I have always struggled with a version of the “Trolley Problem”, which, as classically presented, involves a trolley on a track that is on a path to kill five engineers working on the same track. You are standing next to a lever. You may pull the lever to switch the trolley to a different track, where it will only kill one engineer. Do you pull the lever?
Most people will opt to pull the lever, reasoning that it is better to prevent five deaths, while sacrificing one. I would pull it, too. Calculations such as the Trolley Problem are the foundation of one type of moral theory called utilitarianism. Championed by John Stuart Mill and Jeremy Bentham [3], utilitarianism is focused on maximizing good consequences. Under a utilitarian framework, if all the individuals on the tracks of the trolley are similar (no infants or Nazis), it makes sense to save five and sacrifice one.
Moral philosophers amended the Trolley Problem, creating the Transplant Dilemma [2, 5]: A surgeon has five patients in need of an organ and another patient who is a perfect match for the needed organs. Without an immediate transplant, the other five patients will die. Should you euthanize the one patient and harvest his or her organs to save the other five?
My colleagues and other moral philosophers who argue about this dilemma often focus on the doctrine of double effect (that it is morally acceptable to do something that leads to a morally bad side effect as long as the side effect was not intended). Indeed, there are distinctions between killing and letting die and where to draw lines of acceptability in maximizing the good [6]. The Transplant Dilemma and the debates, distinctions, and doctrines that come with it make me uncomfortable. In fact, I believe it is an error even to frame the scenario within a clinical relationship because surgeons have special obligations to their patients.
The phrase “special obligations” is an important concept within philosophy because it helps to clarify whether unique relationships are permissible, even within a utilitarian framework. The Stanford Encyclopedia of Philosophy notes: “Special obligations are obligations owed to some subset of persons, in contrast to natural duties that are owed to all persons simply qua persons” [4].
The concept of special obligations is not only present in one’s personal life; there are also special obligations in our professional lives, particularly for physicians. For example, the American Academy of Orthopaedic Surgeons Code of Medical Ethics mentions the following obligations:
“The orthopaedic profession exists for the primary purpose of caring for the patient.”
“The physician-patient relationship has a contractual basis and is based on confidentiality, trust, and honesty.”
“The orthopaedic surgeon should maintain a reputation for truth and honesty. In all professional conduct, the orthopaedic surgeon is expected to provide competent and compassionate patient care... and maintain the patient’s best interests as paramount” [1].
The Transplant Dilemma thought experiment was not designed to account for the patient-physician relationship; it was designed to consider what ethical boundaries are needed in the pursuit of good consequences. But I think my discomfort with the experiment illuminates another important fact. In these times of ever scarcer resources, it is important for physicians at the bedside to focus on their special obligations and each particular patient’s best interests, never calculating how resources might be better spent on other patients. This is why medical school ethics training focuses on promoting patient-focused principles, such as respect for autonomy, non-maleficence, and beneficence.
In contrast, public health ethics are based on consequentialist moral theories balanced by the principle of justice. Public health ethics permit calculations about consequences and utility. In fact, in Great Britain, the National Health Service allocates resources according to Quality Adjust Life Years, or QALYs (a generic measure of health quantifying both the quality and the quantity of life lived). These decisions are purposefully made away from the bedside, and the decisions are made for unnamed individuals in aggregate. Making policy at a population level prevents deliberate harm to any particular person, although it may harm in aggregate one group of people (or those with one particular illness) for the benefit of another group of people (or group with another illness). Public health ethics inevitably leads to trading the well-being of some for the greater well-being of the larger group.
Committees making decisions at the population level are necessary because allocating resources on a case-by-case basis creates substantial moral hazard. How is a physician to judge an individual patient’s deservingness? For this reason, when resources are scarce, it is especially important that government and healthcare institutions create resource allocation frameworks and do not push this burden onto individual physicians. Suppose there is a scarcity of blood products, and I have a patient in need of a life-saving transfusion. I have special obligations to my patient, and thus it is my duty to advocate for his or her best interests, ordering the blood product. Public health ethics are designed to accommodate rationing of scarce resources, such as blood or organs. Bedside clinical ethics are not built for this task. It would be impossible for me to justify harm to my patient under the principle-based rubric of respect for autonomy, beneficence, and non-maleficence.
We need to have physicians in gatekeeper roles at the societal level, wearing their public health hats as they determine parameters for the allocation of scarce resources. But, at the bedside, physicians must avoid such a gatekeeper role. Their special obligations require that they promote each patient’s best interests. Imagine the alternative. Who would want to be a patient in a world in which your physician was constantly evaluating your utility and value, trying to determine if your organs might be better used in the service of others?
Footnotes
A note from the Editor-in-Chief: I am pleased to share the next installment of “Virtue Ethics in a Value-driven World.” In this quarterly column, Casey Jo Humbyrd MD uses virtue ethics—the branch of normative ethics that focuses on moral character—to explore controversies relevant to the practice of medicine and orthopaedic surgery. Dr. Humbyrd is both an orthopaedic surgeon on faculty at Johns Hopkins University and an ethicist at the Berman Institute of Bioethics at that institution. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org.
The author certifies that neither she, nor any members of her immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research® or The Association of Bone and Joint Surgeons®.
References
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