The moral quandary of ‘The Last of Us’: Scientific and ethical implications in the search for a cure

This article contains spoilers for Naughty Dog and HBO’s “The Last of Us.”

The recent television adaptation of Naughty Dog’s critically acclaimed video game “The Last of Us” has sparked renewed attention to its source material. The game paints a dismal picture: Humanity has fallen to the cordyceps fungus, which infects humans and takes complete control of their minds to violent ends. Society and civilization have crumbled, giving rise to a constant power struggle between military rule and factions of rebels fighting for freedom and the elusive “cure.”

The main protagonist, Joel, is tasked with the transport of Ellie, a young girl who is immune to the fungus. She is purportedly the key to unlocking the cure the world desperately needs. Throughout the game, Joel’s relationship with Ellie strengthens as they fight their way across the ravaged landscape of the United States. Where first he merely views her as goods to be transported, by the end of the game she is much more. It is clear the need for a cure is dire. Simultaneously, both the player and Joel grow attached to Ellie throughout their quest. This places the player in an interesting ethical situation in the final scenes of the game. The surgery required to biopsy Ellie’s brain will be fatal. Is the potential for a cure worth the sacrifice of the child the player has bonded with? Joel faces a similar dilemma, ultimately choosing to save Ellie and escape.

“While it is likely that his character was acting on emotion, would Ellie’s death via surgical biopsy have been to any scientific benefit at all?”

The player has no agency in how the events unfold in the game. However, Joel’s choice has provoked much discourse in the fan base. Some view his decision as moral, others as selfish and to the detriment of humanity. To explore such questions, one might consider aspects of the decision that Joel likely did not. Would Ellie’s death have been to any scientific benefit at all? Is a vaccine for a fungus actually possible, is this surgical biopsy a wise approach, and is informed consent given?

As mentioned in a 2021 review by Lorena Oliveira and colleagues, there are currently no approved vaccines against fungal infections. This is due to issues ranging from the accessibility of animal models to challenges caused by the fungal cell structure. All vaccine development studies need animal models to determine safety and efficacy before human trials. The context of the game is relevant here. It is exceedingly unlikely they have access to sufficient animal models to test any vaccine that would result from Ellie’s sacrifice. Moreover, even if the scientists had access to animal models, there are inherent barriers to developing vaccines that target fungal cell walls.​​ Some fungal cells have the ability to alter the components of their cell wall throughout the course of infection. This means the fungal cell can decrease host recognition, impair the body’s inflammatory responses, and increase the fungi’s virulence. If today’s society, with its boundless resources, cannot develop a fungal vaccine, what are the chances for the deteriorating world depicted in “The Last of Us”?

“It is exceedingly unlikely they have access to sufficient animal models to test any vaccine that would result from Ellie’s sacrifice.”

Secondly, scientists in the game plan to harvest Ellie’s brain to develop a cure. As mentioned in a review led by the International Vaccine Institute, vaccine development typically takes between 5 and 10 years. Suppose the surgeons were successful in biopsying Ellie’s brain; what then? Infrastructure has crumbled in the in-game world. How can they ensure adequate refrigeration to protect the samples? It is highly risky to immediately carry out the surgery without this assurance. Furthermore, once Ellie has died, there are no second chances. If something happens to the samples, they may not get another chance. The rash decision to perform the surgery could have resulted in the loss of life for nothing.

Lastly, the game raises the important subject of informed consent for medical procedures. As outlined in guidelines by Timothy Paterick and colleagues, informed consent is essential for the patient’s right to accept or deny treatment. In a physician-patient relationship, it is the responsibility of the physician to identify the best treatment for the patient and discuss the possible benefits and risks. In “The Last of Us,” informed consent is not obtained. Ellie is merely anesthetized without the explicit knowledge that she will die. This goes beyond failing to inform her of possible risks, as her death is framed as certain. The physicians in this scenario completely disregard any semblance of patient autonomy and informed consent. Thus, ethically, Ellie’s death for the sake of a vaccine is dubious.

All in all, not only is the science behind the cure in “The Last of Us” shaky, but the ethics are as well. Many regard Joel’s decision as impulsive and ill-advised, but the doctors involved in the quest for a cure are guilty of the same infractions. While it is unlikely that Joel took these technical notions into consideration, they nonetheless remain true, perhaps making his decision more palatable on both a scientific and ethical level.

Image courtesy of Pxfuel