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Utilitarianism, United Healthcare, and the Trolley Problem

Many people misunderstand the trolley problem. It was not designed to illustrate the appeal of Utilitarianism – the modern, popular variation of the idea that good and evil lies solely in the results produced by an action. In fact, it is part of an argument against Utilitarianism, one designed to show that it is essentially incomplete and thus inadequate as a model of morality. The argument concludes that Utilitarianism fails because it fails to track our moral intuitions, by being unable to capture the distinction we tend to draw between acts (intentional acts done knowingly) and omissions (failures to act whether these be due to refusal, refraining, forgetting, overlooking, neglecting, etc.).

The trolley problem (originally designed by Phillipa Foot) confronts readers with a pressing dilemma: An aspiring murderer, or mass murderer, has tied some people down to two separate branches of a trolley track. There is one person on branch A, and five on branch B. You find yourself next to a lever at the junction between the branches, with the trolley currently headed down branch B. If you pull the lever, the trolley will divert to branch A, killing the one person (saving a balance of four people). Should you pull it?

A utilitarian analysis yields a definitive answer, and claims it is obvious. No matter how we finesse the calculation of likely outcomes – go ahead and factor in the possibility that you will be wracked with guilt, even eternally damned, if you pull the lever! – the best, because least awful, outcome is the one with a single victim.

However, a fair number of people disagree. Many of us find the choice to be a tough one to make, and more than a few refuse to pull the lever. Some of them refuse to accept that moral responsibility can be foisted on us so as to force our hand in this way. Others don’t want to get blood on their hands by intentionally killing an innocent person, a strict religious injunction or personal commitment.

The problem for Utilitarianism here is that such a conversation arises at all. If Utilitarianism is a final and complete moral theory, then there seems to be no moral basis for this disagreement (i.e., for any of us to prefer a worse outcome over a significantly better one). If Utilitarianism is correct, the moral situation is as clear as day: given the choice between five deaths and one, we are obligated to act. Inconveniently for the theory, however, many people also resist Utilitarian efforts to discredit our hesitance to pull the lever as merely a cultural or psychological quirk. Indeed, many philosophers see Foot’s thought experiment as doing decisive damage; it reveals that Utilitarianism is not the complete, final accounting of morality which it is advertised as being, but only a partial account.

As is often the case in philosophy, this isn’t the end of the argument. Utilitarianism wasn’t killed off by Foot’s hypothetical. But it did highlight a moral difference between actions and omissions – between switching the lever or allowing the trolley to run its predetermined course. When Foot wrote her paper, enough people felt the pull of those considerations for the argument to be regarded as seriously problematic for Utilitarianism. As a sociological matter, the thought experiment did significant work in moving moral-philosophical discourse in Britain and the US away from the Utilitarian orthodoxy of Henry Sidgwick (the dominant figure in early and mid-20th century).

Today, however, we are at a moment in American public life where the acts/omissions difference seems to be in danger of collapse. This can be seen clearly in how people talk about Luigi Mangione’s murder of Brian Thompson. Despite what opinion-polls suggest, not many people worth taking seriously will argue that a cold-blooded murder (shooting someone in the back in an ambush) is morally permissible. No one worth taking seriously thinks that it is morally “acceptable” to murder someone in cold blood (shooting them in the back in an ambush). And tidy equivocation will not do. “Killing people with paperwork instead of a gun doesn’t make you any less of a murderer…” wrote Arwa Mahdawi in the Guardian. There are real and significant differences between manslaughter and murder. And there are differences between shooting someone to death, and serving a for-profit bureaucracy which kills people by denying them access to essential medical care. A health insurance company does not murder people. It creates, and implements, rules which foreseeably cause huge numbers of people to live in more pain, and die much earlier, than would happen without the “efficiencies” driven by the commitment to maximize profits. Unlike an ambush killing, the misdeeds of the insurance industry are wrongs of omission, instances of denying people care (not letting them get a drug, treatment, or operation). The industry allows misery, sickness, and death by failing to act to protect people (its customers!) from injury and disease.

The impersonal nature, and massive scale, of this deeply unjust system drives many people to see the killing in equally impersonal, representational terms. One reason why there has been less shock at the murder than we might expect is because we have a sense that the CEO was not killed not as an individual person – a man named Brian, who was a father, with a personal history and life story – but rather as a CEO, in his role or office as the leader of that particular commercial enterprise. What strikes people as significant about the killing is its symbolism (presumably this is also what led the state of New York to indict the alleged shooter for terrorism rather than simple murder). From this symbolic view – where individuals disappear and what remains are the abstract roles, positions, and structures which they represent – the act versus omission distinction gets washed away. From that view, structural violence is just as real a source of social evils (unjust outcomes such as crippled and shortened lives) as acts of direct interpersonal violence is. For many people, at the moment, there seems little temptation to say that it is worse to murder a person than to participate in, facilitate, and personally enrich oneself through the for-profit killing-by-omission of hundreds of thousands, or millions, of persons. The systematic injustice of American health insurance (and the healthcare system more broadly) is an industry which wrings private wealth out of human suffering.

I guess you could count this as a win for Utilitarianism. It delivers the clearest of moral answers in the grimmest of circumstances. And perhaps it accurately captures how many reflexively respond to the killing of the United CEO. In the context of the abomination that is American health insurance, maybe utilitarianism is the theory best suited for thinking about the right thing to do. (Should we take that as vindication for the theory, or a damning indictment of the industry and the system which enables it?) Still, it should worry us that on such a serious and prominent social issue as this, so many Americans no longer feel the pull of the act/omission distinction – the moral concept seems to be giving out on us….

I remain convinced, however, that there is a moral difference – sometimes a big difference or “all the difference in the world” – between doing something which has terrible consequences, and allowing terrible things to happen through not doing something. As a matter of personal responsibility – as a matter of what I have to live with – it matters to many of us whether we have to live with having done something, or live with having allowed something to happen. That difference shows up in how we think and feel about ourselves, in the sleepless nights we suffer after a wrongdoing or morally culpable oversight, where we doubt our decency, honesty, or bravery. This is not to say that there is anything necessarily better about an act or an omission. Both can do great damage, and both can be the cause of genuine remorse.

The difference matters enough to us that it is part of a cliché: it is better to regret something you have done than something you didn’t do. The Japanese have an idiom which captures it beautifully: “kiku ha ittoki no haji, kikanu ha isshō no haji” “聞くは一時の恥、聞かぬは一生の恥” (“to ask is embarrassing for a moment (one time), not to ask is shameful for life”). I don’t know if that’s an objective (timeless, universal) moral truth. It is vague enough that it is probably useful to say to someone, at some time. The point to consider here is that a theory which says there is no difference between asking and refraining from asking, and which insists that the only things to be mourned or cherished are the outcomes of asking or not asking, seems to deprive us of something we find useful.

The Ethical Dilemma of Extraditing Meng Wanzhou

photograph of Meng Wanzhou on a moblie phone at business function

When students take an introductory ethics course, they are often given thought experiments where they are asked to consider whether it is morally acceptable to sacrifice a few for the interests of the many. Often these thought experiments are fanciful — a running trolley, a South American dictator telling you to choose one person to die rather than twenty — but problems like this can reflect real world choices that must be made. The recent example of the extradition case of Meng Wanzhou is one such case where the ethical road ahead is unclear and solving the dilemma may require sacrifice in the name of the “greater good.”

Wanzhou is the deputy chair of the board and CFO of Huawei, the company founded by her father Ren Zhengfei. In late 2018 she was arrested by the RCMP in Vancouver at the request of the United Stated for conspiracy to commit fraud. The case is owing to the close links between Huawei and Skycom, a company that claimed to be a fully independent but that may be entirely controlled by Huawei. Meng is charged with engaging in a scheme to obtain goods and technology as well as transferring money through Skycom in violation of international sanctions against Iran. The United States has formally requested extradition of Meng, with the matter now before Canadian courts.

The case is complicated by several other important factors. The Chinese government protested to the Canadian ambassador and threatened “grave consequences” for the arrest. Two Canadians, Michael Kovrig and Michael Spavor, have been arrested and detailed in China for endangering state security in a move seen as retaliation against the arrest of Meng. Prime Minister Justin Trudeau has called the arrests arbitrary. Meng has been released on bail, but wears an ankle monitor and has surrendered her passport. She is living in Vancouver in a $13 million-dollar mansion. Kovig and Spavor on the other hand were interrogated for six to eight hours a day for months, kept under 24-hour artificial lighting without being able to go outside, and were only able to have monthly consular meetings without being able to talk to friends or family. There is also the case of Robert Schellenberg, initially found guilty of smuggling drugs and sentenced to 15 years only to be hastily retried and sentenced to death. It’s been intimated that the fate of these three Canadians Kovig, Spavor, and Schellenberg rests on the Canadian government’s treatment of Meng.

Meng’s extradition case recently suffered a setback after a British Columbia court ruled that the charges met the double criminality criteria for extradition. Meng’s legal team argued that since Canada did not have sanctions similar to those the United States had against Iran, she isn’t being charged with something that would be a crime in Canada. The ruling held that the charges are about fraud, which is a crime in Canada. Despite this, the Canadian government possesses the ability to set Meng free. Under extradition law, Canada’s justice minister may at any time intervene and withdraw the government’s support for the case which would allow Meng to return home and possibly get the release of detained Canadians and smooth out relations.

In the meantime, there is very little upside for Canada to detain Meng. Canada-Chinese relations have been hurt by the affair, and experts have claimed that this is likely to affect trade talks and lead to a reduction in tourism and investment in the Canadian economy. China has apparently not tried to retaliate against the U.S. due to their desire to improve their relationship. Canada, meanwhile, has been squeezed between the U.S. and China in an issue that some experts believe is a direct result of their ongoing trade war. Unsurprisingly, there are a significant number of Canadians who would rather be rid of the matter. In 2019 a poll found that 45% of Canadians believe that Canada should have resisted the U.S. request and not arrested Meng at all. A group of over a dozen prominent former Canadian politicians and policy advisors from different political parties have issued an open letter calling on the Trudeau government to release Meng in the hopes of securing the release of Kovig and Spavor, even if it means straining U.S.-Canada relations.

So what reason is there for Canada to not release Meng immediately? One of the reasons, and the one touted by the Trudeau government, is that it would be inappropriate for the government to intervene with a matter before the courts and that the rule of law should be respected. Trudeau has stated that “Canada has an independent judiciary and these processes will unfold independently of any political pressure, including by foreign governments.” Indeed, the reliance on an independent judiciary to settle the matter has been labelled a win for the rule of law. Despite this claim, those seeking Meng’s release have cited the opinion of a lawyer well-versed in extradition proceedings who notes that government discretion is “explicitly codified” in the law and that intervention would not endanger judicial independence and would be consistent with the rule of law.

But the Trudeau government, and others, have also argued that releasing Meng on the condition of securing the release of Spovor and Kovig would set a bad precedent. The government believes that cancelling the extradition process for Meng would put “millions” of Canadians in danger. Trudeau has argued that

“The idea of solving a short-term situation by creating a precedent that demonstrates to China that all they or another country has to do is randomly arrest a handful of Canadians to put political pressure on a government to do what (they) want…would endanger the millions of Canadians who live and travel overseas every year.”

On the other hand, the idea that this would set a precedent smells of a slippery slope fallacy. One way to avoid situations like this would be to practice more restraint regarding who is (and is not) detained. Also, we need to consider the unique qualities particular to the situation. How many nations would likely try to detain traveling Canadians if they have a dispute with the Canadian government? Would releasing Meng in this case actually cause this to happen again? What countries would likely do this? What issues would likely prompt governments to do this? While we are considering these things, we may also consider how a concept like “rule of law” is interpreted. As was pointed out during the standoff with indigenous groups back in February, the concept is not singular, universal, or absolute. What are the assumptions we make in this case when we interpret the concept of “rule of law” in this case?

There is also the matter of Spovor and Kovig and whether they may be sacrificed for such principles and precedents. Kovig’s wife Vina Nadjibulla does not agree with the government’s refusal to intervene, arguing that we can both protect Canadians and secure the release of her husband. She notes, “There is no cost-free solution. We have to pay a price. The question becomes, who pays the price, and at the moment Michael Kovrig and Michael Spovor are paying that price.”

Finally, there is also the risk of violating agreements with the U.S. over extradition. Canada and the U.S. are allies and it makes sense to not antagonize America for the benefit of China. However, given the U.S. administration’s “America First” motto, one wonders whether the favor would be returned if the shoe were on the other foot. Indeed, there is a sense that “Washington is using Canada in its trade battle with China.” Even President Trump has mused about using Meng as a bargaining chip in trade negotiations, suggesting that this process may not be about the rule of law at all, despite John Bolton’s recent claim that the criminal charges are not politically motivated.

As Nadjibulla noted, there is no cost-free solution, and this is essentially at the heart of all moral dilemmas. The goals Canada is trying to achieve in ending the situation are incompatible. What combination of ends are the right balance is difficult, and it will require determining how much value we place on a given conception of the rule of law, economic gains and losses, creating political tensions (what kinds? with who?), creating possible dangerous precedents, and the suffering of those few who are detained.

Emergency Rationing in Italy

blurred photograph of crowded hospital waiting room

When facing rationing health care resources, how can we ethically make decisions regarding directing care? In answering, we may attend to a famous thought experiment that brings out the tensions of making choices facing lose-lose options: The Trolley Problem. Originally articulated by Philippa Foot in 1967 in order to draw out tensions in utilitarian moral frameworks, this thought experiment has highlighted distinctions in common moral intuitions in domains from bioethics to military ethics. The classic trolley case was posed in a series of cases that press on whether considering the consequences of a presented choice is the correct deliberative path:

“Suppose that a judge or magistrate is faced with rioters demanding that a culprit be found for a certain crime and threatening otherwise to take their own bloody revenge on a particular section of the community. The real culprit being unknown, the judge sees himself as able to prevent the bloodshed only by framing some innocent person and having him executed. Beside this example is placed another in which a pilot whose airplane is about to crash is deciding whether to steer from a more to a less inhabited area. To make the parallel as close as possible it may rather be supposed that he is the driver of a runaway tram which he can only steer from one narrow track on to another; five men are working on one track and one man on the other; anyone on the track he enters is bound to be killed. In the case of the riots the mob have five hostages, so that in both examples the exchange is supposed to be one man’s life for the lives of five.”

This last case has been taken up as The Trolley Problem: a runaway tram must be directed either towards a track with five working men on it or a track with one man on it. Each case is presented in terms where the decision is between an action that results in the deaths of five or the death of one.

Morally relevant features in the deliberation favor different schools of thought in ethics: the consideration in favor of minimizing lives lost highlights the importance of the consequences of the choice, diverting the tram at all may speak to implicating an agent in the deaths (however many result), or, on the other hand, we may think that facing the choice implicates the agent whether she acts or not, or that making a choice between the paths qualifies vicious or problematic because it suggests that lives can be reduced to figures and statistics instead of adopting an appropriate respect for the incommensurate value of human lives.

The confounding tension of these (and likely other) morally relevant features in the trolley problem makes it an ethical puzzle that has stuck with philosophers and non-philosophers for decades. Though it was originally presented to draw out the tensions between favoring the morally relevant consequences of an act and any other features, the difficulty in squaring our explanation for the morally permissible response to cases like the trolley problem has led to various interpretations of moral intuitions and ethical principles in their own right.

For instance, Foot uses the case to discuss the Doctrine of Double Effect, which dates back to Thomas Aquinas in the history of “Western” philosophy. It draws a distinction between what you aim to do and the side effects of your action. If your aim is morally permissible, but it has morally bad effects, the Doctrine of Double Effect delineates when such actions are permissible. If you foresee negative side effects of your choice, but they are not part of your aim, then your choice is morally permissible. If the morally bad effects of your action are part of your aim, or are a necessary part of achieving your aim, then we attribute the effects to your action and it is not morally permissible.

Thus, if you redirect the tram to collide with one person rather than five, this would qualify as a morally permissible action because your aim is not to kill the one person, rather it is to save the five people (or to minimize deaths), and the death of the one person is a foreseen side effect. If the one person did not die, all the better, from the perspective of your aims and choice.

Between consequentialist reasoning (minimize deaths!) and principles like the Doctrine of Double Effect (bad effects are permissible as long as your aim is good and outweighs the bad!), there are multiple ethical frameworks that can make sense of permissible harm, even deaths, that result from one’s actions.

The healthcare choices facing the medical community in Italy are reaching a selection framework similar to the trolley problem. In the case of triage, or prioritizing some patient care over others, the side effects are clearly unfortunate; some people will not be receiving care that they need. Typically, decisions regarding triage prioritize care roughly in terms of first-come, first-served mitigated by severity. But when resources become extreme in terms of scarcity, or conditions become extreme in terms of survival, the stakes change. On battlefields and in the conditions we are seeing in Italy, the situations of need are such that physicians are facing incredibly difficult rationing decisions. By giving resources to one patient, they can anticipate others experiencing significant harm, deteriorating health, or even death.

The reality of the effects of COVID-19 in Italy is that resources have become incredibly scarce remarkably quickly. Resources include staff time and intention, materials like masks and respirators, and space like beds and rooms. There are limited amounts of each, and decisions regarding how to allot them are particularly fraught when lives are at stake.

In an opinion article for the New York Times, medical experts articulated the difficulty facing physicians:

“The goal should be saving as many people as possible, and treating those who are likely to get the greatest benefit from care. This will mean that treatment cannot be allocated on a first-come-first-served basis, as it normally is. Traditionally, patients on ventilators are not displaced for other patients, and later arriving patients can be turned away in a shortage.

But in the coronavirus pandemic, business as usual would make patients with a good prognosis if treated suffer for want of treatment, while patients who arrive earlier but have a grave, or even hopeless, prognosis would receive treatment. Under that standard of care, more lives would be lost.”

The advice here adopts a standard of care that aims to maximize lives saved, similar to the majority of respondents to the Trolley Problem. In crises like the one affecting areas currently hit hardest by this pandemic, the calculation that saves the most lives means an alteration in how we ration care, in how we triage.

A major concern is maintaining the health of those professionals who are treating the ill. Thus, the role of the patient will play a large role in allocating health care. The perennial press for the Trolley Problem is what the physicians are currently facing: “What if the one person on the tracks opposite the five is the leader of a country?” “What if the one person is in charge of their family?” “What if the one person is a doctor?”… Unfortunately, this last question is particularly pertinent. As health care professionals treating the ill are currently in high demand, it is crucial to keep them healthy. Keeping one health care worker able to serve the ill population has ripple effects for the health of the community.

Deciding which principles to adopt in order to protect the health of our communities in the face of this pandemic are going to be difficult. The decision to withhold care is heart-wrenching, and should put pressure on our global community to increase the resources available to those in need to reduce the necessary triage and rationing. Indeed, that is almost always a response when the Trolley Problem is posed – surely, there’s a way out of making this decision. We have a moral obligation to help one another, and as Italy is part of the EU, perhaps the EU is specially positioned to provide aid and resources (and is, perhaps, failing in this duty).

Just How Useful is the Trolley Problem?

Image of a streetcar in a city.

Philosophy can be perceived as a rather dry, boring subject. Perhaps for that very reason, divulgers have attempted to use stimulating and provocative thought experiments and hypothetical scenarios, in order to arouse students and get them to think about deep problems.

Surely one of the most popular thought experiments is the so-called “Trolley Problem”, widely discussed across American colleges as a way to introduce ethics. It actually goes back to an obscure paper written by Philippa Foot in the 1960s. Foot wondered if a surgeon could ethically kill one healthy patient in order to give her organs to five sick patients, and thus save their life. Then, she wondered whether the driver of a trolley on course to run over five people could divert the trolley onto another track in which only one person would be killed.

Continue reading “Just How Useful is the Trolley Problem?”

Who Should Program the Morality of Self-Driving Cars?

An image of a self-driving Uber

On Sunday, March 18, Elaine Herzberg died after being hit by Uber’s self-driving car on the road in Tempe, Arizona. Out for a test-run, the video of the collisions suggests that there was a failure of the self-driving technology as well as the in-car driver meant to supervise the testing of the test drive.  Uber has removed its self-driving cars from the road while cooperating with investigations, and discussions of the quickly advancing future of driverless vehicles have once again been stirred up in the press.

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Do Self-Driving Cars Reinforce Socioeconomic Inequality?

A photo of the steering wheel of a Mercedes car.

Recently, Mercedes-Benz stepped into the spotlight after making a bold statement concerning the design of their self-driving cars. The development of autonomous cars has presented a plethora of moral conundrums, one of which is the most ethical way to program cars to respond to emergencies. The dilemma, as presented in a previous article, is one of trying to determine the value of and prioritize human life. Mercedes has declared that they will “program its self-driving cars to save the people inside the car. Every time.” This declaration sheds light on a new issue: is it ethical for car companies to create technology that widens the gap between socioeconomic classes and threatens current societal values?

Continue reading “Do Self-Driving Cars Reinforce Socioeconomic Inequality?”