Loops of Death and Denial

The trolley problem is a philosophical thought experiment that pits action against inaction. In the original version, a person faces a choice: a trolley hurtles down a track toward five people tied to the rails, but a lever allows the trolley to be diverted onto another track, where one person is tied. The dilemma is simple in its grotesque arithmetic: let five die or actively kill one to save them. A perennial favourite of ethics classes, the trolley problem is most often used to explore Consequentialism, particularly Utilitarianism, and its cool calculus of harm minimisation. Over the years, countless variations have been conjured, but few approach the nightmarish reality of its real-world application: the for-profit healthcare system in the United States.

With the recent death of UnitedHealthcare CEO Brian Thompson, the trolley dilemma takes on a new and morbid relevance. Let’s reframe the challenge.

The Healthcare Trolley Loop

Picture the trolley again on a bifurcated track. The lever remains, as does the moral agent poised to decide its fate. This time, the agent is Brian Thompson. The setup is simple: one track leads to the deaths of five people, and the other is empty. But here’s the twist: the trolley doesn’t just pass once in this version—it’s on a loop. At every interval, Thompson must decide whether to pull the lever and send the trolley to the empty track or allow it to continue its deadly course, killing five people each time.

But Thompson isn’t just deciding in a vacuum. The track with five people comes with a financial incentive: each life lost means higher profits, better quarterly earnings, and soaring shareholder returns. Diverting the trolley to the empty track, meanwhile, offers no payout. It’s not a single moral quandary; it’s a recurring decision, a relentless calculus of death versus dollars.

This isn’t just a metaphor; it’s a business model. For-profit healthcare doesn’t merely tolerate death—it commodifies it. The system incentivises harm through denial of care, inflated costs, and structural inefficiencies that ensure maximum profit at the expense of human lives.

Enter the Shooter

Now, introduce the wildcard: the shooter. Someone whose loved one may have been one of the countless victims tied to the track. They see Thompson at the lever, his decisions ensuring the endless loop of suffering and death. Perhaps they believe that removing Thompson can break the cycle—that a new lever-puller might divert the trolley to the empty track.

Thompson is killed, but does it change anything? The system remains. Another CEO steps into Thompson’s place, hand on the lever, ready to make the same decision. Why? Because the tracks, the trolley, and the profit motive remain untouched. The system ensures that each decision-maker faces the same incentives, pressures, and chilling rationale: lives are expendable; profits are not.

The Problem of Plausible Deniability

The shooter’s actions are vilified because they are active, visible, and immediate. A single violent act is morally shocking, and rightly so. But what of the quiet violence perpetuated by the healthcare system? The denial of coverage, the refusal of life-saving treatments, the bankruptcy-inducing bills—all are forms of systemic violence, their harm diffused and cloaked in the language of economic necessity.

The for-profit model thrives on this plausible deniability. Its architects and operators can claim they’re simply “following the market,” that their hands are tied by the invisible forces of capitalism. Yet the deaths it causes are no less real, no less preventable. The difference lies in perception: the shooter’s act is direct and visceral, while the system’s violence is passive and bureaucratic, rendered almost invisible by its banality.

A System Built on Death

Let’s not mince words: the current healthcare system is a death loop. It’s not an accident; it’s a feature. Profit-seeking in healthcare means there is always a financial incentive to let people die. During the Affordable Care Act (ACA) debates, opponents of universal healthcare decried the spectre of “death panels,” bureaucrats deciding who lives and who dies. Yet this is precisely what for-profit insurance companies do—only their decisions are driven not by medical necessity or moral considerations, but by spreadsheets and stock prices.

This is the logic of capitalism writ large: maximise profit, externalise harm, and frame systemic failures as unavoidable. Healthcare is merely one example. Across industries, the same dynamic plays out, whether in environmental destruction, labour exploitation, or financial crises. The trolley always runs on tracks built for profit, and the bodies left in its wake are just collateral damage.

How to Break the Loop

The death of Brian Thompson changes nothing. The system will simply produce another Thompson, another lever-puller incentivised to make the same deadly decisions. Breaking the loop requires dismantling the tracks themselves.

1. Remove the Profit Motive: Healthcare should not be a marketplace but a public good. Universal single-payer systems, as seen in many other developed nations, prioritise care over profit, removing the incentive to let people die for financial gain.
2. Recognise Passive Harm as Active: We must stop excusing systemic violence as “inevitable.” Denying care, pricing treatments out of reach, and allowing medical bankruptcy are acts of violence, no less deliberate than pulling a trigger.
3. Hold the System Accountable: It’s not just the CEOs at fault; the lawmakers, lobbyists, and corporations sustain this deadly status quo. The blood is on their hands, too.

Conclusion: The Real Villain

The shooter is not the solution, but neither is their act the real crime. The healthcare system—and by extension, capitalism itself—is the true villain of this story. It constructs the tracks, builds the trolley, and installs lever-pullers like Brian Thompson to ensure the loop continues.

When will it end? When we stop debating which track to divert the trolley toward and start dismantling the system that made the trolley inevitable in the first place. Until then, we are all complicit, passengers on a ride that profits from our suffering and death. The question isn’t who’s at the lever; it’s why the trolley is running at all.