Beyond the Pillars:

(Attempting to) Understand Bioethics

Through Thought Experiments
Joshua Kornbluth, MD
Disclosures
• Financial: None
• Most media used via freely-available sources (Wiki, local, regional, and national
news media)
Ground Rules
• Dialogue > Didactic
• Polite interruptions encouraged
• If you disagree, suggest an alternative
Warning!!!
• There will be questions asked, and answers expected.
• No volunteers = I call on random people in the audience
•
The hunt for answers
• How do we know the answers to basic questions?
• Observe and report
• Reproducibility
• Experiments

• How do we find answers in clinical medicine?

• Gold standard?
• RCT

• How do we do RCT’s of morally ambiguous situations?

• Applied Clinical Bioethics
What is the point of Clinical Bioethics?
• Practical discipline that provides a structured approach to assist
physicians in identifying, analyzing and resolving ethical issues in
clinical medicine. (Clinical Ethics, 4th Ed.)

• Q: What is an ethical quandary?

• A: basically everything, but we press on
Bioethical Pillars
• Autonomy
• (Distributive) Justice
• Beneficence
• Nonmaleficence (primum non nocere)

• Recognizing society-level and person-level conflicts

• Autonomy and beneficence/non-maleficence
• Autonomy/beneficence and justice
• Futility
Applied Bioethics
• Medical Indications
• Patient Preferences
• Quality of Life
• Contextual Features, i.e, the social, economic, legal, and
administrative context in which the case occurs.
The hunt for answers
• How do we know the answers to basic questions?
• Observe and report
• Reproducibility
• Experiments

• How do we find answers in clinical medicine?

• Gold standard?
• RCT

• How do we do RCT’s of morally ambiguous situations?

• Applied Clinical Bioethics
Thought Experiments
• Thought experiments are devices of the imagination used to
investigate the nature of reality (including physical, psychological, and
social/ethical).
• They have been used in natural sciences, social sciences, history,
mathematics, and philosophy
Why use thought experiments?
• Real experiments might not be able to account for multiple variables.
• Real experiments may be very time consuming and/or expensive.
• Real experiments may be unethical.
• Real experiments may be physically impossible.
• Also – fun and interesting?
Why use thought experiments?
• Repetition and visualization
• Not enhance morality, but
enhance detection of moral
distress
• Moral distress can have an
objective negative impact on
providers and patients (Weber, 2016)
• Train our minds to analyze
possible outcomes
• Case analysis skills > being able
to look up the answer
Process of a thought experiment
• A scenario and a question are introduced.
• The experimenter goes through the scenario and arrives at some
result via imagery, thought, discussion.
• A conclusion is drawn with respect to some end point (e.g., an
ethically relevant claim or distinction).
Deontology
• Many ways to analyze ethical dilemmas
• For the most part we will use deontological ethics
• What ‘ought’ you to do in any circumstance
• Consequences aren’t as important as motives
Some typical ethical quandaries
• Are we morally obliged to give the maximum amount to poverty
relief?
• A child has fallen into a pond and is about to drown; ought you hurry
to rescue him/her even if doing so ruins your shoes and your plans for
the day? (Singer 1972)
• A terrorist has hidden a bomb that will kill thousands of people if set
off; are we morally permitted to torture her given that we know that
only in this way we will learn how to defuse the bomb? (Shue 1978)
Respect for Autonomy and Consent
• Theoretical case:
• Mr. M has gangrene of his foot requiring an amputation
• Without this amputation, he will likely become septic and die.
• Mr. M refuses…. What do you do?
Which is the Truth?
A person is morally
responsible for an
event because they
are the cause of it.

A person is the cause

of an event because
they are morally
responsible for it.
Cause and effect
• What is directly responsible for the California wildfires?
• Faulty power equipment?
• Santa Anna winds?
• How about hundreds of years of climate change?
• Oxygen?
• Although the presence of oxygen is a necessary cause, it is not a
salient cause in this case
• When we are asked what causes an event, we are asked about the
salient causes.
• In normal situations, either we have already known that the presence
of oxygen causes fire or we are not interested in knowing this cause.
• Hence, what makes a cause a salient cause depends on our interest.
Salience
• When we ask who causes an
event, we are interested in
finding out who is morally
responsible for the event.
• who is morally responsible for
the event is the salient cause.
• We can use thought experiments
to support this point.

Parvisi 2013
Example
• Peter made a mail bomb and sent it via UPS to John.
• The UPS delivery person places the parcel at the door.
• Peter opened the box and was immediately killed.
• Who is responsible for Peter’s death?
Example
• Peter, the UPS guy, and John all are
involved in the causal chain resulting
in the death of John
• If John had not opened the box, he
would not have been killed.
• If the UPS guy had not delivered the
parcel, John would not have been killed.
• If Peter had not mailed the parcel, John
would not have been killed.
• However, since only Peter is morally
responsible for John’s death, we think
that only he is the cause.
Which is the Truth?

A person is morally
responsible for an event
because they are the
cause of it.

A person is the (salient)

cause of an event
because they are morally
responsible for it.
Classic thought experiments
• The businessman and the environment
• The Trolley Problem
Double Effect Thought Experiment
Double Effect Thought Experiment
Double Effect Thought Experiment
The Trolley problem (Foot 1967)
• You arrive at a situation
• If you do not act, five people will die
• If you act, one other person will be killed and the five will be saved

• Most people’s intuitions do not correspond either with pure

deontology or with utilitarianism (Greene et al. 2001; Waldmann and Dieterich 2007; Hauser et
al. 2008)
The Trolley problem
• Basic dilemmas
1. The Switch
2. The Bridge (and bridge +)
3. The Loop
4. The Rockslide
The Trolley problem – The switch
• You are standing at a switch
• Train is coming down the track
• Inaction will allow 5 people to die
• Action will cause 1 death but
save 5 lives.
• Which is the most ethical choice?
• About 90% of respondents say it
is morally acceptable to flip the
switch (Hauser 2008)
The Trolley problem – The bridge
• Train is still hurtling down a track
towards five people.
• You are on a bridge under which it will
pass, and you can stop it by putting
something very heavy in front of it.
• As it happens, there is a very fat man
next to you – your only way to stop the
trolley is to push him over the bridge
and onto the track, killing him to save
five.
• Should you proceed?
• Why or why not?
The Trolley problem – The bridge
• Hauser 2008 - ~10% of people
thought pushing the man was
morally acceptable
• Most people refused or even
condemned pushing the fat man
The Trolley problem – The bridge
• Train is still hurtling down a track towards
five people.
• You are on a bridge under which it will pass,
and you can stop it by putting something
very heavy in front of it.
• As it happens, there is a very fat man next to
you and your only way to stop the trolley is
to push him over the bridge and onto the
track, killing him to save five.
• It also just so happens that he is the person
who tied the poor victims to the track!
• Should you proceed?
• Why or why not?
The Trolley problem – The Loop
• Train is still hurtling down a track
towards five people.
• Inaction still leads to 5 people dying
• In this case, flipping the switch will kill
the one person
• In this case though the death of the 1
is part of the plan to save the 5
• Should you proceed?
• Why or why not?
• ~50 of respondents say it is OK to flip
the switch
Small divergence – Transplanted organs
• A brilliant transplant surgeon has • Travelling stranger shows up to a
5 patients, all who need a clinic and happens to be a
specific organ perfect match for all 5 recipients
• Lets say they are all outstanding • Can we sacrifice his life for the
members of the community benefit of the 5?
• No organs available • What if he had no relationships
and wouldn’t be missed?
• What if he was a terrorist?
Back on track….The landslide
• A train is hurtling down a track
towards five people.
• You can divert its path by
colliding another train into it
• Doing so will cause a landslide
into a yard where a man is
sleeping in a hammock. He
would be killed.
• Should you proceed?
• Unger 1992
• Responses to this seem to be
partly dependent on whether or
not the person has been
exposed to other scenarios
• Naïve people are more likely to
say this act is wrong
Conclusions -
• The consequences of many of these scenarios are the same, despite
very different interventions
• The moral permissibility of an action depends on things other than
consequences.
• What are they?
• Intention?
• Social norms?
My role as an educator
• Your level of functioning as a resident is poor.
• I give you honest feedback.
• I am fulfilling the duty of an educator and physician.
• The feedback makes you a better doctor.
• A) My intention is to support and nurture you.
• Is my action right or wrong?
• B) My intention is to humiliate and discourage you.
• Is my action right or wrong?
Scenario
• A patient with painful terminal cancer requests a doctor to withdraw
her chemo and avoid CPR to let her die.
• Doctor A is willing to do so in order to prevent her from suffering
unnecessarily, even willing to give medications such as morphine.
• Doctor B is also willing to do so.
• But it is ecause he thinks that this patient is too annoying and is happy
to get rid of her.
• If the permissibility of an action depends on its intention, we have to
say that Doctor A is permissible to withdraw the patient’s respirator but
Doctor B is not.
The Doctrine of Double Effect
• Typically applied to sedation at the end of life or euthanasia
• But can also be applied to abortion

• If doing something morally good has a morally bad side effect, it's ethically OK to do it
providing the bad side effect wasn't intended. This is true even if you foresaw that the
bad effect would probably happen.

• How does this apply to the wealthy businessperson?

• How does this apply to the Trolley Scenarios?
• Can a person be a means to an end? Are we allowed to cause intentional harm ?
• Do we, as physicians, nurses, allied healthcare providers, need to adhere to a different
standard?
Feelings of the Victim (Thomson 1993)
• Focus on what the potential victim would feel about what the agent
(you) does.
• If you were thrown from a bridge you might feel differently about the
agent, than if a trolley were directed towards you.
• And it is this difference that plays a role.
• It does not yet solve the trolley problem, because one can imagine
switch and bridge situations where the victim feels the same.
• How can this translate into your practice?
Personal vs Impersonal dilemmas (Greene 2001, 2008)
• Does your relationship with the victim matter?
• What if it was your parent/friend/spouse?
• Turning a switch is very impersonal where pushing someone off a
bridge is very up close and personal
• Personal relationships with our patients and their families.
JJ Thompson 1972
• A virtuoso violinist has a horrible kidney • Defending Abortion despite the
ailment that will probably get better in 9
months.
right to life
• You have been kidnapped and wake up • Via this argument abortion does
with this person’s circulatory system not violate the fetus’s right to life
grafted to your own
• Is it morally permissible for you to ask to
• A pregnant woman does not
be severed from her even if this will kill normally violate the fetus's right
her? to life, but merely withdraws its
• “[I]f you do allow him to go on using your use of her own body, which
kidneys, this is a kindness on your part, usually causes the fetus to die
and not something he can claim from you
as his due”
Other interesting and odd cases
• Local scientists find two unknown species, and they have no reason to
presume either is more valuable ethically or in its potential benefits to
mankind.
• Seeing that one species is absolutely adorable and about to be killed
by the other, should you shoot the attacking creature? It is not
adorable.
Other interesting and odd cases
• A child is being raised according to the views of their parents.
• As it turns out, these beliefs are both undoubtedly false and
potentially harmful to society.
• Is there an ethical obligation to inform the child concerning the truth
of the matter, or do parents have a moral license to misinform their
children?
Other interesting and odd cases
• An old women is in a coma and will die within the hour.
• Her family is dead, and rowdy teens steal the body and toss it off a
cliff.
• Consequently, money is saved as a result of their unusual tendencies.
• What should be the ethical evaluation of such circumstances?
•Thank you