Here I describe a variation of the trolley problem in which a doctor is faced with the prospect of killing one patient for the benefit of saving five others, considering the institutional limitations of medicine. Includes comment over self-sacrifice and euthanasia.
A variation of the original trolley problem is the idea of a doctor in a small town. In this thought experiment a doctor has five patients which are all terminally ill and in need of organ transplants with a long life expected should there be a successful transplant. However, none is available and the patients will die soon. Then, a stranger comes to the doctor for minor complications. Coincidentally the stranger is a good biological match for the five patients in need or an organ transplant. However, harvesting the stranger’s organs will result in death. This stranger has no family or friends and will not be therefore missed.
The dilemma is: should the doctor kill the stranger in order to save the five terminal patients? (Here one could play similar scenarios of how meaningful each patient is to society, their job, the size of their family, life expectancy, and indeed paint the stranger as a homeless person or an alcoholic (to say nothing of how this might affect his organs.))
This seems like the same question as the original trolley problem to kill one in order to net four lives. Cognitive reasoning would point again to the utilitarian option of sacrificing the stranger. But the fact that the subject in this case is a doctor fundamentally changes the nature of the question. Doctors are bound by the Hippocratic oath which argues that first and foremost doctors must do no harm. If the doctor were to kill the stranger, although this is a net benefit for society, doing so would damage society’s trust in the medical institution. We place special trust in hospitals and doctors to take care of us when we are sick and to treat our own illness uniquely; meaning regardless of other patients. Not to mention the fact that it is certainly illegal for the doctor to take the stranger’s life.
Of course another way to look at this is to take the position of one of the patients or the stranger. We may be more likely to argue one action over another if the subject or his/her loved ones might benefit or be harmed.
Further, the concept of doing harm remains open to interpretation. Euthanasia, or the purposive taking of life, can be interpreted as either harm or as relief. In The Netherlands, for example, patients are allowed to select euthanasia if they meet the following criteria:
1- the patient suffers with no prospect of improvement
2- the patient’s request must persist over time (about which I’d love to clarify “persist over time”)
3- the patient must be fully salient of their condition, prospects and options
4- at least two doctors must offer consultation to the patient
5- a doctor must be present when the life taking drugs are administered
6- the patient is at least 12 years old (with parental consent when aged 12-16)
Once these conditions are met then euthanasia is considered a relief and not harm. This departure is only to support arguments that taking the life of the stranger could be interpreted as giving life rather than doing harm.
Granted this dilemma, the trolley experiment and cases of natural disaster and triage, are highly extreme cases. Which is why they make great thought experiments. These decisions and the legal frameworks which facilitate them should be made in the deliberate circumstances of debate before one has to address them in extremis when emotions and tempers run away with us.
My own opinion is that the doctor should not personally decide to take the stranger’s life nor is it permissible that the law allows the doctor to do so. Because special trust is placed in the medical institution to protect life and cure illness. I may be willing to change this stance in an extreme instance in case of i.e. an epidemic or a natural disaster, but this should be qualified with an * which sets up specific limitations. For example, let’s imagine the stranger has an illness with a 99% probability of death. However, taking his blood and giving it to other patients who will die without it with a 100% chance of recovery might be an acceptable sacrifice. As with the trolley problem subjects say they would throw themselves in the way of the trolley if it would save the five. Perhaps one could encourage the stranger to sacrifice himself.
Because this warrants comment, I remain in support of euthanasia and death with dignity laws for those extreme cases in which there is no prospect of recovery and suffering is immense. Granted, I’m privileged to deal with this question only theoretically.