Matters of life and death

A shocking memo leaked to Prospect, drafted by civil servants from the treasury and the department of health, exposes the stark reality of future cutbacks. Harsh decisions are inevitable, says the memo; in one NHS trust people on life-support systems are to be “finished off” on 1st November—either by smothering, or by having the plugs pulled out. Their organs are then to be used to save the lives of others on transplant-waiting lists, who have themselves become a considerable burden to the taxpayer. The total saving to the trust is estimated at £2.3m a year.

Hogwash, of course. But the government will make some tough choices in its spending review on 20th October, and these will cost lives. Whether “efficiencies” are made in the department of transport, the military or the NHS, there will be victims, even if they are unidentifiable. Governments always have to prioritise—choosing, for example, between a cheap medicine which benefits few people a little, and an expensive one which benefits many people a lot. But in hard financial times, such predicaments become more acute.

Moral philosophers have long debated under what circumstances it is acceptable to kill and why, for example, we object to killing a patient for their organs, but not to a distribution of resources that funds some drugs rather than others. To understand the debate you need to understand the trolley problem. It was conceived decades ago by two grande dames of philosophy: Philippa Foot of Oxford University (click here to read more about Foot) and Judith Jarvis Thomson of MIT. The core problem involves two thought experiments—call the first “Spur” and the second “Fat Man.”

In Spur, (see diagram one, below), an out-of-control trolley—or train—is hurtling towards five people on the track, who face certain death. You are nearby and, by turning a switch, could send the trolley onto a spur and save their lives. But one man is chained to the spur and would be killed if the trolley is diverted. Should you flick the switch?

In Fat Man (see diagram two), the same trolley is about to kill five people. This time, you are on a footbridge overlooking the track, next to a fat man. (The Fat Man is now sometimes described as a large gentleman. But fat or large, the fact of his corpulence is essential.) If you were to push him off the bridge onto the track his bulk would stop the trolley and save the lives of those five people—but kill him. Do you push him?

Study after study has shown that people will sacrifice the spur man but not the fat man. Yet in both cases, one person is killed to save five others. What, then, is the relevant ethical distinction between them? This question has spawned a thriving academic mini-industry, called trolleyology.

Trolleyology encapsulates the deepest tensions in our moral outlook. To tease out our moral intuitions, philosophers have come up with ever more ingenious scenarios. The trolley is usually racing towards five unfortunates and the reader is presented with various means to rescue them at the cost of another life, involving props such as obese gentlemen, footbridges, trapdoors and lazy Susans. Some of the examples are so complex that, in the words of one exasperated philosopher, this branch of ethics “makes the Talmud look like Cliffs Notes [a US brand of study guides].” But at its root the trolley problem is a philosophical detective story, attracting some of the smartest minds in moral philosophy.

One of them is Jeff McMahan of Rutgers University. McMahan is a good liberal, open to debate on any topic—except tea. Green tea is sent to him every two months from the Indian estate where it is grown. His cup of tea has to be brewed in a certain way: steeped for precisely six minutes in distilled water.

McMahan brings a similar attention to detail to moral ­philosophy. He believes that the trolley problem lends weight to a doctrine first established in the 13th century by Thomas Aquinas, the ­philosopher and theologian. Aquinas drew up the principles required for a war to be just and he was the first thinker to outline the ­doctrine of double effect, a cornerstone not just of Catholic ethics, but of common-sense morality too. Crudely put, the doctrine allows you to perform an act that has some bad ­consequences, if on balance the act is good, and if the bad effects are unintended.

Applying the doctrine to the trolley problem, it’s been argued that in the first scenario, there is no intention to kill the man on the spur. If you diverted the train but spur man miraculously escaped, you would be delighted. But in the second scenario, you intend the death of the fat man. If he were to bounce off the track and flee out of the trolley’s path, this would thwart your aim, because the five people would still be killed. You need the chubby projectile to be hit by the trolley.

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