The trolley problem is a classic example of an ethical thought experiment. The fictional conundrum is as follows: you are an onlooker watching a trolley come towards you, and it is going to hit five people. You have a lever that can divert the trolley, killing one person instead of five. What do you do? Initially, it may seem like a simple choice (1). Kill one person to save the five, but the trolley problem touches on larger, more nuanced moral questions. Are you, as bystander, committing active murder by pulling the lever and subjecting someone who would have otherwise been spared death, and is this active participation any different than not interfering, letting the trolley continue on the path it was going to take and killing five people? It plays at a bigger question about moral responsibility and blame and active vs passive involvement.
The trolley problem can roughly be divided into two fields of normative ethics: deontology and utilitarianism. Deontological ethics believes there are intrinsic rights and wrongs, independent of any consequences the action may bring about. The morality of an action does not depend on any actions it may bring, whether that action is good or bad (2). Essentially, the ends do not justify the means. An action or choice cannot become morally or comparatively right, even if it minimizes harm. Opposingly, utilitarianism is a consequentialist moral theory: the most moral choice is the one that brings about the greatest good and minimizes harm (3).
If we return to the trolley problem and the question of if it is morally permissible to sacrifice one person to save five, it becomes clear that the two theories above would produce opposing answers. Deontology believes murder is wrong. That is an absolute, and it does not matter whether the net effect is four lives saved. Interfering is a form of murder, and therefore one should not pull the lever. On the other hand, utilitarianism would argue that by pulling the lever and killing one person instead of five, the action is justified, and doing nothing would be wrong because you are passively allowing more people to die.
The trolley problem has been expanded into more detailed iterations. For example, would it matter if the five people were all convicted murderers and the one person was an innocent child or world-renowned surgeon that could save dozens of lives in the future?
Most of us would agree sacrificing one person to harvest their organs and save five people is wrong, but these thought experiments become more applicable when limited resources like organs or ventilators during unprecedented pandemics are scarce and need to be allocated “fairly.” In the context of medicine, decisions about resource allocation often involve weighing fairness against outcomes. The United Network for Organ Sharing’s (UNOS) waitlist is not static. People move up or down based on medical necessity, among other factors. Most transplant centers require six months of abstinence from alcohol prior to liver transplantation (4). People have criticized this practice as being discriminatory against people with alcohol use disorder, which is often stigmatized as a lifestyle choice versus addiction as a disease with a genetic component (5). One could make a similar argument for nonalcoholic steatohepatitis for which obesity is a major risk factor, and yet no stipulations exist in those cases. Furthermore, there are concerns that these measures are punitive, and lead to worse outcomes by requiring patients in need of a liver to undergo a waiting period in which their physical condition deteriorates. Many argue anything but unequivocal equity in terms of organ transplantation is unethical. On the other hand, ethicists like Alvin H. Moss and Mark Siegler posit a very different opinion, much of which rests on the “dire, absolute scarcity” of available livers. They argue giving a liver to a child with primary biliary atresia is more ethical than giving a “second liver to a patient with “alcohol-related end-stage liver disease who was born with a normal liver” (6,7). In their opinion, one must avoid always equating blanket equality with fairness; would it be fair to let someone have two attempts at an exam but grade them on the same scale as everyone else? Either way, we are subscribing value to life, whether that be an equal value or one that takes into account additional factors in the pursuit of fairness. While we try to make these decisions as fairly as possible, neither utilitarianism nor deontology fully encapsulate what it means to be forced to make a decision that saves someone else’s life at the cost of another, whether via direct action or through the indirect prioritization of life-saving resources.
Medicine is not just a number’s game. Beneficence is one of the fundamental tenets of all moral principles. As the Hippocratic Oath states, “first, do no harm” (8), but what happens when harm is unavoidable? Clinical trials require some people to bear more risk for the masses to benefit. An organ given to one person is in effect taken from another. The ethical dilemma cannot be avoided when the proverbial trolley is racing ahead and someone will be hit. It is not a question of doing no harm, but picking what harm is most morally and ethically tolerable, hence why the trolley problem is such a long-standing, interesting thought experiment. We would all choose to stop the train if possible, but when we cannot, should the lever be pulled?
References
- Merriam-Webster. (n.d.). Trolley problem. Merriam-Webster. https://www.merriam-webster.com/wordplay/trolley-problem-moral-philosophy-ethics
- S. E. R. (2023). Deontological ethics. In The Stanford Encyclopedia of Philosophy (E. N. Zalta, Ed., Fall 2023 Edition). https://plato.stanford.edu/entries/ethics-deontological/
- Boudreaux, D. (2020, October 15). Applying utilitarianism: Are insider trading and the bailout of GM ethical? Seven Pillars Institute. https://sevenpillarsinstitute.org/ethics-101/applying-utilitarianism-are-insider-trading-and-the-bailout-of-gm-ethical/
- National Health Service Blood and Transplant. (n.d.). Looking after yourself before a liver transplant. NHS Blood and Transplant. https://www.nhsbt.nhs.uk/organ-transplantation/liver/receiving-a-liver/looking-after-yourself-before-a-liver-transplant/#:~:text=If%20you%20have%20alcohol%2Drelated,will%20give%20you%20more%20information.&text=If%20you%27re%20overweight%20or,be%20encouraged%20to%20lose%20weight
- Callahan, D., & Pippin, J. (2015). Ethics and organ transplantation: The case for deontological principles. Transplantation Proceedings, 47(4), 1262-1265. https://doi.org/10.1016/j.transproceed.2015.01.045
- Dwyer, J. (1991, April 2). Liver transplants for alcoholics. The Washington Post. https://www.washingtonpost.com/archive/lifestyle/wellness/1991/04/02/liver-transplants-for-alcoholics/62cc4053-e02b-4391-9319-bb4088af1719/
- Detsky, A. S. (1996). Responsibility and priority in liver transplantation. Cambridge Quarterly of Healthcare Ethics, 5(4), 547-558. https://doi.org/10.1017/S0963180100007867
- U.S. House of Representatives, Committee on Ways and Means. (2022, July 19). Hearing on liver disease and transplantation in the United States (HHRG-117-IF02-20220719-SD007). U.S. Government Printing Office. https://www.congress.gov/117/meeting/house/114995/documents/HHRG-117-IF02-20220719-SD007.pdf
Nicole Varda is a medical student at the University of Arizona College of Medicine-Phoenix. She’s particularly interested in bioethics and narrative medicine. She also enjoys reading, exploring new coffee shops and breweries, and spending time with family and friends. Please feel free to reach out at nvarda@arizona.edu.