Archives > Volume 18 (2021) > Issue 2 > Item 08
DOI: 10.55521/10-018-208
Frederic G. Reamer, Ph.D.*
Rhode Island College
freamer@ric.edu
*Full disclosure: Frederic G. Reamer is a member of the JSWVE editorial board. JSWVE uses an anonymous review process in which authors do not review their own work, reviewers do not know authors’ identities and authors never learn the identity of the reviewer.
Journal of Social Work Values and Ethics • Volume 18(2), Copyright 2021 by IFSW
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of IFSW.
Abstract
Since around 1980, social work students and practitioners have been introduced to a wide range of conceptually rich ethical decision-making protocols. Ambitious ethics education in social work emerged in conjunction with the maturation of the broader field of applied and professional ethics. Comprehensive ethics education is required by the Council on Social Work Education’s Educational Policy and Accreditation Standards. What is known in professional ethics as The Trolley Problem, or trolleyology, has become a staple in ethics education in many professions. The Trolley Problem provides educators, students, and practitioners with complex ethics scenarios that require careful analysis, particularly with respect to their implications for practical decision making. In contrast to other health and human services professions, the social work literature has not featured any discussions of The Trolley Problem. This article fills that gap, provides an overview of The Trolley Problem and related concepts, and explores their implications for social work ethics.
Keywords: Ethical decision making, ethical theory, The Trolley Problem, trolleyology, utilitarianism
Introduction
The Trolley Problem is legendary in ethics education (Thomson, 1976, 1985). The classic scenario, which is a staple in moral philosophy, goes like this: You are standing beside a set of train tracks. In the distance, you spot a runaway trolley hurtling down the tracks towards five workers who cannot hear it coming. Even if they do see the trolley, they won’t be able to move out of the way in time. As this disaster unfolds, you glance down and see a lever connected to the tracks. You realize that if you pull the lever, the trolley will be diverted down a second set of tracks away from the five unsuspecting workers. However, down this side track is one lone worker, just as oblivious as his colleagues. If you divert the trolley to the side track, the lone worker will die. Then comes the compelling moral question: Would you pull the lever, leading to one death but saving five lives?
On its face, the moral dilemma is clear: Is it ethically justifiable to sacrifice one person in order to save a group of people, or is it inherently wrong to take an action that will clearly kill an innocent person, regardless of the consequences for the other at-risk people whose lives would be saved? For decades, The Trolley Problem has provided educators, students, and practitioners in a wide range of professions with a rich heuristic protocol designed to enhance ethics analysis and decision-making skills.
Social Work and The Trolley Problem
The classic Trolley Problem scenario, which is the stuff of mere intellectual exercises in philosophy seminars, takes on different and much more practical significance in professions, including social work. Consider, for example, a social worker who is deeply committed to social justice in her work as a community organizer. The community development agency of which she is executive director has embarked on an ambitious plan to promote economic development in a low-income section of a large metropolitan area. The social worker and her board of directors secured a large federal economic development grant which was matched by funds from a local community foundation. The comprehensive plan includes razing several blocks of deteriorated housing and replacing these structures with state-of-the art “mixed use” housing that includes a combination of subsidized apartments, market-rate apartments, and commercial businesses (such as restaurants, clothing stores, hair salons, food stores) which would be owned by people from the neighborhood who represent ethnic and racial minorities.
However, to make this space available, the developers would need to displace current low-income residents, many of whom are people of color. A group of these residents organized to protest the economic development plan. They argued that their well-being and rights are being violated. Most members of the board of directors argued that the larger community will benefit from the displacement of this relatively small group of people. From an ethics perspective, they assert that sacrificing the interests of a small group is justifiable to benefit a larger group.
Comparable ethics challenges arise in clinical social work. Consider, for example, a social worker who is the clinical director of a residential program serving high-risk adolescents. The teens admitted to this program typically struggle with significant mental health and behavioral issues, such as mood disorders, anxiety, substance use, self-harming behavior, and aggressive behavior. Historically, the program’s revenue has included a mix of private health insurance payments and state Medicaid payments. The per diem rate paid by the state Medicaid program is much lower than the per diem rate paid by private insurers.
The program has been struggling to balance its budget, in part because of the relatively low state Medicaid payments the agency receives for a large percentage of its clients. The social worker and the agency director convened the organization’s board of directors to review the agency’s financial condition and vulnerability and to consider options. It was clear that the agency’s survival required budget cuts, staff layoffs, or other drastic measures.
After considerable discussion, the board recommended that the agency discontinue accepting youths whose care would be covered by the state Medicaid program and, instead, serve only youths whose families have private health insurance that reimburses at a higher rate. The board concluded that this is the only way for the agency to remain solvent. The social worker was distressed about this proposal, given the agency’s long-term commitment to serving low-income youths and their families.
A social worker who applies a classic rights-based perspective to this dilemma might argue that excluding low-income, Medicaid-eligible youths is morally wrong on its face and inconsistent with social work’s values-based mission. According to the National Association of Social Workers (NASW) Code of Ethics (2017), “The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (emphasis added). In the context of The Trolley Problem, this would be akin to an unconscionable sacrifice of one worker’s life to save the others.
In contrast, a social worker who is more concerned about the potential consequences of her actions might argue that the agency was morally permitted or even obligated to shift its clientele entirely to those whose care was covered by private health insurers that reimburse at a rate that would enable the agency to survive and serve vulnerable teens. In the context of The Trolley Problem, this would be akin to sacrificing the one lone worker because of the greater good that would result.
In short, The Trolley Problem has profound practical implications in social work and the broader human services. As the philosopher David Edmonds (2014) observes in his thought-provoking exploration of The Trolley Problem in his book Would You Kill the Fat Man: The Trolley Problem and What Your Answer Tells Us About Right and Wrong,
Sometimes you can’t save everyone. Politicians do have to make decisions that are a matter of life and death. So do health officials. Health resources are not limitless. Whenever a health body is faced with a choice between funding a drug that is estimated to save X lives, and funding another that would save Y, they are, in effect, confronted with a variation of The Trolley Problem, though these are dilemmas that don’t involve killing anybody… Indeed, to an outsider, the curious incidents of the trains on the track may seem like harmless fun—crossword puzzles for long stay occupants of the Ivory Tower. But at heart, they’re about what’s right and wrong, and how we should behave. And what could be more important than that? (pp. 11, 12)
The Trolley Problem: Key Concepts
The Trolley Problem has been used for nearly a half century to teach moral reasoning (Andrade, 2019; Dzionek-Kozlowska & Rehman, 2019; Hallborg, 1997), although to date the social work ethics literature has not included any application of these rich analyses. The British philosopher Philippa Foot introduced The Trolley Problem in 1967, initially in the context of debate about the morality of abortion. In her classic paper “The Problem of Abortion and the Doctrine of the Double Effect,” Foot lays the foundation as follows:
Suppose that a judge or magistrate is faced with rioters demanding that a culprit be found for a certain crime and threatening otherwise to take their own bloody revenge on a particular section of the community. The real culprit being unknown, the judge sees himself as able to prevent the bloodshed only by framing some innocent person and having him executed. Beside this example is placed another in which a pilot whose airplane is about to crash is deciding whether to steer from a more to a less inhabited area. To make the parallel as close as possible it may rather be supposed that he is the driver of a runaway tram which he can only steer from one narrow track on to another; five men are working on one track and one man on the other; anyone on the track he enters is bound to be killed. (p. 2)
Since its introduction, this pedagogical tool has been used to pose vexing ethical challenges in a variety of contexts. Moral philosopher Judith Jarvis Thomson (1976, 1985) introduced several well-known variations of Foot’s initial framing, including these:
- David is a great transplant surgeon. Five of his patients need new parts. One needs a heart, the others need, respectively, liver, stomach, spleen, and spinal cord. But all are of the same, relatively rare, blood-type. By chance, David learns of a healthy specimen with that very blood-type. David can take the healthy specimen’s parts, killing him, and install them in his patients, saving them. Or he can refrain from taking the healthy specimen’s parts, letting his patients die.
- Irving is President, and has just been told that the Russians have launched an atom bomb towards New York. The only way in which the bomb can be prevented from reaching New York is by dropping one of our own atom bombs on Worcester: the blast of the American bomb will pulverize the Russian bomb. Irving can do nothing, letting all of New York die; or he can press a button, which launches an American bomb onto Worcester, killing all of Worcester.
Sadly, a real-life version of The Trolley Problem presented itself on June 20, 2003, when a runaway string of 31 unmanned Union Pacific freight cars barreled toward Los Angeles along a main track (Streeter, Mehta, & Garvey, 2003). To keep the runaway train from entering the Union Pacific yards in Los Angeles, where it would not only cause damage, but where a regional passenger train was thought to be located, dispatchers ordered the shunting of the runaway cars to track 4, through an area with lower density housing of mostly lower income residents. The switch to track 4 was rated for 15 miles per hour, and dispatch knew the cars were moving significantly faster, thus likely causing a derailment. The train, carrying over 3,800 tons of mostly lumber and building materials, then derailed into the residential neighborhood in Commerce, California, crashing through several houses. A pregnant woman asleep in one of the houses was injured but managed to escape through a window and was uninjured by the lumber and steel train wheels that fell around her.
Traditionally, educators introduce The Trolley Problem to help students appreciate the relevance of theories of normative ethics and conceptual distinctions between, and implications of, deontological and teleological perspectives (especially utilitarianism and consequentialism). The Trolley Problem has proven to be a valuable heuristic and pedagogical device that brings classic ethical theories to life by connecting otherwise abstruse concepts to hard, imaginable moral choices.
For example, the Trolley Problem forces social workers to critically examine the merits and limitations of ethical choices based on one’s beliefs about clients’ inherent rights and other obligatory actions, as defined by classic deontological theories. Deontological theories (from the Greek deontos, “of the obligatory”), typically associated with the eighteenth-century German philosopher Immanuel Kant, claim that certain actions are inherently right or wrong as a matter of fundamental principle (Rachels & Rachels, 2015; Reamer, 1993). From a strict deontological perspective, for example, social workers should always obey laws and regulations, even when they think that violating a law or regulation is in a client’s best interest. From this point of view, social workers should always tell the truth and should always keep their promises to their clients, no matter how harmful the consequences may be. Social workers should always obey mandatory reporting laws, even when they think notifying protective service officials would likely cause more harm than good. In the case scenarios presented earlier, the social worker concerned about the rights of low-income community residents should consider whether displacing them for economic development purposes would violate their fundamental rights, regardless of the positive consequences for the broader community. Similarly, the clinical social worker who considers excluding clients whose care would be covered by Medicaid should consider whether this course of action would violate these individuals’ fundamental right to care, regardless of the positive impact on the agency’s fiscal solvency. This is comparable to concluding in The Trolley Problem that one should never intentionally cause harm to an innocent person.
In contrast, teleological (from the Greek teleios, “brought to its end or purpose”) or consequentialist theories suggest that ethical decisions should be based on social workers’ assessment of which action will produce the most favorable outcome or consequences. This approach to ethical decision making entails what is commonly referred to as a cost-benefit analysis, as opposed to analysis of people’s fundamental rights. According to the most popular teleological perspective, utilitarianism—typically associated with the eighteenth century British philosopher Jeremy Bentham and the nineteenth century British philosopher John Stuart Mill—ethical choices should be based on thorough assessments of what will produce the greatest good for the greatest number (positive utilitarianism) or the least harm (negative utilitarianism). From this perspective, lying to a client about his poor prognosis may be justifiable if a social worker has reason to believe that telling the client the grim truth, which deontology would require, would likely cause significant emotional anguish. Similarly, teleologists and consequentialists might argue that failing to report a client’s assets, as required by law and deontology, may be justifiable if the deception would enable a vulnerable client to become eligible for much needed health care benefits. With regard to the case scenarios presented earlier, the social worker concerned about the rights of low-income community residents should consider whether displacing them for economic development purposes would be justifiable ethically because of the greater good that would likely result. Similarly, the clinical social worker who considers excluding clients whose care would be covered by Medicaid should consider whether this course of action would result in greater good because it would ensure the financial survival of the agency and its ability to assist struggling adolescents. This is comparable to concluding in The Trolley Problem that one should make ethical decisions in a way that maximizes good, even though this course of action may include some collateral harm.
From a strict teleological or consequentialist perspective, the bystander witnessing the runaway trolley would be morally justified if he chose to pull the lever in order to divert the trolley down a second set of tracks away from the five unsuspecting workers, even though this would likely kill the lone worker on the side track. In contrast, a deontologist may argue that it is inherently wrong, in a moral sense, to engage in a deliberate act that will likely result in killing an innocent human being, no matter the possible benefit to other people.
More recently, social workers and other professionals have broadened their application of ethical theory to include so-called virtue ethics and the ethics of care, perspectives that trolleyology does not typically consider. According to virtue ethics, professionals’ ethical judgments should be guided by certain core virtues, such as kindness, generosity, courage, integrity, respectfulness, justice, prudence, and compassion (Beauchamp & Childress, 2019; MacIntyre, 2007; Reamer, 2018). The ethics of care, which is related to virtue ethics, was developed mainly by feminist writers (Held, 2006). According to this view, men tend to think in masculine terms, such as justice and autonomy, whereas women think in feminine terms, such as caring. Proponents of the ethics of care argue that professionals should change how they view morality and the virtues, placing more emphasis on virtues exemplified by women, such as taking care of others, patience, the ability to nurture, and self-sacrifice.
The Limitations of a Utilitarian Perspective
Trolley problem analyses typically focus especially on the relevance of utilitarian thinking, where the rightness of one’s actions is determined by the goodness of the outcomes and consequences. One problem with utilitarianism is that this framework sometimes can be used to justify competing options. For example, one utilitarian might argue that enhancing economic development in a low-income community justifies displacing some current residents against their wishes. Another utilitarian, who assigns different weights to the potential benefits and costs involved in the options, might enter different variables into this complex equation and conclude that the harm likely to be endured by the displaced residents, along with the damage that may befall the social worker’s and her agency’s reputation and corresponding effectiveness, outweighs the potential benefits of the proposed economic development.
Many moral philosophers argue that distinguishing between act and rule utilitarianism is important and helpful (Gorovitz, 1971). According to act utilitarianism, the rightness of an action is determined by the goodness of the consequences produced in that specific case or by that particular act. One does not need to look beyond the implications of this one instance, for example, whether a program that serves high-risk adolescents should stop accepting clients whose care would be covered by Medicaid payments in order to ensure the organization’s financial viability. In contrast, rule utilitarianism takes into account the long-term consequences likely to result if one generalizes from the case at hand or treats it as a precedent. Thus an act utilitarian might argue that sacrificing low-income people (for example, for economic development or any other purpose) whenever doing so might produce a positive net benefit for the broader community would create a dangerous and ethically impermissible precedent which, if followed consistently in comparable circumstances, would cause widespread harm in the broader society.
Another illustration of the distinction between act and rule utilitarianism concerns the well-known mandatory reporting laws related to child abuse and neglect. According to these statutes, social workers and other mandated reporters are required to notify child welfare or protective service authorities whenever they suspect child abuse or neglect. However, circumstances sometimes arise that lead social workers to conclude that a client’s best interests would not be served by complying with the mandatory reporting law. In these instances, social workers believe that more harm than good would result if they obeyed the law. What these social workers are claiming, at least implicitly, is that violating a law is permissible when it appears that greater good would result. Of course, social workers are likely to be troubled by this conclusion.
This is a classic example of act utilitarianism. An act utilitarian might justify violating a mandatory reporting law if it can be demonstrated convincingly that in this individual case this would result in greater good (for example, if the social worker is able to show that he would not be able to continue working with the family if he reported the suspected abuse or neglect and that his continuing to work with the family offers the greatest potential for preventing further neglect or abuse). A rule utilitarian, however, might argue that the precedent established by this deliberate violation of the law would generate more harm than good, regardless of the benefits produced by this one particular violation. A rule utilitarian might argue that the precedent established by this case might encourage other social workers to take matters into their own hands in comparable situations rather than report suspected abuse or neglect to local protective service officials, in accord with the law, and that this would, in the long run, be more harmful than helpful.
In addition, when taken to the extreme in a way that social workers would find troubling, classic utilitarianism can justify trampling on the rights of a vulnerable minority in order to benefit the majority. In principle, a callous utilitarian social worker could argue that policies that protect the interests of low-income community residents who would be displaced are too costly, especially when compared to the benefits of comprehensive economic development. In light of countless instances throughout history in which the rights of minorities and other oppressed groups have been insensitively violated to benefit the majority, social workers have good reason to be concerned about such strict applications of utilitarian principles that undergird trolley problem analyses.
Perhaps the best-known alternative to utilitarianism is proposed by philosophers who embrace what is known as rights-based theory. According to this perspective, statements about people’s fundamental rights—for example, the right to life, liberty, expression, property, and protection against oppression, unequal treatment, intolerance, and arbitrary invasion of privacy—provide the basic language and framework for ethical guidelines (Beauchamp and Childress 2013). In his A Theory of Justice (1971), philosopher John Rawls offers a rights-based perspective that has profound implications for social workers who are concerned about reconciling competing interests and protecting vulnerable people—circumstances embedded in classic formulations of The Trolley Problem. In his analysis, Rawls assumes that individuals who are formulating a moral principle by which to be governed are in an “original position” of equality such that each individual is unaware of her own attributes and status that might produce some advantage or disadvantage. The assumption is that under what Rawls calls the “veil of ignorance,” in which people have no awareness of social or status differences among them, individuals will formulate a moral framework that ultimately protects the least advantaged based upon a ranking of priorities (for example, low-income community residents who would be displaced by an economic development initiative).
Rawls’s work highlights a concept that has become critically important in ethics and in social work: the ranking of values and ethical duties, including those that arise in trolley-type problems. For Rawls and many other moral philosophers, ethical decisions often reduce to difficult judgments about what values or duties take precedence over others. Rawls called this lexical ordering. Should a client’s right to privacy or the need to protect a client from harm take precedence over the need to respect the law and avoid being associated with fraud perpetrated by the client? Should the needs of low-income residents of a community take precedence over potential beneficiaries of an ambitious economic development project? Should the needs of vulnerable adolescents whose care would be paid for by Medicaid take precedence over the needs of a larger group of adolescents who have access to more generous health insurance benefits that would generate more revenue for the program? To use Ross’s (1930) valuable terminology, which of various conflicting prima facie duties should take precedence, that is, which should be one’s actual duty?
Other moral philosophers have also offered important rights-based theories about the most appropriate way to rank conflicting duties that arise, as in trolley-type scenarios. The philosopher Donagan argued in The Theory of Morality (1977) that when choosing among duties that may result in harm, one should do that which results in the least harm. Popper (1966) called this the minimization of suffering, and Smart and Williams (1973) called this negative utilitarianism. According to Donagan (1977),
What [common morality] provides depends on the fact that, although wrongness, or moral impermissibility, does not have degrees, impermissible wrongs are more or less grave. The explanation of this is simple. Any violation of the respect owed to human beings as rational is flatly and unconditionally forbidden; but the respect owed to human beings may be violated either more or less gravely. It is absolutely impermissible either to murder or to steal; but although murder is no more wrong than stealing, it is a graver wrong. There is a parallel in the criminal law, in which murder and stealing are equally felonies, but murder is a graver felony than stealing. In general, every wrong action impairs some human good, and the gravity of wrong actions varies with the human goods they impair. Although there is room for dispute in some cases as to whether or not this action is a graver wrong than that (for example, whether theft of one’s reputation is worse than theft of one’s purse), when they find themselves trapped… in a choice between wrongs, not only do most moral agents have opinions about whether these wrongs are equally grave, and if they are not, about which is the graver; but also, if they adhere to the same moral tradition, their opinions on these questions largely agree. And, given that wrongs can differ in gravity, it quite obviously follows from the fundamental principle of morality that, when through some misdeed a man is confronted with a choice between wrongs, if one of them is less grave than the others, he is to choose it. This precept is a special application of a more general principle which I shall refer to as the principle of the least evil, and which was already proverbial in Cicero’s time: namely, minima de malis eligenda — when you must choose between evils, choose the least. (p. 152)
From this perspective, then, the social worker’s obligation in the context of a trolley-type circumstance involving conflicting duties is to follow the course of action that results in the least harm. This might produce results quite different from those yielded by a strategy that seeks to produce the greatest good.
In another prominent example of a rights-based theory that is relevant to social work, moral philosopher Gewirth (1978) has offered a number of arguments that are particularly relevant to social workers’ thinking about the ranking of conflicting duties (Reamer, 1993). Gewirth’s approach in his Reason and Morality (1978) also provides a useful illustration of the ways in which moral philosophers think about the kinds of ethical dilemmas that arise in circumstances comparable to The Trolley Problem. Following a series of complex philosophical arguments and derivations, Gewirth ultimately claimed that human beings have a fundamental right to freedom (similar to social workers’ conceptualization of self-determination) and well-being and that there are three core “goods” that human beings must value: basic goods—those aspects of well-being that are necessary for anyone to engage in purposeful activity (for example, life itself, health, food, shelter, mental equilibrium); nonsubtractive goods—goods whose loss would diminish a person’s ability to pursue his goals (for example, as a result of being subjected to inferior living conditions or harsh labor, or as a result of being stolen from, cheated on, or lied to); and additive goods—goods that enhance a person’s ability to pursue her goals (for example, knowledge, self-esteem, material wealth, education).
Like all moral philosophers, Gewirth recognized that people’s various duties and rights sometimes conflict and that we sometimes need to choose among them; social workers certainly encounter such conflicts. Gewirth argued that conflicting duties can be ranked or placed in a hierarchy based on the goods involved. Given this hierarchy, Gewirth claimed, several principles can be derived to help make choices among conflicting duties (1978).
First, if one person or group violates or is about to violate another’s rights to freedom and well-being (including basic, nonsubtractive, and additive goods), action to prevent or remove the violation may be justified. Whether that action is justified depends on the extent to which the violation jeopardizes an individual’s ability to act in the future. Thus, if a social worker’s client discloses in confidence that he plans to harm his partner, the practitioner’s duty to protect the partner from harm would override the client’s right to confidentiality. The partner’s right to well-being would justify violation of the client’s right to self-determination and privacy. Similarly, displacing low-income residents for economic development purposes in a way that seriously compromises their ability to act in the future, because of these individuals’ inability to have basic housing, may not be justifiable because of the basic goods involved.
Second, because every individual has the duty to respect others’ right to the goods that are necessary for human action (freedom and well-being), one duty takes precedence over another if the good involved in the first duty is more necessary for human action and if the right to that duty cannot be protected without violating the second duty. Therefore, protection of a client’s partner from violent harm by the client would take precedence over the client’s right to privacy, because the good involved in the first duty (protection from serious bodily injury) is more necessary for human action and functioning than is privacy. Protection of vulnerable community residents may be more necessary for human action than broad-based economic development that would enhance the well-being of more affluent people.
Third, rules governing interactions among people can, in particular cases, override the duty not to coerce others, but such rules must meet several conditions. Any coercion must be necessary to prevent undeserved coercion and serious harm; permissible coercion must not go beyond what is necessary for such protection; and the rules that permit occasional coercion must be arrived at democratically. Thus, it would be permissible to coerce one’s client (for example, forcing disclosure to authorities of his threat to harm his partner) in order to prevent undeserved coercion (bodily assault) and serious harm. However, coercion with regard to disclosure of confidential information must not go beyond what is necessary to protect the client’s partner, and public policy regarding such disclosure should be the result of the democratic process (for example, public policy formed by elected legislators or judges).
Gewirth’s framework is particularly helpful in addressing many ethical dilemmas in social work that involve conflicting duties of the sort that arise in trolley-type circumstances. His concept of basic goods, for example, is consistent with social work’s long-standing preoccupation with basic human needs (Towle, 1965). Further, Gewirth’s ranking of values, goods, and duties provides compelling support to social work’s enduring commitment to addressing the needs of society’s most vulnerable members, as reflected in the preamble in the NASW Code of Ethics (2017) that highlights social workers’ predominant commitment to addressing the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.
The Doctrines of Double Effect and Distributive Exemption
Moral philosophers’ analyses of The Trolley Problem often invoke what is known as the doctrine of double effect. This, too, has implications for social workers.
Put simply, the doctrine of double effect states that if doing something morally good has a morally bad side-effect, it is ethically permissible to do it providing the bad side-effect was not intended (Saemi, 2019). This is true even if one foresaw that the bad effect would probably happen. Thus, from this point of view, intent matters. According to Philippa Foot,
The doctrine of the double effect is based on a distinction between what a man foresees as a result of his voluntary action and what, in the strict sense, he intends. He intends in the strictest sense both those things that he aims at as ends and those that he aims at as means to his ends. The latter may be regretted in themselves but nevertheless desired for the sake of the end… By contrast a man is said not strictly, or directly, to intend the foreseen consequences of his voluntary actions where these are neither the end at which he is aiming nor the means to this end… The words “double effect” refer to the two effects that an action may produce: the one aimed at, and the one foreseen but in no way desired. By “the doctrine of the double effect” I mean the thesis that it is sometimes permissible to bring about by oblique intention what one may not directly intend. Thus, the distinction is held to be relevant to moral decision in certain difficult cases. (p. 1)
Thus, viewed narrowly through the lens of the double effect, the social worker whose community agency displaces low-income residents to enhance economic development more broadly may be justified in doing so because the board of directors does not intend that any harm should befall the displaced residents; whatever misfortune they experience is an unintended byproduct in pursuit of a morally noble goal. Similarly, under the doctrine of double effect, the fiscally troubled residential treatment program whose clinical director is a social worker would be morally justified in limiting admissions to teens whose care is paid for by private insurance companies, even though low-income teens whose care would be paid for by state Medicaid funds would be denied services, because whatever harm results for low-income teens would be unintended in pursuit of a broader good (the agency’s financial stability).
Social workers can benefit from lessons embedded in longstanding philosophical discussions of the doctrine of double effect, which have focused especially on issues related to women’s reproductive rights, allocation of limited resources, euthanasia, and war. With regard to women’s reproductive rights, for example, some argue that the doctrine of double effect offers support for abortion when necessary to save the life of the mother. Specifically, according to this view, the death of the fetus is the unintended consequence of medical treatment whose goal is saving the life of the mother.
With regard to euthanasia, the doctrine of double effect may be used to justify giving high doses of drugs, such as morphine, to a terminally ill patient who is experiencing unrelenting pain. The doctor who prescribes and administers the medication does not intend to kill the patient, although this may be a predictable consequence of the doctor’s attempt to relieve suffering.
In the military, the doctrine of double effect might be advanced to defend a decision to launch an attack on an enemy target in order to prevent widespread harm, knowing that innocent civilians may be injured or killed as a result (collateral damage). From this perspective, it matters that the goal was not to harm innocent civilians who, sadly, may be collateral damage.
In the social policy arena, the doctrine of double effect might be advanced to defend a decision to allocate limited resources (for example, housing development and job creation subsidies) to enhance opportunities for vulnerable individuals and communities, knowing that dedicating funds to one group will have a detrimental impact on others whose interests may be sacrificed in the resource allocation process.[1]
Critics of the doctrine of double effect make two principal arguments. First, people are responsible for all of the anticipated consequences of their actions. If we are able to foresee the “double” or multiple effects of our actions, we are obligated to accept moral responsibility for their consequences. We cannot dodge responsibility by deciding to intend only the outcomes with which we are comfortable.
Second, some argue that it is simply too convenient to couch the moral justification of our actions, some of which may have negative consequences that accompany positive effects, in the nature of our intention. That is, what matters is whether the actions we engage in are objectively right or wrong (consistent with deontology), not whether we intended particular outcomes. From this perspective, what matters is whether a social worker’s efforts to enhance a community’s economic health led to the actual displacement of vulnerable citizens, as opposed to whether or not the social worker intended this negative outcome. Similarly, what matters is whether the residential treatment program for struggling teens deprived care for low-income youths, as opposed to whether or not the shift in the program’s admission criteria was intended to cause this negative outcome.
One key counterargument is that, historically, our widely accepted system of jurisprudence has acknowledged the critical importance of intent, especially in criminal court matters. The legal concept of mens rea (Latin for “guilty mind”) originated in English courts around the thirteenth century. Before the introduction of mens rea, an individual could be found guilty of a crime based solely on his or her actual conduct. Mens rea developed from the notion that a person should not be found guilty of a crime if he or she had an innocent mindset and did not intend harm.
Mens rea, also called criminal intent that entails culpability and fault, has become a required element of some, although not all, criminal offenses (Chiesa, 2018; Levin, 2019).[2]
[1] Social workers concerned about maximizing good when allocating limited resources may connect key trolleyology concepts with the well known economics concept known as Pareto optimality (or efficiency). “Pareto optimality” is an analytic tool for assessing social welfare resource allocation developed by Italian economist Vilfredo Pareto, a pioneer in the study of distributional efficiency. An allocation is considered Pareto optimal if no alternative allocation could make someone better off without making someone else worse off (Cudd, 1996).
[2] Some laws require that the prosecution in a criminal court case demonstrate that the defendant intentionally committed the act in question (committing the act with the conscious desire for the harmful conduct to occur), while others require that the act be done knowingly or with reckless disregard of the harm it may pose. Some contemporary statutes require no mens rea at all; these are commonly referred to as strict liability offenses (Samaha, 2015).
In her classic discussion of The Trolley Problem and the role of moral intention, Thomson offers a useful distinction known as the doctrine of distributive exemption. This is particularly relevant in the case scenario similar to one described earlier involving organ transplantation: Suppose that Ozzie has entered the hospital for a routine physical. There are five people in that hospital who will die unless they receive various organs. Andy needs a heart, Bert a liver, Cindy a kidney, and Darla and Edith each need one lung. Assuming that it is physically possible for the hospital’s star surgeon to transplant Ozzie’s organs into each of these patients, may the surgeon do so against Ozzie’s consent if it is assured that the operations will each be successful?
Many moral philosophers draw a significant distinction between sacrificing one person for the greater good when there is an existing threat that is in motion (the out-of-control trolley problem) and circumstances where one would have to initiate the threat that entails sacrificing one person for the greater good (the organ transplant problem). Throwing the switch in the trolley-problem scenario merely deflects a force that is already in motion. In the transplant scenario, by contrast, the surgeon creates an entirely new threat. Thomson’s solution is that the concept of “distributive exemption” applies to the trolley case, but not to the transplant case (Stelzig, 1998). In her classic discussion, Thomson (1985) introduces the concept of the distributive exemption as follows:
The bystander who proceeds does not make something be a threat to people which would otherwise not be a threat to anyone; he makes be a threat to fewer what is already a threat to more. We might speak here of a “distributive exemption,” which permits arranging that something that will do harm anyway shall be better distributed than it otherwise would be—shall (in Bystander at the Switch) do harm to fewer rather than more. Not just any distributive intervention is permissible: It is not in general morally open to us to make one die to save five. But other things being equal, it is not morally required of us that we let a burden descend out of the blue onto five when we can make it instead descend onto one. (p. 1408)
Accepting the doctrines of double effect and distributive exemption in social work requires accepting that practitioners’ actions may be morally defensible, even though there are negative consequences, so long as social workers did not intend the negative outcomes or initiate actions to address a challenge that is not already in motion. In this regard, social workers must have a full understanding of the moral implications of the concept of intent.
The concept of intent has a rich history in moral philosophy and is an essential element in our judgments about the morality of actions and behaviors (Anscombe, 1957; FitzPatrick, 2003; Liao, 2012; Scanlon, 2009; Shaw, 2006). According to Paul (2013),
The investigation of what we are morally permitted to do is integrally bound up with the puzzle of what it is to act. Intentional actions are paradigm objects of moral evaluation; therefore, grasping what it is to act is part of understanding and justifying such evaluation. In turn, the study of intentional action is integrally bound up with the notion of intention. What is done intentionally stands in some relation to the intention with which one acts: the very same physical event of an arm rising might on one hand be an unintentional spasm, and on the other any of the intentional actions of hailing a taxi, voting, stretching, or signaling for the revolution to begin. And in addition to contributing to the determination of what is done, the intention with which an action was performed may influence our moral assessment of that action. (p. 2658)
Conclusion
Every corner of social work comes with difficult ethical choices that entail potentially serious moral tradeoffs. The Trolley Problem, along with its extensive array of permutations, provides social workers with a useful analytic and heuristic framework to help practitioners think through the moral problems they face.
Specifically, what has become known as trolleyology can help social workers engage in rigorous analysis of fundamental moral rights and obligations; the merits and limitations of different ethical theories (such as deontology, teleology, utilitarianism, virtue theory, and the ethics of care); and the justifiability of diverse ethics-based courses of action. Trolleyology also provides social workers with a way to reflect on the relevance of intention when they make moral decisions, particularly with regard to the implications of the doctrines of double effect and distributive exemption.
Trolleyology has a wide range of practical applications throughout social work’s diverse domains. This includes clinical social work, in which practitioners must make ethical decisions that affect their ability to simultaneously protect the interests of individual clients and third parties; agency administration, in which social workers must make agonizing budget allocation and personnel decisions that may entail moral compromises and tradeoffs; and policy practice, in which social workers have to make complex moral judgments about the distribution of limited social and economic resources.
Trolleyology concepts are especially relevant in a profession such as social work, whose principal code of ethics and moral mission highlight practitioners’ fundamental duty to address the needs of the most vulnerable members of our society. As Edmonds (2014) concludes, “The aim of trolleyology is to provide a principle or principles that make sense of our powerful reactions and that can reveal something to us about the nature of morality. It’s been a protracted philosophical detective story: different scenarios have provided different pieces of evidence to support different conclusions” (p. 176).
References
Andrade, G. (2019). Medical ethics and The Trolley Problem. Medical Ethics and History of Medicine, 12(3), 1-15.
Anscombe, G. (1957). Intention. Harvard University Press.
Beauchamp, T., & Childress, J. (2013). Principles of biomedical ethics (7th ed.). Oxford University Press.
Brown, D. (2012). Federal mens rea interpretation and the limits of culpability’s relevance. Law and Contemporary Problems, 75(2), 109-131.
Chiesa, L. (2018). Mens rea in comparative perspective. Marquette Law Review, 102(2), 575-603.
Cudd, A. (1996). Is Pareto Optimality a criterion of justice? Social Theory and Practice, 22(1), 1-34.
Donagan, A. (1977). The theory of morality. University of Chicago Press.
Dzionek-Kozlowska, J., & Rehman, S. (2019). Career choices and moral choices: Changing tracks in The Trolley Problem. Studies in Logic, Grammar, and Rhetoric, 59(1), 177-189.
Edmonds, D. (2014). Would you kill the fat man: The Trolley Problem and what your answer tells us about right and wrong. Princeton University Press.
FitzPatrick, W. (2003). Acts, intentions, and moral permissibility: In defence of the doctrine of double effect. Analysis, 63(4), 317-321.
Foot, P. (1967). The problem of abortion and the doctrine of double effect. Oxford Review, 5, 5-15.
Gewirth, A. (1978). Reason and morality. University of Chicago Press.
Gorovitz, S. (Ed.). (1971). Mill: Utilitarianism. Bobbs-Merrill.
Hallborg, R. (1997). Comparing harms: The lesser-evil defense and The Trolley Problem. Legal Theory, 3(4), 291-316.
Held, V. (2006). The ethics of care: Personal, political, and global. Oxford University Press.
Levin, B. (2019). Mens rea reform and its discontents. Journal of Criminal Law and Criminology, 109(3), 491-558.
Liao, S. (2012). Intentions and moral permissibility: The case of acting permissibly with bad intentions. Law and Philosophy, 31(6), 703-724.
MacIntyre, A. (1984). After virtue. (2nd ed.) University of Notre Dame Press.
National Association of Social Workers (2017). NASW Code of Ethics. Author.
Paul, S. (2013). Intention. In H. LaFollette (Ed.), International encyclopedia of ethics (pp. 2658-2670). John Wiley & Sons.
Popper, K. (1966). The open society and its enemies (5th ed.). Routledge and Kegan Paul.
Rachels, J., & Rachels, S. (2015). Elements of moral philosophy (8th ed.). McGraw-Hill.
Rawls, J. (1971). A theory of justice. Harvard University Press.
Reamer, F. (1993). The philosophical foundations of social work. Columbia University Press.
Reamer, F. (2018). Social work values and ethics (5th ed.).Columbia University Press.
Ross. W. D. (1930). The right and the good. Clarendon.
Scanlon, T. (2009). Moral dimensions: Permissibility, meaning, blame. Harvard University Press.
Saemi, A. (2019). Intention principle and the doctrine of double effect. Analysis, 79(1), 91-99.
Samaha, J. (2015). Criminal law (12th ed.). Cengage.
Shaw, J. (2006). Intention in ethics. Canadian Journal of Philosophy, 36(2), 187-224.
Smart, J. J. C., & Williams, B. (1973). Utilitarianism: For and against. Cambridge University Press.
Stelzig, T. (1998). Deontology, governmental action, and the distributive exemption: How the trolley problem shapes the relationship between rights and policy. University of Pennsylvania Law Review, 146(3), 901-959.
Streeter, K., Mehta, S., & Garvey, M. (2003, June 21). Runaway train jumps track in Commerce. Los Angeles Times. Retrieved from https://www.latimes.com/archives/la-xpm-2003-jun-21-me-train21-story.html
Thomson, J. J. (1976). Killing, letting die, and The Trolley Problem. The Monist, 59(2), 204-217.
Thomson, J. J. (1985). The Trolley Problem. Yale Law Journal, 94(6), 1395-1415.
Towle, C. (1965). Common human needs. National Association of Social Workers.