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A Philosophical Thought Experiment in Medical Ethics

Published:September 07, 2021DOI:https://doi.org/10.1016/j.amjmed.2021.08.003
      Recently, I have been thinking about a number of subjects that excited me during my undergraduate year at Yale many years ago. In an earlier editorial, I mentioned my engaging year-long course on Shakespeare and his contemporaries taught by one of the world's most prominent Elizabethan scholars, Maynard Mack.

      YaleNews. Obituary: Maynard Mack, distinguished Yale scholar and literature teacher.| Available at:https://news.yale.edu/2001/03/19/obituary-maynard-mack-distinguished-yale-scholar-and-literature-teacher. Accessed August 3, 2021.

      Continuing this quest to refresh what had interested me as an undergrad, I twice read through Nigel Warburton's concise and informative tome, A Little History of Philosophy.
      • Warburton N
      A Little History of Philosophy.
      This book reviews the thinking of a series of influential philosophers starting with Socrates and ending in the 21st century with Peter Singer. Warburton describes a common device used by philosophers, the thought experiment, which he defines as follows: “A thought experiment is an imaginary situation designed to bring out our feelings, or what philosophers call ‘intuitions,’ on a particular issue.”
      • Warburton N
      A Little History of Philosophy.
      An interesting sidelight is that Einstein used this same technique when he considered general and special relativity and quantum mechanics at a time before experimental evidence could test his theories.

      Einstein's thought experiments. Available at: https://en.wikipedia.org/wiki/Einstein%27s_thought_experiments. Accessed August 3, 2021.

      One might even say that at that point in his career, Einstein was a philosophical physicist.
      From a medical point of view, I was particularly taken by examples of philosophical thought experiments created by philosophers Philippa Foot, Judith Jarvis Thomson, and John Rawls.
      • Warburton N
      A Little History of Philosophy.
      One example, from Philippa Foot involved a runaway train heading toward 5 unfortunate workers who would not have time to get out of the way. You, an observer of this event, are close to a switch that will move the train to a different track where only 1 worker would be killed. The philosophical quandary is “Should you activate the switch thereby killing only one person rather than five?” It seems that most people would be willing to pull the switch even though this involved “playing God.” Foote then describes a medical thought experiment in which there are 5 patients, 1 healthy individual and 4 patients desperately needing liver, kidney, and heart transplants. The ethical question here is “Should you kill the healthy patient and donate his organs to the four terribly ill individuals?” No one accepts this latter solution even though it involves a situation resembling the railroad thought experiment: killing 1 person to save a number of others. My personal response to the railroad thought experiment would be to reluctantly activate the switch and save 5 lives while sacrificing 1.
      Thinking about these thought experiments, I devised one involving a clinical ethics quandary: You are a physician seeing a young patient with a family history of a fatal heritable disease associated with great suffering and developing first in late middle life. There is no therapy available for this pathological entity. Your patient is unaware that this is an inherited condition and that he has a 50% chance of carrying the dominant gene for the disease. A genomic test exists that will determine whether the patient will develop this disease. The ethical quandary is “Should you inform your patient about the prognosis and heritability of this condition and the possibility of making the diagnosis with a genomic test?”
      I think this thought experiment is particularly challenging. The decision to discuss this condition with the patient would depend a great deal on how well I knew him or her and my assessment of their ability to deal with the resulting uncertainty. Whether or not I would discuss the possible options for testing in such a patient would also depend on my assessment of possible and probable outcomes. A parallel clinical situation occurs in patients who may be carrying the gene for Huntington's chorea. Suicide is common in these patients when they learn that they are carrying the gene or when they begin to have symptoms.
      • Schoenfeld M
      • Myers RH
      • Cupples LA
      • et al.
      Increased rate of suicide among patients with Huntington's disease.
      ,
      • John A.
      Bissell, recently retired chief of Neurology.
      Like our clinical ethics experiment patient, Huntington's chorea is inherited as an autosomal dominant gene. Thus, if one is carrying the gene, the condition will invariably develop and result in severe neurological deterioration.
      Of course, our thought experiment patient might decide not to have the genomic test, but this would still leave him or her with an enduring sense of possible impending doom. One would expect that knowing the result of the genomic analysis would certainly affect future decisions such as family and career determinations. This clinical ethics quandary is quite challenging, and I remain uncertain about whether to present all the options to such a patient.
      I welcome the readers of The American Journal of Medicine to write to me and relate their take on this difficult medical and philosophical dilemma. I respond to all emails at [email protected]

      References

      1. YaleNews. Obituary: Maynard Mack, distinguished Yale scholar and literature teacher.| Available at:https://news.yale.edu/2001/03/19/obituary-maynard-mack-distinguished-yale-scholar-and-literature-teacher. Accessed August 3, 2021.

        • Warburton N
        A Little History of Philosophy.
        Yale University Press, New Haven, CT2011
        • Warburton N
        A Little History of Philosophy.
        Yale University Press, New Haven, CT2011: 223
      2. Einstein's thought experiments. Available at: https://en.wikipedia.org/wiki/Einstein%27s_thought_experiments. Accessed August 3, 2021.

        • Warburton N
        A Little History of Philosophy.
        Yale University Press, New Haven, CT2011: 222-233
        • Schoenfeld M
        • Myers RH
        • Cupples LA
        • et al.
        Increased rate of suicide among patients with Huntington's disease.
        J Neurol Neurosurg Psychiatry. 1984; 47: 1283-1287
        • John A.
        Bissell, recently retired chief of Neurology.
        Kaiser South Sacramento Medical Center. Personal Communication, August 8, 2021