The Last of Us finale: A bioethicist comments on this final scene

HBO’s season finale The last of us – Based on the video game of the same name – posed a philosophical question that has long been in the cultural spotlight: Is it ethical to kill one person for the welfare of many others?

If you haven’t seen the show or played the game, an actual type of fungus is called for cordyceps It has evolved the ability to live in humans, turning them into mushroom creatures that bite. Twenty years of horrific chaos.

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spoilers for The last of us less.

The series follows a gruff man named Joel (Pedro Pascal) and a young girl named Ellie (Bella Ramsey), the only person who has ever shown immunity to the fungus. The duo travel to find a section of the splinter group known as the Fireflies, who plan to engineer a vaccine using Ellie. What the two don’t know is that vaccine engineering surgery will kill her.

Ellie was given no opportunity to provide her consent, and the surgery had dubious prospects of success at best in delivering the vaccine. Upon discovering this, Joel saves Ellie from surgery, killing plenty of fireflies in the process, while also bringing an end to the best shot – perhaps only – of saving humanity with a vaccine.

The epilogue presents a bioethics question: When entire species are at stake, should our decision-making logic change? So I spoke with Arthur Kaplan, chair of the department of medical ethics at New York University Grossman School of Medicine and professor of bioethics.

conspicuously absent from The last of us He was Institutional review board (IRB), the group charged with reviewing and monitoring biomedical research involving humans in line with FDA regulations. We discussed whether today’s independent review bodies are flexible enough to deal with apocalyptic decision-making, what considerations are relevant, and whether higher metrics and risks justify impermissible actions.

This interview has been edited for length and clarity.

Suppose there was a fungal disaster, and the IRB had to decide whether to allow an experimental surgery that kills the person, but offers a chance to save millions. How will they deal with this question?

So there are two ways to approach this question. One is to think about what an IRB looks like today. If someone came to you and said there was a terrible disease, we wanted to do an experiment. We think we can get something that can save many, but we have to kill you. The answer to that will be the end of the discussion. Killer experiments will not clear the standard IRB research ethics committee in the world today, even with the promise of large returns.

But in an apocalyptic scenario like in the show, where people have been dead for 20 years and someone suggests experimenting, I think you might get more. We almost came to this with Covid when the business idea came about Challenge studiesIntentionally infecting people with the COVID-19 virus [to help speed up vaccine research]They have no way to save them if they get very sick. She defended the experiment.

Some said you can’t do that, it’s immoral. Others said, well, look, if you’re really volunteering, imagine the girl on the show [Ellie] She says she wants to help save the world and be an influencer, so as long as you choose knowingly and understand the risks – that’s critical – and as long as you’re absolutely sure of the science, because the odds of an experiment succeeding will drive some answers, but my point is yes, in the end of the world with the possibility of A real hack, if a person volunteers and really says, “I want to help, I’m going to be a believer,” I think I can agree to that.

HBO/Warner Bros. Discovery

On the show, Ellie isn’t given the option to provide consent, but let’s say she did, and she was an adult. There is still a lot of uncertainty about whether the surgery will work, whether it will actually produce a vaccine, or whether there are other options. So even when someone agrees, does the presence of uncertainty still make the experiment unethical?

Yes, the IRB’s job is to interpret science-in-action opportunities; Consent is not enough. A little bit of the Early pioneers of artificial hearts He agreed and said, “I’ll take my chances, I’m going to die anyway,” but the IRB had to step in and challenge whether the scientific protocol was sound, and whether the basic information they pointed in the direction was likely to get an answer. The IRB’s job is to ensure that consent is in place, but also to make sure that the science is sound.

Let’s say we find ourselves somewhere between the covid pandemic and We delay On the scale of the end of the world. Do you imagine that current IRB operations are flexible enough to adapt to those types of situations? Is the IRB apocalypse ready?

IRBs can be flexible; Let me turn to something similar. Sometimes people go out for a walk and eat poisonous mushrooms. They show up in the emergency room, unconscious. There is no antidote and no one knows what to do, and no time to bring in an IRB. Well, we’ve made a space where you can try an experimental antidote without the person’s consent. We have the idea of ​​an emergency research waiver that says, in the face of certain death from this poisoning, most people would reasonably agree to the empirical agent.

You’re supposed to get approval after the fact, if they survive. You’re supposed to do what you can to warn people in advance, but the flexibility is there to search under emergency conditions, so it’s not a default. So yeah, I think the IRB is facing a 20-year pandemic that’s been killing everyone, if you really have an approved altruistic volunteer, I think they can keep up.

in “Trolley problem“,” You have to decide whether saving five people justifies killing one. In the show, the scale of the decision is much greater. Killing a person can save the entire human race. From a bioethic point of view, does the scale factor in sacrifice in decision-making?

This actually has a name in ethics; It’s called “Do You Count the Numbers”. My answer is yes, it makes an ethical difference.

This also shows when you start thinking about the kinds of problems that destroy the world, like the argument we had over torture. A lot of people just said torture is off the table. But there were people who wrote memoirs who said, well, if there really was no other way, if you knew a man had planted a nuclear weapon, and the clock was ticking, you might as well go to torture for an answer. I’m not for torture, but you could spin a scenario or two where I would say, we know for sure the bomb is going to blow up an entire city and all we have is this guy who has two minutes on the clock, and then I guess I’d say try to torture an answer from him, because numbers matter.

The height of the Covid-19 pandemic wasn’t horrific, but it did stress test our institutions and force us to make tough decisions. I’m curious about how our institutions think. Are you optimistic that they are well prepared to deal with future scenarios, from the epidemic to the end of the world, or have cracks been revealed?

I’ve been involved in things like trying to put in place ventilator policy when we didn’t have enough, and I’ve been involved for a long time in rules about who gets organs for transplants, and I think institutions broke down at both ends at the state and national levels. But they have held up, oddly enough, on smaller scales like hospitals or domestic settings. We all knew what we were going to do at NYU and who was going to be on the ventilator, who was going to be out. We talked about it and there was agreement on that. But if you ask the Trump administration when things first started, no, they haven’t given guidance. Even New York State, or Connecticut, don’t have a directive.

So in a sense, the people who set policy on larger scales haven’t done a very good job. But Covid was moving so quickly, and we were arguing about who gets a mask, who gets protective equipment, who gets a ventilator — that was a real-time decision.

But on the TV show, they might have time to put together a national committee to discuss whether to allow the girl to volunteer for the surgery. But if there’s a critical period and you have to decide in a month or something like that, I don’t think you’ll get national guidance. You likely have a local organization, where context will be important.

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