Some Dilemmas

There is a massive car crash outside the hospital. Five people are rushed in. It is immediately apparent that they all need transplants. Two of them need a kidney transplant; one needs a heart; another needs a lung; the last needs a liver. If they do not get the transplant, they will die. Meanwhile, another man walks through the door to get a routine check-up. The question is whether you can kill that man to harvest five separate organs and save the five involved in the car crash. Clearly, this is unethical, despite being utilitarian. There are many reasons; no one would go to the doctor if there was a remote chance that they'd be sacrificed for the greater good. But, in comparing this scenario to the trolley case, what's the fundamental difference?

Farfetched, perhaps, but consider another ethical question. Is withholding treatment any different than withdrawing treatment? Doctors are usually more comfortable with not starting a treatment in the first place (letting the disease kill the patient) rather than stopping treatment once it has started (yet, isn't the disease still killing the patient?) This is a question of omission versus commission.

Is there a difference between killing someone and letting them die? Of course, euthanasia is a hugely complex topic that spans philosophy to law to policy to medicine. Here, I just want to point out that we should not conflate cause of death with responsibility of death. The cause of someone's death is biological. Responsibility comes about if a person makes an ethically charged decision (or refrains from it). If I take a patient off of life support, I do not kill him. His underlying disease kills him. But I may be responsible, depending on the moral status of that action.

This is very important for physicians to understand. Not everything that happens is caused by human agency. Since human agency is necessary for moral responsibility, not everything that happens will hold someone morally responsible. For example, if you can't help but do something; that is, you have no free will with regards to something, then you can't be responsible for it. If, no matter what I do, a patient will die, then I am not morally responsible for the patient's dying. If I could have given the patient medication to save his life, then I do not cause his death, but I am morally responsible for it.