Are alcoholics less deserving of liver transplants?

Hastings Center Report

Volumn 37, Issue 1, 2007, Pages 41-47

  Brudney, Daniel ^a  

^a NONE

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EID: 33846964845     PISSN: 00930334     EISSN: None     Source Type: Journal    
DOI: 10.1353/hcr.2007.0001     Document Type: Review

References (34)

1. E. Wittenberg et al., "Rationing Decisions and Individual Responsibility for Illness: Are All Lives Equal?" Medical Decision Making 23, no. 3 (2003): 194,
2. For a discussion of this general attitude toward the sick, see R. Galvin, "Disturbing Notions of Chronic Illness and Individual Responsibility: Towards a Genealogy of Morals," Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 6, no. 2 (2002): 107-137.
3. See also P. Ubel et al., "Allocation of Transplantable Organs: Do People Want to Punish Patients for Causing Their Illness?" Liver Transplantation 7, no. 7 (2001): 600-607.
4. IV drug use might also cause liver disease. However, the issue of holding someone responsible is more complicated here be cause it is possible to contract liver disease from one dirty needle. The impulse to penalize the alcoholic comes in part from the fact that her disease is a consequence of long-term, repeated conduct.
5. For a fine discussion of the conditions for holding an alcoholic responsible for her alcoholism, see W. Glannon, "Responsibility, Alcoholism, and Liver Transplantation," Journal of Medicine and Philosophy 23, no. 1 (1998): 31-49.
6. The issue of what follows from saying that the alcoholic is responsible for her condition fits in with the extensive philosophical debate on distributive justice and luck. Canonical texts in that debate include R. Arneson, "Equality and Equal Opportunity for Welfare," Philosophical Studies 56 (1989): 77-93,
7. and "Liberalism, Distributive Subjectivism, and Equal Opportunity for Welfare," Philosophy and Public Affairs 19 (1990): 158-94;
8. G.A. Cohen, "On the Currency of Egalitarian Justice," Ethics 99 (1989): 906-944;
9. and R. Dworkin, Sovereign Virtue: The Theory and Practice of Equality (Cambridge, Mass.: Harvard University Press, 2000).
10. Perhaps it would be sufficient that there was a point, prior to her liver disease, at which we could reasonably have expected Jane to get herself into treatment. For this suggestion, see A.H. Moss and M. Siegler, "Should Alcoholics Compete Equally for Liver Transplantation?" Journal of the American Medical Association 265 (1991): 1295-98.
11. Moss and Siegler make the proposal as early as 1991. See Moss and Siegler, "Should Alcoholics Compete Equally for Liver Transplantation? "
12. Glannon, "Responsibility, Alcoholism, and Liver Transplantation, " 41 and 43.
13. R. Veatch, Transplantation Ethics (Washington, D.C.: Georgetown University Press, 2000), 315. See also Moss and Siegler, "Should Alcoholics Compete Equally for Liver Transplantation?" 1297.
14. Readers inclined toward a stricter standard should simply remove "repeatedly" from the Principle and have the relevant phrase read, "knowingly and voluntarily."
15. The fact that one is responsible for one's health-risky conduct does not entail that such conduct is morally wrong. It might even be praiseworthy (imagine Alice, who rushes into the toxic waste pit to pull out the baby who has fallen in). Failure to make the distinction between prima facie and all-things-considered assessments vitiates Peter Ubel's example of a person who risks his health (and so needs scarce medical resources) by excessive work helping others. See P. Ubel, "Transplantation in Alcoholics: Separating Prognosis and Responsibility from Social Biases," Liver Transplantation and Surgery 3 (1997): 343-46. Ubel says that if one would not criticize such a person but would criticize the alcoholic, then one must be criticizing the alcoholic because one thinks drinking is morally wrong. The inference is invalid. If the hard worker ruins his health (and so needs scarce medical resources) as part of an activity that produces significant benefits (for a few other people, for society generally - it may not matter), then on balance his conduct might be permissible or even praiseworthy.
16. We are responsible for voluntarily and repeatedly engaging in (easily avoidable) conduct that a reasonable person would know holds a high risk of generating severe health problems. This applies to the smoker and the overeater as much as to the alcoholic. It applies as well to the habitual rock climber and hang glider. In a straight-forward sense, certain kinds of repeated voluntary conduct do make me responsible for my medical condition. But how medical institutions should respond to that fact is a separate matter. Here, many considerations are relevant. A partial list would include the epistemic question of how easy it is to ascertain that the agent's voluntary conduct was in fact the cause of her medical condition, the administrative question of how costly such a determination would be, and the moral question of how invasive it would be. One could accept that in many cases agents might be responsible for their conduct but that, for one or another reason, institutions should ignore that fact.
17. Moss and Siegler simply say that Jane should be given a "lower priority." See Moss and Siegler, "Should Alcoholics Compete Equally for Liver Transplantation?" 1298.
18. See Glannon, "Responsibility, Alcoholism, and Liver Transplantation," 43, where he says that alcoholics' control of their conduct makes them "either more or less responsible for their condition and in turn determines the strength of their claims to receive treatment."
19. And of course there are moral luck cases in which alcoholism is only the indirect cause of organ damage. Susan repeated
20. ly drives drunk and as a result has an accident in which she suffers liver damage. Should she be penalized with respect to her place on the transplant list? And what about Frank who also drives drunk, never has an accident, but simply contracts liver disease? Should he be penalized? I thank John Lantos for pointing out this class of cases.
21. See E.S. Anderson, "What Is the Point of Equality?" Ethics 109, no. 2 (1999): 295-300;
22. and S. Scheffler, "What Is Egalitarianism?" Philosophy and Public Affairs 31, no 1 (2003): 18-19.
23. This is one of John Rawls's themes. See J. Rawls, A Theory of Justice (Cambridge, Mass.: Harvard University Press, 1971), 102, where Rawls remarks on die tendency to rationalize unjust political arrangements on the ground that the natural distribution of talents is unjust. His point is that just institutions alter or at least mitigate natural injustice.
24. That may be why someone like Veatch, whose analysis ought to entail a severe sanction for Jane, ends up in fact recommending only the most modest sanction, the tiebreaker. See Veatch, Transplantation Ethics, 320-21.
25. Or at the very least the offender has taken steps toward doing something bad to someone else.
26. This is of course an idealization. Most serious drinking leads to harm of some kind to the drinker, her family, and so forth. However, as J.S. Mill noted, these are not harms directly from drinking (see J.S. Mill, On Liberty [Indianapolis, Ind.: Hackett Publishing, 1978], chapter 5). My point is that Jane's drinking directly harms nobody but herself.
27. Note, incidentally, that the ultimate justification for the proposed policy need not be consequentialist. It might be chosen behind Rawls's veil of ignorance, or it might be chosen for its consequentialist benefits. Either way, however, it seems unfair to impose it on Jane.
28. Sometimes a new law grandfathers in those who have relied on the earlier law. But this is done precisely to mitigate what is thought to be an unfair hardship for those suddenly subject to new rules. And if some financial losses are thought to be an unfair hardship, then dearly a dramatic increase in the likelihood of near term death is unfair.
29. See Feinberg: "It is an essential and intended element of punishment, however, that the victim be made to suffer." J. Feinberg, Doing and Deserving (Princeton, N.J.: Princeton University Press, 1970), 67. That is not the situation with case 2 Jane.
30. I suspect that this claim could be justified in many ways, but my hope is that the basic thought will be common ground for diverse moral views. For instance, the maxim to engage in such conduct could surely not be universalized (Kant); a rule permitting such conduct could be reasonably rejected, say, by Jack (Scanlon's contractualism); and engaging in such conduct is almost certainly utility-reducing.
31. There is also a third possibility. Suppose Jane knows of liver shortages and so on, but as yet there is no promulgated rule announcing the consequences for bringing one's liver disease on oneself. In this case, Jane is morally guilty, but whether she should be institutionally sanctioned is not clear. I would say that in such a case, moral guilt is both a necessary and a sufficient condition for a severe sanction, but different views about this seem likely.
32. This may also explain why it is fair to sanction a case 2 Jane but not a case 2 Jill. Their conduct has been equally immoral and places them equally at the mercy of luck. Case 2 Jill simply has better luck than case 2 Jane. I thank Walter Glannon for pressing this point and urging that here might be a case in which leaving someone exposed to luck is morally proper.
33. I thank Mary Simmerling for pointing out the need to make explicit these practical consequences of my analysis.
34. I thank John Lantos for bringing up this case.