The Last of Us finale: A bioethicist weighs in on that final scene

HBO’s season finale The Last of Us – based on the video game of the same name – thrust a long-standing philosophical question into the cultural spotlight: Is it ever ethical to kill one person for the well-being of many others?

If you haven’t seen the show or played the game, a real species of mushroom called cordyceps he evolved the ability to inhabit humans, turning them into biting mushroom-zombies. Twenty years of apocalyptic chaos follow.

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Spoilers for The Last of Us under.

The series follows a grumpy man named Joel (Pedro Pascal) and a young girl named Ellie (Bella Ramsey), the only person to have shown an immunity to the fungus. The two travel to find a division of the renegade group known as the Fireflies, who are planning to design a vaccine using Ellie. What they don’t know is that the operation to engineer the vaccine will kill her.

Ellie is given no opportunity to provide consent, and the surgery had questionable odds of success at best for delivering a vaccine. Upon discovering this, Joel saves Ellie from having surgery, killing loads of fireflies in the process, also putting an end to the best – perhaps only – attempt to save humanity through a vaccine.

The ending presents a bioethical question: when the whole species is at stake, should our decision-making logic change? So I spoke to Arthur Caplan, chief of the division of medical ethics at NYU Grossman School of Medicine and a professor of bioethics.

Notably absent from The Last of Us it was a Institutional review committee (IRB), the group charged with reviewing and monitoring biomedical research involving human subjects in line with FDA regulations. We discussed whether IRBs today are flexible enough to handle decision making in an apocalypse, what considerations would be relevant, and whether scales and higher stakes ever justify actions otherwise not permitted.

This interview has been edited for length and clarity.

Let’s say there was a fungal apocalypse and an IRB had to decide whether to allow experimental surgery that would have killed the subject, but offered a chance to save millions. How would they approach this question?

So there are two ways to approach this question. One is to think about what the IRB looks like today. If someone comes to you and says there is a terrible disease, we want to do an experiment. We think we can get something that could save many, but we have to kill you. And the answer is that that would be the end of the discussion. The fatal experiments would not obliterate the standard IRB research ethics committee in today’s world, even with the promise of big returns.

But in an apocalyptic scenario like in the show, where people have been dying for 20 years and someone comes up with the experiment, I think you could go further. We almost got there with the Covid when the idea to do was born challenge studiesdeliberately infecting people with Covid [to help speed up vaccine research], having no way to save them if they became seriously ill. And I defended the experiment.

Some have said you can’t do that, it’s unethical. Others said, well, look, if you’re really volunteering, how do you imagine the girl in the show [Ellie] says he wants to help save the world and be an altruist, so as long as you choose consciously and understand the risk – that’s crucial – and as long as you’re pretty certain about the science, because the odds of the experiment’s success will drive some of the answers, but my view is yes, in an apocalypse with the possibility of a real breakthrough, if the person volunteered and truly said, “I want to help, I’m going to become an altruist,” I think he might approve of that.

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In the show, Ellie wasn’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 she will actually produce a vaccine, or whether there may be other options. So even when someone gives consent, can the presence of uncertainties still make the experiment unethical?

Yes, the IRB’s job is to interpret the possibilities of science working; consent is not enough. Some of early pioneers of artificial hearts he agreed and said, “I’ll take my chances, I’ll die anyway,” but the IRB had to step in and question whether the scientific protocol was sound, whether the background information they had pointed in the direction where they were likely to get an answer. The IRB’s job is to ensure that there is consensus, but also to make sure that the science is sound.

Let’s say we are somewhere between the Covid pandemic and The Last of Us on the scale of the apocalypse. Imagine that current IRB processes are flexible enough to adapt to these kinds of situations? Is the IRB apocalypse ready?

IRBs can be flexible; let me move on to something similar. Sometimes people are out hiking and eat a toadstool. They show up at the emergency room, unconscious. There is no antidote and nobody knows what to do, and there is no time to get the IRB involved. Well, we’ve carved out a space where you could try an experimental antidote without the person’s consent. We have an emergency research waiver idea that says, faced with certain death from this poisoning, most people would reasonably consent to the experimental agent.

You should get consent after the fact if they survive. You should go out of your way to warn people in advance, but flexibility is available to research in emergency circumstances, so it’s not hypothetical. So yeah, I think an IRB faced with a 20 year old plague that was killing everyone, if you really had a willing, selfless volunteer, I think they could take that.

in philosophy”Trolley problem”, you have to decide if saving five people justifies killing one. In the show, the scope of the decision is much broader. Killing that could save the entire remaining human race. From a bioethical point of view, does the extent of the sacrifice affect the decision-making process?

This actually has a name in ethics; it’s called “the numbers count”. My answer is yes, morally it makes a difference.

This also comes up when you start thinking about the kinds of issues that destroy the world, like the debate we had about torture. Many people have just said that torture is out of the question. But there were people who wrote memos that said, well, if there really is no other way, and if you knew that some guy planted a nuclear weapon and time is running out, you could go to torture to get an answer. I’m not into torture, but you can shoot a scenario or two where I could say, we know for a fact that a bomb is going to blow up a whole city and all we have is this guy with two minutes on the clock, so I guess I’d say try to torture him with an answer, because numbers matter.

The peak of the Covid-19 pandemic was not apocalyptic, but it strained our institutions and forced us to make difficult decisions. I’m curious to know how our institutions have behaved. Are you optimistic that they are well prepared to handle future scenarios, from pandemic to apocalyptic, or have cracks been revealed?

I’ve been involved in things like trying to make policy on ventilators when we didn’t have enough, and I’ve been involved in rules about who gets organs for transplants for a long time, and I think institutions have failed at both the state level and national level. But they’ve held up oddly enough on smaller scales like in hospitals or local places. We all knew what we were going to do at NYU and who was going to get on the ventilator, who was going to come off. We talked about it and there was agreement on this. But if you asked the Trump administration when things first kicked off, no, they weren’t giving guidance. Even in upstate New York, or Connecticut, you didn’t have a guide.

So, to some extent, the people who set policy on larger scales haven’t done a very good job. But Covid was moving very fast and we were discussing who had a mask, who had protective gear, who had a ventilator – that was real-time decision making.

But on the TV show, they may have time to set up a national commission to discuss whether they’d let the girl volunteer for the surgery. But if there was a critical period and you had to decide within a month or something, I don’t think you would get national guidance. You will likely have a local institution, where context will matter.


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