By Daniel Tippens
This is the first of what will be several rounds of dialogue between Dan Kaufman and Dan Tippens on “moralizing medicine.” As in a real conversation, each entry will consist of relatively short bursts of points and counterpoints that not only will keep the exchange moving, but will leave room for development of the relevant ideas in the comment threads that follow.
I have been concerned about the way in which we moralize medicine, and after several chats about the topic with my dear friend Dan Kaufman, I’ve decided to put down a few brief thoughts. My concern is with our occasional reliance on the concept of punishment in medical practice, and particularly with regard to organ transplantation. In the United States, organ scarcity is a serious problem. An estimated twenty-two people die each day, because we lack a sufficient number of organs to save them. Our supply of transplantable livers is no exception, and this raises a question that has implications for the ethics of scarce resource allocation more broadly: Should an alcoholic and nonalcoholic be given equal consideration on the liver transplant wait-list?
When answering this question, we often begin with medically-related utilitarian considerations, regarding who would receive the most benefit from the organ, which may be a way of prioritizing transplant-applicants that does not imply that we are punishing or rewarding them in any way. So, imagine that we have one available liver and two people waiting for it, one of whom is a twelve year-old boy and the other who is an eighty six year-old man. It seems relatively clear that the boy ought to receive the liver, for he has the opportunity to benefit the most from the transplant, a judgment that in no way suggests that the elderly person is being punished for anything.
Or suppose instead that we have two patients of the same age. One has a problematic immune system while the other’s is normal. Again, it would seem that we have a straightforward, utilitarian reason to prioritize the second person over the first, as the second’s operation is more likely to be successful, conferring the maximum benefit and not wasting an organ.
People frequently try to appeal to these sorts of utilitarian considerations, in order to deprioritize alcoholics waiting for liver transplants claiming either that (1) alcoholics generally have a shorter life expectancy than non-alcoholics or (2) the transplant is less likely to be successful, due to their alcoholism.
There is a difference, however, between deprioritizing all alcoholics, and deprioritizing some particular alcoholic. As is often pointed out in this literature on the subject, alcoholics may not have a shorter life expectancy than other patients, so this factor will have to be considered on a case-by-case basis. Also, the fact is that transplants are not necessarily less likely to be successful in alcoholics. This, again, has to be determined in a context-sensitive manner.
In any number of cases, then, such considerations will lead us to a dead end. Consequently, many have turned to other, more explicitly moral considerations. In a short article in the American Medical Association Journal of Ethics, an author put this sort of argument in following way:
Imagine that there are two homeowners, and that each has his or her home destroyed. In one case, the homeowner sets his own house on fire and watches it burn down. In the other, the homeowner watches her house be destroyed by a tornado. If we only had enough relief to provide for 1 of the homeowners, whom should we choose? Intuitively, we would fund the second homeowner since her house was destroyed through no fault of her own. This intuition might drive some more general moral principle which says that we must hold individuals accountable for what they do and prioritize those who are blameless over those who are blameworthy. If we accept this principle—and I expect most all of us would—then we might have a reason to deprioritize alcoholics on the grounds that they are to blame for their condition .
By this logic, if alcoholics choose to drink they should be deprioritized, because they are responsible for their actions. While the author says that he shares this intuition, he also observes that alcoholics might plausibly be described as not really choosing to drink. Thus, the crucial point in the case for deprioritization is whether or not alcoholics can be said to genuinely choose to drink.
I am more concerned here, however, with the author’s inclination to hold the alcoholic “accountable”; with the idea that punishment of bad behavior seems to be doing most of the moral work here, in determining who should and who should not receive life sustaining medical interventions.
Responsibility can be a means not only of locating those deserving of punishment, but also those deserving of praise. I personally agree that when utilitarian considerations have been exhausted, alcoholics should be deprioritized. But I don’t think we should do this by emphasizing that the alcoholic is responsible for his punishable behavior.
Here’s the analogy I would use. Consider “automatic enrollment” scholarships. When students apply to a university, they may be automatically considered for a scholarship, in the sense that they don’t have to fill out a special application or jump through hoops of any kind. When somebody is awarded that scholarship, we don’t think that those who didn’t receive it are being punished or that they don’t deserve it or even that they have done anything wrong. Perhaps there wasn’t enough money to award the scholarship to all deserving applicants (which could be all of them), and perhaps those who didn’t get it simply preferred to spend their time doing things other than what this particular scholarship was looking for. Perhaps those who weren’t awarded some particular scholarship won a different one or are simply better suited to others.
Analogously, those who spend their time living a liver-healthy lifestyle might deserve this particular medical intervention more. It’s not that alcoholics, even if they choose of their own accord to drink in health-compromising quantities, don’t deserve an organ, have necessarily done something wrong, or ought to be punished. It’s simply that those who don’t drink deserve it more — we reward them, but we don’t punish others.
This reward-based idea applies not only to those who are actively trying to live a healthy lifestyle, but those who just happen to live that lifestyle. Again, with automatic-enrollment scholarships, many students might not have been trying to get any scholarships, they just happen have cultivated a CV that is conducive for this or that one.
This shifting of the emphasis strikes me as important, because it moves us away from viewing people who choose to drink regularly as engaging in punishable behavior. It also allows us to more easily acknowledge that while an alcoholic might not get equal consideration for a liver transplant, he should get equal consideration in a lung transplant.
You might think this is obvious, but remember what the author’s previous intuition was: if you are responsible for burning down your house and another isn’t, then the one who is blameworthy should be “held accountable” for his actions.
This author obviously invites the reader to analogize the house with the liver, but who is to stop one from analogizing the house with, say, one’s body. If one understood the argument in this way, then when alcoholics or smokers enter a wait-list, they will always be deprioritized, because they are responsible for damaging their bodies.
I acknowledge the author wouldn’t want to say this, but I just emphasize it to illustrate how important our analogies in medical ethics are. They carry all sorts of value-laden undertones that shape our attitudes toward others, and I think we should be very careful to ensure that we aren’t subtly condemning certain behaviors, as opposed to simply rewarding others.
- Allhoff, Fritz. Should Alcoholics Be Deprioritized for Liver Transplantation? American Medical Association Journal of Ethics, September 2005, Volume 7, Number 9.
5 responses to “A short note on the ethics of liver transplantation”
The usual justification I have seen is forward looking: that an individual who it is likely to continue to drink dangerous amounts of alcohol is more likely to develop problems with the new liver. This is interesting in terms of discrimination – as a class we may have evidence that the risk of the expensive new liver being compromised is higher for people with such-and-such a past history, but can we argue for this to any particular individual? Obviously, at a “population” level we can, and if we wished to alter this policy, we might consider some kind of randomized trial. However, depending where you are, there are different priority models (“justice” v. “utility”).
Hi Dan, while the writing is good I am not sure I agree with your argument.
You are right that many people use a punishment model in rationing medical care. And like you I am critical of that approach. I believe this stems from the same Protestant/puritan ethic I mentioned in your earlier thread on palliative care. So (to run with your example) the alcoholic in some sense deserves his “fate” more than someone who did not engage in behavior which put their liver at risk.
This demonizing of the patient is clearly built into the unusual analogy from Allhoff where the alcoholic is equated to a homeowner who “sets his own house on fire and watches it burn down” while the nonalcoholic is the homeowner who “watches her house be destroyed by a tornado”. Really? Unless the alcoholic is a suicide case, they did not intend to do anything destructive to their liver nor sit idly by as it stopped functioning (otherwise they wouldn’t be on a list).
I can think of more apt analogies, the simplest (if we stick with the house fire) is that the alcoholic is a homeowner who likes to set off fireworks on his property to celebrate all sorts of events and stores them in his garage (along with a lot of gasoline around for his race bikes), while the non-alcoholic is the homeowner who keeps little if anything flammable around. In each case their house burning down is an undesired and wholly unintended accident, even if the habits of the former increase the odds their house will catch fire.
Your analogy and alternative way of framing the choice to deprioritize alcoholics does not change the mechanism at play. It simply makes the decision sound “nicer”. We replace demonizing the alcoholic, with rewarding those lucky enough not to suffer from alcoholism (as if that is always the result of virtue or prudent intentional action, like your student).
To me the mechanism is still screwed up, and if accepted lead to awful results. In this case we will find ways to deny medical service to the undesirables (as we have for gays, prostitutes, drug users, the poor, etc under the previous model), in the name of prioritizing the saintly.
Hi Dan (part 2), Ultimately, it seems like the question really being asked here is whether it is just (or perhaps when is it just?) to withhold a medical service from one person (or group of people) to the benefit of another, when that service is limited and not everyone can be served. Whether it is a liver or not seems besides the point, except as an example case (which is fine). Thus any answers pertain equally to cases of limited resources, time, or budgets.
To me the only relevant criteria for justice in medicine can be found in triage. Who is the most in need? For whom is it most likely to succeed? And if these are equal, either who came first, or who is likely to get the longest/most profitable use from the service?
If alcoholism does not effect in any practical sense that second question or the last, then it shouldn’t play a role in any decisions.
Of course that is according to my way of thinking, where medicine should be as blind to the social status of those it serves as justice (in law) is supposed to be.
I disagree profoundly with virtually all of this, but I will be writing a response piece soon, so I don’t want to frontload things.
A few things I will be looking at with a critical eye —
1. For those who want to prioritize on the basis of utility, the net cast is far too small. Considerations of utility have to take into account *all* the ways in which the relevant choices affect the general happiness, of which the relative usefulness of the organ to the person receiving it is only the tiniest of tiniest fractions.
2. It’s unclear to me why we should take scarcity in general as an immovable fact or given. Obviously, the case of organs is special, but with respect to all the other scarcity one finds in the medical system, it seems simply a matter of willingness to spend money.
3. Like db, I am highly suspicious of the idea that something that is really mean can be turned not-mean just by changing a few words around.
4. I don’t think anyone has really thought through what a consistent application of these sorts of principles would look like. Indeed, such approaches always seem to me to rely upon deliberately applying them unequally and inconsistently to those who’ve been designated the villains of the month (or the decade), in order to work. In that sense, it is straightforwardly a kind of moral punishment via the withholding of life-saving treatments.
Hi Dan K, I look forward to your full response, however I do want to respond briefly to what you said in your second point…
I agree with this statement in general. Where I might add some caveats…:
a) There may always be a local deficit in something, regardless of money invested into the system, which causes a need to choose between patients when delivering a service. This is especially true if we move away from liver transplants. Enough/appropriate doctors, materials, or time may not be available at the moment an emergency occurs in the locality where it is needed.
b) Regardless of what we want there is a reality that we can’t spend all our money on healthcare, so at some point we will have to choose between funding one thing over another. This will impact someone’s health. But I would agree this can be mitigated to a large degree if people have an interest in doing so.