More threads by David Baxter PhD

David Baxter PhD

Late Founder
Moral and Ethical Choices
By Roy on ethics

Dr. Richard Schloss posed the following conundrum recently:

The following 2 vignettes are sometimes used to illustrate that there
are universal moral standards that transcend religion, culture, and
ethnicity, because everyone, regardless of background or belief system,
always gives the same answers. See what you think.

Suppose there is a runaway trolley car that is about to mow down and
kill 5 people. Now suppose that there is one observer standing next to
the track watching this, and he realizes that, by throwing a switch, he
can divert the car onto a different track so that it will kill only one
person, but spare the other 5. Virtually everyone says that the morally
correct thing to do is to throw the switch and sacrifice one person to
save 5; most even go so far as to say that it would be morally
reprehensible for him just to stand there and do nothing, once he
realizes that throwing the switch is an option.

Now, a different scenario: there is a hospital with 5 patients who will
die very soon if they do not receive organ transplants, and there are no
donors immediately available. (They all need different organs.) Now,
suppose someone is brought into the emergency department of that
hospital after having suffered a life-threatening, but easily
repairable, injury -- and he has and organ donor card in his wallet.
Would it be ethical for the ER staff to deliberately withhold treatment
and let him die so that his organs can be used to save the other 5
patients? Everyone says "no" to this question. Why? How is it different
from the trolley car scenario? Aren't they both cases of sacrificing one
to save 5? Why is it right to do so in the first case, but wrong in the
second? And why does everyone, regardless of background, give the same
answers to these two illustrations?

Just for fun, I'd like to throw a few qualifiers into the second
scenario. Would your answer change if the potential organ donor who can
be easily saved, but will die without treatment, had been driving drunk?
Would it change if he were a paroled murderer? What about if he had been
speeding at the time of his accident and had killed a family in another

just mary

One important difference exists between these two scenarios. In the trolley example, the person who makes the decision to throw the switch is physically removed from the person he is about to kill. In the hospital example, the death of the person will be much more personal, that is, the surgeons or doctors will use their own hands to kill the person. I personally think it's a significant difference and shouldn't be ignored.

I also recall reading an article which offerred an explanation as to why human beings go to war and kill each other much more often than other animals. It was because we rarely kill each other with just our hands but rather use weapons that distance us from what we're doing.



David Baxter PhD

Late Founder
I also recall reading an article which offerred an explanation as to why human beings go to war and kill each other much more often than other animals. It was because we rarely kill each other with just our hands but rather use weapons that distance us from what we're doing.

An extremely important factor in war is that the enemy is always, ALWAYS demonized and dehumanized. That way, even in hand-to-hand combat or acts of torture or brutalization, the soldiers have been conditioned to view the victims as less than human in order to allow them to carry out their acts of violence without remorse.

Daniel E.
Simple solution: Kill the patients who have no family members to grieve their loss. Sell the extra organs on an online auction site to the highest bidder. Use the revenues to start an orphanage. (This is just one example of the simplicity and horror of utilitarian thinking.) Personally, I would just go with the status quo: treat the organ donor guy even if he is 89 years old and the other patients are 5 years old and younger.

just mary

Use the revenues to start an orphanage.

Since the orphans have no family members to grieve their loss, the orphanage would be a "supply house" then? Okay, this is getting very gruesome. :(

And I agree, most of us would go with the status quo but I think the author is asking why we would. I think he's saying that morality is something we're born with, it's not something we learn, some sort of genetic moral code.


The first scenario feels more like preventing death and the second one feels more like you are causing a death. Maybe there is a difference between dying a natural death due to health failure versus an accidental death. :?

just mary

But I guess in both scenarios people are going to die irregardless. You can prevent 5 people from dying by flipping a switch in the first scenario while in the second scenario you can prevent 5 people from dying by grabbing hold of the healthy guy, putting him under and taking all his organs. I think the second scenario is a little more difficult than flipping a switch.


First scenario: As usual, I immediately find myself looking for other alternatives. If I can see the people on the tracks then, if I start running down the tracks, yelling at the top of my lungs, they ought to be able to hear me. I'm gonna start running and yelling. I guess, that's because I don't want to be held responsible for the decision to end anybody's life (or to fail to save one).

Second scenario: This is one that's very close to me because I'm a nurse. I cannot make the call to end one life to save another, no matter what my judgement might be as to the moral implications of the way either life is led. It's just not my call.

Now, I'm going to spend the rest of the day hoping I never have to be faced by anything even close to these two situations! :panic:

just mary

I immediately find myself looking for other alternatives. If I can see the people on the tracks then, if I start running down the tracks, yelling at the top of my lungs, they ought to be able to hear me. I'm gonna start running and yelling.

There are no alternatives, you are in a closed but see-through box, what do you do? That's the point.

Why is it okay in one scenario and not in the other? Or maybe in the first scenario you can see it as being up to God (or higher power etc.), those five people on the track are meant to be killed by the oncoming trolley and not the one person on the other track (if you pulled the switch).

It's a wierd little scenario and I don't see his point for bringing it up, other than to divide us.

It makes me angry. :(

David Baxter PhD

Late Founder
It was raised by a psychiatrist with the intention of getting other psychiatrists and mental health professionals to think about the ethics or morality of certain decisions they might make regarding patients and regarding policy.

To me, it links to the whole civil rights versus societal rights versus sopcietal obligations to make decisions for those who cannot - e.g., the []Kendra's Law[/[wiki]] issue.[/wiki]

just mary

I took it completely differently, that it was some sort of genetic thing that "some" human beings have developed, that morality was genetic. I just saw it going in a completely different direction. Every situation is different.

David Baxter PhD

Late Founder
This may put it into context:

I Wish I had a Crystal Ball
By Dinah on ethics
Thu, May 10 2007

I wish I could make decisions knowing how things would play out. Don't we all? In my Johnny Get Your Gun Post below, I presented the case of the episodically violent substance abuser who wants to buy a gun and his therapist tells his family, stopping the gun purchase as well as the psychotherapy. In Roy's post on moral and ethical conundrums, he makes us consider the value of one life versus five with a couple of different scenarios. Some of the commenters pointed out things like how we don't know if we sacrifice someone for his organs that the other folks would live, and it got people asking who even deserves an organ.

I love this blog.

So, Roy and others pointed out that it was the wrong thing for the therapist to violate confidentiality and tell the patient's family that he was thinking of buying a gun, given that the patient is an adult, he was purchasing the gun in a sober state, there was no intended victim, it's legal to own guns. It's not okay for a therapist to tell a family member of such things unless there is a clear and identified victim (and then, our Tarasoff-abiding ClinkShrink tells us, in California we should tell the police or the victim, not the patient's family member) or the imminent risk of suicide or homicide. In the short run, I think it's good that the periodically substance abusing episodically violent patient doesn't have a gun. Roy and others have pointed out that the now ex-therapist may have compromised this patient's ability to continue with anyone in a meaningful psychotherapy, that the patient may lie or hide such potentially important issues in the future, that the therapist missed the boat by not exploring exactly why the patient was telling both his psychiatrist and psychotherapist this anyway (Roy, you are sooo good, you can be my shrink anyday). Maybe the psychotherapist was worried about being sued, and that's perhaps sad or bad.

I would contend that for the moment, we just don't know, and it would be so nice if we did. If the mental health professionals all kept quiet, if the patient on his own decided not to buy a gun, or did buy a gun but didn't use it, this would be good (Though perhaps many sleepless Saturday nights for the shrink & therapists for ages to come), and perhaps the patient would have continued on in a healing nurturing wonderful relationship with his treatment team. Not violating confidentiality is the right answer here, now that we know the outcome.

If the patient bought the gun, got drunk, wandered home angry and impulsive, and shot his sister, it would have been the wrong decision. Family member paying for treatment would never understand that the treatment team knew about the gun and chose not to violate confidentiality. They might sue, though perhaps unsuccessfully, and I assure you that regardless of what was "right" the treating professionals would be beside themselves over any bad outcome that resulted in the injury or death of anyone. Even the patient, now sober in his jail cell, might wish that someone had stopped him. And if he killed 32 innocent people in a school, the treatment team would feel really bad, especially given that they'd contemplated other options.

So, the patient didn't buy the gun and fired the therapist. Is this bad/? Roy worries he'll sour on all therapists, that down the line he might not let someone in to prevent an even worse event. If that happens, if he kills someone 5 years down the line and that could have been stopped if he was in therapy but he wasn't because those damn therapists can't be trusted, then violating his confidentiality was the absolute wrong thing to do.

But what if the patient gets drunk on Saturday night and gets into a fight, and then thinks, "Good thing I didn't have that gun." (He won't think this until late Sunday afternoon). Or what if he seeks help from another psychotherapist who he clicks with better than the first and he feels much better, now he's had an opportunity he wouldn't have had if he'd remained in therapy with his first therapist. At this juncture, he remains in treatment with the psychiatrist who prescribes his meds, maybe he'll go into therapy with him, since knows he can be trusted, and maybe that won't be such a bad thing.

What if, what if, what if ?

So I don't know the patient, but I do know the psychotherapist, the one who snitched to the family about the patient's plans to buy the gun. On a sobering note, she had a personal and terribly tragic violent event touch her own life-- one which I imagine precludes sitting by and allowing a substance abuser to buy a gun. It's probably best that they not work together.

just mary

I'm not sure what to say, I don't see how it relates. I swear I picked up a book (briefy) on this subject and it had nothing to do with psychiatrists and their patients. I think the author was trying to get across the idea that morality/ethics was genetic not learned.

I recall a radio interview with an author on a similar subject and the host brought up the following: how do you explain that in some cultures it is accepted to stone a woman to death if she has committed adultery (or been raped which is most often the case), where is the inborn "ethical" code at that point or is it just "mob mentality". This is where I'm coming from.

I understand "kendra's law" but these people obviously had a mental disorder (i.e. schizophrenia). What about people who don't have schizophrenia or a serious mental disorder (more often than not)?


I thought the same as you, JM. I did not read the blog before posting or know about the context it was related too.

On the same train of thought, I was also recently thinking about the morality and inhumanity of certain practices in other countries and wondered if education makes a difference in people's behaviour or if it is the fear of receiving punishment themselves that allows them to do the most cruel and inhumane things to others.

I wondered how many in the population are really humane and moral through instinct.

With regards to mental health law and practices, I have experienced and witnessed some very inhumane, cruel and unethical events, in my opinion. It is not only the law that drives these events it is philosophical beliefs and at times...just a power struggle between lawyers and psychiatrists. It's enough to make me :cry:
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