First, Do the Least Amount of Harm

In Season 2, Episode 5 of The Good Place (I know what you’re thinking: “Oh for pete’s sake, is she talking about this show AGAIN?” Yes. Yes I am.) “The Trolley Problem” Michael transports Eleanor and Chidi to a physical trolley in order to act out this ethical thought problem:  

You see a runaway trolley moving toward five tied-up (or otherwise incapacitated) people lying on the tracks. You are standing next to a lever that controls a switch. If you pull the lever, the trolley will be redirected onto a side track and the five people on the main track will be saved. However, there is a single person lying on the side track. You have two options:

1. Do nothing and allow the trolley to kill the five people on the main track.
2. Pull the lever, diverting the trolley onto the side track where it will kill one person.

Which is the more ethical option?

Chidi gets hit in the face with blood and guts a few times as Michael makes slight adjustments to the parameters. In one scenario, Michael places a friend of Chidi’s on the train tracks. In another, it’s a question of whether Chidi would kill 5 Shakespeare’s to save one Santa. It’s funny and gross. And informative. Chidi is faced with an emotional choice as opposed to a merely theoretical one and it is torture. 

After Eleanor mentions that seeing people’s heads fly off is fun and all, but they should move on, Michael agrees and changes the scene to a hospital.

Michael: These five people all need organ transplants, or they will die. Eleanor’s perfectly healthy. Chidi, do you want to slice her open and use her organs to save the five sick people?

Eleanor: Chidi, Chidi, think about this. I’m your hottest friend No, Tahani. I’m your nicest friend. No, Jason. I’m your friend.

Chidi: I-I won’t do it. As a doctor, I’ve taken the Hippocratic Oath to do no harm, and although five people will die, I cannot harm one innocent person to save them and forsake my oath. It’s unethical.

The Good Place: The Trolley Problem

When I volunteered to donate my liver to my husband, I had to go through a series of meetings and tests to see if I was healthy and a match, and also to make sure I wasn’t being coerced. In the above scenario, Michael is proposing that Chidi is the one making the decision, not Eleanor. When I volunteered, a team of people needed to make sure I was the one making the decision to risk my life (granted, I was only giving up part of a vital organ which carries a small risk of death and a not so small risk of later complications, not five organs which would absolutely kill me) in order to save another. 

In one of the conversations with the surgeon who would ultimately slice open my abdomen and carefully remove the largest lobe of my liver and my gallbladder, we talked about the ethical quandary of living donation. He talked about the Hippocratic oath, and vowing to not do harm and how in living donation he thought a lot about whether or not he was violating that oath. I was a healthy young woman, I had to be in order for them to approve the surgery, and over the course of a several hours long surgery he would most certainly be causing me harm. Living donor transplant surgeons do everything in their power to make the surgery for the donor as smooth as possible. Tests are currently underway in the United States to see if living liver donation can be done with the aid of a robot and several small incisions instead of a large incision that starts at the base of the sternum and runs a straight line to the belly button. Smaller incisions would mean less recovery time and a decreased chance of incisional hernia.

There was no ethical dilemma for me. I felt confident I could help and I wanted to help, desperately. I had spent the entirety of my relationship with my husband worried about his health, fearful of his death, and helpless to do anything about it. As I am wont to say: homemade soup is nice, but it doesn’t cure rare diseases of the liver. I was tired of making soup and watching his body waste away and turn a sickly yellow as his liver slowly failed. The idea that I could do something to help save his life was a gift to me. A way for me to finally help ease his suffering. There were no guarantees it would work, despite the best efforts of the doctors and nurses and surgeons, he might die, I might die, we both might die. But the risk of death and potential complications were not enough to outweigh my desire to be of help.

As of today there are 13,587 people waiting for a liver transplant. Some of those individuals will get a new liver, some will become too sick to undergo the grueling surgery and be removed from the list, and many will die waiting for an organ. Of the people who receive a liver, the majority come from deceased donors, people who have signed up to be an organ donor and have died in what can only be described as the perfect circumstances to make them viable candidates. The supply and demand of organs is lopsided in the extreme towards demand. There are simply not enough organs to go around.

When transplant surgeons began taking parts of livers from living donors, it was in an effort to give desperate parents a chance to save the lives of their children, many of whom were born with a low functioning liver. Surgeons eventually began including adult-to-adult living liver transplants in order to decrease the number of people on the waiting list. People who volunteer for this surgery believe the risk of death is outweighed by the possibility of giving a second chance of life to a person who might not otherwise receive it.  Doctors, for their part, have to wrestle with the ethical implications of harming one patient in order to save another patient who would otherwise die.

This tradeoff happens with medicine as well, though one might argue to a lesser degree. Your doctor may prescribe a drug to treat one symptom/disease even though they know the side effects that will likely occur as a result are also damaging. They are willing to recommend you take the risk because the likelihood of the drug helping you outweighs the side effects. Think of chemotherapy. It’s poison. Ideally it will kill the cancer ravaging your body,  but it might also kill you in the process, or at least damage you. First, do no harm perhaps needs a rewrite for the modern medical world: First, do the least amount of harm. Ethically, it seems like the best choice.

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