Organ Harvesting is Wrong, Actually

In which Bentham's Lapdog is returned to his kennel

Consider the following case:

Organ Harvesting: Five people are dying. Each needs a new organ, but none are available. The only way for the surgeon to avert their deaths is to kidnap an unwilling stranger, kill him, harvest his organs, and give them to the ailing five. Assume that this would have no bad consequences beyond the death of the stranger. (He won’t be missed, and no-one will find out.)

Should the surgeon harvest the organs? Most people, on hearing this case, respond that he shouldn’t.

Some don’t. Some think that killing the stranger to save the five is not only permissible, but obligatory. One such person is Matthew Adelstein—good friend, gentleman-scholar, and author of a widely-read Substack which defends bad things, like utilitarianism, but also good things, like veganism, and the destigmatisation of non-offending paedophiles.

Here, Adelstein gives a litany of arguments to the effect that our intuitions about Organ Harvesting are unreliable, and that, on reflection, it would be good to harvest the stranger’s organs.

Some of his arguments are against deontology simpliciter. I won’t address those here, because they’re long and I don’t know what to say about them. The others, though, are arguments specifically against the Organ Harvesting intuition. I’ll address each of these arguments in turn.

First, Adelstein tries to explain our intuitions away, giving two utilitarian-friendly suggestions for why the doctor’s actions seem wrong:

[T]here’s a way to explain our organ harvesting judgments away sociologically. Rightly as a society we have a strong aversion to killing.  However, our aversion to death generally is far weaker.  If it were as strong we would be rendered impotent, because people die constantly of natural causes. 

And…

[W]e have good reason to say no to the question of whether doctors should kill one to save five.  A society in which doctors violate the Hippocratic oath and kill one person to save five regularly would be a far worse world. People would be terrified to go into doctor’s offices for fear of being murdered.  While this thought experiment generally proposes that the doctor will certainly not be caught and the killing will occur only once, the revulsion to very similar and more easily imagined cases explains our revulsion to killing one to save 5.

Matthew’s first just-so story has a veneer of plausibility, but it’s a just-so story nonetheless. Absent some strong reason to doubt our intuition against killing in this particular case, we shouldn’t doubt it just because, as a society, we have a strong aversion to killing generally.

Consider, by analogy, an ethical egoist who uses a similar story to argue that our intuitions against killing people when it maximizes personal gain are unreliable, claiming that justifiably, as individuals, we’ve formed a strong (though sometimes irrational) prejudice against killing people, because killing people isn’t usually in our long-term self-interest. This is possible, but it isn’t plausible: without some good reason to accept ethical egoism, we have no reason to believe the egoist’s just-so story. The same goes for utilitarians who use the “society-has-an-indiscriminate-prejudice-against-killing” just-so story when trying to explain our intuitions about Organ Harvesting.

Not only could we say same the same about the second story; I think we can also see that it’s false. If it were true, we’d expect our intuitions to change if we modified the case so that the person facing the dilemma is not a doctor, and made it very, very clear that this is an isolated case that will never be heard of by wider society. (Imagine, if you like, that the story is set on a distant planet, far removed from any other humans.) I take it that your intuition probably doesn’t change when we make these modifications. Thus, the second story probably isn’t true.

Beyond his (possibly sexist) intuition-splaining, Matthew gives three modified scenarios which, he claims, make his depraved bullet-biting less painful on the teeth:

First, imagine that the six people in the hospital were family members, who you cared about equally.  Surely we would intuitively want the doctor to bring about the death of one to save five. The only reason why we have the opposite intuition in the case where family is not involved is because our revulsion to killing can override other considerations when we feel no connection to the anonymous, faceless strangers who’s death is caused by the Doctors adherence to the principle that they oughtn’t murder people.  

I don’t know about the rest of you, but I totally do not have this intuition. I wouldn’t want a family member – of even a stranger – to be violently dismembered to save the rest of my family from dying. If you have the opposite reaction, and you live in the Oxfordshire area, hit me up and I’ll send you the Sunday service times for the church across my street.

Similarly, if we imagine that 90% of the world needed organs, and we could harvest one person's organs to save 9 others, it seems clear it would be better to wipe out 10% of people, rather than 90%.

Again, like before, I don’t share this intuition. Perhaps it’s just a vibes thing, but I don’t think it would be okay to dismember 10% of people to save the other 90%. Maybe that sounds heartless, but it’s my heart, and I don’t want it to be forcibly cut out of me by the WHO.   

Finally, Matthew cites a case from Julian Savulescu:

Epidemic. Imagine an uncontrollable epidemic afflicts humanity. It is highly contagious and eventually every single human will be affected. It cases people to fall unconscious. Five out of six people never recover and die within days. One in six people mounts an effective immune response. They recover over several days and lead normal lives. Doctors can test people on the second day, while still unconscious, and determine whether they have mounted an effective antibody response or whether they are destined to die. There is no treatment. Except one. Doctors can extract all the blood from the one in six people who do mount an effective antibody response on day 2, while they are still unconscious, and extract the antibodies. There will be enough antibodies to save 5 of those who don’t mount responses, though the extraction procedure will kill the donor. The 5 will go on to lead a normal life and the antibody protection will cover them for life.

Asserts Adelstein: “It seems in this case that it’s obviously worth extracting the blood to save 5/6ths of those affected, rather than only 1/6ths of those affected.”

This is a better case. My feelings on it are mixed. According to Savulescu, Epidemic is more philosophically probative than Organ Harvesting, because our intuitions about Organ Harvesting are muddied by our intuitions about other things (the general badness of killing, a fear that killing the one man will trigger a slippery slope leading to other killings, etc.), whereas our intuitions about Epidemic are not so muddied.

While Savulescu is right that our intuitions about Epidemic might not be muddied by the same specific factors – the general badness of killing, the prospect of a slippery slope, etc. – that he thinks are playing a role in our intuitions about Organ Harvesting, our intuitions about Epidemic are, plausibly, muddied by other factors. One factor I’m thinking of especially is the difficulty of imagining a very, very, very large number of unconscious people in one’s head, and simultaneously keeping the distinction between the medical conditions of the minority (the ones who’ll wake up if left alone) and the majority (the ones who are on a trajectory towards death) separated clearly in the forefront of one’s mind. This is a problem for large-number hypotheticals generally: our intuitions about them tend to be unreliable, because humans are bad at thinking about large numbers.

Additionally, despite what I said about Matthew’s case where you can kill 10% of the population to save the other 90%, it could be that, in the back of our minds, we suspect that the consequences of losing five-sixths of the world’s population would be so, so disastrous that it would justify killing a whole bunch of people to prevent those consequences, even on a non-consequentialist theory. Whatever you think are the merits of that, the issue doesn’t apply at all to the original organ-harvesting case, which only involves six people—not the whole world.

These might sound like lame just-so stories, just as lame as the ones told by Matthew. To test whether my just-so stories really are lame, consider a different version of Epidemic involving fewer people:

Blood Harvesting: Five people are dying of Covid-23. Dr. Dre – who is not, in fact, a doctor, and who never swore the Hippocratic Oath – can save them by painlessly extracting the antibody-rich blood of a sleeping person and giving it to the five. This kills the sleeping person but saves the five from death. All of this is happening in perfect isolation, so, if the Good Doctor kills the sleeping person, this will have no adverse affects on anyone in the outside world.

In this case, it seems far less clear – to me at least – that killing the sleeping person is completely kosher. In fact, it seems wholly haram. And, given that this case lacks the distorting factors present in Epidemic, even if you had the intuition there that the 1 in 6 should be killed, we should put greater stock in our intuitions about Blood Harvesting than in our intuitions about Epidemic. According to a peer-reviewed survey that I conducted privately in my head and can show you if you send me a £250 Greggs voucher in the mail, most people will have the same intuitions about Blood Harvesting as me.

Ploughing on, Matthew writes:

A fourth objection is that, upon reflection, it becomes clear that the action of the doctor wouldn’t be wrong.  After all, in this case, there are [five] more lives saved by the organ harvesting.  It seems quite clear that the lives of [five] people are fundamentally more important than the doctor not sullying themself.  

Upon reflection, it does not seem to me that the doctor’s action wouldn’t be wrong. Axiologically, it would be better to lose one person than five. But, morally, it would be wrong to violate rights in the process.

I also think there’s something fishy about Adelstein’s choice of wording: “It seems quite clear that the lives of [five] people are fundamentally more important than the doctor not sullying themself.” He’s right: it does seem clear that the lives of five people are more important than one person not sullying themselves. However, the non-consequentialist doesn’t have to say that the doctor not sullying themself is what’s important. They can say that what’s important is that the doctor doesn’t violate any deontic principles, including whichever principle it is that debars him from killing one to save five.

You might object that these amount to the same thing, because violating a moral principle necessarily entails sullying oneself. But that’s wrong. Wrong as rocks. It’s true that violating a moral principle necessarily entails sullying oneself. But <violating a moral principle> and <sullying oneself> can be conceptually distinguished, as two distinct sites of moral importance. And if <violating a moral principle> and <sullying oneself> can be conceptually distinguished as two distinct sites of moral importance, then deontologists can say it’s the violation of moral principles, not sullying oneself, that’s fundamentally important for you to avoid.

Finally, Adelstein argues the following:

[I]f we use the veil of ignorance, and imagine ourself not knowing which of the six people we were, we’d prefer saving five at the cost of one, because it would give us a 5/6ths, rather than a 1/6ths chance of survival.

This is the problem with veil of ignorance reasoning generally. If you design a social arrangement from behind a veil of ignorance, with the single-minded aim that you yourself would have the best chance of being well-off were you randomly dropped in it, then you will sometimes design arrangements that involve violating the rights of the few for the good of the many. But this doesn’t show we really should violate the rights of the few for the good of the many. It just shows that a single-minded focus on your own self-interest will sometimes lead to immoral outcomes, something we knew already.

I conclude: Adelstein’s arguments against the deontic intuition about Organ Harvesting fail. Common-sense prevails—bloodied, but unbowed.