Homicidal ethics – on the use of trolley thought experiments and other such nonsense in health care ethics

There are five people standing on the train track. A train runs uncontrollably towards them. You can save these people. All you have to do is to pull the lever that directs the train to another track.

Here’s the twist: there’s someone standing on the other track too. This person is morbidly overweight and a smoker. Perhaps even a pensioner. What do you do? Do you let the train run over five people or do you pull the lever causing the death of one person?

But wait. There’s another twist. You could stop the train by pushing something heavy in front of it. A fat guy is conveniently standing next to you. Do you push the guy on the tracks to save the other people?

Would you change your mind if one of the five people on the first track was a brain surgeon? A millionaire who gives to charity? A child perhaps?

These trolley thought experiments are among the stupidest things human mind has ever spawned on earth. They are extremely dangerous simplifications. They are homicidal. Someone has to die. And you have only equally bad options to choose from. You have to weigh lives, conduct an “ethical” calculus, where the good of the many outweighs the good of the few. The criteria you are given are age, income, health, lifestyle, and so on. But even for Utilitarianism (and I’m not a fan) the trolley problem is a poor excuse.

Despite this, it is not unheard of that they are used as analogies for scarce resources in health care. The ethics of prioritization in health care fits all too well to the homicidal model of the trolley problem. The obvious example is organ donation. Would you kill a healthy prisoner if his/her organs could save five people?

Prioritization is something that health care workers face everyday. This is an undeniable fact. However, trolley problems offer a limited model for ethical decision-making. Although it might often be the reality of prioritization that only limited and equally bad options exist, why should the situation be simply accepted as given? Why should the complexity of moral life and the complexity of the human capacity for thinking be reduced to a game that is rigged from the start?

Trolley thought experiments and other such nonsense in health care ethics take moral distress – the resulting suffering from bad conscience of not being able to do one’s job as ethically as one would like to, often due to external (read: political and economic) circumstances – as a necessary evil. They claim, borrowing an argument from a paper at a bioethics conference I attended a while ago, that moral distress is necessary for the cultivation of the virtue of moral sensitivity.

To me this is unacceptable. The starting point for health care ethics ought not be to accept that things that are bad are also unchangeable. The starting point ought to be to resist whatever might stand in the way of moral practice. In other words, to use the trolley problem against itself, why the **** are the people forced to stand on the track in the first place?


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