I was finishing loading my groceries into the car last week when I was presented with the regular challenge for any suburban grocery shopper. Do I leave the shopping cart by the car or do I return it to the designated cart area 75 feet away? Those who have read my previous columns may remember that grocery stores are of particular interest to me for elucidating complex ethical dilemmas. Earlier, when there were widespread discussions for how to fairly allocate life-saving resources like ICU beds and ventilators, I wrote how grocery stores’ use of priority queues for certain customers could illuminate principles of equitable resource allocation frameworks: Who gets first access to a scarce resource and why.

The shopping cart question may be less charged, but when presented with this challenge, it still begs the question, what is the right thing to do?1 The answer to this question is particularly important because if we can understand more clearly what drives us to do the right thing in a low stakes setting like a grocery store parking lot, it may provide some helpful insights when deciding more important questions as a health care professional. 

The easy and “cocktail party” answer to this question is to simply return the shopping cart because that is the pro-social thing to do. There are no laws that require us to return the cart, we won’t be arrested if we choose not to oblige. However, we are social beings who live in communities that require people to cooperate with one another. When we shop at stores, convention, and not rules, can compel us to return the cart to its receptacle area. So even if we should return the cart, anyone who has ever walked through a parking lot knows that plenty of people do not follow this norm.  

Is it simply that people are selfish and choose not to be helpful? We are probably more likely to feel that way when a cart is blocking the parking space we are trying to pull into, but this claim of a moral failing is perhaps an unfair indictment and an oversimplification. There are numerous reasons why we might find ourselves choosing to leave a cart behind. Some may not return a cart because they have left a small child in their car seat. Others might have a disability or avoid returning the cart only when it is pouring rain or oppressively hot. Some people might believe that it is someone else’s job to return the carts. 


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A number of social science studies have helped us to understand complex human choices when presented with similar norm-challenging scenarios.2 In general, when people see that others have already disrupted norms, they are less likely to follow the norm as well. In one study, participants were 3 times more likely to violate a parking lot’s “No Trespassing” sign if they saw that many others had already violated the “No Bike Parking” sign. Other studies with similar findings suggest that while there will be outliers who always follow or ignore norms, the majority of us are likely to be influenced by the good or bad behavior of others.  

Which brings us back to the central importance of norms in life and in medicine. Ethics asks us to critically reflect on our judgments to determine the right thing to do. When Dr Martin Luther King in his 1963 sermon concluded that to be a good neighbor was to be altruistic, he asked us to be willingly obedient to unenforceable obligations.3 He reminded us that rules and laws, “enforceable” obligations that have legal consequences, are not necessarily sufficient for us to do the right thing. They are often just the floor beneath which we cannot go, but they do not necessarily inspire us to do good for those around us.

What then can the lone shopping cart teach us about our obligations as health care professionals? In many cases, how we decide to care for our colleagues and our patients will not be dictated by a rule, but rather by a norm. A code of ethics, an oath at medical school graduation, or an ethics committee opinion are all generally advisory, aspirational, and unenforceable. We choose to do the right thing for numerous reasons: it makes us feel good to help even if it means more work; we were taught that way by a respected mentor or colleague; we think the world will be a little better off even if we’re never recognized for it; or we remember that we are part of an honorable profession that relies on public trust and embodies a willingness to be obedient to unenforceable obligations. 

Whatever the reason, these normative decisions deserve our continued attention. We may all be susceptible to occasional moral failings because we are human. I will admit that I do not always return the shopping cart, but the last time I was in that situation I felt a stronger obligation to do so because the person next to me was returning his cart. I hope my decision was not simply to avoid a minor public shame, but to try to be part of a community of people who try to be their best. We may not always succeed, but trying is always the right thing to do. 

David J. Alfandre MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

References

  1. D’Costa K. Why don’t people return their shopping carts? Sci Am. April 26, 2017.
  2. Keizer K, Lindenberg S, Steg L. The spreading of disorder. Science. 2008;322(5908):1681-1685. doi:10.1126/science.1161405
  3. King ML Jr. On being a good neighbor. Draft of Chapter III. Available at The Martin Luther King, Jr. Research and Education Institute, Stanford University.

This article originally appeared on Renal and Urology News