Liver Transplants For Alcoholics, By: Nathan Patel Brudney s discussion on the issue of liver transplants for alcoholics attempts to defend their moral rights to liver donation. The ratio of available livers for donation to the number of people needing livers is very low. This short supply of livers makes them a precious lifesaving resource that must be dispensed in a fair and systematic way. Policy attempts to make this process fair but as an artifact of the problem it is trying to tackle, serious moral and ethical questions about how to distribute organs will remain unaddressed in a narrow view of liver transplants for alcoholics. The specific issue this paper will defend is the claim that alcoholics and nonalcoholics have the same moral claim to a liver transplant. Alcoholic s moral claim to a liver transplant is clouded by a layer of sentiment of visceral strength that alcoholics did this to themselves and therefore they are morally weaker people. If alcoholics are to be held responsible for their outcomes than their current predicament is a result of their choices, therefore they are responsible for their choices outcomes. This is based on the accepted logic that people believe they make choices for themselves. I am are not going to discuss the theories of choice or free will, but I would like to highlight that deprioritizing someone on a liver transplant list because of a history of alcohol abuse is a consequence for their past choices for which they are being held responsible. This axiom is the context under which this argument will proceed. While the responsibility for the outcome of a choice is uniform and simple, it leaves some unanswered corner cases. For instance Brudney presents the following case: two people drink excessively, one develops alcohol related liver disease, while the other person has no problems. If someone is responsible for their decisions outcomes, in this case only the person needing the liver transplant would be penalized for their actions. This seems unfair on the grounds that treating two people differently despite the same choices is wrong.
Society s judicial system is constructed around the framework of consequences for outcomes 1. For example, murder and attempted murder, there is no moral difference between killing someone and attempting because the choice made was to kill this person, in one case they succeed and in the other they failed. Also there any many negligent drivers who do all sorts of things other than drive. Many of them go entire lives without hurting anybody and some do not. The significance of moral luck as proposed by Thomas Nagel defines the phenomenon that humans tend to correlate responsibility and voluntary action 1. Since there exist no current method by which justice can be served to both people who choose to drink and a consequence to discourage excessive drinking. The moral luck argument is not accounted for in the legal system's outcomes and consequence relationship, from which policy attempts to address the issue of liver transplants for alcoholics. Since the moral luck argument uncovers asymmetric punishment based on outcomes than how can society structure the punishment to fit the crime? Societies put people in jail for many things ranging from theft, all the way up to murder and beyond and for these crimes very few are sentenced to death. For diabetic patients the outcomes for kidney transplants are the same for non-diabetic patients 2. Type II Diabetes can be caused by overeating and lack of exercise which can progress to kidney failure where the only cure is a kidney transplant 3. Society does not punish diabetics, in fact resources are showered upon them because their situation is considered a disease and not a voluntary choice even though it is clearly a voluntary choice to overeat and not exercise. This discrepancy exposes the problems with punishing alcoholics by limiting their access to healthcare as unfair. In the instance of an alcoholic requiring a liver transplant, the punishment of moving them down the list or off the list is morally equivalent. If you deprioritize someone because 1 Moral Luck: The Justification of Laws and Punishment, Stanford Encyclopedia of Philosophy, http://plato.stanford.edu/entries/moral-luck/ 2 Renal Transplantation in Diabetic Patients. J. Bittar, P. Cepeda, J. de la Fuente, W. Douthat, J. de Arteaga, P.U. Massari, Transplantation Proceedings 3 Type 2 Diabetes. U.S. National library of Medicine,http://www.nlm.nih.gov/medlineplus/ency/article/000313.htm
of alcoholism and they die before they get a liver, then there is no difference between deprioritizing and taking someone off the list. Since society judges people based upon the outcomes of their actions, then the action of deprioritization is equivalent to removing someone from the list. On the other hand if someone is deprioritized and they still get a liver then someone else is still deprived of a liver. This is a zero-sum game for trying to define a continuous punishment for a finite outcome. The punishment of deprioritizing someone is to provide a consequence that makes it less desirable for people to drink in excess. This type of punishment does not guarantee that someone will or will not get a liver and therefore the punishment is like Russian Roulette. Since the outcome of death is irreversible and for most people an undesirable outcome the punishment of possible death seems disproportional to the crime and the probabilistic outcome is not consistent with the legal system s strict relationship between outcome and consequence. Brudney's conclusion that deprioritizing alcoholics is immoral is explained as he explores the issues of luck and how to weight alcoholism during transplant list selection. The argument for treating liver transplants as the same for alcoholics and non-alcoholics: is for someone to be penalized for ruining their liver they must be aware that livers are in short supply. They must comprehend that their liver transplant is a compromise, where somebody else does not receive a liver and will die waiting for a liver. While Brudney's argument of responsibility for understanding that their need for a liver deprives someone else of a lifesaving liver is a moral argument, it is not consistent with our society s notion of responsibility for outcomes and is difficult to enforce. As discussed in the case of moral luck, regardless of how someone ends up in a bad situation, all that matters in the judicial system is the outcome. In the end an alcoholic is sitting in front of a board of review that determines whether or not they deserve a liver transplant at the cost of somebody else not receiving a liver. The claim that when people drink in excess they do not know that their actions are hurting other people is a strong
claim. Alcoholics may not be able to understand that their actions can hurt somebody that they have never met or interacted with before. But alcoholics in fact hurt many people along their path other than themselves starting with friends and family and eventually expanding to professional life. These negative reinforcing experiences in themselves are enough to discourage normal people from excessive drinking. The continuation of social consequences and drinking by people to the point of needing a liver transplant seems to suggest that someone under the control of alcohol is not necessarily making rational decisions and/or acting under voluntary control. While alcoholic s choices are not necessarily their own, this does not absolve them for their actions. Viewing alcoholism as a disease allows society to allocate resources to help alcoholics back onto their feet, analogous to resources for diabetics to manage their illness, and therefore there is no difference between a recovering alcoholic needing a liver and a normal person needing a liver for idiopathic disease origins. The balance between holding alcoholics responsible for their actions and dismissing their actions as a consequence of an addiction that is out their control is a fine line. If society structures it so alcoholics are not responsible for their actions because the decisions they make are out of their control. Then there are no consequences for excessive drinking and therefore people are more likely to engage in this destructive behavior. Alcoholics must be responsible for the outcomes if they hurt other people like maiming or killing someone due to drinking and driving. But that responsibility does not extend to liver transplants because a liver transplant is not intrinsically harmful to others, it is just a side effect of liver shortages in the context of society. Brudney's argument of culpability for knowledge of liver transplant system reinforces that liver transplants are not intrinsically harmful to others because people are not necessarily aware of the consequences to other people and requires abstraction of one's place in society s social contract. Treating alcoholism as a disease in the field of medicine reinterprets a behavior that
in the social sphere is a stigma to a problem of behavior/biological conditioning akin to self-inflicted type II diabetes. The purpose of medicine is to help people achieve their goal of attaining a fulfilling life. Addiction is a disease as is liver failure; both are a combination of environment and genetics which are complicated, unique, and non-deterministic. So when a patient engages in excessive drinking to the point of alcoholism they are losing control and research seems to suggest that they are involuntarily consuming an addictive substance 4. It is well documented in the literature of addiction medicine that the lack of social acceptance of alcoholism as a disease has demonized alcoholics and fostered public sentiment that alcoholics are morally weak people 5. Society does not demonize people who are diagnosed with cancer or diabetics who are partially responsible for their situation because their genetics and environment led to this outcome. The medical needs of alcoholics have been contested as not being necessary and the result of special interest groups and rationalization for inappropriate behavior 5. This contradiction on how society treats people with alcoholism stems from a cultural history that lends itself to discrimination and unfair practices. The portrayal of alcoholism as a choice leads to significant moral quandaries while the perspective of alcoholism as a medical illness implies equal access to healthcare and hospital services. This is to be distinguished from other legal punishments for alcohol addiction wherein an alcoholic directly harms somebody through their actions like stealing or manslaughter. Deprioritization for past alcohol abuse does not fit into the model of crime of punishment and furthermore the act of receiving a liver donation is not intrinsically harmful to others. So we conclude that deprioritization for past alcoholism is immoral because access to healthcare is an unjust punishment that does not fit society s model of outcome and consequence. 4 Responsibility for Addiction. Richard J. Bonnie, Journal of American Academy of Psychiatric Law 5 Is Alcoholism a Disease? David J. Hanson, http://www2.potsdam.edu/hansondj/controversies/is-alcoholism-a-disease.html