The Transplant Surgeon
A surgeon has five patients who will each die without an organ transplant. A healthy patient arrives for a routine checkup and is a perfect match for all five. Should the surgeon kill the healthy patient to harvest the organs and save the five?
Judith Jarvis Thomson introduced this scenario in 1976 to examine what the trolley problem actually proves. The arithmetic is identical, but almost no one thinks the surgeon should act. Understanding why illuminates the moral difference between killing and letting die, and between redirecting harm and using someone as a means.
Thomson, J. J. (1976). Killing, Letting Die, and the Trolley Problem. The Monist, 59(2), 204–217.
The scenario
A healthy patient arrives for a checkup. Five other patients in the same hospital are dying: one needs a heart, one needs a liver, two need kidneys, one needs a lung. Their blood types are all a perfect match with the healthy patient.
The utilitarian arithmetic is the same as in the trolley problem: one person dies, five people live. But almost nobody thinks the surgeon should do it, including most people who would pull the trolley lever without hesitation.
The question is not whether the surgeon should harvest the organs. She should not. The question is why the arithmetic that settled the trolley case doesn't settle this one.
The doing/allowing distinction and the doctrine of double effect
Several moral principles converge on prohibiting the surgeon's action.
The doing/allowing distinction holds that there is a morally relevant difference between killing someone and letting someone die. In the trolley case, the five people are already in danger from the trolley; you redirect an existing threat. In the transplant case, the healthy patient is in no danger until the surgeon makes them a means to other ends. The surgeon would be the originating cause of death, not a modifier of an existing trajectory.
The doctrine of double effect distinguishes between harm that is intended as a means and harm that is merely foreseen as a side effect. Pulling the trolley lever foresees the death of the one but does not use it as the means of saving the five. The transplant surgeon intends the healthy patient's death; it is the mechanism. That intended use of a person as a tool is what makes the action impermissible, regardless of the outcome.
What the contrast reveals
The transplant scenario and the trolley problem together do important philosophical work. They show that utilitarian arithmetic, on its own, is an incomplete guide to moral permissibility.
If five outweighing one settled the trolley case, it should settle the transplant case. But it doesn't. So either we were wrong about the trolley case, or the trolley case is permissible for reasons other than the arithmetic, reasons having to do with rights, the distinction between doing and allowing, or the role of the victim as means versus bystander.
The transplant surgeon is useful precisely because it exposes that something beyond numbers is doing the moral work in these cases.
Discussion questions
- If it is wrong to kill the healthy patient but right to pull the trolley lever, what makes the difference?
- Should we have rules against beneficial killing that hold even in extreme cases?
- Is the intuitive wrongness of the transplant case evidence of something philosophically important?
Take it to the dinner table.
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