Public Health and the Trolley Problem
The Trolley Problem is a thought experiment proposed by the English philosopher Philipa Foot in 1967. It's a problem of the sort "What do you do when all choices are bad?" - a kind of thought experiment philosophers love. You can argue about it forever.
The Problem has many variants - here's one: 5 workers are working on a track. A runaway trolley is fast approaching but the workers can't see it. You are standing at a switch and can see the runaway trolley and the endangered worker. You could throw a switch to divert the trolley onto another track where there is another single person who also doesn't see the trolley.
Would you throw the switch to protect the 5 workers and kill the single worker?
There were variants. Say, if instead of a switch you had the choice of pushing a "large person" into the path of the trolley and thereby save the 5 workers; what would you do then?
It's exactly the kind of problem that freshman philosophy students like to argue about in a coffee shop late into the night.
Some studies were done. Most people would have spared the large person. But almost as many would not have flipped the switch.
Fast forward to 2025 and researchers have found that the difference in the 2 responses could be seen in brain scans. The thought of sacrificing the large person activated one part of the brain and the thought of flipping the switch activated another part.
Whichever was activated though it seems like most people would prefer to passively let the workers be killed than to actively kill another person to save 5 others.
This must be a major problem for medicine and public health. There are many occasions where what is rational for society runs counter to people's natural inclinations. One might say that ethics is an attempt to give the rational a legal advantage over the natural inclinations.
When I was quite young I got measles, chicken pox and mumps. At the time everybody just shrugged those diseases off as just normal childhood sickness. Everybody got them. Nobody was talking about the many thousands of deaths those diseases were causing each year. The survivors all thought - "what's the big deal?" and the ones who died had no voice.
The MMR vaccines basically almost eradicated those diseases. Some people stopped doing the vaccine and measles is coming back.
When the covid vaccines were first available everyone was told that there were risks - a very small percentage of recipients would have a reaction (that was treatable) and we were asked to wait for a while as a precaution.
Those mass vaccination events were interesting in their own right. How do you vaccinate thousands and thousands of people when everyone is practicing social distancing?
I never have any sort of reaction to vaccination. My friend Denise isn't so lucky. A vaccination makes her sick for a day. She is stalwart and gets her shot and just stays home in bed the next day,
Public health deals with the health of many millions of people. The rare case that most of us never encounter can represent a significant threat when the statistics are gathered.
The National Institute of Health reports that after more than 8 billion doses 55 cases of death after the vaccination. 17 of those had causes of death that might have been causally linked to the covid vaccine.
NIH reports that over 14 million lives were saved by the vaccine.
In terms of the Trolley Problem this is like allowing the 14 million to die to prevent the death of 17.
Public health is more than medicine. I've seen cars evolve from unsafe at any speed to vehicles that could almost be passed down through the generations. I think that that was motivated by public health concerns. I think that drivers probably drive much more safely now than 50 years ago. Similarly the highways are much safer to drive on.
But we must be careful. If we go too far down the utilitarian slope that the Trolley Problem proposes then we might find a prisoner sent to El Salvador to have their body parts harvested to save lives for the public good. After all - one 'gangster' might save 20 other lives.
What do you think?
I present regular philosophy discussions in a virtual reality called Second Life.
I set a topic and people come as avatars and sit around a virtual table to discuss it.
Each week I write a short essay to set the topic.
I show a selection of them here.