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.

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

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.



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

Cost-Effective Health Care Compromise

President Obama has mounted a new full-court press this week to finally pass a version of the Senate Health Care bill, using the "nuclear option" if necessary.

It seems he is assuming that the televised summit conference between Democratic and Republican politicos this Thursday (25 February) will fail to reach a bipartisan compromise. I hope a cost-effective compromise can be reached, but I am not sanguine.

If there is no compromise, the plan is for the Democratic-controlled House to pass a version of the bill already passed by the Senate (before Sen. Ted Kennedy passed away). Then the Senate, by a simple majority of 51, can confirm it and it will become law. I hope this "nuclear option" is not attempted. I do not believe it will work because anyone who votes for it and is up for re-election this year will understand that he or she faces a high probability of being defeated.

Here is my outline for a bipartisan compromise, based on my previous postings here and here, partially based on Democrat David Goldhill's reasonable proposals in his 2009 piece in The Atlantic. This is a very serious plan that I think has a chance of gathering bipartisan support.

1) Universal digititized patient data, securely accessible by any doctor chosen by the patient. This part should be easy to sell to President Obama and both political parties and all medical specialties. It has been technically feasible for a decade and it is past time we do it.

2) Mandatory Catastrophic Insurance coverage for all that would cover only medical costs incurred in any one year of over $50,000 or a chronic condition that incurs costs of over $5,000 per year for ten years. That coverage would include a voucher for a basic checkup once a year. The government would subsidize coverage for those who could not afford the relatively low premiums for catastrophic coverage. Goldhill estimates a yearly premium of $2,000 for this type of coverage. (By comparison, my wife and I are paying around $10,000 each if you include our out-of-pocket insurance and Medicare costs plus the contribution of my former employer and of government Medicare funding.) This is an approximation of the universal health insurance that President Obama and the majority party favors in a cost-conscious form that should be palatable to the minority party.

3) Nationwide competition by health insurance companies certified in any state to sell insurance in any other state. This will provide far more competition and bring down costs. This will be an easy sell to most members of the minority party but may be resisted by the majority party that is obligated to state health care regulators and to insurance companies that have near-monopoly positions in some high-cost states.

4) Mandatory Health Savings Accounts for all that would be tapped into for actual medical costs incurred, but would remain the property of the owner of the account (you, or your heirs) if not fully expended, as proposed by Goldhill. Employers and employees/retirees would pay into the Health Savings Accounts the difference between what they are currently paying for comprehensive insurance and out-of-pocket medical costs now and the lower cost of Catastrophic-only insurance. (For example, my wife and I would see about $8,000 per year for each of us pass into our Health Savings Accounts.) Young, healthy families with low medical expenditures would see their Health Savings Accounts grow by thousands of dollars per year, accruing as savings to prepare themselves for the likely increasing medical costs as they age. Those not so fortunate, who incur medical costs, would expend the funds in their Health Savings Accounts until the accounts were tapped out, and would then pay the remainder out of their pockets and savings, until they hit the catastrophic limits and then Catastrophic-only insurance would kick in. This is a further approximation of the universal health insurance that President Obama and the majority party favor in a cost-conscious form that should be palatable to the minority party.

The point would be to make the recipients of health care more conscious of the actual costs. Instead of calling an ambulance for every event, they would be more likely to drive the injured person to the hospital or use public transit if possible. Instead of accepting the first doctor's advice for expensive medicines or tests or procedures (that may be in the doctor's self-interest - he or she may have a boat payment due) they would be more likely to shop around for lower-cost options. That would drive down the costs of medical care for everybody and make the providers more responsive to their customers, who would be the actual recipients of health care rather than the government and insurance companies.

5) Tort reform to eliminate high malpractice premiums and defensive medicine with unnecessary tests that add up to 10% to costs. This will be a hard sell to the majority party that is in the pocket of trial lawyers, but it is an absolute necessity for support by the minority party.

6) Outcome-based reimbursement to eliminate costly surgery and medications that do not yield comparative effectiveness based on quality-adjusted life years. Though President Obama earlier seemed to favor an approach of this type, it will be a hard sell to the minority party. Some politicos in both parties who originally proposed it have backed away due to the onslaught of opposition based on "death panels" and "pulling the plug on granny".

7) No denial of insurance based on pre-existing conditions or boosting of premium costs due to illness. Given (2) and (4), anyone who has complied with the mandatory coverage requirement, which would be partly subsidized by the government for those who cannot afford it, would be protected from subsequent denial of coverage or premium increases based on illness.

Ira Glickstein

How American Health Care Killed My Father

When I saw the title of the health care story in the current issue of The Atlantic:

How American Health Care Killed My Father by David Goldhill

I expected a horror story that ended with a desperate call for a single-payer solution. My suspicions were intensified when Goldhill identified himself as a Democrat!

Instead I found a well-reasoned, long and detailed analysis of problems with American health care that I mostly agreed with, plus a solution approach that has some merit, though I do not buy it completely.

I strongly recommend you read it all at http://www.theatlantic.com/doc/200909/health-care

In brief, Goldhill's 83 year-old father checked into "a well-regarded nonprofit hospital in New York City" with a case of pneumonia. Some weeks later, he went out feet first, dead from a hospital-acquired infection. His wife received a bill for over $636,687.75, all but about $992 paid by insurance.

Goldhill blames the hospital, of course, for the hospital-acquired infection. Clearly, some doctor or health-care worker failed to properly wash his or her hands. However, he does NOT take the conventional "lesson" that more government regulation and rules would have solved the problem. Nor does he blame the insurance company and Medicare for a lack of monitary support in this case. Quite the contrary, he blames the availability of Medicare and insurance money for both the high cost and lack of quality of American health care!

Please read the whole story, but here is the final part:

Ten days after my father’s death, the hospital sent my mother
a copy of the bill for his five-week stay: $636,687.75. He was charged $11,590
per night for his ICU room; $7,407 per night for a semiprivate room before he
was moved to the ICU; $145,432 for drugs; $41,696 for respiratory services. Even
the most casual effort to compare these prices to marginal costs or to the costs
of off-the-shelf components demonstrates the absurdity of these numbers, but why
should my mother care? Her share of the bill was only $992; the balance,
undoubtedly at some huge discount, was paid by Medicare.

Wasn’t this an extraordinary benefit, a windfall return on American
citizenship? Or at least some small relief for a distraught widow?

Not really. You can feel grateful for the protection currently offered
by Medicare (or by private insurance) only if you don’t realize how much you
truly spend to fund this system over your lifetime, and if you believe you’re
getting good care in return.

Would our health-care system be so outrageously expensive if each
American family directly spent even half of that $1.77 million that it will
contribute to health insurance and Medicare over a lifetime, instead of
entrusting care to massive government and private intermediaries? Like its
predecessors, the Obama administration treats additional government funding as a
solution to unaffordable health care, rather than its cause. The current reform
will likely expand our government’s already massive role in health-care
decision-making—all just to continue the illusion that someone else is paying
for our care.

But let’s forget about money for a moment. Aren’t we also likely to get
worse care in any system where providers are more accountable to insurance
companies and government agencies than to us?

Before we further remove ourselves as direct consumers of health
care—with all of our beneficial influence on quality, service, and price—let me
ask you to consider one more question. Imagine my father’s hospital had to
present the bill for his “care” not to a government bureaucracy, but to my
grieving mother. Do you really believe that the hospital—forced to face the
victim of its poor-quality service, forced to collect the bill from the real
customer—wouldn’t have figured out how to make its doctors wash their
hands?

A few weeks ago I posted We Need COST-EFFECTIVE Health Care Reform, in which I called for three basic changes:

1) Universal digititized patient data, securely accessible by any doctor chosen by the patient. This part should be easy to sell to both political parties and all medical specialties. It has been technically feasible for a decade an it is past time we do it.

2) Tort reform to eliminate high malpractice premiums and defensive medicine with unnecessary tests that add up to 10% to costs. This will be a hard sell to the majority party that is in the pocket of trial lawyers.

3) Outcome-based reimbursement to eliminate costly surgery and medications that do not yield comparative effectiveness based on quality-adjusted life years. This will be a hard sell to the minority party, some of whose members originally proposed it but who have backed away due to the onslaught of opposition based on "pulling the plug on granny".

After reading the above story, I would add the following:

4) Mandatory Catastrophic Insurance coverage for all that would cover only medical costs incurred in any one year of over $50,000 or a chronic condition that incurs costs of over $5,000 per year for ten years. That coverage would include a voucher for a basic checkup once a year. The government would subsidize coverage for those who could not afford the relatively low premiums for catastrophic coverage. Goldhill estimates a yearly premium of $2,000 for this type of coverage. (By comparison, my wife and I are paying around $10,000 each if you include our out-of-pocket insurance and Medicare costs plus the contribution of my former employer and of government Medicare funding.)

5) Mandatory Health Savings Accounts for all that would be tapped into for actual medical costs incurred, but would remain the property of the owner of the account (you, or your heirs) if not fully expended. Employers and employees/retirees would pay into the Health Savings Accounts the difference between what they are currently paying for comprehensive insurance and out-of-pocket medical costs now and the lower cost of Catastrophic-only insurance. (For example, my wife and I would see about $8,000 per year for each of us pass into our Health Savings Accounts.) Young, healthy families with low medical expenditures would see their Health Savings Accounts grow by thousands of dollars per year, accruing as savings to prepare themselves for the likely increasing medical costs as they age. Those not so fortunate, who incur medical costs, would expend the funds in their Health Savings Accounts until the accounts were tapped out, and would then pay the remainder out of their pockets and savings, until they hit the catastrophic limits and then Catastrophic-only insurance would kick in.

The point would be to make the recipients of health care more conscious of the actual costs. Instead of calling an ambulance for every event, they would be more likely to drive the injured person to the hospital or use public transit if possible. Instead of accepting the first doctor's advice for expensive medicines or tests or procedures (that may be in the doctor's self-interest - he or she may have a boat payment due) they would be more likely to shop around for lower-cost options. That would drive down the costs of medical care for everybody and make the providers more responsive to their customers, who would be the actual recipients of health care rather than the government and insurance companies.
Ira Glickstein

We Need COST-EFFECTIVE Health Care Reform

Shout it from the rooftops!

WE NEED COST-EFFECTIVE HEALTH CARE REFORM!

This posting details the THREE changes we need in US health care to save the money we will need before we expand the system further.

1) Universal digititized patient data, securely accessible by any doctor chosen by the patient. This part should be easy to sell to both political parties and all medical specialties. It has been technically feasible for a decade an it is past time we do it.

2) Tort reform to eliminate high malpractice premiums and defensive medicine with unnecessary tests that add up to 10% to costs. This will be a hard sell to the majority party that is in the pocket of trial lawyers.

3) Outcome-based reimbursement to eliminate costly surgery and medications that do not yield comparative effectiveness based on quality-adjusted life years. This will be a hard sell to the minority party, some of whose members originally proposed it but who have backed away due to the onslaught of opposition based on "pulling the plug on granny".

WARNING: This posting will make you angry no matter which side you are on in the current debate. Please give it a chance because I think it is the best we can do now to control health care costs and get the best "bang for the buck".

1. Universal Digititized Patient Data

This is the easy one.

Every time I go to a new doctor I have to complete a detailed medical history form. Fortunately, my wife has all the major stuff memorized, but I think most people forget some of their medical history and just guess at the dates for past medical procedures if they do remember, so the new doctor does not have complete or correct information. At each doctor visit I have to update my list of pills. Every time I get my blood and other fluids tested along with a record of my blood pressure, weight, temperature and other information, it is done by computerized equipment, but the records are printed out and sent to my doctor in hard-copy form.

All this is error-prone and a waste of time for the patient. Since the data is hand-written and hard-copy the doctor has to paw through pages and pages of paper records. There is no opportunity for a computer to assist him or her in detecting counter-indications for various medications or procedures.

By now, all hospitals and most doctors store at least some of their data on computers, most of which are networked. We buy our prescription medications from large companies that are fully computerized. Even my non-prescription pills are purchased online so there is a computer record of all those transactions.

There is role here for the government to work with a medical industry organization to standardize the format and contents of universal digitized patient medical data. Of course, with universal patient data there is a security issue. We want only doctors and hospitals authorized by the patient to have access to our medical data, and only to that portion of the data that is applicable to the type of medical procedure being performed.

The government has already specified the Real ID drivers license that is being issued by some states. The security aspects of Real ID have been watered down to something called Pass ID, which is unfortunate in my opinion, but even Pass ID will be secure enough for medical record access. Nearly all adults have drivers licenses. Children could be ID'd via their parent's ID and non-licensed adults could be ID'd by their spouses or adult children's or medical proxy's IDs.

Your regular doctors and hospitals would scan your Real ID or Pass ID to access your records. If you change doctors, or go to an emergency medical facility, they would scan your ID card to get secure access to your medical records. Of course, each doctor or hospital would have a specified set of medical specialties and his or her ID card would limit their access to only those parts of your medical records applicable to that specialty. Periodically, doctor and hospital access would expire and require a new ID scan.

All the government needs to do is: 1) Authorize a medical industry organization to set up the data standards, the rules for secure access, and to certify the competing companies that will securely store the data for patients, funded by fees when the data is accessed, 2) Authorize the use of Real ID and Pass ID for secure access, 3) Require all doctors, clinics and hospitals to adopt the new standards within five years and, 4) Where necessary, subsidize computer equipment and software for doctors, clinics, and hospitals in less affluent areas.

It is estimated that at least 10% of Medicade/Medicare funds are stolen by fake or unscrupulous doctors and medical equipment and service providers. A side-benefit of use of Real ID and Pass ID will be a double check that the actual patient has really been serviced. The government and insurance companies will also be able to check the frequency of use of services by any given patient ID number which will help identify unscrupulous providers who claim to have serviced a given individual with unreasonable or conflicting items.

2. Tort Reform and Defensive Medicine

If passed, this will be costly to the trial lawyers (like former Presidential hopeful Senator John Edwards). The current system is a full-employment program for lawyers. They make emotional arguments and parade the sad cases of patients who have had bad outcomes from medical treatments and expect to be reimbursed for both the cost of the care and "pain and suffering".

Medicine is not an exact science and some patients will have bad outcomes no matter how competent their doctors and hospitals. Trial lawyers can always find an "expert" who, for pay, will testify convincingly that "if only" such and such a test had been done, or a different course of treatment had been followed, the patient might have recovered to full health and vigor. This type of "Monday morning quarterbacking" is easy because, after the fact, the actual outcome is known, and the "expert" is free to speculate on what might have been had a different path been chosen with absolutely no way to prove him or her wrong.

We already have caps on "pain and suffering" awards in some states. This helps the medical malpractice insurance companies a bit. Unfortunately, when a doctor is accused of malpractice his or her time is not compensated, nor is the inner turmoil he or she feels, even if the accusation is baseless and the plaintiff's case fails. I would like to see our legal system more in line with other countries that require the losing side to pay the reasonable legal costs of the winner as a way to discourage frivolous cases.

We need a professional review system that prevents cases from being filed unless the accuser can show not just that he or she has had a bad outcome -all too often juries will award big damages out of sympathy for a seriously ill plaintiff- but that the doctor or hospital has willfully ignored the normal standards of care. A review board should determine if there is probable serious malpractice and not simply a misdiagnosis within the limits of professional practice or ordinary human error. The review board should have the power to dismiss the case or offer some reasonable compromise.

Our current system has doctors ordering unnecessary tests as a form of defensive medicine that adds upwards of 10% to medical costs while inconveniencing the patients.

Medical malpractice is a full employment program for lawyers. Will we get tort reform? Probably not, since trial lawyers control one of the major parties and most of the senators and representatives of the other are also lawyers.

3. Outcome-Based Reimbursement

This should have bi-partisan support. Unfortunately, some of the more extreme conservative talk-radio hosts and opinion writers have blown it out of proportion "pull the plug on granny?" On the other side, proponents of the congressional bills have been ordered not to use the words "rationing" of health care - in other words be dishonest. We need an honest discussion here, so, please, check you emotions at the door for the next few paragraphs.

The main reason health care costs have gone up so much faster than inflation is that health care technology is advancing rapidly. We can now save people with medical conditions that would have been considered terminal only a decade or two ago. That is great news for those people who can be restored to high quality, healthy and productive lives. The problem is that this new technology can also extend the low quality lives of people who will have to be connected to machines for the rest of their lives or be bedridden or undergo expensive periodic medical procedures or take high cost medications, or all of the above.

Last April President Obama gave an interview to the New Your Times Magazine (reported here by Blooomberg) where he said some important things that I agree with.

Some opponents say the Congressional health bill limits expenditures for the elderly. They have been accused of raising "fishy" issues and talking about "rationing health care". But they are correct when they say Pres. Obama has recently favored such limitations.

Obama's opinion is (or was as of last April) that we should limit major cost surgeries for the aged and chronically or terminally ill, BUT, if they have the money or their children or grandchildren are rich (like Obama) it is OK to pay for major cost items with private money! I AGREE!

He said it is NOT a "sustainable model" if paid for out of public money because, in Obama's words “The chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total healh-care bill out here.”

Now, I assume Obama got that 80% number from some expert on health care. He is not an expert and would not have just made it up. I have heard that the current number is around 50% which means, on average, half of the money that will ever be spent on your health care is likely to be spent in the last year of your life! Of course, that is an average of those people who have very little spent on medical during the last year of their lives, the majority of people who have a moderate amount spent, and the relatively few people who have hundreds of thousands of dollars spent during that period. Perhaps the experts are projecting that, as health care technology advances further to the point where we can extend life indefinitely, the costs of care for the chronically and terminally ill will grow to 80% of the total. We should be spending our limited resources on preventitive care for the young, and on care that will restore health and vigor.

Regarding hip replacement for his terminally ill grandmother, Obama said “I would have paid out of pocket for that hip replacement just because she’s my grandmother.” (Obama's grandmother had her hip replacement mere WEEKS before she passed away - tragically just a couple days before her grandson won election to the highest office in the land).

Based on his statement that major expenditures for the chronically and terminally ill are not a "sustainable model" and that these costs could grow to 80% of the total, it would appear Obama favors some level of rationing of public-funded health care for those who are near the end of their lives.

UNLIKE SOME CONSERVATIVE TALKERS, I TOTALLY AGREE WITH OBAMA ON THIS ISSUE. DO YOU ???

For some reason, Obama and the proponents of the Congressional health care bills -and both the conservative and liberal press- have been absolutely silent on two key concepts:

• Comparative Effectiveness Research (CER), and


• Quality-Adjusted Life Years (QALY)

Have you heard either term and, if so, do you know what they mean?

They are discussed in a 2007 report from the Congressional Budget Office (during the Bush administration, so I am not making points againt the current administration): http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf

Here are some key quotes from that report [emphasis added]:

More generally, the relative cost-effectiveness of treatment
options is clear when a less expensive treatment yields
comparable or superior health gains. In other cases, however,
determining whether the additional medical benefits
of a more expensive treatment warrant their added costs
is complex. Typically, the benefits of different treatments
are summarized as an increase in life expectancy or, more
commonly, as an increase in quality-adjusted life years
(QALYs) to account for effects on morbidity as well as
mortality. That calculation reflects estimates of how
much people value improving their health or avoiding
various side effects, which are combined to create a single
metric. By convention, cost-effectiveness analyses report
results as the cost per QALY gained, so a lower dollar
amount indicates a more cost-effective service. If that
metric is used to determine whether specific health procedures
are covered by an insurance program, choosing a
cost-effectiveness threshold can be a controversial
endeavor—but that need not be the manner in which
such research is applied.

A variety of evidence suggests that opportunities exist to
constrain health care costs both in the public programs
and in the rest of the health system without adverse
health consequences. Perhaps the most compelling evidence
of those opportunities involves the substantial geographic
differences in spending on health care—both
among countries and within the United States—which
do not translate into higher life expectancy or measured
improvements in other health statistics in the higherspending
regions. For example, Medicare’s costs per beneficiary
vary significantly among different regions of the
country, but much of the variation cannot be explained
by differences in the population, and the higher-spending
regions perform no better on available measures of average
health outcomes than the lower-spending regions do.

As applied in the health care sector, an analysis of comparative
effectiveness is simply a rigorous evaluation of
the impact of different options that are available for treating
a given medical condition for a particular set of
patients. Such a study may compare similar treatments,
such as competing drugs, or it may analyze very different
approaches, such as surgery and drug therapy. The analysis
may focus only on the relative medical benefits and
risks of each option, or it may also weigh both the costs
and the benefits of those options. In some cases, a given
treatment may prove to be more effective clinically or
more cost-effective for a broad range of patients, but frequently
a key issue is determining which specific types of
patients would benefit most from it. Related terms
include cost–benefit analysis, technology assessment, and
evidence-based medicine, although the latter concepts do
not ordinarily take costs into account.
Just last month President Obama gave a hint of his thinking when he said on ABC:



"What I've proposed is that we have a panel of medical experts that are making determinations about what protocols are appropriate for what diseases. There's going to be some disagreement, but if there's broad agreement that, in this situation the blue pill works better than the red pill, and it turns out the blue pills are half as expensive as the red pill, then we want to make sure that doctors and patients have that information available to them."



It is a pity Obama took the easiest case. The blue pill costs half as much and works better than the red pill. That is a "no-brainer" - use the less expensive AND more effective blue pill. But, what if the blue pill is only 90% as effective as the red pill but it costs 50% less? On the basis of CER and QALY, you would use the blue pill even if it is a bit less effective because, based on cost per QALY, the blue pill is much more cost-effective.



What do you think?

Ira Glickstein

PS: Yes, that is me pictured on the roof of our house. A couple days ago I screwed up the courage to go up and clear out some rain gutters that were full of leaves from the live oak tree in front of our home. This was the first time I've been on a roof in at least six years. In my younger days I was more happy using a ladder, going up on the roof of our two-story NY home many times. Of course, the hardest part is getting off the ladder onto the roof and, especially, off the roof and back onto the ladder. My dad, even in his senior years, had no trouble with ladders. I would watch in amazement and envy as he climbed them as if they were a set of stairs. He would step off and onto the ladder with absolutely no hesitation.

"Runaway Trolley" Moral Problem

While working on my review of Dawkins' God Delusion book, I came across his enlightening discussion of a tangential issue, the famous "runaway trolley". Dawkins [pg 225] introduces an ingenious twist.

Dawkins (and I) believe Darwinian natural selection has ingrained some "moral universals". These "deep structures", like our inherent capacity to learn language, may vary a bit from culture to culture, but are evidence of a natural sense of right and wrong. The trolley example is designed to tease out this basic sense.

The traditional example assumes a trolley is running amuck along the main tracks and will kill five people if it is not switched onto a siding or stopped in some way.

1) A moral person, Denise, is standing by a track switch and could divert the trolley from the main line to a siding. Everyone would agree Denise should throw the switch to save the people.

2) However, there is one man on the siding, and he will be killed if she throws the switch. (Assume Denise does not know any of the potential victims and there is no time to warn them, etc.) What should she do? Should she kill one innocent person to save five innocents? Write down your answer and proceed as the example gets more and more difficult.

3) Alternatively, a moral person, Ned is on a bridge over the trolley tracks. If he could throw a large weight off the bridge onto the tracks, that would stop the trolley and save the lives of the five innocents. Everyone would agree he should throw the large weight off the bridge to save the people.

4) However, the only large weight available at the moment is a very fat man resting near the low railing and in a perfect position to be dropped to the tracks. Ned is strong enough to push him over and the man is certainly fat enough to stop the trolley. What should Ned do? Should he kill one innocent man to save five innocents? Write down your answer and proceed as the example gets more and more difficult.

5) Alternatively, a moral person, Oscar is standing by a track switch that could divert the trolley to another line. A large weight (say an empty stationary trolley) is parked on that line and would certainly stop the runaway trolley and save the innocents. Everyone would agree Oscar should throw the switch and have the runaway trolley crash into the large weight to save the people.

6) However, there is a hiker on the other line. Unlike the fat man thrown off the bridge, his body will not be used to stop the runaway trolley, but he will surely be killed. Should Oscar kill the innocent hiker to save five innocents? Write down your answer.

If you think Denise and Oscar should act, but Ned should not, you are with the vast majority of people surveyed. That this is a moral universal is attested to by the fact there was no statistically significant difference on this issue between religious and non-religious people. An analogous problem, featuring crocodiles and canoes, was posed to primitive tribesmen in Central America with similar results.

I'd appreciate discussion of why you think Ned should spare the fat man and condemn to death five equally innocent people. Why should Denise and Oscar "play God" and condemn one innocent to save five? Do you agree with Dawkins and me that there are certain "moral universals" that have been hard-wired into each of us by Darwinian evolution?

Ira Glickstein