Ethical dilemmas in Emergency Medicine Part 2

Last week we published our first ‘Ethical dilemmas in Emergency Medicine’ post, complete with a hypothetical scenario that hopefully got you thinking! I was quite humbled by the quality of the responses that came in. It shows that there are people out there with a big interest in medical ethics, who have a great deal of expertise. I guess this highlights how important medical ethics is to our practice.

If you haven’t already read the hypothetical scenario, take a look now – you’ll need it to make sense of this post. In the scenario, we have a difficult choice. On the face of it, we can choose to save either 1 life (the old chap under the car) or 5 (the family in the car). Given a straightforward choice like this, I’m sure that everyone would choose to save the 5 lives.

There is, however, a caveat… To save the 5 lives you actually have to kill someone. You’re not just letting him die. You’re actually causing his death. Of course, this raises all sorts of further questions. If it’s OK to kill the old guy here, is it OK to kill another old guy from the local nursing home in order to harvest his organs and save 5 others who need urgent transplants? If not, what’s the difference?

Among the comments last time, Michael Stewart would have saved the family and killed the old chap – but he adds an important caveat, that his judgement on this one can’t necessarily be generalised to other similar situations. That’s a nice get out clause (not quite as blatant as kangaroobeach and David Menzies who both wanted a third alternative  [You can’t have it by the way!]) but I totally understand what Michael’s saying.  What’s the difference between the two situations described above? Is it about how blatant the killing is; is it entirely rational; or is it mainly emotive? Alex Kobzik recognised the case I presented as a modified version of the ‘trolley problem’. Here’s the first version of that scenario:

Imagine you’re standing on a railway bridge overlooking a train line. You see a train coming and realise that, unless you do something, it’s going to run over and kill 5 people working on the train line. There’s a set of points and you can control the lever. By pushing the lever, you’ll divert the train to save the 5 people. However, if you do so you’ll send the train down another route and kill 1 person. What do you do?

If you’ve not heard this before, think about what you’d do.  Now, here’s another version of the same scenario (as mentioned by Tom Leckie in the comments to the previous post):

This time, as you stand on the railway bridge, you realise that there’s a fat man standing next to you.  This train’s going to take some stopping and a fat man will be just about sufficient.  If you push him onto the rails, you’ll kill him but save the 5 people further down the line.  What do you do?

Interestingly, in the first version most people would choose to save the 5.  However, most people would save the fat man in the latter.  Perhaps this is the qualitative or emotive value we attach to actually physically killing someone versus the more remote and impersonal feelings we attach to simply flicking a switch.

How do the issues in this case relate to the basic principles of medical ethics?

You’re probably aware of the 4 pillars of medical ethics first described by Beauchamp and Childress.  What are the implications for each of these 4 pillars from our original hypothetical scenario?

Beneficence

We have a duty to do good.  In this scenario, our intentions are good.  Whether we wish to save the 5 or avoid actively killing the 1, our intentions are generally beneficent.  But can an action intended to kill someone ever really be described as beneficent?  If so, which course of action is really more beneficent in our scenario and does having an intention to kill influence this?  And is it the intention or the consequence that really matters?

Non-maleficence

We also have a duty to ‘do no harm’.  Here we have a problem.  If we choose to kill the old man, it’s quite clear that we’ve committed a pretty serious breach of this duty.

However, there is another question here about whether an act of omission (neglecting to flick a switch or push the fat man) is as bad as an act of commission (flicking the switch or pushing the fat man).  Here we have a problem.  If we assume that an act of omission can ‘actively cause’ harm just as an act of commission can, then it would be impossible to “do no harm” in this scenario.  Either way, some harm will result – and we will have had a part to play in that.

Of course, this is a completely unrealistic hypothetical scenario.  It would never happen in real life.  So perhaps we don’t need to worry?  Don’t be so sure – we’ll explore this more in part 3!

Autonomy

As Tom pointed out in the comments on the previous post, we should respect the autonomy of the individual.  Nobody would argue with that, right?  But who chose to kill the old man?  What about his autonomy?  There was no time to ask for his consent.  You just killed him, right?  How does that fit in?  Didn’t he have a right to autonomy?

Do we always respect the autonomy of the individual in medicine?  This is something we’ll examine a bit more carefully as this series evolves.

Justice

In this scenario, we are the judge and the jury.  Our decision determines what’s just and we’re making our own judgements, right?  Perhaps you feel it would be unjust to let 5 people die when they could be saved at the cost of only 1.   The reverse – to save 1 to let 5 die – really does seem unjust.  But what about justice at the individual level for the old man?  He was just minding his own business walking down the pavement when a car ploughed into him.  He must’ve been pretty glad to see the doctor and realise he was going to be OK.  You could imagine how he would feel when he realised the doc was going to kill him – that’s not justice!

But can we ever achieve justice in medicine?  And what exactly is justice?

These are all issues we can explore as we go on.  But for now, I’ll leave you with a last thought.  Those of you who chose to let the car fall because it’s wrong to kill are practising deontology.  Perhaps you recognise that there are moral absolutes and you feel it’s always wrong to act against them.  On the other hand, those who were happy to kill the old chap to save the family were being utilitarian.  You were aiming to maximise the benefit for the greatest number.  This really does have implications for our practice – as Casey Parker alluded to in his comment.  And that’s what we’ll look at in greater detail next time.

Hope you’re enjoying the series.  Thanks for all your comments last time and please do keep giving your feedback.  It really does make the posts so much better.

Posted by Rick Body

Professor Richard Body MB ChB, FRCEM, PhD is Professor of emergency medicine in Manchester. He is honorary Consultant in Emergency Medicine at Manchester Foundation trust. He is also the director of the Manchester Diagnostics and Technology Accelerator (DiTA) and Research Director of the Emergency Medicine and Intensive Care Research Group (EMERGING). His research interests include diagnostics, cardiac disease and the philosophy of emergency medicine. He is an acclaimed international speaker on cardiac diagnostics . He can be found on twitter as @richardbody

  1. For me, the moral choices in these scenarios are based on Natural Law and consequently simple – one may never directly intend an evil act (such as killing an innocent person). However an evil effect (i.e death) may be permitted if the effect is not intended in itself but is indirect and justified by a commensurate reason.

    A really interesting aspect of this discussion is are we able to formulate moral guidelines when there is no common societal consensus on medical ethics?

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  2. You could kill me and save a lot of people with my organs…

    Another interesting question is to imagine you are a surgeon with 2 incoming trauma cases. One is a life threatening case and the other is a limb threatening case. Which do you perform? Obviously everyone would attempt the life threatening case first. But what if you were the guy who was about to lose his arm? Is your arm worth more or less to you than a stranger’s life?

    Tricky how perspective changes things.

    Really enjoying the discussion.

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  3. These judgements have to made at times, but not really sure that clinicians are capable of making them. Our thought processes do not permit this, except in the most blunt and clear cut situations. (5 traumas, most of us think we can leave the one least likely to survive)
    Perhaps we need to train a specialty speciifcally without the “value judgements” we make on a daily basis, who can sit back and make the tough calls.

    Which drugs will we fund?
    Age limits to ICU admissions?
    Organ Transplant Policies?
    Public / Preventative Health vs Acute Care Funding
    Caps on Specialty Training?
    Location based restrictions on practice?
    etc, etc etc.
    All of these create the life changing, life altering, or life ending dilemmas above, and are all being currently made by people who cannot really be capable of the genuinely objective decisions that these questions demand. Yet in a setting of unlimited demand, escalating costs, and limited resources, the correct (or lesst worst???) answer to these questions will do more for global health than any of the ED interventions that we so passionately discuss.
    The sci-fi model of this, would be that the real life questions are posed to people who believe they are acting in a simulated environment, but who’s thus less stressed decisions are enacted in the real world. Maybe a step too far….

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  4. Sounds cruel but you have to make a choice, otherwise 6 people die, so flip a coin to see who you save, the 5 or the 1.

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  5. […] you’ve already seen the other posts in this series but, if not, you should check out part 1, part 2 and part 3. This time let’s take a look at triage – something we do every day in the […]

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  6. […] you haven’t been following this series, you can also find part 1 and part 2 on the […]

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