Who to push in front of the trolley?

I admit to only vaguely following the recentfurore over the decision to supplement bread with folic acid.   The underlyingprinciple behind such decisions seems straight-forward.   But economics can onlytake us so far when we start to examine the moral dimension.       

The benefits to folic acid supplementationarise from fewer cases of spina bifida.   The costs are the costs of changingbread-making procedures, and a possible enhanced risk of prostate cancer.   Ifthe benefits exceed the costs, there is a strong argument for proceeding withsupplementation.

Not being a medical specialist myself, I am(like most people) in a poor position to judge whether the estimates of costsand benefits are robust.   But let’s assume that it is true that adding folicacid to bread will lead to more prostate cancers.       

The heated debate over this issue impliesthat there is more at stake than just the precision of the estimated values.   Clearlya cursory cost-benefit analysis is ignoring some important dimension of thisquestion.  

The most obvious complaint is that the"winners" from this decision are not the same group as the "losers".   Now thisis true of almost all real-world policy decisions.   And compensation of thelosers is not always possible or feasible – redistribution via the welfaresystem being the obvious example.   In these situations, we must base ourdecisions on some sort of utilitarian calculus, whereby we try and maximisetotal welfare over the whole population.  

Since we can’t directly quantify humanwell-being, we are forced to make a number of value judgements.   We normallyassume that an extra dollar is worth more in terms of quality of life for apoor person than a rich person; we may also value improvements in health forchildren higher as opposed to adults.         

The distribution of gains and losses bringsa complicated philosophical dimension to our cost-benefit analysis.   Further,I’d argue that when the distribution relates to physical health, as opposed tosimply income, these questions become even thornier.   Is it right to force theexchange in health status between the potential victims of spina bifida caseand prostate cancer, even when the cost-benefit analysis supports the transfer?

There is no right answer to this question.  In fact, laboratory experiments tend to suggest that these decisions are highlycontext-critical.  

One famous example is the trolley problem: anout-of-control trolley car is running down a track that has five people tied toit; but there is a switch you may pull that will divert it on to a second trackwhich only has one person tied to it.

Faced with this situation, most people canrationalise pulling the switch: killing one to save five.  

But what about this alternative scenario:the train car is heading towards five people, but this time there is noswitch.   Instead, there is a fat man nearby; throwing him in front of the trolleywould derail it, again saving the original five through the sacrifice of one.  

This version of the problem produces farfewer people willing to kill one person to save five.   Although the calculusremains the same, it is much harder to condone the deliberate homicide of aninnocent bystander.  

Analysis of these problems raises a host ofquestions about how we make moral judgements; the relevant one for our topic iswhat precisely drives the differing responses?   Common answers are the intentof the decision-maker, or their control (or lack thereof) over the situation.

Returning to bread supplementation, we arestill none the wiser as to whether we can justify swapping a certain number ofspina bifida cases for prostate cancer cases.   Should we view this as aneither/or situation (throwing the folic-acid switch in the bread-makingmachine), or is this an active intervention (throwing some men, prostates andall, on to the track)?  

If the bread example seems too uncommon towarrant much thought, an earlier academic paper suggested a broaderapplication.   High-income groups in New Zealand have a lower mortality riskthan low-income groups, although there are diminishing marginal returns toextra income.   If the relationship is causal, redistributing money from rich topoor would also redistribute some of that mortality risk, producing a longer-livedsociety (on average).  

Of course, the direct result of that policyintervention would be that some high-income people would die earlier than theywould otherwise do so.  

So, are such welfare interventions more orless palatable when phrased in terms of life and death as opposed to dollarsigns?  

The trolley car results offer a predictionfor how one would answer that question.   If one views the current incomedistribution as arising from the "natural" state of society, one might regardactive intervention into health outcomes as immoral.   If instead, one regardsthe income distribution as simply being a consequence of a broader nexus ofpolicy, the trade-off in health outcomes may be perfectly acceptable.  

Economists have created a number of cleverways for assigning values to costs and benefits, even on tricky questionsrelating to the value of life.   But unravelling the moral dimensions of suchdecisions remains elusive.  

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