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JGWeissman comments on Open Thread: March 2010, part 2 - Less Wrong
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These "act" trolley problems have the same difficulty as the original.
It's so implausible that the only way to stop a runaway truck/trolley would be to make it run over a person, that one doesn't know if one's intuition is reacting against the sheer implausibility or the moral dimension.
IMO, telling the subject that "pushing the fat man is the only way" is not helpful. We can't imagine ourselves in that epistemic position.
The best "fat man" scenario is the Unwilling Transplant Donor, but sadly it does not have a good omission counterpart.
Suppose the potential organ donor is choking to death, and you have the opportunity to perform the heimlich manuever and save him.