Here is an interesting story from over the summer: researchers were investigating moral decisions made by three groups of people – the general public, practicing physicians, and health administrators (i.e. those who work in administrating hospitals, health plans, etc., but do not actually see patients.) Participants were asked questions about distributing limited health-care resources as well as presented with a traditional moral dilemma which runs like this: a runaway trolley is about to collide with five railroad workers. You can stop the trolley by shoving a giant man next to you into the path of the trolley. Basically, the question is: which is the right thing to do — sacrifice the innocent man to save five others? Or refrain from deliberately killing the innocent man, even knowing the result will be the deaths of the other five?
The interesting thing about the study was this: both the general public and the physicians overwhelmingly refused to deliberately sacrifice the one man in order to save the others. Only 12% of the public and the physicians thought it was right to push the man into the path of the trolley. The administrators, on the other hand were almost twice as likely (21%) to suggest that pushing the man was the right thing to do.
When it came to healthcare decisions, the results were similar. Doctors and the public preferred continuing treatment of patients rather than stopping treatment in order to redistribute resources towards cheaper and more widespread efforts. Administrators were more willing to cease treating some patients in order to direct resources elsewhere.
The study’s authors note that the traditional medical ethics begins with the injunction to “First, do no harm,” thus encouraging doctors to look to their patients first. Christian ethics similarly insist that it is always better to suffer evil than to commit it – an intrinsic evil may not be done even in order to bring about a “greater good.”
According to this study, though, the administrative class is more likely to be willing to do evil that good may result. Of course this is not entirely surprising, given that the very job of administrators is to figure out how to best distribute scarce resources. It is not disturbing that administrators are more willing to accept the difficult facts of limited resources. That is simply a hard fact of life, as in triage situations, for instance. What is more disturbing is that the administrators are more willing to condone outright destructive action in order to bring about what they think is a better result.
Doctors are taught to try to see patients as individuals. Administrators have to deal with the temptation to see them as data. I am reminded of C.S. Lewis’ warning in The Abolition of Man that the rise of “men without chests”, men who do not know what it is to be human, would result in a class of “Conditioners” who manipulate the rest of society for their own ends, without respect for what Lewis called the Tao, or Natural Law. This study shows just how such an impulse begins, and with the increasing bureaucratization of medicine, the threat will only become more urgent.