Sunday, February 27, 2011

Runaway Trolley - Applied to End of Life Issues

The Runaway Trolley thought experiment was introduced in a previous Topic, on this Blog.

The basic lesson was that there are situations where it is quite ethical to take an action that saves (or benefits) a number of people, even if that action has, as an inevitable side effect, the death (or detriment) of a smaller number of people.

This posting has to do with End of Life Issues, and how we might apply the lesson of the Runaway Trolley to the public-funded medical care system. An earlier posting related the Runaway Tolley to Criminal Recidivism

POWERPOINT SHOW AVAILABLE

Click HERE to download a narrated PowerPoint Show that includes animated charts for the Runaway Trolley thought experiment. After the Runaway Trolley is explored, the charts continue and apply the ethical lesson to two real-world issues: 1) Criminal Recidivism and 2) End of Life Issues. The PowerPoint Show is based on a talk I gave to The Philosophy Club at The Villages, FL, on 04 February 2011. NOTE: The Powerpoint Show is Narrated and plays and advances automatically after download to your computer.

PRESIDENT OBAMA'S VIEWS

President Obama, in a moment of unusual candor, expressed his views on end-of-life health care for those with chronic or terminal illness, published in the New York Times Magazine in April 2009. (full text from NY Times website, see section V). I have reproduced the text of that section at the end of this posting. [Some material here is from my earlier posting END-OF-LIFE: Honest Brokers (not Death Panels :^)]

DIRECT OBAMA QUOTES

“… government can … be an honest broker in assessing and evaluating treatment options. … when it comes to Medicare and Medicade, where the taxpayers are footing the bill …

“… using comparative-effectiveness studies as a way of reining in costs, …

“… the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here. …

“…there is going to have to be a conversation that is guided by doctors, scientists, ethicists. … you have to have some independent group that can give you guidance.”


PRESIDENT OBAMA'S GRANDMOTHER

As a case-in-point, the President brought up the hip replacement received by his terminally-ill grandmother mere weeks before she passed away. During his campaign, she was diagnosed with terminal cancer and then, probably due to a mild stroke, she fell and broke her hip. Her condition was analyzed by her doctors who told her she had three to nine months to live due to the cancer. They also told her that a weak heart posed risks for the invasive surgery hip replacement.

In the absence of cost-effectiveness data or guidelines to the contrary, she chose the hip replacement, which was approved by Medicare and done mostly at public expense. She passed away two weeks later, sadly just days before Obama won. It appears the stress of the operation may have shortened her life by several months.

I don't know if Obama's grandmother got approval for the hip replacement because she was related to a prominent person. That would be bad enough, but it would be even worse if we are giving hip replacements and other stressful and expensive treatments to all terminally ill grandmothers and grandfathers.


QUOTING THE PRESIDENT AGAIN


"... in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. ... So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here."

QUALITY ADUSTED LIFE YEARS

A concept called "Quality Adjusted Life Years" (QALY) is in use in the UK and, IMHO, should be adapted for use in the US. The basic idea is to estimate, before approving very expensive, public-funded medical procedures, the probability the procedure will be successful, and, if successful, the number of years the recipient is likely to live and the subjective quality of those years.

Subjective quality is a difficult measure. Fortunately for us, based on experience and practice in the UK and elsewhere, there are fairly well-established guidelines. For example, mobility is an issue in quality of life. If a person is able to walk without assistance that is better than being wheelchair-bound, and a wheel chair is better than being bedridden. Being alert and awake and mentally competent is better than lack of those qualities. Being able to take food by mouth is better than IV, etc.

In the UK, if each QALY is estimated to cost less than about $40,000, and if the recipient wants the medical procedure, it is approved for public funding. On the other hand, if the cost is more than $40,000 per QALY, or if the recipient does not want the procedure, only palliative care, consisting of pain management along with love and attention, is provided, even if this level of care will reduce the likely life span of the patient.

The QALY concept may also be utilized to compare alternative treatment options. For example, if medical treatment procedure A will cost substantially more per QALY than medical treatment procedure B, only B will be approved, even if both are under the $40,000 limit.

Examples:

1) Alice is a candidate for treatment A that is estimated to cost $150K for the treatment and care, has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 60%. Based on her age and medical condition, if the procedure is successful, Alice has a life expectancy of 10 years. The calculation gives her QALY = 5 years, so each QALY will cost about $31,000, which is below the limit of $40,000. The Treatment A is therefore approved for public funding if Alice is willing to accept it.

2) Bob is a candidate for treatment B that is estimated to cost $90K for the treatment and care, has a probability of success of 50%, and, if successful, will provide a subjective quality of life of 40%. Based on his age and medical condition, if the procedure is successful, Bob has a life expectancy of 5 years. The calculation gives him QALY = 1 year, so each QALY will cost about $90,000, which is above the limit of $40,000. The Treatment A is therefore NOT approved for public funding and Bob is entitled to palliative care only.

3) Carl is a candidate for treatment C that is estimated to cost $50K, or treatment D that is estimated to cost $100K.

Treatment C has a probability of success of 90%, and, if successful, will provide a subjective quality of life of 60%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $19,000, which is below the limit of $40,000.

Treatment D has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 70%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $36,000, which is below the limit of $40,000.

Both treatment C and D are below the limit of $40,000 per QALY, but C is substantially less expensive and, therefore, only treatment C is approved for public funding if Carl is willing to accept it.

A STORY MY FATHER TOLD ME

Once upon a time, there was a boy in China and he saw his father carrying a large basket on his shoulders. "What do you have in the basket?" he asked.

"Well," said the father, "It is your grandfather."

"What are you doing with grandpa?" asked the boy.

"Well," he replied sadly, "Your grandfather is quite old and he is so sick that we cannot take care of him anymore, so I am going to dump him in the river."

The boy thought about it awhile, and then he said: "OK, Dad, ... But remember to bring back the basket!"

Of course the point of the story is that the boy will learn from his father's actions and will, when the time comes, uses that same basket to dispatch his father.

When my mom's cancer roared up after a year of chemo and radiation, she decided to accept only palliative care. Our family travelled to San Francisco where they lived and said goodby. Hospice provided morphene and a hospital bed for their apartment. We spoke by phone every evening for about a month until she passed away.

My dad made it clear that was what he wanted when the time came.

About five years later he had a stroke and fell and was taken to the hospital where an MRI confirmed a major bleeding in his brain that was terminal. He could not speak or hear or see and was being kept alive with IV hydration and nutrition and oxygen to help his breathing. My brother and I asked the doctors to remove all artificial life support, including the IV and oxygen, and he passed away a few days later.

I have asked my children to do the same for me when the time comes. "Remember to bring back the basket!"

ACT! OR FATE?

If we Accept FATE?
  • Do next to nothing to change US health care.

  • Health care not fair.

  • Given medical advances, End of Life costs escalate out of control.

  • Neo-natal care and preventative care are under-funded.

  • USA goes bankrupt (like Greece, hedonistic socialism).


If we ACT!
  • Enact QALY End of Life guidelines.

  • Health care is more fair.

  • Given medical advances, End of Life costs are controlled.

  • Neo-natal and preventative care are well-funded.

  • USA avoids bankruptcy.

  • Death with dignity and loving care.


CONCLUSIONS

Although I did not vote for him, and oppose much of his economic policy, I agree with President Obama's remarks on end-of-life treatment.

I wish he and his Democratic allies would be similarly honest and I wish the Republicans who are characterizing the issue as "pulling the plug on granny" would be more thoughtful and helpful and honest as well.

I do not like to hear people call these "honest broker" government medical and ethical tribunals "death panels". However, the 'honest broker" guidelines, when imposed on Medicare and other public-funded medical decisions, will, in effect, cause many of the terminally and chronically ill to be given palliative treatments that will undoubtedly shorten their lives.

Whatever you call them, I believe we need ethical end-of-life guidelines to prevent doctors and hospitals from ordering expensive treatments that are not cost-effective (and that may be done more for reasons of fear of malpractice suits and/or simple greed to increase their incomes).

I am not if favor of further nationalization of US health care. However, with Medicare the primary payer for nearly all of us over 65, we need national guidelines to prevent the program from going bankrupt. (See this and this for more details on my views of what we really need in cost-effective health care reform.)

Let us take the ethical lessons of the Runaway Trolley to heart and ACT! rather than accept the hand of FATE?


Ira Glickstein


PS: For the record, and in case the NY Times takes the page linked above out of their free access, here is the full text of the applicable section of the document from which I quoted Pressident Obama's words.
V. Post-Reform Health care
You have suggested that health care is now the No. 1 legislative priority. It seems to me this is only a small generalization — to say that the way the medical system works now is, people go to the doctor; the doctor tells them what treatments they need; they get those treatments, regardless of cost or, frankly, regardless of whether they’re effective. I wonder if you could talk to people about how going to the doctor will be different in the future; how they will experience medical care differently on the other side of
health care reform.
THE PRESIDENT: First of all, I do think consumers have gotten more active in their own treatments in a way that’s very useful. And I think that should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being — that, I think, can be helpful.
I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to
Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.
And right now we’re footing the bill for a lot of things that don’t make people healthier.
THE PRESIDENT: That don’t make people healthier. So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies (see note below
) as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions.
Won’t that be hard, because of the trust that people put in their doctors, just as you said? Won’t people say, Wait a second, my doctor is telling me to take the red pill, and the government is saving money by saying take the blue —
THE PRESIDENT: Let me put it this way: I actually think that most doctors want to do right by their patients. And if they’ve got good information, I think they will act on that good information.
Now, there are distortions in the system, everything from the drug salesmen and junkets to how reimbursements occur. Some of those things government has control over; some of those things are just more embedded in our medical culture. But the doctors I know — both ones who treat me as well as friends of mine — I think take their job very seriously and are thinking in terms of what’s best for the patient. They operate within particular incentive structures, like anybody else, and particular habits, like anybody else.
And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.
Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —
Yes, where it’s $20,000 for an extra week of life.
THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.
So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.
And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.
I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.
And it’s going to be hard for people who don’t have the option of paying for it.
THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.
So how do you — how do we deal with it?
THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Note: Comparative-effective studies — which are now done by academic researchers, but not systematically across the medical system — review data to determine which widely used treatments do not improve outcomes and which effective treatments are not used often enough.

Wednesday, February 16, 2011

Runaway Trolley - Applied to Criminal Recidivism

The Runaway Trolley thought experiment was introduced in a previous Topic on this Blog.

The basic lesson was that there are situations where it is quite ethical to take an action that saves (or benefits) a number of people, even if that action has, as an inevitable side effect, the death (or detriment) of a smaller number of people.

This posting has to do with Criminal Recidivism, and how we might apply the lesson of the Runaway Trolley to the justice system.

POWERPOINT SHOW AVAILABLE

Click HERE to download a narrated PowerPoint Show that includes animated charts for the Runaway Trolley thought experiment. After the Runaway Trolley is explored, the charts continue and apply the ethical lesson to two real-world issues: 1) Criminal Recidivism and 2) End of Life Issues. This posting covers Criminal Recidivism only. A subsequent posting will cover End of Life Issues. The PowerPoint Show is based on a talk I gave to The Philosophy Club at The Villages, FL, on 04 February 2011. NOTE: The Powerpoint Show is Narrated and plays and advances automatically after download to your computer.

WAS MAIMONIDES RIGHT ABOUT CRIMINAL JUSTICE?

Moses Maimonides, the 11th Century Rabbi and medical doctor shown in the sketch above, is one of the most highly regarded ethical teachers in Jewish tradition. He famously wrote that it was better to let 1000 guilty go free rather than wrongly convict a single innocent. Do you agree with that ideal? Is an error rate of 1/1000 the correct standard for a criminal justice system?

Juries in criminal cases are charged with the responsibility to convict only if the evidence meets the standard of being beyond a reasonable doubt. The 1/1000 standard corresponds to a certainty of 99.9%. Is that a good working definition for beyond a reasonable doubt? Is that number too high? For example, in civil cases, the standard is the preponderance of the evidence, which means, if one side proves its case to a certainty of 51%, the other side loses. Is 51% a good working definition for beyond a reasonable doubt?

Well, Benjamin Franklin, US Founding Father, said the number of guilty released to save one innocent from being wrongly convicted was 100, which corresponds to 99%. William Blackstone, the 18th century jurist who codified British Common Law, said the correct value was 10, corresponding to 90% certainty. Benjamin Cardozo, 19th century US Supreme Court Justice, said the number was 5, corresponding to 80% certainty. And, Voltaire, the 18th century French philosopher, said the number was 1, corresponding to 50% certainty.

How in the world can so many respected men have such different standards for criminal justice? How may we use the Runaway Trolley to arrive at a reasonable number?

CRIMINAL RECIDIVISM RATES

The graphic lists criminal recidivism rates for a number of crimes. Notice that nearly all violent crimes, including assault, murder, robbery, and sex crimes have recidivism rates above 50%. That means that, when a person has been convicted of a violent crime and has served his sentence and is released, there is a greater than 50% likelihood that he will commit another violent crime, be caught, and convicted again.

FUTURE VICTIMS CONDEMNED BY FAILURE OF JUSTICE

Criminal Recidivism rates for violent crimes teach us that, every time we release two convicts, we are, in essence, condemning at least one innocent to become the victim of a future crime. The number of innocents condemned is probably considerably larger than one because: 1) Many violent crimes have more than one victim, and 2) The released convict is likely to commit more than one violent crime before being caught and convicted again.

Extending this lesson to criminal trials, if, after weighing the evidence of a violent crime we the jury believe there is a greater than 50% likelihood the defendant is guilty, we should vote him guilty!

If there is only a 51% chance he is actually guilty, and we release him on a technicality or because we feel sympathy for him, and it turns out he was actually guilty, we are denying justice not only to his victims in the current case, but there is a high likelihood we are also condemning future victims to violence.

If we convict him on 51% certainty, and he turns out to have actually been innocent, we are doing a serious injustice to an innocent man. But, what is the likelihood he is totally innocent? Unless corrupt police have purposely framed him (in which case they would most likely have manufactured overwhelming evidence, which is not the case here), we are probably dealing with a person who has an extensive rap sheet and other indicators he has not lead a respectable life. He may not be guilty of this particular crime, but his incarceration will not be much of a loss to society - certainly not as much as the death or serious injury for one or more totally innocent victims if we make a mistake and release someone who is actually guilty.

The justice system is so dominated by lawyers and legal technicalities that rich people with clever lawyers can literally get away with murder, as many of us think happened to OJ Simpson.

RECOMMENDATIONS

1) Reform the Court System. Change the rules of evidence. Make it harder to get off on a technicality or with a clever lawyer.

2) Change the way we handle people convicted of violent crimes. DO NOT release them after their sentence is served. Keep them in some type of work camp.

3) Perhaps modern technology provides a humane and affordable solution for dealing with released convicts and others with extensive rap sheets. Stick a chip up their butt so they may be tracked for the rest of their lives. If there is certainty they will be caught and convicted if they commit any kind of infraction, they may learn to stay on the straight and narrow.

My free online novel, 2052 - The Hawking Plan, envisages a society, several decades from now, when everybody "voluntarily" carries an RFID device that effectively tracks their every move and activity.

Does that sound too drastic? Well how about your total lack of privacy right now? Those of us with homes and computers and cell phones and cars and jobs are effectively tracked by various computers and video cameras as we go on with our lives. We leave video and computer records dozens of times every day. The only people who have any privacy anymore are the drifters and criminal class, one of whom is likely to steal your car or credit card!

NOTE: Subsequent postings in this series will extend this lesson to the real-world situation of End of Life Issues.

Ira Glickstein

Tuesday, February 8, 2011

Picking Howard Pattee's Brain (He says he enjoys it)

A person who calls him-or-her-self "Nikman" showed up with a Comment at A Previous Topic on this Blog, and had some great things to say about our regular participant, Prof. Howard Pattee.

I think this deserves a new Topic. Here is what we have so far:
nikman said... I stumbled across this blog for the first time a few minutes ago and discovered that Howard Pattee is posting.

I don't know what more to say right now. Except that there should be a system in place enabling us to pick his brain regularly on a vast array of topics relating to the philosophy of science. If he doesn't want that he should have posted using a pseudonym. You reap what you sow, dude. [Nickman] February 6, 2011 9:23 PM
Ira Glickstein said... Thanks Nickman for your positive comments on a regular here, Prof. Howard Pattee. Howard was Chairman of my PhD committee at Binghamton University. I consider it a real privilege to have him as a continuing positive influence in my life.

Please let us know how you know Howard. We can always use intelligent and courteous Comments here, so please join us.

Ira Glickstein February 6, 2011 11:29 PM
nikman said... IIRC [If I Remember Correctly] it began with "Artificial Life Needs a Real Epistemology" which was almost literally a breath of fresh air. At last, something besides all those stultifying functionalists.

The best thing up till then had been another HP, Hilary Putnam, who's still not chopped liver. More recently, of course, the computational complexity folks (Scott Aaronson et al.) have weighed in to the advantage of sanity. Anyway, I particularly love this:

"The problem also poses an apparent paradox: All signs, symbols, and codes, all languages including formal mathematics are embodied as material physical structures and therefore must obey all the inexorable laws of physics. At the same time, the symbol vehicles like the bases in DNA, voltages representing bits in a computer, the text on this page, and the neuron firings in the brain do not appear to be limited by, or clearly related to, the very laws they must obey. Even the mathematical symbols that express these inexorable physical laws seem to be entirely free of these same laws."
You asked. [Nickman] February 7, 2011 11:15 AM
Howard Pattee said... nikman,
Thanks for the complement. If time permits, I enjoy having my brain picked. That 1995 quote is indeed what I had thought about for many years. From childhood we are taught that every event has a cause, and that every event is the result of natural laws. In fact, the evidence for both beliefs is weak or mythical.

The evidence is that we (living systems) choose what we perceive as an event and we favor events that can be described as causal and that that can be predicted by laws. We survive by that choice because it is ultimately the result of natural selection. The evidence is that most of the structures in the universe including organism are undetermined by laws and are mostly selected frozen accidents.

We have also been saddled with Aristotle’s logic of causality that can prove the existence of God as the First and Final Cause or the uncaused cause. His logic also implies determinism.

In contrast, modern quantum cosmology sees causality and determinism as just the illusion of good statistics of primordial uncaused spontaneous creations and symmetry breaking. Of course we could still say that God is a (gratuitous) uncaused cause; but how do we know S/He is not just playing dice?

Howard February 8, 2011 9:20 PM
[Emphasis and notes added by Ira] Please continue this Topic with Comments here.

Ira Glickstein

Sunday, February 6, 2011

Prediction: Soft Landing in Egypt

I'm no expert on Egypt, but Vi and I spent a couple weeks there back in 1997. [Double click the image for a larger version.]

I think Egypt will recover from the current unrest with a reasonably soft landing.

IMHO, Egyptian President Hosni Mubarak will hang on as a figurehead leader for some time, perhaps weeks to months. His presence in Egypt serves as a kind of lightning rod covering the other government leaders there. Control will be maintained by the leadership of the Army.

They have installed Army-connected men in charge. They have wisely allowed the demonstrations to continue and, to some extent, have restored the Internet and cell phone service. The demonstrations will continue, but at reduced intensity.

Come September, the Army-connected leadership group will preside over a somewhat controlled general election, with some participation from "liberal" elements. The new government will be less dictatorial than the current one.

Fortunately, Egypt is a good bit more secular than other Moslem countries, particularly the Iran of decades ago. The Internet and cell phones that helped spark and organize the rebellion will help keep the secular leaders on both the government and uprising sides from allowing Egypt to slide into extremist Islamic ideology. At least that is what I hope will happen. Time will tell.

The photos are from my old http://pages.prodigy.net/ira/egypt.htm website, were you can read a blow-by-blow account of our Egyptian adventure, including:

  • Our visit to the Queen Hatshepsut Temple in Luxor, only weeks before several dozen tourists were killed there,
  • My solo bicycle ride through the downtown Luxor rabbit warren of dirt streets,
  • Our police-escorted convoy to Alexandria,
  • Our Nile River cruise, including a galabia party where they said I looked like a rabbi,
  • Traffic in Egypt where lane markers and traffic lights are merely for decoration,
  • Our camel rides at the Pyramids,
  • Our subway ride to old Cairo where we got stoned,
  • Our visit to the Ben Ezra Synagogue (attended in the 11th century by Maimonides),

and, of course,

  • My solo walk from our hotel to the McDonalds near Tahrir Square!

As we watch the news on TV we sympathize with our tour guide, Mona, whose business must have been devastated by the current crisis.

Prior to our trip in 1997, there had been unrest as well. Due to that uncertainty, there were only five people on our tour, Vi and I and another couple and their adult son. Our tour bus was a Volkswagen van. We therefore received a very personal tour, including a visit to Mona's apartment, where we met her three young children and her sister. During our time in Cairo, we talked Mona into her first ride on bumper cars (just like Coney Island).

Ira Glickstein

Wednesday, February 2, 2011

Runaway Trolley - Applied to Real-World Issues

The Runaway Trolley ethical choice thought experiment is a classic that has been tested on tens of thousands of people in different societies with remarkably consistent results. This may expose at least one basic human ethical value.

Photobucket

POWERPOINT SHOW AVAILABLE


Click HERE to download a narrated PowerPoint Show that includes animated charts for the Runaway Trolley thought experiment. After the Runaway Trolley is explored, the charts continue and apply the ethical lesson to two real-world
issues: 1) Criminal Recidivism and 2) End of Life Issues. This posting covers the Runaway Trolley only. Subsequent postings in this series will cover Criminal Recidivism and End of Life Issues. The PowerPoint Show is based on a talk I gave to The Philosophy Club at The Villages, FL, on 04 February 2011. NOTE: The Powerpoint Show is now Narrated and plays and advances automatically after download to your computer.

RUNAWAY TROLLEY - PART 1 - The Siding Guy

The graphic illustrates the issue. A trolley has lost its brakes and is roaring down a hill. If nothing is done (FATE) the trolley will crash into the station at the foot of the hill, certainly killing at least five people.

There happens to be a junction and a siding. If that trolley can be switched over to the siding, the trolley will certainly stop safely in a pile of sand, and the five or more people on the trolley and in the station will not be killed.

YOU happen to be standing by the junction and see a switch that may be thrown to redirect the trolley from the Main Line to the Siding.

You are about to throw the switch (ACT) when you notice there is one person who happens to be sitting in the sand pile and that person will certainly be killed if the trolley is switched to the siding. What should you do?

NOTE: This type of thought experiment is intended to illustrate an ethical concept, so it is somewhat artificial. To play this game, you MUST ASSUME that all the facts stated are absolutely certain and, further, that all the people involved are total strangers and completely innocent. Therefore, you cannot avoid the ethical issue and suggest you could shout a warning to the guy on the siding - he is too far away to hear you. You cannot defer to a trolley company employee or another passer-by who happens to be at the junction - you are totally alone. You cannot phone the trolley company - time is short and you must let FATE take its toll or ACT and save several lives.

OK, now, what is THE RIGHT THING TO DO? Should you do nothing (FATE) or throw that switch (ACT)? Please decide now, before you read on.

RUNAWAY TROLLEY PART 2 - The Fat Man

The situation is similar to Part 1, the trolley is roaring down the track and five people will die when it certainly crashes into the station. But, this time, there is no siding. OY!

However, there is a footbridge that crosses over the trolley tracks, and, guess what, YOU happen to be on that footbridge. You see the trolley approaching the footbridge and you realize that if you do nothing (FATE) at least five people will die when the trolley crashes into the station.

Thinking quickly, you imagine yourself jumping from the footbridge onto the tracks in the path of the trolley. If you do so, you will certainly die but there is a chance your body will slow the trolley and save some or all the lives. Should you jump? You will die but five or more will live!

You notice that there is a very fat man standing on the other side of the footbridge, looking towards the station. He is totally unaware of the emergency, and there is no time to talk to him about it. He happens to be standing right above the trolley track and all it would take would be an easy nudge and he would tumble onto the tracks. He is so heavy he will certainly stop the trolley and save all the people, but, sadly, he will certainly die. He will die but five or more will live!

OK, now, what is THE RIGHT THING TO DO? Should you do nothing (FATE) or nudge that fat man down onto the tracks (ACT)? Please decide now, before you read on.

ANALYSIS AND PAST RESULTS

This problem, and versions suitable for "primitive" societies who do not know what a trolley is, has been posed to tens of thousands of people. I will tell you the remarkably consistent results further down in this posting.

Principle of Double Effect

But first, we need to learn about the Principle of Double Effect. It holds that:

You may take action which has bad side effects, but deliberately intending harm (even for good causes), is ethically wrong.
Thus, it is OK to act if your intent is to save many lives, even if, indirectly, some few lives are lost. This clearly applies to the Runaway Trolley Part 1 - the Siding Guy. Your INTENT is to save many people, and the Siding Guy's death, though clearly forseeable, is an UNintended side effect.

It is similar to the aircraft pilot whose plane is certain to crash. If he allows FATE to take its course, the airplane will crash into the center of a large metropolitan area, killing hundreds of people. If he ACTS he can divert the airplane to a less populated place, preferably a deserted area, but, if that choice is not available, he should crash into an area of single-family homes rather than apartment buildings.

Conversely, it is NOT OK to act if your intent is to kill someone, even if, indirectly, many lives will be saved. This clearly applies to the Runaway Trolley Part 2 - the Fat Man. Your INTENT is to kill the fat man, and the saving of the many lives on the trolley and in the station, is a side effect of a wrong intent.

(A strict Utilitarian might have trouble with that argument. What if killing one innocent person was certain to save 100 lives? 1,000? 1,000,000???)

This type of reasoning applies to an ethical thought experient called the Surgeon and the Stranger. A Surgeon at a hospital has five patients, each of whom needs a different organ transplant (heart, lung, etc.) or they will certainly die. There are absolutely no organs available from any normal source in time to save their lives.

Then a total Stranger checks into the hospital emergency room for a minor problem. The Surgeon learns that he is a drifter, with no relatives or friends, and no one in the world knows where he is or even cares. And, guess what, his blood type happens to match all five patients who need transplants. Your compassionate nurse suggests they fake the medical record of the Stranger to claim he died unexpectedly and they use his organs to save the five patients who need them desperately. "The five people who will die if we do not ACT have lived in our town for their whole lives. No one will miss this worthless Stranger. God must have sent that drifter to us for this purpose!" she says.

Well, as tempting as it is, the Principle of Double Effect says the Surgeon should let FATE take its course and not ACT. What do you think?

Statistical Results

The Runaway Trolley was presented to The Philosophy Club a year ago and everyone (100% of the 45 people in attendance) would ACT (throw the switch) to save five or more innocents despite the death of the Siding Guy. In the case of the Fat Man, 7% (three of the 45) would ACT (nudge him off the footbridge) while 93% would let FATE take its course.

A BBC poll found similar results, with 77% ACTing to save five or more innocents to the demise of the Siding Guy and only 27% ACTing to nudge the Fat Man to his demise, despite that opportunity to save five or more innocents.

NOTE: Subsequent postings in this series will extend this lesson to the real-world situations of: Criminal Recidivism and End of Life Issues.

Ira Glickstein