The Trolley Problem

The "Trolley Problem" is one of the most well - known thought experiments in the field of ethics.

The version widely circulated on the Internet comes from the public course of Professor Michael Sandel at Harvard University.

Professor Sandel asked, "Suppose a madman has tied five innocent people to a trolley track. An out - of - control trolley is hurtling towards them and will hit them in a moment. Fortunately, you can pull a lever to divert the trolley onto another track. However, the problem is that the madman has also tied another person to this new track. In this situation, should you pull the lever?"

From a utilitarian perspective, it is obvious that one should pull the lever - sacrificing one person to save five is a valuable and meritorious act. But critics of utilitarianism argue that once you pull the lever, you become an immoral person - you are responsible for the death of another innocent person, and your act can even be regarded as equivalent to killing. In short, this is an ethical dilemma that leaves one in a quandary.

Some netizens commented that this kind of discussion is "a waste of time" and suggested that people pay more attention to practical problems around them.

However, today's discussion focuses on a very practical problem. It is not just about the lives and deaths of five people but involves the fates of millions of people. It can be said to be a "new version" of the Trolley Problem.

The professor continued, "Suppose there is a train departing once a year. We call this train 'Blue Sky Express'. The 'Blue Sky Express' carries 20 million passengers. In fact, about 40% of the world's population will board this train sooner or later. Once the train departs, it runs on autopilot. Although the exact arrival time is uncertain after years of operation, the destination is clear - the end of the track - a cliff. All passengers will'melt into the blue sky' without exception."

"Most passengers don't know the end of the 'Blue Sky Express'. They don't care much about the outcome and are more focused on enjoying the luxurious facilities and considerate services on the train."

"There are several engineers at the station. They are well aware of the tragic ending of the 'Blue Sky Express'. They know there is a remote - intervention option that can change the train's direction. However, they also face the 'Trolley Problem' because the new track is not 100% safe. Although it's definitely not a cliff and can prevent the deaths of millions of passengers, the train may derail or overturn, resulting in certain casualties."

"One can imagine that although the number of casualties is small compared to the death of all passengers on the train, the families of the victims and public opinion may not forgive the engineers because these casualties are the result of the engineers' active intervention. Most people on the train, even if they survive, won't be grateful to the engineers for saving their lives because they are unaware of the train's ultimate ending and may even condemn and hold the engineers accountable."

"Facing such a dilemma, rational engineers probably won't make a decision easily. After all, this is an autopilot train, and the engineers have no responsibility to intervene in the train's operation. Moreover, once they intervene, the responsibility is huge. Most likely, they will choose to do nothing or postpone the decision. But postponing the decision also carries risks. They may miss the best time to intervene, and the train will speed up and get closer to the cliff."

"Okay, now it's your turn to think about this problem. If you are on the 'Blue Sky Express' and know all these circumstances but can't control the train's direction, what will you do?"

Student A: "I wouldn't board the 'Blue Sky Express' in the first place."

Professor: "Haha, indeed, this is the best choice. But what if you've unfortunately boarded the train?"

Student B: "I'll get off the train immediately and call on others to do the same."

Professor: "Correct answer! Congratulations. Although it seems to be an obvious answer, it can be said to be a 'gift - score question', but not many people answer it correctly. This is worth our deep thought."

In the following part, we will further explore the story of the "Blue Sky Express", with the theme of the disaster and prevention of cardiovascular diseases. Through the metaphor of the "Blue Sky Express", we hope to deepen everyone's impression and present the essence of the problem more clearly. Of course, most importantly, we hope everyone can gain some insights and know how to "get off the train" once they are on this death train.

The Greatest Killer of Mankind

Nearly 20 million people die from cardiovascular and cerebrovascular diseases globally each year, making it the number - one killer among all causes of death. The so - called "Blue Sky Express" actually exists in real life.

More than 40% of us will board this death train, the "Blue Sky Express".

Compared with 40 years ago, the total number of people with cardiovascular and cerebrovascular diseases has nearly tripled. The main reasons for this increase are not only the aging population but also unhealthy lifestyles.

"Unhealthy lifestyles are the most important cause threatening the health of global residents. According to WHO data, lifestyle accounts for 60% of the causes of chronic diseases.

The problem is clear. But solving the problem is a long - term task.

The Portrait of the Number - One Killer

Let's first understand the "portrait" of this "number - one killer".

Cardiovascular and cerebrovascular diseases mainly include ischemic heart disease (i.e., myocardial infarction) and stroke. Stroke is divided into two types: cerebral infarction and cerebral hemorrhage.

By etiology, about two - thirds of patients with cardiovascular and cerebrovascular diseases suffer from atherosclerotic cardiovascular disease (ASCVD), and its etiology is closely related to vascular plaques and high blood lipid. Secondly, there are hypertension - related cardiovascular diseases, and hypertension has a direct relationship with cerebral hemorrhage. In fact, high blood lipid and hypertension are interrelated and ultimately closely related to unhealthy lifestyles.

The key point is that atherosclerosis is the biggest cause of cardiovascular diseases.

When doctors look at medical examination reports, they will comprehensively consider several indicators, such as the relative ratio of HDL - C and LDL - C. But simply put, the most important thing is to see if the LDL - C (bad cholesterol) indicator is elevated.

The current mainstream medical consensus is that an elevated LDL - C is the most crucial driving factor for atherosclerotic cardiovascular disease (ASCVD). Therefore, almost all international authoritative guidelines regard it as the primary target for intervention.

Numerous studies have proven that:

There is a linear positive correlation between the LDL - C level and the incidence of cardiovascular events. For every 1 mmol/L reduction in LDL - C, the risk of cardiovascular events decreases by 22%.

There is no "safe lower limit" for LDL - C; the lower, the better.

The earlier and more sustained the intervention, the greater the benefit.

This means that, unlike blood sugar and blood pressure, which usually have a "normal range", the lower the LDL - C, the lower the risk. Low blood sugar may cause coma, and low blood pressure may cause dizziness or even shock, but no such physiological risks have been found for low LDL - C.

This discovery on the one hand confirms that LDL - C is the root cause of cardiovascular diseases. More importantly, it is actually relatively easy to intervene in LDL - C. There is evidence that at extremely low LDL - C levels, ASCVD can be completely avoided.

From this perspective, the greatest cause of death in mankind, and also the biggest problem for healthy longevity, seems to be a difficult problem but is actually a "gift - score question".

The question is, if it's a gift - score question, why do we all get it wrong?

The Lever of the "Blue Sky Express": The Medical Version of the "Trolley Problem"

Let's return to the metaphor of the "Blue Sky Express".

Dr. Sai:

"If we control the entire population's LDL - C to an extremely low level (<1 mmol/L), it is estimated that 80% of cardiovascular events can be prevented - that is, 6 million cases of onset can be reduced! This is the lever to change the trajectory of the 'Blue Sky Express' and should be pulled immediately!"

Dr. Wen:

"It's not that simple. Will extremely low LDL - C affect nutrient absorption, hormone synthesis, and brain health? Will it increase the risk of hemorrhagic stroke or cancer? These side effects are worrying."

Dr. Sai responded:

"Actually, infants and some people with genetic defects naturally have extremely low LDL - C but develop well. Research on PCSK9 inhibitors also shows that extremely low LDL - C is safe. The risks mainly come from the unknown, but the current evidence is very clear."

Academician Wei summarized:

"Currently, it is not yet mature to reduce the LDL - C of the entire population to an extremely low level. Even reducing it to the 1 - digit range (1 - 2 mmol/L) may be suspected of over - treatment. A more prudent approach is to set 'hierarchical intervention': the target for high - risk groups should be controlled in the 1 - digit range (1 - 2 mmol/L), and for medium - and low - risk groups, it should be controlled in the 2 - digit range (2 - 3 mmol/L)."

This is actually a balance: taking into account both the intervention effect and practical feasibility.

But the price is that we can only prevent some "passengers", and the risk for millions of people still looms large.

Dr. Sai sighed helplessly:

"Do we have to hope that people choose to get off the train by themselves?"

Academician Wei smiled:

"Correct answer. Ultimately, the initiative for health lies in everyone's own hands."

How to "Get Off the Train": Practical Suggestions

Following the guidelines and scientific evidence, here are some highly operational suggestions summarized by the author for your reference:

1. Take 2.6 mmol/L as the warning line Most medical examination reports regard 3.4 mmol/L as normal. But for men over 45 (or women over 55), 2.6 should be the warning line. Once it exceeds the standard, you should immediately seek medical advice, assess the risk, and consider intervention.
2. Obtain professional opinions from multiple sources Doctors in top - tier hospitals have rich experience, but due to their heavy consultation tasks, the communication time is limited. It is recommended to combine resources from private hospitals, community clinics, preventive medicine centers, etc., listen to different suggestions, and you can also consult your friends' real experiences and even use AI tools for auxiliary analysis. Only with sufficient information can the plan be comprehensive and truly meet your individual needs.
3. Maintain a rational attitude towards drugs If the doctor clearly recommends intervention, don't delay the best time for prevention and treatment due to stereotypes.
4. Consider a "higher - level" target According to the latest scientific trends, the lower the LDL - C, the better. If you are evaluated as a medium - risk group (target 2.6), you can, under the guidance of a doctor, raise the standard to 1.8 to gain more benefits in advance. But remember, any adjustment should be evaluated and approved by a professional doctor.
5. Systematically intervene, and lifestyle is fundamental While controlling blood lipid, don't ignore the management of other risk factors such as hypertension and diabetes. And changes in lifestyle - quitting smoking, losing weight, having a balanced diet, exercising moderately, having good sleep, and emotional management - are the fundamental solutions.

My "Bet" with the Doctor

"That's impossible."

When the doctor said this, his tone was calm but his stance was firm.

In a recent medical examination, he advised me to start taking medicine. Although his tone was gentle, I could feel his seriousness. I also understood the reason: I have had high blood lipid for more than a decade, and I also have hypertension (which is being controlled with medicine) and carotid artery plaques. I am indeed in the medium - to - high - risk group.

But I was still resistant to statin drugs.

I had successfully controlled my blood lipid through exercise and weight loss and didn't want to give up this way easily. I was also worried about the side effects of statins, especially the impact on liver function. More importantly, I didn't want to rely on drugs from then on.

So I asked him about a certain drug. Several of my friends were using it and spoke highly of it.

The doctor explained that this drug is a new type of lipid - lowering drug. Its mechanism of action is PCSK9 inhibition, and it has a significant effect on reducing LDL - C. It can be used alone or in combination with statins. The side effects are mild, and it has little impact on liver function. But he still insisted that statins are more cost - effective and suggested that I start with them.

I said:

"I want to try to reach the standard through lifestyle first. I plan to try the following:

1. Exercise every day.
2. Lose 3 - 5 kilograms.
3. Control my diet, especially reduce cholesterol intake (such as egg yolks).
4. Supplement with fish oil.
5. Wear a continuous blood glucose monitoring device to control blood glucose fluctuations.

After listening, the doctor still calmly responded, "These measures are good, but your current BMI and exercise level are already quite good, and there is limited room for improvement in lifestyle. It's impossible to get your blood lipid to reach the standard just by these."

I was unconvinced. "Give me 6 months, and let's see who wins."

He smiled and replied, "Okay, I hope you win."

Six months later, the results were out - my LDL - C dropped slightly from 3.7 to 3.4, still exceeding the standard (the critical value is 3.37). More importantly, according to the latest version of the blood lipid management guidelines, my actual target is 2.6.

I lost this "bet".

I started taking statin drugs. Except for occasional muscle soreness, my liver function was good. Three months later, my LDL - C dropped to 1.54, which was an ideal result and even exceeded the "higher - level" target of 1.8.

The doctor suggested that I try to halve the dosage as long as it is controlled within 2.6. I agreed with a tentative attitude, but in my heart, I actually preferred to maintain it below 1.8 for a long time. If it rebounds, I will discuss with the doctor again whether to resume the original dosage. Doctor Peng should understand, after all, he also mentioned that Trump's recent medical examination report showed that his LDL - C was 1.3, which was controlled by two lipid - lowering drugs.

Three more months passed, and with the halved dosage, my LDL - C still remained at 1.62. Everyone was happy.

My experience and reflection: Although the current result is good, I should have actively intervened in my blood lipid 5 to 10 years ago. Don't wait until you are troubled by hypertension, plaques, and metabolic syndrome to take remedial measures.

No matter how dedicated the doctors are and how advanced science is, you are the one who needs to make decisions and take actions.

Health is never a game for onlookers.

It's time for the passengers on the "Blue Sky Express" to get off the train actively.

Getting off the train is not giving up but waking up. It is a transformation from a "potential high - risk passenger" to a "health helmsman".

Summary

Don't get it wrong with the greatest gift - score question for healthy longevity:

Atherosclerotic cardiovascular disease (ASCVD) can be prevented and treated. An elevated LDL - C is the core driving factor for the formation of arterial plaques. Reducing LDL - C can significantly reduce the risk, and "the lower, the better". For people over middle - age, the warning value of LDL - C should be set at 2.6 mmol/L. Drug intervention and lifestyle changes work together, and only long - term adherence can bring real benefits. Ultimately, everyone needs to be the first responsible person for their own health.

Finally, here are two questions for readers:

Why is cardiovascular disease a gift - score question? How do you know if you are on the "Blue Sky Express"? If you are already on the train, how do you get off?