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How the Abstraction of 'RimWorld' Highlights Real-Life Medical and Moral Dilemmas

How much is that kidney in the window?
All screenshots captured by the author

This post originally appeared on VICE UK.

Let's say you're managing a space colony with five people. It's all going well, when a minor injury means one has to take to the medical ward—whereupon the wound becomes infected. Obviously you try to save them with the best possible care. But what if you can't? What if, with their life visibly ebbing away, you could harvest their organs and refrigerate them for future use or sale?


Ludeon Studios's sci-fi management sim RimWorld—available in early access since July 2016—gives you this choice, among many others, thanks to focusing on the human side of colonizing. No matter your fancy technology, people have needs—everyone eats, even if it's only nutrient paste; everyone sleeps; and if they live in a shithole for too long, they get angry and depressed. Over time, they form relationships, create art, fall out with each other, and some go crazy. The gaming foundation for all this is Dwarf Fortress, a brilliant-but-daunting simulation that has been creating great player stories for years, and RimWorld's pitch is presenting this kind of social depth in a more comprehensible and playable format.

A substantial part of RimWorld's simulation is health and medicine, whereby colonists can get injured or become sick and then require treatment. The success of this treatment depends on where they're being treated, who's treating them, and what equipment there is. Given that most colonies are mainly constructed from wood, to start off with, the dream scenario of sterile floors, silver beds, and particularly potent Glitterworld medicine is a rarity. Most colonists get better over time, of course, because most maladies are minor. But some don't and in other cases—sad as it is to say—you just don't have the tools to save them.

'RimWorld,' trailer

Many articles about RimWorld, now and in the future, will focus on the great stories the game generates—how much it makes you care about your starting colonists, your genius artist with the alcohol problem, or the irreplaceable researcher who's got a thing for starting fires. These little algorithm-sacs do a brilliant job at creating the illusion of personality, mainly by letting you imagine the motivations for their actions. But at the same time, you're always aware of the illusion, and in my case, you know the one true god is the efficient running of the colony.


When colonists died in my first few games, I was sad. As I became more experienced, I realized I was missing a trick—death for these NPCs may be inevitable, but that doesn't mean they've finished contributing to the colony's financial health. Especially if you've got a fridge and some patience. The medical side of RimWorld goes deep enough to allow you to schedule operations, which in turn allow you to harvest organs. A colonist can survive, of course, with only one lung or one kidney. But you can also remove their liver or heart, which I like to think of—when they're in the final stages of an agonizing death—as a kind of silver-lined mercy.

There are two things to do with these organs—the first is to use them in transplants for your other colony members, curing heart disease or asthma or replacing a diseased organ, and increasing their longevity. Mainly, however, I store and then flog them to visiting traders. The value is so high that, especially in your colony's early years, it feels like letting someone die naturally is just saying goodbye to an enormous pile of money. Yeah the other colonists don't like it, in fact there's a mood debuff that will stack depending on how many organs you harvest at once, but in a relatively well-run homestead, this isn't a gigantic problem—and they forget about it after a week, just like real people would.

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As with the magnificent Crusaders Kings 2, RimWorld is full of situations that, out of context, sound absolutely monstrous. But the level of abstraction such games provide, simulating a potential situation with mini-humans, can offer a surprising perspective on real-world issues.

My penchant for organ harvesting made me think, for the first time in decades, of my donor card. In the UK, we have an opt-in donor system, meaning people have to actively declare themselves a willing donor before death, except in Wales, which is currently trialling an opt-out scheme—whereby everyone is presumed happy to be a donor, unless they claim otherwise. The difference between these two systems is literally life and death. The United States has an opt-in donor system, and it is estimated 22 people die every day because the organs required are not available, adding up to more than 8,000 deaths per year.

"As a doctor, it is difficult to see your patients dying and suffering when their lives could be saved or dramatically improved by a transplant," John Chisholm, chair of the British Medical Association's public health medicine committee, said to the Guardian in June. "It is even more difficult when we know that lives are being lost unnecessarily because of poor organization, lack of funding, or because people who are willing to donate organs after their death simply never get around to making their views known, resulting in relatives making a decision without knowing whether the individual was willing to donate."


"Thinking about these things in the abstract, as part of an overall system, can sometimes help you to focus on the real argument."

The arguments against an opt-out system are poor, and often ludicrous—such as the idea doctors will have less motivation to save the life of a potential organ donor. Which didn't stop the Scottish National Party from recently blocking an opt-out scheme in Scotland for the utterly incredible reason that the motion had been proposed by a Labour MP.

Such pettiness is not exclusive to any one political party, of course, but demonstrates why thinking about these things in the abstract, as part of an overall system, can sometimes help you to focus on the real argument. You can't go around talking about organs as resources in the real world, because people would think you're crazy—incidentally, the only class of person in RimWorld that doesn't get a mood debuff for organ harvesting are those with the psychopath trait. But in terms of the NHS-as-a-system, and society in a wider sense, organs are a resource. A constrained supply, with an opt-in system, means that otherwise healthy people die, and an opt-out system means that these same people live.

I don't have a dog in the fight, by the way—I've never needed a transplant nor know anyone who has. RimWorld just made me see the politics with a new degree of clarity. This is something games are potentially brilliant at and in all sorts of different future scenarios. The Massachusetts Institute of Technology recently produced the Moral Machine, which, although more of a multiple-choice quiz than a video game, puts you in the position of making life-and-death decisions for a self-driving car.


'Moral Machine' screenshot captured by the author

In each scenario, an AI car is in a crisis situation, and you must choose how it crashes—whether it goes straight into the concrete barrier ahead, killing the occupants, or swerves into the wrong lane and takes out a party of innocents crossing the road. The factors that the Moral Machine chooses to emphasize—the career and age of potential victims, as well as whether they're crossing the road appropriately—may make some of us feel uneasy.

Is it the case, for example, that a doctor is more worth saving than a criminal? Do we want AIs to "rank" careers? Do we want them to prioritize saving children, or do the elderly deserve equal consideration? Do we always save pedestrians, under the logic that people who choose to get in a self-driving car in the first place have made their own decision—or simply go with brute mathematics each time, and kill as few people as possible?

The Moral Machine offers only questions, and you do the answers, but in doing so, it raises awareness of a philosophical dilemma around our increasingly automated technology. Self-driving cars do seem to have a great safety record, and no doubt endless advantages over human drivers, but as they become more of a presence on our roads, accidents are inevitable. The Moral Machine is representing decisions that, in some form or another, a team of Google or Tesla engineers must have already made—and do we know on what basis? It makes you wonder if, for example, a self-driving car's design team would de-prioritize its vehicle's occupants in favor of innocents—or whether the company's loyalty to its customers comes first. To return to the career distinction of a doctor and a criminal, if an AI car had a choice of killing you or a Google employee, can we trust the algorithm doesn't take such factors into account—and how would we ever know?


The Moral Machine is a great "game" because, as with RimWorld and organs, it abstracts something we don't like thinking about. The small cartoon people may have characteristics and in one case even the illusion of personality—but they are not real people. So we think of them at one remove, whether that's a beloved hardworking colonist on their last legs or someone who survives a car crash just because she's a baby and the alternative was older.

Both show how games—quite beyond the simplistic idea of "moral choices" applied in the mainstream—can take their players onto ethically interesting territory, where decision making is more likely to be guided by logic. In the real world, our thoughts are more influenced by empathy and emotion. The AI car quandaries are not the same question if you're thinking about getting an AI car. RimWorld's sophisticated simulation, in which people are resources-with-personality in such a bleakly amusing way, happened to clarify in my mind why an opt-in organ donation system is good healthcare policy.

This is not a call for government-by-video-games, which would cause a nuclear apocalypse faster than Trump in the White House. But when you consider that it's 2016 and the UK still hasn't made what—let's be honest—is a simple change advocated by medical professionals and anyone who knows about it, it seems to me that RimWorld accidentally puts us to shame.

The potential of games is nascent, and developers increasingly use them to explore social and political topics—often at one remove, and perhaps sometimes without intent. Video game designers have a great habit of looking at something like human behavior, which is unfathomably complex and deep, then building a hacky but approximate system that mimics some specific part of our social structures so well. You might never want to live in a dwarf fortress or a space colony, but it's surprising what you can learn by building one.

Follow RIchard Stanton on Twitter.

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