Utilitarianism and the Transplant Surgeon Objection

» Downloadable RTF of this piece

One of the most commonly-posed objections to the moral doctrine of hedonistic utilitarianism (read: principle of greatest utility, principle of greatest happiness, or whatever label pleases), the consequentialist prescription that advocates actions only which increase pleasure and decrease pain for all affected, is a thought experiment sometimes referred to as the “transplant surgeon.” It is so popular because, at best, it necessitates an examination of the lowest levels of the utilitarian philosophy, and at worst seems to present insurmountable difficulties for the died-in-the-wool utilitarian. In this piece I will examine the scenario and explain how it dovetails perfectly with standard utilitarian precepts, and how its objections are largely irrelevant.

Philippa Foot poses the example as such: Five mortally ill patients are in care at a hospital, all of whom will soon die. At the same time, a sixth man is undergoing a routine checkup at the same hospital. A transplant surgeon in residence finds that the only medical means of saving the five ailing patients would be to slay the sixth and transplant into them his healthy organs. Legal ramifications and other peripheral matters disregarded, it morally right to do so? *

Most observers intuitively say it is not right. Thus a challenge is posed to the utilitarian, for it seems to go without saying that the operation would indeed be the action of greatest utility—for only the cost of one man’s life and the surgeon’s time, five other humans can be saved! That is a one-to-five cost-to-benefit ratio, which is not only a preponderance, but weightily so.

Foot avoids the problem by suggesting a “doctrine of doing and allowing,” which draws a moral distinction between actions we willfully execute and those we merely allow to occur. In this case, it would be morally sound to let the five men die, because to kill the sixth would be to actually perpetrate a murder, which would be wrong no matter how many others we saved. Conversely, doing nothing, while unfortunate, seems justified because we at least are “doing” no wrong of our own accord—only allowing it to happen.

The shortcoming of Foot’s argument is systemic, not internal. While it is valid as far as it goes and does indeed explain away many of the examples thought to be difficult for utilitarianism, it is not itself couched in any well-reasoned morality. That is to say, it is merely a descriptive system of thought, and makes no attempt to justify its motivations from the standpoint of actual utilitarianism.

A better means of explaining the transplant case is needed, and preferably one that uses only the fundamental tenets of utilitarianism. One solution would be to simply ignore the intuitive answer and assert that performing the operation would indeed be the moral action. However, this is self-sealing, and only sound as long as utilitarianism is held to be a failproof deontological axiom. To effectively argue that the intuitive answer is false, we must do more.

Let us sketch an equivalent, but much larger case. Consider the system of criminal justice present in the United States today, and in most modern societies. Individuals who breaks laws—which are generally formulated, at least in theory, to protect others—are arrested, tried, convicted, and often placed behind bars for a significant portion of their lives. It goes without saying that involuntary imprisonment (or other punishments, even as far as execution) effects a drastic decrease in the felon’s quality of life. This would be true for an individual and is only more true for the entire body of criminals that passes through the system every year. Yet we feel justified in our system because it is necessary to maintain the safety and peace-of-mind of the greater public.

I offer this example to show that there is no importance to the interests of the affected party. Obviously most convicts would prefer not to be imprisoned, but we do so regardless. And the crucial reason is because of the good it does for us, the public, the whole of society. The reason is not, as some might say, because the criminal deserves his punishment. This is probably true from another standpoint, but wholly irrelevant for the utilitarian—indeed, any intelligent observer would agree that the good of the justice system comes from the maintenance of our safe society, not from any sense of revenge or “just desserts” for the evildoers. (One could also argue that it acts as a deterrent, making criminal acts seem less appealing due to their potential consequences, but this just another aspect of the same function: prison exists for the public, not against the criminal.)

Applying this same thinking to the transplant surgeon case, we can eliminate one of the major underlying objections to the operation. It may be true that the healthy man does not wish to be killed, and has done nothing to merit such treatment. It may also be true that the five sick men wholly deserve their fates. But as far as utilitarianism goes, such factors are inconsequential. The death (vice imprisonment) of the healthy man (vice the criminal) serves to better the five patients (vice society). Therefore, by the same reasoning we apply in our society, whether it be imprisoning a murderer or sealing a submarine hatch to stop a leak while sailors still drown behind it, we are ethically justified in performing the operation . . . and the desires of the individual are immaterial. (Indeed, we are forced to ignore them, because he almost certainly would choose his own interests above the greater good.)

Another obvious objection to the scenario is based on value. Suppose the healthy man was a precious member of society, a scientist, a charity worker, someone whose existence benefited many; suppose likewise that the five sick men were fools, sadists, lazy and incompetent, essentially meaningless to the world. Surely then the outcome should be clear. This is a tempting argument but specious, as it could be framed however we wish; we could just as easily reverse the qualities. Some utilitarians would argue that such matters are relevant to the overall decision; others would argue that the only relevant factor is human life. But this has no bearing on the core analysis.

A third objection, and almost certainly the one most dear to the detractors, is simply that “it’s not fair.” That is to say, it is unfair for the healthy man to be killed merely because he walked into the hospital on the wrong day, and it is unfair for the sick men to benefit from his unwilling sacrifice, since neither party necessarily deserves such a thing.

“Fair” can be defined as consequences that are warranted by the actions undertaken, and in this sense, it is true that the operation would be unfair; the donor did nothing to “earn” his death, the patients did nothing to “earn” their salvation. This is a very human way to think. But can it be morally substantiated?

It cannot, at least not in this situation. Notwithstanding the question of “value” posed above (that is, assuming there is not actually any reason one party deserves to, or ought to, live longer), the only reason we could object to this murder is psychological, not ethical. We identify with the healthy man and would not wish to be placed in his situation—possibly even if we were one of the dying patients, though opinions could vary there.

The last easy argument is purely deontological, stating that killing is wrong no matter what good could come of it. The value of such cast-iron principles is an argument for another time, but it is relatively easy to cast in absurd tones here. Is it then wrong to kill Adolf Hitler? A convicted serial murder? Wrong for a policeman to shoot a terrorist before he can detonate a bomb? The deontologist could argue that such situations exemplify a different issue, for the victims are all themselves evil men. But then is it wrong for a paramedic to perform triage and devote his efforts to saving one moderately-wounded crash victim while another one, near death, is ignored? Is it wrong for a Federal Air Marshal, in accordance with his training, to shoot an innocent civilian that gets in the way of his attempt to take back a hijacked aircraft, and thus save many more? And is it wrong for a soldier in a time of war to kill an enemy combatant, likely no different from himself?

The deontological objection is a weak one, requiring much further elaboration to bear fruit in the transplant surgeon scenario. (Such elaboration is possible, but beyond my scope here.)

With the above objections thus neutralized, it follows naturally that the utilitarian view of the transplant surgeon case advises executing the operation, and the intuitive objection to this stems merely from non-substantive psychological sources. There are practical reasons why such an action is shunned and would rightly be forbidden in most modern societies (the detriment it would have on check-up attendance, if nothing else), but within the stripped-down thought experiment, there are no such reasons; the operation should be performed, and utility-wise, rightly so.

* The Problem of Abortion and the Doctrine of Double Effect, Virtues and Vices and Other Essays in Moral Philosophy, 1978