Doctors are shackled by the stigma of ignorance

Are you familiar with the trolley problem? It is an ethics dilemma first formulated by the great Philippa Foot as a part of a series of such dilemmas. Her formulation goes roughly like this. Imagine there is a tram hurtling down a track. If it keeps going straight, it will hit and kill 5 people who are working on that track. The conductor is able to throw a switch and divert the train to another part of the track, where 1 single worker will be killed by the trolley. The question is what should the conductor do? Most people when asked respond that yes, he should throw the switch and sacrifice 1 life to save 5. After all, the net benefit is n=4.

There are literally thousands of alternative formulations of this problem, but one of them from the philosopher Judith Jarvis Thomson merits special consideration. The problem starts out similarly, with 5 lives on a track in potential peril. The vantage point and the solution are quite different, though. Now there is a bridge over the rail track, and a very large man is looking at the tracks from the bridge. One way to stop the train is to throw a heavy object in its path, like this large man, for example. You are on the bridge standing behind the man. Would you be justified in pushing him off the bridge in front of the tram to meet his death in order to spare the 5 workers down the tracks? Most people when faced with this formulation say an emphatic “no.” This is somehow puzzling, since the net benefit is the same, n=4, as in the original Foot formulation.

Philosophy professors have puzzled over this difference for decades, and there are several potential explanations for why we respond differently to the two scenarios. One explanation has to do with the proximity of the operator (conductor in the first case and the person doing the pushing in the second) to the sacrificial lamb — in the first case one is enough removed from the action of killing by merely redirecting the tram, whereas in the second the action is, well, more active, and the operator is actually pushing an innocent person to his death.

Though in some ways the scenarios seem to bear no practical distinction from one another, we see the morals and ethics of each differently. This difference in the view point is instructive to the field of medicine, where it has implications to how policy relates to the individual patient encounter. Here is what I mean.

Suppose you are a policy maker, and you recommend that every woman at age 40 start to receive an annual screening mammogram to reduce deaths from breast cancer. At the population level, if we screen 1,000 women for about 30 years, we will save approximately 8 of them from a breast cancer death. (Yes, it’s 8, not 80, and not 800). At the same time, among these 1,000 women, there will be over 2,000 false alarms, and over 150 of these will result in an unnecessary biopsy. Some of these biopsies will incur further complications, though currently we  do not seem to have the data to quantify this risk. But what if even one of these biopsies were to lead to death of or another dire lasting complication in a woman who turned out not to have cancer? And by the way the accounting is not all that different when applying the new USPSTF mammography screening recommendations. Well, then we have the trolley problem, don’t we? We are potentially sacrificing 1 individual to save 8. And who does the sacrificing is where the variations of the trolley problem come in.

Payers levy financial penalties on primary care physicians when they fail to comply with screening recommendations in their patient panels. The payer certainly sees this issue as the original formulation of the problem: Why not throw this financial switch to achieve net life savings? But for a clinician who deals with the individual patient this may be akin to pushing her over the bridge toward a potentially fatal event. Because we don’t have a crystal ball, we cannot say which woman will die or incur a terrible complication. But the same population data that tell us about benefits must also give us pause when reflecting on the risks. Add the ubiquitous uncertainty (and lack of data) into this equation, and the implications are even more shocking. So, while making policy recommendations based on population data is sensible, policing uniform application of these recommendations to individual patients is fraught: of course, clinicians and patients need to be cautious about making individual decisions even when in population data benefits outweigh risks.

On the surface risk-benefit equations for many interventions may appear favorable, leading to blanket policy recommendations to employ them on everyone who qualifies. In the office, the clinician, caught in a tug of war between mountains of new literature and the ever-shrinking appointment times, is hard-pressed to take the time to consider these recommendations in the context of the individual patient. And furthermore, financial incentives from payers act as a short-hand justification, a “nudge,” for doing as recommended rather than for giving it thought. So, who must look out for the patient’s interest? The patient, that’s who. Who understands the patient’s attitude toward the risks and the benefits? The patient, that’s who. Who now has to be responsible for making the ultimate informed decision about which track to stand on? The patient, that’s who.

For me the trolley problem gives clarity to the reservations that I walk around with every day. I have done a lot of soul searching about why it is that, even if the benefits seem to outweigh the risks, I am still more often than not skeptical about whether a particular intervention is right for me. And since every intervention in medicine has a real risk, though mostly quite low, of going terribly awry, my skepticism is justified. This is my approach to evaluating these risks and benefits, based on my values and my understanding of the data as it is today.

What’s the answer to this ethical conundrum in medicine? I cannot see that policy makers will stop throwing the switch in the near future, and so as a society we will be forced to accept the tram’s collateral damage. And while this may make sense in an area such as vaccination, where thousands of lives can be saved by sacrificing a very few by throwing the switch, in most everyday less clear-cut medical decisions the answer is less clear-cut. Will doctors rebel against being forced to throw some patients on the tracks in order to save some marginally larger number of others? I don’t think that they have the time or the energy or the incentive to do this, since the framing of the switch-throwing is through the rhetoric of “evidence.”

Right or wrong, doctors are shackled by the stigma of ignorance that comes with not following evidence-based guidelines, and this may act to perpetuate blind compliance. This leaves the patients, for some of whom the right thing will be just to get themselves off the tracks altogether, far away from the hurtling trolley until its brakes are fixed.

Marya Zilberberg is founder and CEO of EviMed Research Group and blogs at Healthcare, etc. She is the author of Between the Lines.

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  • Paul Damsma

    The tram story is interesting, but leaves out that the conductor maybe killed if an object is placed on the track, and, is anyone else on the tram? The fact that we are limited in time by government, population and served quick fixes by big pharma is nothing new! The fact that we have so many solutions and not enough time to seek them before the crash of the tram is the true dilemma. Take it one patient at a time. Oh, and by the way, I am a patient!

  • Karen Sibert MD

    This was a terrible headline, which I suspect would not have been the author’s choice, but a great piece. Yet again, another good argument pointing out that mandates and directives from above can harm patients and prevent an individual physician from making the best choice for an individual patient.

  • southerndoc1

    “doctors are shackled by the stigma of ignorance that comes with not following evidence-based guidelines, and this may act to perpetuate blind compliance”
    Great post.
    The apostles of pay for performance and quality measures refuse to acknowledge that what they are selling is not patient-centered care in any sense of the words.

  • Margalit Gur-Arie

    The dilemma is a bit contrived for health care because it assumes that the conductor knows for sure how many workers are on various tracks (e.g. there may be 1 worker at a time on average on the other track, but at any given time there may be 100) and because the fat man has been shown to stop the train most of the time, if hurled off the bridge, but other times he may actually derail the train and kill all passengers.

    The solution may very well be to quit kibitzing conductors from bridges and let each conductor be responsible solely for the passengers on his/her train and make sure that all people are on trains with conductors instead of hanging out on tracks and bridges and let conductors do the job they were trained to do.

  • Kerry Willis

    Better choice ….write our own senario and choose our own destiny

  • Jackie Swenson

    ammogram saves lives. I know that because I was diagnosed when I was 43. Mammogram can give false sense of security – I know that because my recurrence was overlooked for almost four years. We need to educate women to pay attention to their health – to be alert of certain signs: weight loss, fatigue, loss of appetite, …etc. Doctors do make mistakes sometimes…
    How do we put a price on a human life? Would $300,000.00 be too much to save a life? What about $500,000? or $1,000,000.00?

  • Mary L. Hirzel

    “So, who must look out for the patient’s interest? The patient, that’s
    who. Who understands the patient’s attitude toward the risks and the
    benefits? The patient, that’s who. Who now has to be responsible for
    making the ultimate informed decision about which track to stand on? The
    patient, that’s who.”

    This is a critically important truth, in these days of population-based standards of “care,” which few patients understand to be even something to consider. And, who tells them?

    As currently configured, the “greatest medical intervention in the history of mankind” – the vaccination program – requires physicians to throw the switch with every “well child” visit. The reality is, those physicians have NO IDEA how many are standing on each of those two tracks, since, despite the fact that it has been known for tens of decades that some children will have severe, life-altering (or ending) reactions to vaccination, no effort has ever been made to study those children with an aim to identify what puts them on Track 2. Add the facts that there has NEVER been any double-blind, placebo controlled study of any vaccine to determine if the mere provoking of an antibody response is adequate to protect against disease, there is NO reliable tally of the number of children on Track 2 as the passive reporting system captures somewhere between 1-10% of adverse reactions (which doctors are “educated” to call coincidental, not causal), and you wind up with the current reality, where physicians are required to throw the switch, and parents required to accept it, without any knowledge whatsoever about the number of babies and children on either track.

    As the mother of two children who were on Track 2, sent to hell and then had the medical community turn their backs on them, I call this despicable and am reminded daily of what Hannah Arendt called “the banality of evil.” And, while I applaud the writer of this article for attempting to persuade physicians to stop and think about this ethical dilemma, once in a while, the writer, by accepting, blindly, that

    “while this may make sense in an area such as vaccination, where
    thousands of lives can be saved by sacrificing a very few by throwing
    the switch, in most everyday less clear-cut medical decisions the answer
    is less clear-cut,”

    she has decided that ethical questions need not be asked when sacrificing children to the vaccine program, despite the virtual absence of information on numbers on Tracks 1 and 2, or why each individual child is on that track.

    This is barbarism and magical thinking, not ethical inquiry.

  • forPCP

    You leave out a lot of possible solutions, The worker on the track is used to danger in the rail yard, a horn blowing in his ear would definately create a “flight” response and maybe get him to react and get off of the track before the train reaches him. Railroad tracks are not that wide, hopping from tracts to get out of the way of a train takes seconds so the conductor switches tracks pulls the emergency brake and honks like hell. Now on the other hand there is another possibility, PREVENTION and PROACTIVE MEASURES. The railroad should have policies about workers being aware of train times and not being on tracks at that time for just the reason stated, a train might have to change tracks in an emergency, also have policy of warning signs of “enter at your own risk of death” signs on crossings, etc. This should decrease incidents of “emergency” measures. If then in fact people take the risk then they just may get run over. So it is with medicine. PREVENTION and PROACTIVE MEASURES decrease emergencies. No one likes that people sometimes do things that are unwise for their health and take undue risks with their lives and in those cases emergency measures must be tried but are not always successful. The conductor may feel terrible, but should not be held responsibile for other people’s bad behavior.

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