The Transplant Trolley Problem Doesn’t Prove Anything

The Cambridge Quarterly of Healthcare Ethics published an article in its journal titled The Transplant Trolley Problem in 2022 written by Robert Osorio and Guillermo Palchik.

The article compares the life of a transplant surgeon to The Trolley Problem, a philosophical moral debate. The premise of the Trolley Problem is that there is a set of train tracks that branches into two separate tracks. You're standing at the lever that determines which way the train goes. A runaway train is coming down the track, and at the end of each branch there are people trapped. One track has one person trapped; the other has five. Do you pull the lever or not?

In the article, the authors compare the scarcity of available organs to the runaway train, and the choice of which patients receive those organs to the lever. Every choice the surgeon makes is framed as akin to pulling the lever—or choosing not to.

The Philosophy of Integration asks a very specific question in relation to this problem:
Why is scarcity treated as a natural, immutable moral condition instead of a system-level failure?

Doctors are not personally responsible for the supply and demand of transplant organs. They are not part of the supply-and-demand chain. If we were talking about a car part shortage, we wouldn’t blame the mechanic for not being able to get the parts needed to fix the car. Transplant surgeons are like car mechanics—they only have access to what’s available in the system behind them. Their only real choice is to decide who is best served by the parts on hand.

It’s not a moral dilemma.
It’s a logic problem — the system is incoherent.

The system has been designed to create these artificial moral problems. The problem only exists because of how the story is framed. The so-called moral dilemma dissolves the moment you notice that the structure itself created the crisis. A train does not naturally split itself between two groups of people placed conveniently along its path. The scenario is built to trap the observer into believing there are only two options when, in reality, the dilemma is entirely manufactured by the conditions of the thought experiment.

The system the surgeon works within is built on exactly the same premise. The dilemma only exists because the system created it. The systemic shortage is not the doctor’s moral dilemma any more than there is a moral dilemma for the person standing beside the lever of the train tracks. It’s an artificial choice based on systemic lack and a false moral ideology.

Instead of questioning the structure that created the scarcity, the article elevates the surgeon into the position of a philosophical lever-puller. This is the same distortion that appears in countless moral problems: the assumption that individuals must make ethically impossible decisions because “that’s just how the world is.” But the world isn’t inherently structured around moral trains. Systems are.

Scarcity is not how the world works. Scarcity is the result of systems that create it artificially and then try to impose impossible choices on the people closest to the proverbial levers.

Scarcity is incoherent. It creates a distorted chain of cause and effect that cannot be resolved by surgeons or car mechanics facing ethically impossible choices.

Incoherence is not the natural state of the world. The world has a simple, coherent structure of cause and effect underlying every experience we have. When a chain is not created by the individual coming into contact with it, that individual is not responsible for that chain. Any interference with that chain creates additional fragmentation, incoherence, or further problems.

Because surgeons continue to defend their impossible choices, the cause-and-effect loop continues to repeat itself. If the surgeons simply focused on the idea that the system is incoherent and that it is not their moral dilemma to solve, they could extract themselves from the cause-and-effect chain they find themselves tangled up in.

Why are these surgeons questioning their impossible choices instead of questioning the system that created them?

We have been conditioned to treat systems as something we simply have to deal with—like dealing with the weather—so we don’t question where the problem originated. Who created the problem? Why does the problem exist in the first place? Who is responsible for fixing it?

The truth is that the problem will never be fixed. Transplant surgeons will forever find themselves faced with ridiculous choices because the system has tricked them into believing that it’s their problem to solve.

The system has created its own “solution” to the problem by offering doctors criteria for how to choose who gets an organ and who doesn’t. Everything from lifestyle, age, money, and overall health becomes the metric through which the value of human life is determined. If you’re fat or 80 or broke or already sick, you’re not considered important enough to receive an organ.

The surgeons don’t question this. They don’t seem to see the problem with a system that asks them to do this. Since when is any system — or any human being — qualified enough to decide which life is worth keeping and which isn’t? This isn’t medicine. It’s not how medicine works. But it is a prime example of systemic failure and how systemic failure shows up in human life.

There may be a day in the future when technology and funding catch up, simplifying criteria, lowering rejection rates, and removing financial barriers from the process. What the article accidentally shows is that the problem is solvable, which means it is not an eternal moral dilemma — it’s the temporary problem of a broken system.

If the problem is solvable through technology and funding, then it’s no longer a moral dilemma for doctors to solve. The problem is created through the same distortion as the Trolley Problem: it’s a false choice. It’s a chain with a solution that hasn’t yet been realized. That means the solution to the chain of cause and effect is not available to the doctors. The doctors are not the solution to the problem. The system is its own solution to its own chain of cause and effect.

The system creates a supposed real-life Trolley Problem for the doctors because it refuses to fix its own problem. But it’s not a moral failure of the doctors, who are simply making the best choices they can with the information they have. It’s not even a moral failure of the system, because the system was never designed to be moral. A moral dilemma is only “real” if it exists independently of a failing system—which this doesn’t. The transplant world doesn’t prove the Trolley Problem is real. It proves that systems built on scarcity force people into false binary choices.

The problem will disappear when the system chooses to fix itself. Until doctors, like these transplant surgeons, focus on the true problem instead of making themselves participants in a story they didn't write, the cause-and-effect chain will continue to loop endlessly. To collapse a cause-and-effect chain, it must be seen clearly and walked away from. The doctors have the capacity to do that once they make the choice to see it clearly.