time. The patient's in the Hospital all have organ failure. I will answer the question though just for the heck of it.

I would switch the track. Can't tell you why, but I would. I would not let the organ donor die.

pemdas said...

One reason why the ER staff should save the critically injured patient, rather than let him die and become an organ donor:

There is no guarantee that the donated organs would be given to the 5 patients in the hospital; thereby, saving their lives.

Organ Procurement Organizations (OPO) typically serve more than one transplant center. Their service area may be an entire state. The hospital does not decide who should receive the donated organ; that decision falls upon UNOS (United Network for Organ Sharing). The OPO contacts UNOS to determine which patient on the transplant waiting list is next in line (position on the waitlist and blood type are just a two of the factors evaluated in determining organ placement).

Liver Transplant 2000

Dinah said...

I agree with Jessica and Tim. Issues of random chance versus unknown outcomes. You don't know the trolley car will kill those 5 people, if you divert it, aren't you killing the other person? How do you explain that to their family members (from inside your cell where you're seeing ClinkShrink to analyze your guilt). And you don't know that the transplanted patients will live.

I believe the issue with not transplanting alcoholics is not one of a moral outrage or judgement, but simply that if the patient doesn't stop the behavior that caused his first liver to go, the second liver isn't likely to work very long either. I could be wrong.

Anonymous said...

If given the two choices obviously i would choose both of it. It is because we must have both of it to enhance our live development from being into dump squib site. So, ethics is the way to make anyone to be better.

Anonymous said...

I am so happy happy happy to hear you say that you would not flip the switch. If, I heard correctly. As for the liver, I can se that the alcoholic person probably should not be at the top of the transplant list. That does make sense to me. The mere fact that he or she is at the bottom of the list means no liver since there aren't enough to go around so its the same as not being on the list. The problem I have is with saying that the person will not be placed on the list because he or she caused the problem. Some people do change. Some great people destroy their livers and some not so great people have lousy luck and need a liver transplant, but not because they are lousy people.
Anyway, you are right, the second liver isn't going to work anyway, most likely. BUT, if livers grew on trees and it didn't take away from hospital resources, why not give the guy a few more years. Maybe someone still loves him. Maybe he will discover a cure for bipolar.He could win a Golden Lobe for that.
I hope you are never stuck alone on a trolley track

Your Mother said...

I remember when I first read this conundrum months ago, my immediate answer was: do nothing. Who am I to play God?

Do most people actually choose to flip the switch?

Your Mother said...

It is a conundrum, though, because you CAN kill people by doing nothing. It HAS happened in our world history. No matter what you do, you've killed someone. You had knowledge that could have saved 5 people; you killed 1 person.

It would be interesting to see if this question were reframed yet again, in a way that gets the lizard brain to kick in: you're driving down the street and lose control of the car. Do you plow into the crowd of 5 people on the right, or veer away towards the 1 person on the left? What does the unthinking brain do?

NeoNurseChic said...

I think people who are recovered alcoholics can still get livers as long as they are no longer drinking. I've taken care of patients who were waiting for livers when they used to be alcoholics but had been sober for xx amount of time. I don't think people should forever be punished for the mistakes they made if they do make an active stance to change...afterall, don't we all muck it up from time to time?

As for the first one, I can't get past what the first anon said above - what if the one person was my mom or other family member? I could never sacrifice somebody I know and love for 5 random people. And I agree with Jessica in that it's one thing for a trolley car to kill 5 random people by accident, but it's entirely another to choose to kill one person to save those 5 by flipping a switch. I couldn't do it.

In terms of the hospital situation, everything deserves to be done. Hospital workers are not God - nobody has the right to say, "Your life isn't worth it..." Nobody. Who is perfect, without flaws, that can feel comfortable deeming another person's life not worthy without feeling guilty about it? I bet there are some people out there who could feel okay with it if the person were a mass murderer or something like that. But I still don't feel that mortal human beings have the right to determine who lives or dies in that way. And I agree with whoever said that the organs aren't necessarily going to go to the 5 in the hospital anyway. But even say they are, I still think everything should be done to save the person - if the situation is futile, then organ donation comes into play. I have an organ donor designation on my license - I wouldn't want an ER doc or nurse deciding that they should let me die to save 5 people waiting for organs, if whatever I had was fixable or curable.

This just goes to show that even when you have moral or ethical choices that most everyone answers a certain way about, it can still be changed so that it becomes difficult to answer - and there is not always a clear right or wrong. It depends on the situation, the qualifiers, the person making the decision, and so on. There really is not much that is "rght" or "wrong" in life in terms of these choices - which is why we have ethics committees! :)

Take care,
Carrie :)

Anonymous said...

I am the first, second, and third anon. Yay, someone might actually consider giving a liver to someone who had screwed his up from too much drink. I am going to assume that shrinks hold out the possiblity that people can and do change otherwise, why bother? So still, put the kid with the lousy liver at the top of the list, that's okay but don't write people off. They can surprise you.

Gerbil said...

A Princeton study indicated that different areas of the brain are used to consider the trolley car problem and the footbridge problem (in which the only way to save five people from being hit by a train is to push another person off a bridge in front of the train). There's more personal involvement in pushing someone in front of a train than in flipping a switch; so people tend to be more willing to flip the switch than to push someone onto the tracks.

I would think that there's a similar level of icky personal involvement in intentionally neglecting a patient in order to harvest his/her organs.

Gerbil said...

Mom who thinks too much: I think the answer to your question would depend on handedness, as we instinctively defend our faces with our non-dominant hands. If you're right-handed, your left hand would fly up, thus turning the wheel to the right and causing the car to plow into the crowd of five. If you're left-handed, your right hand would fly up and you'd take out the one person on the left.

Anonymous said...

I don't believe that most of you would do nothing about the trolley car. And if you chose to do nothing, then what would it take for you to take a stand? Everyone seemed to go off in "what if" tangents....a simple question was posed..would you hit the switch or not? You do not know these people--they are not relatives--so, you are going to watch the five get smashed because you don't believe in killing one to save five? By watching and not participating, you have just murdered five people. Either way, flip the switch or not, we'd all feel horrible and have nightmares the rest of our life. Since we are playing "what if"--what it you were the ONE?

Why are we so righteous? Everyone deserves the chance to get a liver if they have gone through the proper channels. Alcoholic or not. I know sober people who are just downright mean. I'd rather give the liver to someone who loves life. (I know that doesn't make sense). The biggest problem with this is that I am also judgemental of other's. I am trying to evolve....need a little help.

This is really a fun blog.....with fun people. Thanks for letting me play.

Sarebear said...

I'd be paralyzed w/indecision, and then hate myself for it, probably. (trolley)

Interesting discussion.

Anonymous said...

The first time I heard the trolley question my immediate response was "no". When I analyzed my reaction, I discovered that it was because, in agreement with the latter part of Jessica's response, I didn't have enough information. More bodies saved on one side of the equation does not necessarily equal more value or more morality or more ethical behavior. The five could be a mini pedophile convention and the one could be Mother Theresa. Without more information, my analytical brain says "no". What my "lizard" brain would do in actual circumstances is open to question.
The only scenario that would justify my throwing the switch that I could think of off the cuff without having any more information than that which I could see was five children vs. one adult. I think that most adults would willingly risk/sacrifice their own lives to save five children. I don't think that *most* adults would willingly risk/sacrifice their lives to save five adult strangers. However, I may be quite wrong in my assumptions. It would be interesting to have some data concerning the circumstances in which individuals would be willing to risk or sacrifice their lives.

Anonymous said...

The difference is the matter of imminent danger.

The five people in the road are in imminent danger, so you throw the switch, with an immediate net savings of four lives.

The five patients who need transplants are not in imminent danger. The ER patient is.

So you save the ER patient for that reason.

I can make this stickier. After you save the five pedestrians, it turns out the one you sacrificed is someone you know and dislike. Are you a savior or a murderer ?