Questions of ethical consideration in the medical field benefit greatly from the discussions within halacha. Conversely, legal-halachic debates in hard decision-making cases are revitalized by the ethical[1] problems presented by medical situations.
In this article, we will observe a popular ethical dilemma - “the trolley problem” - and the current research into its practical aspects. With the aid of neuroscience, light can be shed on some of the ethically challenging medical-halachic questions, such as allocation of scarce medical resources[2], triage decisions[3] and other “either/or” scenarios[4] with which doctors often must deal. In general terms, these questions comprise an intrinsic part of the public health-care systems that must prioritize limited resources.
We will first outline the ethical structure of the trolley problem and its use as a measuring rod for decision-making strategies and pragmatic ethical programs. Current research into this dilemma will introduce the growing field of Neuroethics.[5] [6]
The halachic version of the trolley problem will then be presented, through the lens of past rulings in such cases, and more recently the attention of halachic-medical research. New neurological-ethical (Neuroethical) research illuminates these classical avenues of investigation. Examining the problem in these different conceptual and disciplinary spheres can be illuminating. The "trolley" problems are ethically irreducible to simple directives, pushing the envelope of different ethical and legal systems, prodding an introspection of their own fault lines. A multi-faceted view of ethical problems (including: abstract concepts, legal and even "pedestrian" lay angles) gives the dilemma its deserved appreciation of depth and scope. Such a consideration is fruitful in a joint ethical-halachic conceptual scheme, and in an examination of halacha’s uniqueness as a legal and ethical system.
The classic bifurcation in medical ethics is between two modes of deciding about the ethics of action - deontological and consequentialist (a.k.a teleological or utilitarian) ethics[8]. Whereas deontological ethicists focus on the intrinsic rightness or wrongness of actions themselves, consequentialist ethics judges conduct by the end result. In the field of Jewish medical ethics, the different strokes of general ethical and halachic rulings are mutually instructive (in instances of compatibility or discord alike).
For example, in many medical situations, a pragmatic strategy is applied for optimizing the over-all end result. Such is the case with combat medicine[9] and natural disasters[10] requiring triage decisions. But even the pragmatic medical practitioner will not always have a clear-cut directive for a proper decision. As we will see, in such matters there is no universal compatibility,[11] a common voice of ethics in medicine and in law regarding this problem or even its efficacy for moral analysis.[12] [13]
1.1 The classic trolley dilemma
We will discuss a famous ethical thought experiment (that deals with extremes but is pertinent to every-day situations), one which rabbis and doctors are often confronted with. The evidence provided by neurological examination of laymen exposed to moral dilemmas, can provide insights into professional decision-making in medicine, law and halacha.
At the core of the problem is a situation where someone is going to get hurt, and the range of open possibilities present a choice between different undesirable outcomes. For example, the “classic” problem consists of a trolley headed toward a group of people, and the only available action to save them is pulling a lever that will maneuver it onto another track - where it will hit and kill a single person.
The trolley problem forces both utilitarian (measurable end result) and deontological (an action’s intrinsic merit) ethicists into their respective corners. An optimal decision in the utilitarian sense is to sacrifice the one for the many; but what is the quantitative borderline? What is the calculus for an optimal result? On the other hand, there are claims to the unique value of human lives independent of the circumstances[14]. That approach leaves the decision maker in the position of letting many people die for the sake of one, or attempting to employ an absolute deontological value system in a military situation where people are putting themselves at risk to begin with.
Thus, the theoretical problem intensifies when applied in actual decision-making. Even among ethicists, the answer to the question may change according to its presentation. When asked, in over 90% of the time, a group of participants in an experiment decided in favor of deflecting the trolley towards the one person. A variation of the same problem changed the response:
As before, a trolley is hurtling down a track towards five people. You are on a bridge under which it will pass, and you can stop it by dropping a heavy weight 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?[15]
Most people who answered positively (pulling the lever) in the first case, object to pushing the person in the second story-line, dubbed “the footbridge” version of the trolley dilemma. Of course, there is ample rational backing for each side, and to switching between them.[16] It seems as if the first version of the trolley problem evokes a utilitarian response, while the footbridge scenario prompts a deontological response.
No matter how ethics is perceived, the trolley problem forces one to pick a side or admit to being torn between sides. The ethical charge of the situation cannot be explained away.
1.2 The neurology of tackling moral dilemmas
In recent years, researchers have investigated the neurological nature of actual human reaction to the
diagram a - brain activity in activated areas, Greene et al, Science 2001
trolley problem.[17] [18] Different versions of the trolley dilemmas provoked activities in different areas of the brain: In order to understand the differing results in answers and correlating brain activity, a discrimination between “a-moral”, “moral-personal”, and “moral-impersonal” was employed. A-moral questions are baseline questions containing no ethical dilemmas.
Personal-moral dilemmas such as the footbridge version, showed activity in areas BA 9/10 (medial frontal gyrus) and BA 39 (angular gyrus). Impersonal- moral dilemmas such as the classic version or an even more remote “button pressing” or “driving by” scenarios, showed activity in areas BA 7/40 (parietal lobe) and BA 46 (middle frontal gyrus). These results are visually apparent in the fMRI scan (diagram a).
This neuroelectrical response to the dilemmas, can account for the different answers given to the two versions of the trolley problem, as well as more complex scenarios, such as a case in which the track leading to the one person loops around to connect with the track leading to the five people. Here we will suppose that without a body on the alternate track, the trolley would, if turned that way, make its way to the other track and kill the five people as well. In this variant, as in the footbridge dilemma, you would use someone’s body to stop the trolley from killing the five.[19]
Attempts to understand the decision in this version like that of the classic dilemma, and distinguishing it from the footbridge scenario, include[20] a Kantian
(absolute deontological) refrain from “making
use” of people. But it is clear that this scenario is not fully accountable on utilitarian or deontological grounds. Most cases in real life are of this sort - an intermediate comprised of deontological and utilitarian components.
Run-of-the-mill ethical theorizing simply does not give the solid basis for understanding people’s actual reactions to these situations. Rules like Kant’s imperative or a doctor’s training go only so far, and then comes the inner-workings of the mind, disclosing some other kind of moral parsing. The original research saw this as different levels of personalization of the problem. This theory brought on much of the ethical wrath directed “against those who claim the emotional tail wags the ethical dog”, and the reciprocal replies.
We must clarify the role such research plays here so as not to waste the potential of this research on the aforementioned debate - it is no substitute for ethical analysis of situations and actions - it serves a different angle, a research device to be employed in Jewish medical ethics. Neuroethics has a different take on moral decisions than does a classic ethical explanation, exposing the inner structure of the situations (including the actors themselves) and the measures taken in them. Looking at people’s reaction (in verbal and neurological levels) to ethically challenging situations offers something different.
The working hypothesis of the neurological investigation into ethical action and thought is that there exists an inextricable connection between moral action, logical processing and emotive faculties:
We maintain that, from a psychological point of view, the crucial difference between the trolley dilemma and the footbridge dilemma lies in the latter’s tendency to engage people’s emotions in a way that the former does not. The thought of pushing someone to his death is, we propose, more emotionally salient than the thought of hitting a switch that will cause a trolley to produce similar consequences, and it is this emotional response that accounts for people’s tendency to treat these cases differently. This hypothesis concerning these two cases suggests a more general hypothesis concerning moral judgment: Some moral dilemmas (those relevantly similar to the footbridge dilemma) engage emotional processing to a greater extent than others (those relevantly similar to the
trolley dilemma), and these differences in emotional engagement affect people’s judgments.[21] The ramifications of this type of experimentation and its conceptual background is far-reaching. It has been hailed as the end of ethics on the one hand,[22] a reasonable extension of the ethics field,[23] and even birth of a new and exciting field of Neuroethics[24] on the other end.[25] Either people are no more than automatons (or emotional trolleys on the loose) reacting on chemical impulse rather than taking an active ethical role in things; or on the contrary, we now can show that the ethical realm cannot be reduced to some logical algorithm, and an emotional personal engagement is inseparable from ethical conduct. Expounders of the latter direction in neuroethics point out the cases of frontal cortex damage cases,[26] wherein the logical capacities may be left intact while damage is sustained to emotional faculties. Such patients exhibit extreme difficulty in reaching even the most rudimentary decision making, when confronted with practical multiple-choice questions. They become a real-life example of the famous stalled decision thought experiment - Buridan’s Ass[27],
According to the neuroethical analysis, it is not a lack in reasoning ability that will kill the "Ass" but an impaired emotional capacity, or rather an "affective faculty"[28].
Emotional capacity, often described as a handicap to well formulated decision-making, may turn out to be a prerequisite for the mind’s intentional character, or at least an important and productive[29] aspect of decision-making, especially in trolley-problem situations, which take place in many forms, often in medical crises. Such extreme circumstances can easily stump people that have no trouble in everyday decisions. It is not uncommon to find oneself in extreme situations unable to make a decision. However, emergency, military and medical professionals face such problems constantly and must develop a working approach to the problem (be it a cold algorithmic guideline or an emotional fortitude). We now turn to the Halachic treatment of the problem.
2. The trolley dilemma in Halacha -
“diverting the arrow”
This section of the article is an overview of the halachic perspectives on the trolley problem. It is only descriptive, with no attempt to extrapolate a final halachic ruling on the subject. Moreover, it will show that the subject does not lend itself to absolute directives. The halachic discussions show the different aspects of the problem. The goal here is to examine how halacha deals with problems that are an ethical Gordian-Knot. More specifically, the Halachic rulings illuminates the current neuroethical investigation of the trolley problem with a different perspective.
There has always been a place reserved in Halacha for dealing with ”hard-cases” that strain the limit of “optimal solutions”. The posek is no stranger to lose-lose situations. The most famous example for this kind of halachic debate is the Mishnaic case of limited resources - two people in the wilderness, coming upon enough water for saving one of them.[30] The halachic analysis of these situations far predates that of common law treatments.[31]
Other cases involve a demand by enemy forces to hand over a few where the alternative is mass murder,[32] or forcing one person to hurt another under pain of (personal or group) death. The basic problem is the direct confrontation of two supreme directives: preservation of personal life, and absolute prohibition of taking another’s life.[33] In these cases, these two halachic vectors clash.[34] The key term is "Ein Dochin Nefesh Mipnai Nefesh" (a life is not set aside for the survival of another),[35] although sometimes there is a measuring of soul versus soul (the life of a murderer can be forfeited to save the community), or the level of directedness taken by the people giving away the one person.[36] In any case, it is clear that legal tools exist for the posek to deal with the life-for-a-life scenario, and still the problem is not a-priori resolvable.
Modern responsa bring up the question in a form closer to the trolley problem. For example, Rabbi Avraham Y. Karlitz (the Chazon-I”sh):
“The case should be considered, of one that sees an arrow (in point of fact - a grenade) moving on a trajectory to kill many people, and he can divert it to another side so that only one will be killed on that side and those on this side will be saved, and if he will do nothing many will die and the one shall live”[37]
The Chazon-I”sh deliberates the case: One is obliged to do no harm and yet to achieve an end result of minimal casualties. He ponders on the definition of the situation - is the mortal end result inherent to the saving action, or just a side effect?[38] He remains inconclusive - the different sides of the theoretical problem investigated (the question is not raised in a responsum but in a commentary on the Talmud), but not fully resolved.
Rabbi Eliezer Y. Waldenberg, in his Responsa Tzitz Eliezer refers to this question and describes it as a trolley problem proper:
Let it be known, that this investigation by the Chazon-Ish is not theoretical, an imaginary picture of seeing an arrow about to kill, with the possibility to deflect, as the Chazon-Ish depicts, but rather it is an actual practical question, with ramifications on similar situations, like vehicles that drive as in said example and suddenly come upon a group of people blocking the road so that a sudden stop must be achieved by changing course backwards, but there stands an individual that will clearly be killed, etc. The question at hand is what is to be the choice in such a circumstance, whether to stay passive (sitting and not doing - shev ve’al ta’ase) and letting the ones in front die, or actively change course (standing up to action - kum ve’ase)[39]
The Tzitz Eliezer (unlike the Chazon-I”sh) rules for a consciously passive tact (Shev V’al Ta’aseh): not to change the course of the car, for any involvement will be an actual destructive deed, an active killing that cannot be excused in any way halachically or logically.
In an article focused on the legal, Rabbi S. Dichovsky analyzes[40] the structure and content of the halachic trolley problem within the broader context of public prioritized treatment. He shows the poskims’ deliberations to emphasize different attributes of the same action: According to this analysis, The Chazon- Ish concentrates on the “natural” result of the action. It is only permissible to perform an act of which harmful consequences are not an integral part.
Let us remember such a condition is logically sound, but the case does not supply such an alternative,[41] leaving no final practical conclusion.
Another approach is to see if the action is done directly on the harmful agent (as in the classical situation familiar from Rodef), the person hurt (in which case it is an actual killing) or an indirect manipulation.[42] Again the Trolley problem cannot be parsed into neat options since every setting of the question can be interpreted in either direction.
A third view is that even if the action taken as well as the results, are indirect or passive, a different consideration is necessary: if the harmful agent is already present, affecting the result in any way makes