Hello. In this video I will analyze the knee surgery trolley problem that
I posted a short video about last week. The link is in the description below.
First I want to say a few words about what trolley problems are and what I think they're trying
to establish. A trolley problem is a thought experiment in philosophy. Its classic form is:
a runaway trolley is about to strike five people but if you, a bystander,
intervene and flip a switch the trolley will be diverted onto a track where it will kill
only one person. Then the question is: should you throw the switch? Would you be justified in
throwing the switch to directly kill one person rather than allow five people to be killed?
There's a lot going on in trolley problems and different variations of them but I think one
of the main purposes of a trolley problem is not to get the right answer or even to provoke
disagreement but rather to bring to the surface our intuitions, our sort of gut check judgments
about cases where sudden decision is required like this. It brings them to the surface not so we can
present them to other people or compare them but so that we can do more philosophical work: we can
analyze them, we can evaluate them, we can choose which intuitions we would wish to strengthen and
which to suppress, we could try to connect them to a principle or a moral system which we would
adopt to try to synthesize our ethical character into a whole. All those are things we can do with
our moral intuitions once we are aware of them, and I think a trolley problem can serve to help
us help make us aware of what our what our snap judgment principles are or at least seem to be.
My series of realistic trolley problems is intended to help bring these intuitions to the
surface in a more recognizable environment. One of the, one of the criticisms of trolley problems
is that they seem highly artificial. Nobody is ever the sole bystander able to throw a switch.
The realistic scenarios here allow us to imagine a protagonist like us or let's say a scenario in
which we easily could imagine ourselves having to make a sudden decision like this. In fact some of
these problems are drawn from history: people have had to make decisions precisely like this.
The one I'll discuss today goes like this: you are working at a hospital where the financial
system is such that the hospital only gets paid for knee surgeries if it performs 50 or more in
a calendar year. You can't change the payment system, that is fixed and beyond your control,
but you do work within it. It's December and you've only done 48 knee surgeries and
the question is: should you be willing to do two unnecessary surgeries, do knee surgeries on two
patients for whom surgery is not the best option in your medical judgment, in order to guarantee
the hospital payment for all the work that it's already done? And in the scenario imagine the
hospital itself is in some financial distress and losing this source of income might push it
over the edge into insolvency, closing it down and depriving people in the area of access to
medical care. Again, see the the link in the description below for the full trolley problem.
So like most trolley problems this one presents us with a choice between a principle or rule
which we would follow in ordinary times and a certain utility or avoidance of disutility that
that might be achieved by disregarding the rule, by breaking with the principle in this one case.
So what is the principle and what are the utilities involved? Well here's what I want to do,
a little bit of analysis. So here's a list of some of the materials that I think are,
some of the factors that I think are relevant to the decision that we would make.
By far most of the comments, commenters right now on that video have taken the, the no it's not
proper, not appropriate to do the knee surgery [view]. So let me show you the chart here that
I've typed up with just with a few minutes of thought. Should we do unnecessary knee surgery?
The question here is whether to act or whether to refrain from acting. And on the side of refraining
we have a principle. It seems the principle here I could just describe loosely as professional
obligation: a doctor has an obligation as a doctor to himself, to society, to this sort of corps of
doctors, and also an obligation to the patient, to be a doctor, and to be a doctor means always
to take into, always to take medical decisions and recommendations and actions which are in support
of the patient's health, not for any financial motive that's separate from that. That seems to
be a very strong factor on one side. In fact one might even argue that that principle is enough to
decide the question; it doesn't matter what else is on the chart. But thinking for a little while
I put a few more things on the refrain side. I said there's also the question sort of in general
of patients' trust in their physician, as a sort of cultural factor. Patients trust their doctors
to do what is right for the patient and not to do more than that, not to do things that enrich the
doctors or support the financial health of the medical institution of which they're a part if
it conflicts with what's best for the patient. So this is a general question beyond just mere
professional obligation, duty, the Hippocratic Oath: there's the broader question of patients'
trust their doctors and this, this, this acting in a way so as to do these surgeries abuses that
trust. There's also of course the question of the law. It is certainly in Germany and elsewhere
against the law for doctors to do unnecessary surgery that they know to be unnecessary.
There's the harm and the risk of actually doing the surgery to the two patients:
each of them will have a greater recovery time, it will involve invasive procedures in their bodies
which are not justified by medicine. There's the betrayal of trust, the need to tell a very
specific concrete lie to at the very least the two patients you are deceiving. So I'll
put that sort of in addition to, that's a sort of concrete case of which the abuse of patient trust
is the general case. There's also the question of whether there are other solutions. And it doesn't
take too much thought to imagine that one might say, you know perhaps we can recruit two people
from outside the local area to come and get their knee surgeries done here. I might go to two people
in Munich and say "would you travel an hour out into the country to come to my hospital for your
knee surgery? I'll pay your travel expenses and maybe a couple of days recovery time in
the mountains as well." There might be other solutions beyond the one that's proposed here,
this fairly radical violation of a professional obligation and principle for these two patients.
What can I say on the Act side? Now here's where I would find the utility that's to be balanced
against the principle. If we violate the principle we can achieve some good. What's the good that's
promised in this hypothetical thought experiment? Well one is the preservation of access to care,
to medical care, for thousands of people in this rural area where the hospital is
located. I might specify it's not just medical care period, it's fast emergency medical care,
which is quite important. But we do face the prospect that even if my hospital, my clinic,
closes people will still have access to care. They may have to drive an hour to get it. There is
however the prospect mentioned in the video that there will be additional deaths in the future if
this hospital closes because of a lack of money, that people who would have survived if they had
a 10-minute trip to a hospital will die on the 60-minute trip into the hospital in the city, and
that that would be a foreseeable consequence of my refusing to do these two additional surgeries.
So how do we balance this out? How do we evaluate this? I think looking at all these factors here
the one that seems strongest is of course the first one I've put on the right side. The
professional obligation of a doctor is a powerful principle and it seems that it would require an
immensely powerful utility on the opposite side in order to even begin to justify its
violation. Some people would argue it can never be justified; I'll return to that idea in a moment.
What we have on the left column are some utilities which it would be nice to have and maybe even
quite important, in fact: preventing additional deaths in the future is certainly good. But they
have a couple of characteristics that seem to seem to me to place them in a weaker position relative
to the very strong principle that doctors should always act in their patients' best interest.
The first is that there's simply not enough quantity of utility, benefit, to be gained by
violating the principle. Access to care is good, access to fast emergency care is good, but it
seems like it's it's not of a magnitude sufficient to justify that, I would want to justify, a
potential violation of the principle as important as the professional obligation to patients.
I'll say also: it's not definite enough. It's not for certain that the hospital will close and if it
does I should also say it's not certain that my particular failure to bring in sufficient income
in the knee surgery unit was the deciding factor in causing it to close, which indicates that I
may not bear full culpability for whatever the foreseeable consequences of its closure would be.
And then I'll say as well it seems to me that the the problems that come up with failing to
act on the left column are not immediate enough. There are benefits to be had,
there are losses to be had, but the idea that someone at some point in the future,
some unknown people, may die as a result of not having access to fast medical care,
seems kind of weak when placed up against the fact that I have to lie to and violate the bodies of
and the trust of these two very specific patients in front of me right now. So it seems to me that
if this argument were to work at all as in the case of acting and doing the surgeries I would
want to find something much more powerful on the left side of this chart than I actually
do find. So that's my sort of simple analysis of what I see to be the factors involved and
the weight that we would assign to them. Those are the kind of things that we might debate if
we were to go further through this problem or go over it again from a different perspective.
So, a final word about trolley problems in general. One of the things that comes up is that,
in analyzing a problem like this is: what does it mean to have a principle? Is, is my,
is my principle that doctors must always act in the best medical interests of their patients?
Well if it's a principle it seems like it ought to never be up for negotiation for being violated
under any circumstances, that even to treat it as the thing, kind of thing that might be
balanced against things in the left column is to miss the point of having a principle.
Is it just the case that my principle that a doctor should act in the best interest of
their patients... is that simply a very high utility good that I attach a lot of value to,
which would need to be matched by an even greater value benefit to be had, I mean if Hitler will
take over the world unless I do these surgeries perhaps in that case I would consider doing it. So
maybe the question I'll leave us with, that we'll talk about perhaps if we analyze more of these,
is: once I bring a principle into play, isn't that sufficient to make the decision? Isn't all
the rest of it simply discussing why it is that the utility being brought up is not sufficient
to overwhelm the principle? Or perhaps I'll ask the converse of that: if I do think that utility
could override the principle in question, is it simply the case that it never was a principle in
the first place? That that's not what I'm dealing with what I'm going through my sort of unexamined
moral reasoning about this particular problem? So that's my analysis of the knee surgery
realistic trolley problem. I hope you found it Illuminating. Thanks for watching today; goodbye.