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The Survival Lottery: A Radical Approach to Ethical Dilemmas in Medicine

Would you be willing to die so that two strangers could live?

That’s the uncomfortable premise behind philosopher John Harris’s 1975 thought experiment, The Survival Lottery. It’s one of the most provocative ethical hypotheticals in modern philosophy—raising questions about fairness, sacrifice, and how society should distribute life-saving resources.

This scenario isn’t about dystopian fiction or sci-fi morality plays. It’s about medicine, ethics, and whether a society could—or should—rationally sacrifice one healthy person to save two dying ones.

The Core Idea

Here’s how the Survival Lottery works:

Imagine a world where patients regularly die from organ failure. Two such patients—say, Y and Z—will soon die unless they receive new organs. Meanwhile, you’re perfectly healthy.

The proposal: implement a lottery system that randomly selects healthy individuals to be euthanized and have their organs harvested. If sacrificing one person could save two (or more), wouldn’t that maximize the overall number of lives saved?

Harris’s thought experiment forces us to ask whether it is more moral to let people die of natural causes or to kill one person to save more.

The concept was first introduced in Harris’s essay “The Survival Lottery,” published in the journal Philosophy in 1975. The piece sparked immediate controversy and continues to be studied in bioethics, philosophy, and medical law.

Utilitarian Logic

The ethical engine driving the lottery is utilitarianism—the idea that the best action is the one that maximizes happiness or well-being for the greatest number. By that logic, letting Y and Z die when one healthy donor could save them both seems inefficient—perhaps even cruel.

Why should two people die so that one may live? Isn’t it just mathematical morality?

Ignoring social discomfort and emotional reactions, the survival lottery looks like a highly efficient, morally impartial system. It would:

  • Save more lives than it costs

  • Treat all citizens equally under the law

  • Eliminate emotional or economic biases in organ allocation

So why does the idea feel so wrong?

Deontological Objections

For many people, the idea of sacrificing an innocent person is morally unacceptable, even if the outcome saves lives. This comes from deontological ethics—the school of thought associated with philosophers like Immanuel Kant, which prioritizes the morality of actions, not just the consequences.

According to this framework:

  • Killing an innocent person is wrong, regardless of the outcome

  • Human beings should never be treated merely as a means to an end

  • We have a duty to respect individual rights, including the right to life

Critics argue that The Survival Lottery treats people as disposable resources, not autonomous individuals with dignity and rights. Even if the math works, the ethics may not.

Social Trust and Fear

There’s also a practical concern: a society that enacts such a policy would likely descend into fear and mistrust. Citizens might live in constant anxiety, wondering if they’ll be the next selected. People may avoid hospitals or lie about their health to avoid entering the system.

And what happens when exceptions are made? Would the rich and powerful be excluded from the lottery? Would racial or social bias creep in?

Rather than fostering a sense of collective good, the survival lottery could create moral panic, erode public trust in medical institutions, and lead to dangerous unintended consequences.

Harris’s Response

John Harris anticipated many of these objections. In his original essay, he emphasized:

  • The need for impartiality: No one should be more or less likely to be selected.

  • The principle of fair risk: If all citizens face equal risk, then all benefit equally from the system.

  • The idea that doing nothing—letting Y and Z die—is also a choice, arguably worse.

He argues that we accept some collective risks for the greater good (like conscription, or certain taxation policies), and that our moral instincts about killing may be emotionally driven rather than logically defensible.

His goal wasn’t to propose actual policy. Rather, it was to challenge our intuitions and ask: Why do we view some deaths as unfortunate necessities and others as moral violations?

Real-World Echoes

While no country has implemented a literal survival lottery, the ethical dilemma it raises is surprisingly relevant in modern medicine and public policy.

Some real-world parallels include:

  • Triage protocols: During pandemics or mass casualty events, doctors must decide who gets treatment based on survivability, not first-come-first-served.

  • Organ donation systems: Debates continue about opt-in vs. opt-out systems, living donors, and incentivized donation.

  • Healthcare rationing: Limited access to certain treatments, especially in systems with constrained resources, leads to moral questions about who gets care.

One modern example came during the COVID-19 pandemic, when some hospitals developed crisis protocols for ventilator access. If only one machine was available, and two patients needed it, hard choices had to be made.

The Personal Identity Problem

Another dimension: how do we define “sacrifice” when medical technology blurs the lines between life and death?

Suppose someone is brain-dead but otherwise physically healthy. Should they be entered into the lottery?

Or suppose someone volunteers to donate both kidneys, knowing it will end their life but save two others—does this shift our moral calculus?

The Survival Lottery draws a sharp line—but modern bioethics lives in the gray area.

Ethical Questions That Linger

  • Is it more ethical to allow two people to die, or to kill one person to save them actively?

  • Can a system of random sacrifice ever truly be just?

  • Should we weigh lives saved over lives preserved?

  • Do our instincts against such policies come from reason—or discomfort?

Philosophers continue to wrestle with these questions because they touch on our deepest values about life, agency, fairness, and fear.

Pop Culture and Influence

This thought experiment has inspired a range of fictional and artistic interpretations, from dystopian films like The Island (2005), where clones are used for organ harvesting, to episodes of Black Mirror and The Twilight Zone, which explore utilitarian horror.

You’ll also see echoes of the survival lottery in policy debates around universal healthcare, euthanasia, and the ethics of gene editing, where questions of fairness and benefit collide with fears of abuse.

Glossary of Terms

  • Utilitarianism: Ethical theory prioritizing outcomes that maximize overall well-being.

  • Deontology: Ethics centered on duties and moral rules, regardless of consequences.

  • Triage: The process of prioritizing treatment based on urgency or likelihood of survival.

  • Moral Intuition: An instinctive judgment about right and wrong, often emotional rather than reasoned.

  • Sacrificial Dilemma: A scenario in which one person must be harmed (or killed) to benefit others.

Discussion Questions

  1. Is it ever morally justifiable to sacrifice one person to save two?

  2. How is that different from a structured survival lottery if we accept triage in emergencies?

  3. Would knowing you’re part of a lottery for the greater good change how you view fairness or fear?

References and Further Reading