You are a paramedic arriving at an emergency scene. A group of scouts has entered a cave that is now filling with water. They were led into the cave by a rather large scoutmaster. Unfortunately, while leading them out of the cave, the scoutmaster somehow managed to get stuck in a narrow opening with only his head and shoulders protruding out. With his upper torso stuck outside the cave, it appears the scoutmaster will survive, but all the boys below will drown if they cannot escape.
After you have checked all possible escape routes and have attempted to extricate the scoutmaster, it becomes clear that the only way to save the boys is to sacrifice the scoutmaster, so he can be removed. This is, unfortunately, not the Winnie the Pooh story where Rabbit has the option of waiting until Pooh loses weight. What is the correct action for this case?
Duty-oriented reasoning, otherwise known as deontology, deals with Immanuel Kant’s influential moral theory regarding what a person is obligated to do (Rosenstand, 2003). The reasoning behind deontology is the intention, and is based on universal principles that guide actions (Fremgen, 2009; Rosenstand, 2003). Duty-oriented reasoning concludes that the consequences of the action are not as important as the principle moral law that dictates the action; that the presence of one’s duty is the determining factor as to an action’s morality (Kant, 1785). For example, a person has a moral obligation to be honest, even if that honesty has negative outcomes. To lie, even to save one’s life, would be morally objectionable because there is a duty to be honest.
As applied to the scenario above, it is important to determine the moral obligation. As a paramedic, the implied duties and obligations are to aid those in need. The primary duty is balanced by both parties in the above scenario and does not further the decision process. A second obligation is a sociopolitical obligation to protect the most vulnerable of society.
Given the exigency of the situation, it is reasonable to prioritize. In this scenario, the greater duty would be to protect the innocent and vulnerable: to save the lives of the children. Children are considered to be some of the most vulnerable members of society; therefore assisting them holds a higher obligation in order to fulfill the duty. While this necessitates the sacrifice of the scoutmaster, the greater duty is the protection of the most vulnerable members of society. By following the moral law of protecting the innocent, the sacrifice of the scoutmaster would be a morally sound action given the circumstances.
Consequence-oriented reasoning, or consequentialism, uses a cost/benefit analysis to benefit as many people as possible (Fremgen, 2009; Rosenstand, 2003). The results are regarded as having a greater significance than the actions taken. In other words, consequentialism signifies that the ends justify the means. For example, if one would have to lie in order to save someone’s life, the act of saving the life would be morally sound while the act of lying would be justified through of the final results. “Utilitarians see as their moral guideline a rule that encourages them to make life bearable for as many people as possible” (Rosenstand, 2003, p. 175). This is an important quotation because it clearly states the guiding factor that the needs of the many outweigh the needs of the single person. The greater return for the least amount of effort, in essence an economic consideration, is of primary significance.
As applied to the scenario above, the lives of the scout troop would carry greater significance than the life of the single scout master. As a consequentialist, it would be necessary on moral grounds to assist the most people possible, even at the expense of a singular unit. Following this reasoning, it would be morally necessary to sacrifice the scout master and save the children. In this way, the greatest number of people is served while the least suffer.
Virtue-ethics reasoning is based on what a virtuous person would do; it deals with the character of a person and the responsibilities derived from such a character (Rosenstand, 2003). One concern of virtue-based reasoning is justice (Fremgen, 2009). According to R. G. Rodriguez, “Aristotle defined justice as being treated equally” (2009). Following virtue-reasoning, a virtuous person would act justly, therefore treating all equally. There would be no added value to one party or another.
As applied to the aforementioned scenario, using value-based reasoning would lead a person to the same conclusion as the other methods of reasoning, however for different reasons. The scout master holds ultimate responsibility for the lives and well-being of the troop that he leads. A responsible and virtuous scout master would have allowed the boys to exit first, therefore ensuring their exit before his own. Had he acted courageously, the boys would have been safely outside even had he then become lodged in the entrance; which would not have otherwise been fatal. However, justice would dictate that, as the responsible party, he would be sacrificed to save those for which his selfishness and lack of virtue harmed.
While all three methods lead to the same conclusion, the biggest dilemma with ethics is its subjectivity. There is no absolute right or wrong answer in many difficult situations; the morality is drawn from those involved and the examiners of the situation. This is especially important when considering healthcare ethics, often involving dramatic circumstances and choices. When applying different standards to healthcare practice, different conclusions may be achieved. It is important to understand all parties’ view points, to clarify the ethical issues, and to compromise in resolving the dilemma (Fremgen, 2003).
When determining who is right, it is important to consider the legal and sociopolitical context, including the professional codes of ethics. In this manner, the societal and professional obligations and expectations supersede the expression of the personal morality of an individual. For example, if a nurse feels that the morally obligatory course of action is to euthanize any cancer patient as a way to ease the financial drain on the economy (hence, utilitarianism as the societal needs serve a greater importance than a single person’s life), it would still be legally objectionable due to the standards of care, ethical code of conduct within the profession, and societal laws.
While all of the moral theories examined above result in the same conclusion, it is logical to consider some additional points that are relative due to the nature of the healthcare setting. The first thing to consider is the legality of the action: the paramedic would be operating outside of his or her scope of practice since they have no training on sacrificing a patient. Considering that the scout master is alive and yet unable to be extricated, it is reasonable to conclude that, even following the sacrifice, the paramedic would not be equipped to dismember the body in order to remove the scout master’s remains. In either case, this would be operating outside of the scope of practice, as well as violating the ethical principle of nonmaleficence (Fremgen, 2009). The paramedic would likely be sued in civil court, and may even be charged with murder.
Alternatives to executing the scout master may include dismemberment; losing a limb would be preferential to losing the life. Depending on the logistics of the scout master’s predicament, there may be time to find another way of extraction before the water rises high enough that the boys are mortally endangered. While ethics dictate one’s actions, it is also necessary to use all options available, to think independently and remain conscious of ethical and legal issues within the field (Fremgen, 2009).