Winchester Lectures: Kamm’s Trolleyology and Is There a Morally Relevant Difference Between Killing and Letting Die?

The Winchester Visiting Lecturerships were established in 1995 for the purpose of inviting visiting lecturers in the fields of International Relations, History, Philosophy, Religion, Theology or Law. We are grateful to the committee for this opportunity to bring Professor Frances Kamm to Oxford for this series of two lectures October 21 – 22, 2013.  

Over the series, Frances Kamm considered a kaleidoscope of cases in which one innocent person must be killed to prevent 5 innocent people being killed. She argued in some situations, killing one is permissible to prevent 5 other people being killed, yet in other cases it is impermissible to kill one to save 5. Or so go her intuitions. She points to what she finds are morally relevant considerations that distinguish permissible from impermissible killing.

The most straight forward case of impermissible killing, and the one in which she and many others have a clear intuitions, is Transplant.

In Transplant, a doctor contemplates killing one innocent person and harvesting his/her organs to save 5 people with organ failure. This is John Harris’ survival lottery.

But this is a dirty example. Transplant imports many intutions. For example, that doctors should not kill their patients, that those with organ failure are old while the healthy donor is young, that those with organ failure are somehow responsible for their illness, that this will lead to a slippery slope of more widespread killings, that this will induce widespread terror at the prospect of being chosen, etc, etc

A better version of Transplant is Epidemic.

Epidemic. Imagine an uncontrollable epidemic afflicts humanity. It is highly contagious and eventually every single human will be affected. It cases people to fall unconscious. Five out of six people never recover and die within days. One in six people mounts an effective immune response. They recover over several days and lead normal lives. Doctors can test people on the second day, while still unconscious, and determine whether they have mounted an effective antibody response or whether they are destined to die. There is no treatment. Except one. Doctors can extract all the blood from the one in six people who do mount an effective antibody response on day 2, while they are still unconscious, and extract the antibodies. There will be enough antibodies to save 5 of those who don’t mount responses, though the extraction procedure will kill the donor. The 5 will go on to lead a normal life and the antibody protection will cover them for life.

If you were a person in Epidemic, which policy would you vote for? The first policy, Inaction, is one in which nothing is done. One in six of the world’s population surives. The second policy is Extraction, which kills one but saves five others. There is no way to predict who will be an antibody producer. You don’t know if you will be one of the six who can mount an immune reaction or one of the five in six who don’t manage to mount an immune response and would die without the antibody serum.

Put simply, you don’t know whether you will be one who could survive or one who would die without treatment. All you know for certain is that you will catch the disease and fall unconscious. You may recover or you may die while unconscious. Inaction gives you a 1 in 6 chance of being a survivor. Extraction gives you a five in 6 chance.

It is easy for consequentialists. Extraction saves 5 times as many lives and should be adopted. But which would you choose, behind the Rawlsian Veil of Ignorance, not knowing whether you would be immunocompetent or immunodeficient?

I would choose Extraction. I would definitely become unconscious, like others, and then there would be a 5 in 6 chance of waking up to a normal life. This policy could also be endorsed on Kantian contractualist grounds. Not only would rational self-interest behind a Veil of Ignorance endorse it, but it could willed as a universal law.

Consequentialism and contractualism converge. I believe other moral theories would endorse Extraction.

Since Extraction in Epidemic is the hardest moral case of killing one to save 5, if it is permissible (indeed morally obligatory), then all cases of killing one innocent to save five others are permissible, at least on consequentialist and contractualist grounds.

There is no moral distinction between killing and letting die, despite many people having intuitions to the contrary.

Further reading (some are under a pay wall)

Savulescu, J., and Persson, I., (2005). ‘McMahan & Withdrawal of Life-prolonging Aid’ Philosophical Books. 46 (1): 11-22 (January).

Savulescu J. (2013). Editorial: Abortion, Infanticide and Allowing Babies to Die, Forty Years On. Journal of Medical Ethics. 39: 257-259.

Savulescu, J. (2002). ‘The Embryonic Stem Cell Lottery and the Cannibalization of Human Beings’. Bioethics.  16(6);508-29 (November).

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20 Responses to Winchester Lectures: Kamm’s Trolleyology and Is There a Morally Relevant Difference Between Killing and Letting Die?

  • Marsc says:

    Isn’t this essentially the Jesus allegory? One dies to save the rest. Christians choose extraction and have to continuously sacrifice one to save the rest for generations to come. Naturalists choose inaction and perhaps the resistance gets passed on to future generations. Ideally, the person with the resistance to the virus should choose, but that would mean suicide could be morally obligatory.

    • Malcolm says:

      I think your Jesus example isn’t valid for the reason you finally got to at the end of your comment.
      .
      There’s a big difference between someone ‘choosing’ to be a sacrifice for others and being made a sacrifice against their will.
      .
      In the epidemic example, the choice isn’t being made by the person who will die, it’s being made by a third party. I think the only way that choice would be morally acceptable would be if it were the 1 making the decision for the benefit of the 5.
      .
      It’s the difference between Jesus going to the cross for the salvation of all and Jesus being dragged against his will to the cross as an unwilling sacrifice

      • Kurtis says:

        Yep. Choice matters. Spock’s death in “Wrath of Khan” would not have been as meaningful if Bones threw him in the chamber saying, “Fix it, you pointy eared freak!”

  • Marsc says:

    Isn’t this essentially the Jesus allegory? One dies to save the rest. Christians choose extraction and have to continuously sacrifice one to save the rest for generations to come. Naturalists choose inaction and perhaps the resistance gets passed on to future generations. Ideally, the person with the resistance to the virus should choose, but that would mean suicide could be morally permissable.

  • Lance Nanek (@LanceNanek) says:

    It’s pretty easy in real context, at least. Modern laws prevent killing the one. You could arrange a program people could sign up for where the one is killed when it happens afterwards, though. It would then be perfectly moral as well, since everyone signed up for what happens willingly.

  • Jim says:

    What about extracting some blood, but not enough to kill the person who would normally survive? Save a few of the 5 that would have died perhaps? Maybe in this example, this is not an option, but it seems like it could be.

    If we kill all the people that would have survived this epidemic, would we possibly be dooming the human race? Say the epidemic comes back, mutates, etc., those that may have been able to fight it are now all dead?

    If I had a vote for myself and my family, I’d probably selfishly vote extraction, but it would be much better for this planet to just have the one to survive. Overpopulation is bound to doom a lot of us sooner or later.

    • Thomas says:

      This is what I would argue, as life is rarely ever as cut and dry as outlined; in real life the solution you describe is the only morally acceptable course of action

    • Thomas says:

      This is what I would argue, as life is rarely ever as cut and dry as outlined; in real life the solution you describe is the only morally acceptable course of action, as is the likely consequences as extraction.

  • Amy says:

    It seems that the argument from Kant is incomplete, as one aspect of the categorical imperative is that all people are ends in themselves and cannot be used as means for our purposes. Isn’t killing people for their blood intrinsically an action that treats them as means, rather than ends?

  • Darwin says:

    But the extraction doesn’t strengthen the bloodline. If the epidemic were to reoccur, then there would be no natural antibodies left to inoculate with. If you allow the persons who have the immunity to survive and procreate, there is a higher probability that the offspring would also have the ability to survive a reoccurrence. Save 5 and condem the species. More does not always mean better.

  • Julian Savulescu says:

    It is not treating them as a mere means if they consent in advance. Also, the dilemma would evaporate if Extraction were not lethal. I liked the overpopulation point

  • Emilian says:

    Hi Julian,
    Very interesting the case you imagined. But suppose that Extraction is morally permissible. It does not follow that all cases of killing one innocent to save five others are permissible for the same reason you pointed out in the transplant case. Different Moral intuitions are embeded in these cases. The Epidemic case has huge implications for many people. It has an ultimatum feature, almost causing ultimate harm. Consider a similar case where there is a deadly contagious disease affecting six people in a hospital room. Fortunately the infection is contained. Here, it is not clear that killing one innocent to save five others is permissible. It might be reasonable to accept the misfortune of those who die. A policy for such cases would probably be rejected even by rule consequentialists.

  • Eric Scheie says:

    Assume six people are trapped in an escape-proof container without food but they know help will arrive in 30 days. Are five of them allowed to kill and eat the 6th in order if that is the only way to prevent all six of them from starving to death?

  • TJ Baltimore says:

    Please forgive me for not being classically educated in ethics, but it seems to me that merely comparing statistical probabilities of people being alive at the end makes for poor moral decision-making: it seems inhumanely utilitarian. We choose “right” and “wrong” because they are right and wrong, not because there is a some allegedly objective “better” outcome.

    (I know that I am in the minority here–friends, when asked the trolley questions, have always seemed to disagree with me–but I will seek to educate myself further so that I can either express myself better . . . or change my views. But I feel that I am arguing on deontological grounds, including the idea mentioned above that treating another human as a means is not morally sound. I am not very consequentialist.)

  • TJ Baltimore says:

    I also feel like the issue of consent complicates things: my body is mine, and I feel like I should have the right to say what happens to my body (or in the Epidemic example, to set up guidelines to determine what happens with my body). If I feel that justifiable suicide is permissible, then it is OK for me to give consent . . . but only for my own body. I cannot force others to make the same choice as me: then it becomes homicide. Furthermore, I don’t see why ownership of my body and what I do with it should be accountable to any person’s or institution’s views on any morality whatsoever, either internally consistent or not.

  • Aaron says:

    Ridiculous premise and arguments. Each person by birth has equal value. Utilitarian ethics breaks down because followed to population and logical ends it must (by definition) prioritize essentially cannibalism….Most good for most people with some catastrophic eventuality. Right to self determination must trump utility….otherwise we are little more than a mass if people who’s primary interest is not located in self but society. The formulation of society is\was to vontarily protect us from individual harm. The basis of the social contract breaks down if we forcibly violate one’s reasons for entering into the social contract. If it’s not voluntary, by definition we are enslaved by default (I know of no philosopher advocating this).

  • Aaron says:

    Ridiculous premise and arguments.

    Intentional murder is certainly prioritized differently by every society. By the same definition, we should kill people for their organs if it means saving more lives than the one taken ( lungs, kidneys, heart, liver, plus all the other lives improved with all other organs. We should kill people for their organs by that definition.

    Each person by right of birth has equal value. Utilitarian ethics (premised in this argument) breaks down because followed to population and logical ends it must (by definition) prioritize essentially cannibalism….Doing the most good for most people must logically end with some catastrophic eventuality. Right to self determination must trump utility ….otherwise we are little more than a mob if people who’s primary interest is not located in self but society. The formulation of society is(was) to vontarily protect us from individual harm. The basis of the social contract breaks down if we forcibly violate one’s reasons for entering into the social contract. If it’s not voluntary, by definition we are enslaved by default (I know of no philosopher advocating this).

  • Clifton says:

    I don’t understand why the choice would be between Extraction and Inaction. It seems that there is also Extraction With Consent. In this scenario, everyone chooses only for themselves whether they wish to be in the extraction group or the inaction group once they fall unconscious. Most people will presumably choose the extraction group since this offers 5 times the chance of survival. Some, with a fear of science or government or possessing an irrational faith in their own toughness, will opt into the inaction group. In any case, no one is killed without their consent. Isn’t this clearly morally superior than enforcing either Inaction or Extraction on everyone?

    I admit that, not being a professional philosopher, I’m a bit confused by the need to create far fetched hypothetical situations, when there are more realistic (even historical) examples. Imagine that there’s a particularly evil enemy that needs to be fought. Imagine there’s a draft. Now imagine that there’s a beach to be stormed and that the first few out of the boat will certainly die. (You will note that there is very little imagination actually required.) The question can be asked — is it permissible to order draftees to storm the beach? Doesn’t this pose the same quandary as Epidemic without the easy solution that avoids the dilemma? Is everyone actually thinking of this example but not mentioning it because of Godwin’s Law?

  • Christian Munthe says:

    Just a very simple query: however do you know what you would choose behind that veil of ignorance?? I mean being behind it has massive implications not only for what information you’re assumed to possess (not sure what assumptions you make there), but also your own nature (you’re supposed to be a supremely and perfectly rational individual who only care about yourself (and maybe your children, but that’s an ad hoc addition in Rawls’ setup). In Rawls’ case he develops an argument based on certain (far from self-evident) decision theoretical principles, but what exactly is your argument for why you would prefer one or the other thing re. the options presented behind this particular veil of ignorance?? I propose that you have presented no such argument and that, in fact, the proposal you make is a case of assuming that which you need to deminstrate.

  • Christian Munthe says:

    Just a very simple query: however do you know what you would choose behind that veil of ignorance?? I mean being behind it has massive implications not only for what information you’re assumed to possess (not sure what assumptions you make there), but also your own nature (you’re supposed to be a supremely and perfectly rational individual who only care about yourself (and maybe your children, but that’s an ad hoc addition in Rawls’ setup). In Rawls’ case he develops an argument based on certain (far from self-evident) decision theoretical principles, but what exactly is your argument for why you would prefer one or the other thing re. the options presented behind this particular veil of ignorance?? I propose that you have presented no such argument and that, in fact, the proposal you make is a case of assuming that which you need to demonstrate.

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