The Trolley Problem Breathes

October 24, 2009

This fantastic real-world account from the New York Times deserves closer examination.  Check out this killer scenario:

A 32-year-old man with cystic fibrosis is rushed to the hospital with appendicitis in the midst of a worsening pandemic caused by the H1N1 flu virus, which has mutated into a more deadly form. The man is awaiting a lung transplant and brought with him the mechanical ventilator that helps him breathe.

New York’s governor has declared a state of emergency and hospitals are following the state’s pandemic ventilator allocation plan — actual guidelines drafted in 2007 that are now being revisited. The plan aims to direct ventilators to those with the best chances of survival in a severe, 1918-like flu pandemic where tens of thousands develop life-threatening pneumonia.

Because the man’s end-stage lung disease caused by his cystic fibrosis is among a list of medical conditions associated with high mortality, the guidelines would bar the man from using a ventilator in a hospital, even though he is, unlike many with his illness, stable, in good condition, and not close to death. If the hospital admits him, the guidelines call for the machine that keeps him alive to be given to someone else.

The original trolley problem, for those unfamiliar with our sordid and incestuous body of literature in philosophy, is neatly summarized here. The NYTimes doesn’t offer us an exact parallel to the trolley problem, but I do like that we’re asked whether we should remove the ventilator of the man suffering from cystic fibrosis. (And why not? Shouldn’t we just turn the trolley to save the five? Ethics is a breeze!)

Yeah, so, I think the Times could be clearer on the scenario. From what I gather, the dude isn’t sick with H1N1, he’s just unlucky enough to have the opportunity to stumble into the hospital at the wrong time. Let’s assume that.

Also, it’s not clear if it’s his ventilator or the hospital’s ventilator. If it’s his ventilator, I think a lot of people would say that he shouldn’t have it taken from him. It’s just a contingency that he’s in the hospital at that time. Seems reasonable. He owns it.

If the ventilator is on loan from the hospital, I suspect fewer people would say that the hospital has no jurisdiction to take it from him, but I suspect that most would argue that the hospital still ought not to take it from him. They might argue along “first in time, first in right” style reasoning.

The question is: why would this ever be a guideline at all? Seems in both cases that the ventilator should stay with the man whose life depends on it. Doesn’t make sense to send the ventilator to another room, to save one H1N1 patient, only to have this guy die, particularly since his death isn’t linked directly to H1N1 and it’s not a question of simple ventilator allocation.

Suppose instead a different scenario. Suppose that our hypothetical cystic fibrosis patient is using a special sort of ventilator that could be used to save five people. Maybe H1N1 requires different pressures or something. What then?  Do the numbers change our conclusion that he ought to be allowed to keep his ventilator?


  1. I really don’t follow this at all. If it’s the guy’s own ventilator (“brought with him the mechanical ventilator that helps him breathe”), how could it begin to be reasonable for the hospital to take it from him, and give it to someone else? Tsk, tsk…the NYT usually does a much better job of explaining things.

  2. Yeah, I agree. They could’ve been clearer about that. Even still, there are interesting ethical questions here related to the prioritization of resources, as well as to the more difficult philosophical question of why, if in some cases we feel strongly that we should save the greater number, why we wouldn’t feel equally compelled to simply take the ventilator from him when he walks in the hospital.

    Remember that in the original trolley problem an innocent and healthy young man walks into a hospital, only to face the possibility of being cut up and having five of his vital organs distributed to five ailing patients, including his lungs. Most people find this objectionable, even though they do agree, when asked in a different context, that one should save the greatest number. What accounts for the difference? Here, the ventilator acts as an external lung, an external thing, instead of an internal lung, part of his body.

  3. Well, ethicists will take chopping up innocent people or taking their ventilators as worthy of discussion. But here we have state guidelines that disregard the matter of who owns the ventilator. It seems surprising, given our American regard for private property and all. I wouldn’t be surprised if certain right wing commentators actually die of a heart attack when they read this.

  4. I think most people would agree with you, including those in NY who write and evaluate the rules, which is why they’re revisiting the guidelines.

  5. Much of the answer depends on your view of “property rights”. Are they absolute, subjective, or non existent? Can the State take them by fiat?

    Consider an alternate scenario. The person with CF arrives at the hospital and is admitted to the ICU. Someone else without a preexisting condition enters the ER and there are no beds left in the ICU. Do you throw the CF patient out?

  6. I’m not sure it all depends on property rights. In your scenario, the CF patient doesn’t depend on the bed for survival. Presumably he can find another bed somewhere else. The ventilator functions as an organ for him. Even if the hospital completely owns the ventilator, it seems to me that because it’s already in use by the CF patient, he has some claim to it.

    • Actually those were two different thoughts.

      The second case was one where property rights don’t apply, but prior usage does. Typically once a doctor starts treatment I think the assumption is that they are bound to continue it, so you can’t stop treatment on a patient out just because someone has a better chance of survival. This is assuming that the treatment is dependent on a critical, limited resource.

      This may be part of the emotional reaction in the health care debate: the so called “death panels”. An patient being enrolled in the system is equated with being under care. Denial of a life saving service would be equivalent to throwing them out of a hospital bed, because there was someone who needed it. The care available is limited based on the available resource (insurance money for treatment), but the elderly will consume much more of it with less profitable outcomes (more years of life) than younger patients.

  7. I’d like to find out more? I’d like to find out more details.

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