Suppose you have stumbled your way into the campus philosophy building. There, a group of freshmen have just had their first lecture in moral philosophy and are discussing the trolley problem — the one about letting a trolley run over five people or pulling a lever to change its course toward the other track where only one person would fall victim. One student is on a roll — he’s going on about how he’d obviously pull the lever. The only way ethics can be made meaningful and pragmatic, he says, is to have its rules based in the real world. Saving more lives is always the right answer. Another student cuts him off. She says that while it’s unfortunate that those five people will die, pulling the lever would mean using the one person on the other track as a means to an end. This, she says, is a gross affront to one’s moral duty to respect others as ends in and of themselves.
The discussion ends with little resolution (as it usually does), and yet you find yourself curious about something else. You wonder: Who are those people tied to the tracks? And who is the person pulling the lever? Do they know each other?
Traditional ethics like utilitarianism or Kantianism are foundations to moral philosophy that have remained influential. And for good reason. They are strict and analytical, relatively coherent and, by their design, are accessible to the layman. It’s not so hard to be convinced that the happiness of many should outweigh that of the few, or that everyone should be bound by the same set of moral duties.
However, it’s one thing to believe in a set of rules, and another to apply them in the real world or, to complicate things further, a hospital. We can imagine that the first student might change his answer if the lone person on the track was his mother or father. In fact, one heavily critiqued aspect of traditional ethics is its insistence on rules and its negligence of how we, as moral agents, can’t help but apply importance on personal relationships, identity and context when making serious ethical decisions.
Care ethics, one system that’s emerged because of this critique, leans into the idea that pretty-on-paper rules of arithmetic or universal laws struggle to encompass the real-world variables that inform our daily actions. One of its most important conclusions is that we probably will end up feeling more responsible for certain people based on our own identities and the relationships we share with them. And while traditionalists would condemn this feeling, the care ethicist calls on us to embrace it. After all, the wheelchair user might prefer a lower hospital bed. The patient in for their first pregnancy may be more anxious than the one in for their fourth. And the physician with a history of anorexia might be just the tiniest bit more cautious with their anemic patient. In these scenarios and hundreds of others, the provider’s bounty of personal experiences can impose palpable changes in their clinical practice.
There is certainly a need in medicine to maintain some amount of distance from your patients. Serious decisions made day-to-day require a standard of care, which is another way of saying that personal concerns should come after both scientific and clinical procedure. But, for many care ethicists, providers and other skeptics of problematic trolleys, this rule comes with an asterisk.
Related Content
- How I Want to Die: Teaching Ethics and Death in Medical School
- Anatomy: A Poem
- The Need to Diversify Narrative Medicine
Want to read more from the Johns Hopkins School of Medicine? Subscribe to the Biomedical Odyssey blog and receive new posts directly in your inbox.