Taylor LottHealth 2030 001Sonya Albury-CrandallNovember 22, 2013

Ethics Involved in Organ Transplant Prioritization Based on Past Behaviors

Introduction

Ethics is defined as “rules of behavior based on ideas about what is morally good and bad” (Ethic). In more generic terms, ethics is “right versus right.” It is composed of four principles: (1) Autonomy, (2) Justice, (3) Non-maleficence, and (4) Beneficence. Ethics is also comprised of schools that are virtue-based, duty/rule-based, outcome-based, or care-based. Since ethics is composed of many aspects, it is a complicated subject that is the source of many controversies. Various ethics-based controversies are included in the health care delivery system and health care policies. One ethical argument in the world of healthcare is the consideration of past health behaviors when making the decision of whether to give lower priority to patients whose past behaviors have contributed to their organ failure. More specifically, should organ transplant centers assign lower priority to alcoholics in need of a liver transplant?

Argument For Distributing available organs can be a difficult task since the amount of organs needed greatly outweighs the number of available organs. According to the United Network for Organ Sharing (UNOS), roughly seventeen patients die every day while waiting for an organ (as cited by Starr Foundation et al., 2004). In an attempt to try and avoid unfairness and controversy, the allocation of available organs comes from the concept of distributive justice, which contains a list of criteria on how organs are fairly distributed. Organs are distributed based on equal access, need, effort, contribution, merit, and free-market exchanges (as cited by Starr Foundation et al., 2004). Although this model attempts to eliminate bias and avoid unfairness, there are groups who do not agree with this model. These groups share the belief that transplants should be granted based on how “worthy” an individual may be. One side of this healthcare debate is that it is not ethical for organ transplant centers to prioritize liver transplant recipients based on past behaviors. The idea that alcoholism is a disease and is beyond the individuals control is an opinion held by this side of the argument. Alcoholism can be the result of many psychiatric conditions and mental disorders, along with neurological and biological imbalances, that disable the individual’s responsibility for damage to their liver. One article cites that “chronic alcoholism is considered a mental disorder” and cannot be chosen by the individual with this mental illness (Martens, 2001). Statistical data shows that roughly 78% of those believed to be alcoholics suffer from some sort of psychiatric disorder and many are usually are ailed with two or more of the mental illnesses (Martens, 2001). How can a person decide that individuals with a disease, such as alcoholism, are less important or not worthy to receive

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a possible life-saving procedure than those who, excluding the organ transplant circumstances, are relatively healthy? The ideas about alcoholism come from both “street corner” knowledge and from experience. One study, “Allocation of Transplantable Organs: Do People Want to Punish Patients for Causing Their Illness?” suggests that those individuals with cirrhosis of the liver due to excessive drinking of alcoholic beverages show similar recovery results as those without chronic alcoholism when they underwent a liver transplant (Ubel et al., 2001). Another article states, “most, if not all, transplant candidates have already stopped drinking” (Benjamin, 1997). Those that are the heaviest of drinkers usually undergo rehabilitation and it is recommended they decide on a life of abstinence from alcohol to avoid damaging the gifted liver. In the past, alcoholics were denied liver transplants because it was believed they would abuse the newly donated organ; however, this policy was overturned. Some whispers of public opinion say this policy was overturned for a reason and it is neither fair nor humane to deny sick people the right to live (“Heavy Drinkers Should Be Denied Liver Transplants”). The status quo model involves medical professionals following standard procedures to assess the health of the patient and what the extent of need is for the organ; this is the model various people believe should remain in effect so that prejudice can be avoided. Another aspect of this opinion is the differentiation of alcoholics; this meaning, should liver transplants be denied solely based on past behaviors of all alcoholics or should lower prioritization only be placed on current alcoholics rather than all alcoholics-past and present? Individuals who are recovering alcoholics will most likely show similar liver damage effects as those who are not in recovery. If this differentiation is neglected on this side of the argument, patients who really need the transplant and intend on taking care of this gifted organ could suffer for the actions of generalizing all alcoholics as being the same. The interest of the stakeholders depends on who the stakeholders are and what the situation is. For example, a stakeholder could be a relative or someone that knows the patient on the organ transplant waiting list. Relatives may like the organ transplant policy as it is now since their family member, regardless of their past behaviors relating to alcohol, can receive a liver transplant when a match becomes available. However, if a liver transplant match is found and can either go to an alcoholic or non-alcoholic, the stakeholders of the possible recipients will be in conflict because the non-alcoholic’s family may feel that their relative deserves the liver more. The fine line between determining who deserves the liver cannot really be measured; it is based on a multitude of factors that will include bias no matter the intentions. Stakeholders on either side of the argument will be in conflict because, in this situation, there is not necessarily a “right versus wrong” but a “right versus right.”

Argument Against

The opposing argument to this subject would be that it is ethical to assign alcoholics lower priority for liver transplantation. Since organ resources are scarce, many believe that placing priority over patients awaiting a transplant based on past behaviors is an ethical decision. The other side of the debate offers the idea that alcoholism is a disease and is of no fault to the individual, however, there are opinions that disagree. One article

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argues that individuals do have enough control to be responsible for their decision to abuse alcohol (Glannon, 1998). This same article acknowledges that alcoholism can be seen as a disease and some features may be beyond the individual’s control, but some preventative measures can be taken to not be so susceptible to this disease (Glannon, 1998). For individuals who are on the waiting list for a liver and are alcoholics, rehabilitation should be a requirement. The article “Transplantation for Alcoholic Liver Disease: The Ethical Issues” also states that someone who suffers from alcoholism is not responsible for their disease, but once diagnosed, they are responsible for treatment and prevention of further complications (Benjamin, 1997). A research study adds another piece to this controversy being that alcoholism is seen in a negative light and “scarce life-saving resources should be directed preferentially to those without such pasts” (Ubel et al., 2001). Since alcoholism is seen as socially unacceptable, the opinions of many believe prioritization should be placed on individuals requiring transplants and their past behaviors. Alcoholics may not just be seen as having a disease but behaving in an irresponsible manner and choosing a lifestyle that may result in their death. Alcoholics in our society are seen as blameworthy and that their disease is a result of their negative behaviors. These individuals drink beyond their body’s limits, are placed on a waiting list for a liver, and possibly receive said liver above another possible recipient who had no control over their liver disease. In this particular situation, the gifted liver being granted to the alcoholic is seen as morally wrong. The idea that, due to their bad habits, alcoholics may not have the highest chance for survival after liver transplantation is another part of the organ transplant equation. It is referenced in the article “Alcoholics and Liver Transplantation” (Cohen et al., 1991). Due to alcoholics participating in unhealthy behaviors, they are at risk for developing liver cirrhosis. This disease can become dire enough that the individual with the liver damage will require a new liver. However, because alcohol is very addictive and can be labeled a drug, one public opinion is that once the alcoholic receives a new liver, they will continue their bad habits, which can compromise the new liver; this results in someone who would have taken care of the gifted liver being denied. Few studies have been done on the survival rates for alcoholics with liver transplants; the studies that have been completed contain limited sample sizes and are not quite reliable, based to the “Alcoholics and Liver Transplantation” article (Cohen et al., 1991). According to “Allocation of Transplantable Organs: Do People Want to Punish Patients for Causing Their Illness?” in the year 1995 roughly 27% of liver transplants were given to alcohol abusers (Ubel et al., 2001). This statistic can be used by some stakeholders as an argument for what the survivalship was of those livers compared to the livers granted to non-alcoholics. The interests of family as stakeholders on this side of the controversy is that non-alcoholics will take better care of the liver transplants and may be more valuable to society more so than alcoholics. Stakeholders could be owners of rehabilitation facilities; if alcoholics-past and present-are of lower priority for liver transplants, then rehabilitation clinics may suffer from some potential reduction in the business created by people trying to “get clean” in order to receive an organ transplant. The conflict amongst the stakeholders involves many dimensions. Questions of morals, values, politics, and ethics are being probed and prodded to see which avenue is best. Unfortunately, this subject cannot be seen in black and white; gray areas exist and each condition is different, which causes a detailed evaluation of all cases. Emotions are

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involved in what may be life or death decisions. This leads to conflict amongst the opposing stakeholders.

Position Justification

The discussion points on both sides have plausible reasons for why each case prevails as well as areas that need to be further evaluated. After examining these reasons, logic would conclude that it is not ethical for organ transplant centers to assign lower priority to alcoholics. The idea that alcoholism is a disease is one of the primary reasons that the policy that is in place now is more ethically sound than that involving prioritization. Diseases, whether preventable or not, must be treated. Who is the one that should make the decision over the individual’s worthiness for receiving said treatment? Once an alcoholic is diagnosed with liver damage, conquering the addiction to prevent further harm is their responsibility, however, it is believed that addiction is the manifestation of other things such as certain psychiatric disorders and mental illnesses. Patients with heart disease are not punished for lack of exercise or poor diets, patients with lung cancer are not punished because they smoked, so why should alcoholics be singled out for punishment because they drink? Certain policies should be in place to prevent livers from being granted to individuals who will continuously abuse their bodies, but not all alcoholics should be placed in the same category and assigned lower prioritization for liver transplants. Blame should not be placed on an alcoholic, whether they are a recovering alcoholic or are presently abusing alcohol. The idea that alcoholics should not receive a liver transplant is multi-faceted. How is alcoholism defined, does this include former alcoholics as well as current ones or does it mean anyone who has abused alcohol in the past? If the latter were true, then no one with this addiction would be eligible for the gift of life. The perspective of logic is that it is not fair to say that alcoholics are all the same. Some have controlled their disease, others are still struggling to assume control of it, and a number of alcoholics do not even acknowledge the addiction. Alcoholics need treatment regardless of the circumstances. One quote from the article “Transplantation for Alcoholic Liver Disease: The Ethical Issues” states, “It’s not so much blaming people for their disease as saying that some are more blameless than others” (Benjamin, 1997). My interpretation of this citation is that no one is perfect and those that are less blameworthy should not be more deserving or worthy. Our country was founded on the principle that all people are created equally. The research on this topic shows that alcoholics are more likely to have lower survivalship rates for their newly acquired livers. The research supports that many alcoholics abstain from heavy drinking after being placed on the waiting list for a new liver. To base future results on past behaviors is negligent. If decisions were based on past mistakes, then all individuals would be guilty. The past can be used as an indicator for future trends, but it is not a guarantee. Specific circumstances can cause life to take a different path than what was originally predicted.

Ethical Principles

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Abusing alcohol, no matter if it is seen as bad or good, is a person’s right and with every right there is a consequence. That consequence may be having to wait to receive a liver transplant. This person’s right is one of the ethical principles known as autonomy. While alcoholism might not be seen in society’s view as a positive, it is a person’s choice. The principle of justice is one of the most important aspects related to this controversy. Everyone should be treated equally and the benefits of receiving the liver transplants should be distributed this way. Nonmaleficence is to do no harm, which involves not placing a higher priority for liver transplants on non-alcoholics. This would cause harm to those awaiting liver transplants that are alcoholics. Finally, beneficence should be shown to those alcoholics awaiting liver transplants. They are just as worthy of organ transplantation as non-alcoholics. All should have the same benefits in this respect. The chosen position on this topic prevails due to its logic being the most fair, and it holds true to what our country is founded on-equality. Since limited research is available to suggest alcoholics are more likely to have lower survivalship rates than non-alcoholics, the idea of prioritizing organ transplants based on past behaviors is narrow-minded. Additionally, research refutes that alcoholism can be the result of psychiatric disorders and mental illnesses, which are not the fault of the individual. When alcoholism is categorized as a disease and treatment options are the responsibility of the individual, the disease is not directly in the control of the alcoholic. Finally, worth is not something that can be fully quantified based on numbers and charts-it is also based on opinion. This opinion automatically introduces the element of bias, and thus the decision of someone’s worth should never matter in the situation of organ transplantation.

Conclusion

In conclusion, ethics is a complicated subject involving areas where the situation is “right versus right.” There is not one correct answer; rather there are many situations that will always have benefits and drawbacks. With regard to liver transplant prioritization for alcoholics, everyone should receive equal treatment and care. The only issue is organs are a scarce resource and the number of people needing organ transplants is increasing rapidly. There may never be a right answer to the ethical question presented, since ethics is a subject in which “right” answers are not as simple as they seem.

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Works Cited

Benjamin, M. (1997, May 3). Transplantation for alcoholic liver disease: the ethical issues. Retrieved Nov. 13, 2013 from http://onlinelibrary.wiley.com/store/10.1002/lt.500030322/asset/500030322_ftp.pdf?v=1&t=ho32pm7d&s=ddfa818ea641b3fb145f6ffd6211a2d8a6ff3799

Cohen, C., Benjamin, M., & the Ethics and Social Impact Committee of the Transplant and Health Policy Center, Ann Arbor, Mich. (1991, March 13). Alcoholics and liver transplantation. Retrieved Nov. 13, 2013 from http://www.carl-cohen.org/docs/Alcoholics%20and%20Liver%20Transplantation.pdf

“Ethic.” (n.d.) An encyclopedia britannica company: merriam-webster. Retrieved Nov. 13, 2013 from http://www.merriam-webster.com/dictionary/ethic

Glannon, W. (1998). Responsibility, alcoholism, and liver transplantation. Retrieved Nov. 13, 2013 from http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=d5e6dd89-9ee8-48ff-8add-9b7e94263161%40sessionmgr15&vid=2&hid=6

(n.d.). Heavy drinkers should be denied liver transplants. Retrieved Nov. 13, 2013 from http://debatewise.org/debates/1151-heavy-drinkers-should-be-denied-liver-transplants/

Martens, W. (2001, February 8). Do alcoholic liver transplantation candidatesmerit lower medical priority than non-alcoholic candidates? Retrieved Nov. 13, 2013 from http://link.springer.com/article/10.1007/s001470100306#page-1

Starr Foundation, Paul, B., Valapour, M., Bartels, D., Abbot-Penny, A., & Kahn, J. (2004, February). Ethics of organ transplantation. Retrieved Nov. 13, 2013 from http://www.ahc.umn.edu/img/assets/26104/Organ_Transplantation.pdf

Ubel, P. A., Jepson, C., Baron, J., Mohr, T., McMorrow, S., & Asch, D. A. (2001, July). Allocation of transplantable organs: do people want to punish patients for causing their illness? Retrieved Nov. 13, 2013 from http://onlinelibrary.wiley.com/store/10.1053/jlts.2001.25361/asset/500070706_ftp.pdf?v=1&t=ho32fund&s=8e87bf004d544468221847a61fcd85da5c6709ab

Webb, K. & Neuberger, J. (2004, July 10). Transplantation for alcoholic liver disease. Retrieved Nov. 13, 2013 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC449796/