The field of moral psychology is fascinating. If you’re not familiar with it (and I really wasn’t even a year ago), I’d highly recommend delving into some of the research. Essentially, moral psychology is concerned with understanding the process by which we make decisions about what is right and wrong. The answers to these questions have been overlooked, side-stepped, and met with banalities for much of our history. The idea that we can bring the act of making a moral decision into the labratory and study it is one of the more mind-boggling aspects of the modern era. Granted, as in any field of psychology, the lab and the real world can often be very different places. But, as Philip Zimbardo controversially taught us, that’s not always the case.
I’d like to begin this discussion by considering a thought experiment from the field of ethics, known as the Trolley Problem. I’ll be basing this issue largely on the framework created byJoshua Greene, so I’ll use his descriptions of the two major scenarios in the thought experiment (*think about your response to each dilemma before moving on):
First, we have the switch dilemma: A runaway trolley is hurtling down the tracks toward five people who will be killed if it proceeds on its present course. You can save these five people by diverting the trolley onto a different set of tracks, one that has only one person on it, but if you do this that person will be killed. Is it morally permissible to turn the trolley and thus prevent five deaths at the cost of one?
Then we have the footbridge dilemma: Once again, the trolley is headed for five people. You are standing next to a large man on a footbridge spanning the tracks. The only way to save the five people is to push this man off the footbridge and into the path of the trolley. Is that morally permissible?
You may or may not be surprised to know that the overwhelming majority of people answer “yes” in the first scenario and “no” in the second. Approaching the problems rationally, I wassurprised… and that’s just the point that moral psychology (with much credit to the field of neuroscience) is beginning to elucidate for us.
What is it that makes the first scenario “morally permissible” but the second scenario not? If you’re like me, you see that there is no real difference between the two. We are choosing to sacrifice one person to save five. On a brief side note, the terminology we use is incredibly significant here- by choosing verbs like “sacrifice” and “save”, we may very well actually change the way we mentally construct the dilemma. Thus, I used these terms as an example, rather than because they are the most accurate ones.
So, how does moral psychology answer this question for us? Here is Greene’s explanation:
According to my dual-process theory of moral judgment, our differing responses to these two dilemmas reflect the operations of at least two distinct psychological/neural systems. On the one hand, there is a system that tends to think about both of these problems in utilitarian terms: Better to save as many lives as possible. The operations of this system are more controlled, perhaps more reasoned, and tend to be relatively unemotional. This system appears to depend on the dorsolateral prefrontal cortex, a part of the brain associated with “cognitive control” and reasoning.
On the other hand, there is a different neural system that responds very differently to these two dilemmas. This system typically responds with a relatively strong, negative emotional response to the action in the footbridge dilemma, but not to the action in the switch dilemma. When this more emotional system is engaged, its responses tend to dominate people’s judgments, explaining why people tend to make utilitarian judgments in response to the switch dilemma, but not in response to the footbridge dilemma.
This brings us to the controversial issue of so-called “death panels” within the recent healthcare policy debate. I’m not concerned with the politics of this debate and have little idea what was or was not proposed by which side. What I am concerned with is the violent reaction we have to the concept of applying a cost-benefit analysis to the more polarizing aspects of healthcare. The principle of cost-effectiveness in healthcare is obviously not a new one. Every insurance company does it every time a claim is filed. We also recognize the sense, and even the necessity of this practice. We understand that high-cost treatment that returns marginal health benefits should not be paid for, at least in most cases. In a few cases, however, that principle is not so clear cut…
In the “death panel” debate, we are forced to make difficult decisions based on economic pressures. The following hypothetical scenario describes our predicament:
Say there are $100,000 available to treat 5 patients. To keep patients A, B, C, and D alive for a period of 3 years will cost $25,000 each. To keep patient E alive for 3 years, it will cost the entire $100,000. Which patient(s) do you save?
When presented this way, it’s fairly easy to make the decision. This scenario is almost identical to the switch scenario– the utilitarian neural system takes over and we say “saving 4 lives should be chosen over saving 1 life”. End of story.
But this situation does not describe reality. In reality, we are faced with (or at least, we perceive that we’re faced with) a situation much more like the footbridge scenario. We hear the phrase “pulling the plug”, which, to me, is indistinguishable from “pushing the large man over the bridge” (with the only, albeit rather influential, difference being that “granny” tugs much stronger on the emotional portion of the brain than “large man”). Obviously, the fact that “pulling the plug” is a common phrase in this debate represents the political dimension rather than the economic one. I highly doubt any policy will ever be enacted that actually mandates turning off life-support for a patient already on it (not that that will stop people from truly believing this is on the table). Suffice it to say, I want to be clear that I’m referring exclusively to the concept of applying a cost-benefit analysis to whether future treatment will be approved, rather than the highly politicized example of essentially euthanizing the elderly.
The most comparable situation to the “death panels” might be described by the crying baby dilemma:
It’s war time, and you are hiding in a basement with several other people. The enemy soldiers are outside. Your baby starts to cry loudly, and if nothing is done the soldiers will find you and kill you, your baby, and everyone else in the basement. The only way to prevent this from happening is to cover your baby’s mouth, but if you do this the baby will smother to death. Is it morally permissible to do this?
This situation takes both neural systems to the extreme. For the emotional system, there is nothing more repulsive than killing one’s own child. For the utilitarian, there is nothing more obvious than doing just that- because the baby dies either way.
I want to be clear that I’m not advocating for completely doing away with the emotional system. Though it is increasingly ambiguous and abstract to say this, the emotional system is truly what makes us human. We are repulsed by the idea of determining who lives and dies based on a mere cost-benefit analysis- and there is no other way to describe this than to say that it is “inhumane”. It’s dangerous to make normative claims in these hostile waters, but I think it’s fair to say that the balancing act achieved by these two systems is something that most of us have little desire to be rid of.
Plugging numbers into a computer that prints out one’s destiny in life is clearly not a desirable option. The human element is required. At the same time, I think a deeper understanding of how we make these decisions is healthy. For the first time, we have the ability to get closer to such an understanding.