I don’t see that as moral grounds, when the issue is drinking and a liver transplant. Alcohol can be hard on the liver, and it can be hard to quit drinking.
Organs are scarce, and the practice is to assign them to the candidate who has the best chance of long-term survival with that scarce organ. In the specific case of a liver transplant, I can see the argument that the preferred candidate is someone who does not have a long history of heavy drinking.
I’m sympathetic. But imagine for every available organ there are ten or more possible people. Matching is difficult, donations require a lot of logistical planning to go well. Imagine that you are judged in part at your job by whether these procedures are successful. That you want to get the most benefit from this precious gift.
Some decision making process is hard to avoid. Choosing people more likely to follow medical advice and fully value this gift is one of many justifiable ways to help guide an ethical decision. Have these decisions examined by trained boards of ethicists and modify as needed if found to be unfair in practice or at law.
The case was about Covid, but I would be very surprised if this was the one and only factor.
It’s not moral grounds - it’s as others have said , the long history of heavy drinking will lessen that patient’s chances of long-term survival. In some cases, people have to wait to go on transplant lists until they have demonstrated adherence to treatment ( taking medications, keeping follow-up appointments) for some minimum period of time - because someone who doesn’t take medication before a transplant is very likely to skip the immunosuppressants after the transplant.
I’m not really trying to argue otherwise, but the reasoning seems quite different from the example in the OP where there seem to be solid medical reasons for requiring the COVID vaccination – namely that the transplant may make the person much more susceptible to infection. What is striking about the liver transplant vetting is that someone with liver disease, whether alcohol-induced or otherwise, is not a greater risk for a liver transplant than anyone else; indeed by objective criteria the person I mentioned who had serious advanced disease with very limited life expectancy without a transplant should have been an emergency priority. That he was not makes this a moral rather than medical judgment. I’m not so much arguing the right and wrong of this as saying that I get uneasy when the medical establishment starts to play God.
Anyway, this is a digression from the QZ discussion.
Why?
What is the objective criteria?
People who drink heavily do tend to be at greater medical risk than those who do not, and it is not therefore true all patients requiring liver or other transplants are the same risk. In addition to liver problems, alcohol causes concerns with bleeding, malnutrition, supports, comorbid disease, falls, dementia, dysrhythmia, heart and brain dysfunction, lower survival rates, poorer surgical outcomes, increased risk of not taking the many immunosuppressive medicines required for a transplant to work and a less effective response if they do, and much more.
Aging patients might heal less well than younger people with rare conditions. Some decision making principles are hard to avoid. Doctors without ethical training should not make these decisions in isolation, if this is your concern. They generally do not. Places which do transplants tend to have vetted guidelines and boards with expertise to make things fairer. They may not be perfect, surely they are not, but they provide some basis.
Seen in isolation, the objection criterion is that he would soon die without it, and (again, seen in isolation as an individual case) the medical establishment has a moral and legal obligation to triage according to urgency in order to save lives.
Where it gets tricky is when only a limited number of lives can be saved and the medical system has to make choices. It’s a terrifying obligation to force on doctors.
But consider a hypothetical future where some marvelous technology could produce an artificial liver so that supply was not limited, but this gadget was very expensive. It’s interesting to ponder how this same medical + health care bureaucracy would treat someone who might be deemed “undeserving”. Is there a price point where some people would be deemed eligible and others not? Notwithstanding some of the well-informed medical comments that have been made here and that I appreciate, it’s hard for me to believe that there aren’t going to be moral judgments lurking in the background.
I’ll add to this that I was very happy to see my elderly mother receive extremely good medical care under our system when she was in her 90s – there was no evidence of any belief that the top quality medical care she was receiving was perhaps better directed to younger patients. But I suspect that such objective egalitarianism free of value judgments is not universally true under all circumstances, especially when resources become very constrained.
These are interesting “what ifs”, and equality is important. Yet it is a fiction that a citizen in, say, rural Northern Ontario has access to the exact same resources of those in an enormous city. Decisions should be fair, and re-examined, but will be required since individual circumstances differ. Exact equality is an illusion.
In general, in Canada costs for needed operations are usually covered. Would this change in your example? A long list of medicines are covered for the neediest citizens. A few very expensive medicines for rare diseases may not be covered and this tends to vary a lot from province to province, as do imperfect means of addressing this. Someone born with an imperfect organ may not have made any poor decision contributing to their lack of health, although this should not be the only factor. And it is not.
Twelve months of sobriety may be arbitrary, but it is an attainable goal and seems reasonable to me. People with addictions often “choose” them to cope with other concerns, simply blaming addicts for “poor choices” sometimes obscures a bigger picture and can be unfair - like mental illness, addictions almost always improve coping in some way and nearly always make some sense in the beginning. If decisions must be made they should maximize the likelihood of positive results.
It does, actually… for the 0.3% of the population for which it is actually a useful and effective treatment.
As for the alcoholic who died while waiting for his transplant… OK, maybe this guy really was scared into sobriety, and would actually have abstained for the rest of his (extended) life. Maybe. But it’s a simple fact that a large percentage of alcoholics who attempt to quit drinking relapse, and a person who relapses after getting a liver transplant is going to waste the transplant. They probably have statistics that show that folks who manage to stay sober for a full year are more likely to stay sober indefinitely, than folks who have just quit, and have determined that that’s the reasonable balance point between getting treatment quickly to those who need it, and conserving scarce resources.
The bioethical question was also explored by anthropologist Clifford Geertz. If I remember correctly from grad school, it was about access to dialysis and a drinking Indian (though without reading it again, I can’t say if that now looks racist or inclusive of a stigmatized minority).
They’re in the foreground. The allocation of scarce medical resources is an intrinsically moral question. Even your suggested principle that triage decisions should be made . . .
“according to urgency in order to save lives”
. . . itself rests on a moral judgment about the priority of saving lives over alternative criteria that might be adopted to guide these decisions.
The question is not whether these decisions should be made on the basis of moral judgments, but what moral judgments should drive these decisions. And your thought experiment about allocating extremely expensive resources is not a thought experiment; there are plenty of medical technologies that are extremely expensive, and decisions about allocating them already have to be made in the real world.
I think we need to avoid a discourse in which allocation decisions that we are comfortable with are seen as objectively justified or objectively compelled but the ones we’re squeamish about have “moral judgments lurking in the background”. Given the availability and efficacy of the technology, decisions about when to use it and when not to are all, front and centre, moral decisions.
AFAIK this is a vetted and standard medical practice in Canada and it’s been that way for some time. The court should have refused to hear the case. their response to the plaintiff should have been “smoke em if you got em”.
I was coming back to post, but @UDS1 has already posted what I wanted to say, but more eloquently.
If I had any say into who gets my organs after my death, I would definitely require they go to someone who has demonstrated they can and will maintain sobriety for more than 12 months. While 12 months is a big achievement, in the case you’re referring to, that’s with the immediate threat of death hanging overhead. Once the liver is transplanted, that immediate death threat is gone, and they’re back to willpower alone, with no death threat.
All you have to do is Google this. The rate of relapse in alcoholic liver transplant patients is plenty high enough to justify setting limits on it.
ETA : Ninja-ed by several others.
It varies depending on where you are, but a quick Google showed between 1 in 6 and 1 in 4 people needing a new liver die before they can get one (the odds are different for different organs). The reasons for this variation are complex, but it’s actually better odds than I thought it would be. Probably because of things like live liver donation now being possible and somewhat refined and maybe advancing medical science in general.
The issue of drug use/abuse and organ transplant is a thorny one. Just about any addict can get clean for a very short period of time, it’s the staying clean that’s the hard part. But, as you note, it seems unfair when a person simply does not have the time to demonstrate their ability to stay away from their drug of choice for a long enough period to get on the waiting list.
Until the supply of new organs is plentiful the medical establishment is going to have to pick and choose. When they run out of medical reasons to prioritize people then they’ll have to do something else.
No disagreement with your first statement, but dealing with insufficient medical resources is a profoundly vexing problem for which there are no good solutions. I certainly don’t claim to have one. But let me say a few things about the statements that I just quoted.
I heard about the fellow being denied a life-saving liver transplant because his wife publicized the case in desperation to try to save his life. As a result, it made the news and became the subject of debate. Regardless, the medical establishment was unmoved. Rules is rules, they said, and no matter how you cut it, the net effect is that he was left to die. Due to being deemed “ineligible”, he wasn’t even allowed to go on the transplant waiting list.
Note how different this is from the case in the OP, where all this moron has to do is agree to a vaccination that virtually all of us have already had. But someone who is being judged on their lifestyle history, be it heavy drinking, smoking, or anything else that has led to disease, cannot retroactively go back and change their life.
Let me ask you this (“you” being any poster here who want to venture an opinion). Should smokers be denied treatment for smoking-related diseases? Should the obese be denied treatment for obesity-related ailments? If not, why is it OK to do so when the disease in question is presumed to be alcohol related?
Is triage based on urgent need some sort of arbitrary moral judgment? We can find the answer, at least for Canada, in the fundamental principles set out in the Canada Health Act. Among the five pillars that underlie these principles, three are especially relevant here:
Comprehensiveness – meaning that all medically necessary treatments available in medical facilities must be covered, without exception
Universality – meaning that every citizen and legal resident must be covered, without exception
Accessibility – meaning that financial or other considerations must never be an obstacle to access to necessary medical care for anyone
So, no, “triage according to urgency in order to save lives” does not rest on moral judgment; it is an axiomatic principle that is the foundation of our health care system and is – or should be – the overarching principle guiding the practice of medicine everywhere.
Sure, if there is a sudden surge of critically injured patients into an ER and the system is overwhelmed, then quick decisions have to be made. But the above is the aspirational goal that has mostly been achieved, although as @Dr_Paprika pointed out, there are invariably regional and other inequalities that we have to work hard to eliminate as best we can.
But I worry about institutionalizing even more inequalities with iron-clad rules about who is deserving of access to a certain treatment just because it’s scarce because – as with my examples of drinking, smoking, obesity, or other unhealthy choices – this is potentially a slippery slope. The argument that “you did this to yourself” can be disturbingly compelling to budget mavens and mean-spirited policymakers when health care resources are stretched.
How high is “high enough”? I’m not seeing any clear evidence. In one study of 128 patients, only one developed cirrhosis again; 79% were mostly or entirely abstinent, and 21% relapsed but without significant ill effects.
In another study of 300 transplant patients, just 19% were reported to be drinking to various degrees, not necessarily excessively.
I would think that after such a life-changing near-death experience and surviving such major surgery, anyone who continues drinking heavily has a serious substance addiction problem. While this is a medical problem and not something we should be judgmental about, I would agree that if we can screen for those likely to relapse in this way, as long as transplants are a scarce and precious resource, successful treatment for the addiction should be a precondition for a transplant. But such alcohol addiction appears to be a fairly small percentage of the cases.
A couple of things:
First, it appears that the widely accepted standard for evaluating alcoholics for liver transplant is six months of sobriety, not twelve. And some have questioned whether even waiting that long is justifiable.
Note that key factors in success post-transplantation without an extended period of abstinence were found to be otherwise good health, a strong support network and demonstrated patient recognition of alcohol’s role in causing their liver failure.
Thanks for that. FWIW, I’m certain that “12 months” was what I heard on news reports about the story I mentioned. But I just checked and now, at any rate, it is indeed six months here in Ontario. Maybe they changed it, or maybe the media got it wrong. Still, everything I said previously still stands.
IF the treatments for those “smoking related disease” or “obesity-related ailments” are abundant and readily available then treatment should be provided.
IF, however, a given treatment is rare, that is, there are far more people who could benefit from it than “doses” available, then decisions must be made. In that case, there is an argument (not the only argument, but one of several) that the treatments should be applied where the greatest good can be had.
Let’s take it out of the realm of transplants for a moment and visit a scenario where the concept of “triage” was invented. The concept actually goes back to the 15th Century when decisions had to be made on battlefields regarding which wounded could or should be saved. This was codified (and named) by the French in the early 19th century, again, on the battlefield. The basic notion is that there are people who will likely survive with or without treatment, those who require treatment to survive, and those who will likely die no matter what.
Applied to organ transplants… well, everyone is going to die without treatment, if you weren’t that bad off you wouldn’t be discussing a transplant. Some people are too sick/debilitated/have other conditions as well which means it’s not worth transplanting them because it’s not going to help them live longer (and might even kill them sooner).
That leaves the remaining group - those who could benefit. If transplant organs were abundant and resources unlimited then it wouldn’t matter, we’d treat them all. But that’s not the world we live in.
OK, so who will benefit MOST? Those who will live longer and better lives after transplant? This is were age can be a factor - someone 30 is likely to benefit more than someone 80. There have been some instances of people getting transplants at advanced ages, but those are typically organs that simply couldn’t go to anyone else due to compatibility, or were damaged/less than perfect. So… if post-transplant the typical organ in question could last 15-20 years and you have to choose which of several candidates could get it you’d probably prefer it to go to someone who is likely to live 15-20 years after the surgery rather than someone who isn’t likely to live more than, say, 5-10. But if the organ is such it can’t work with many people then why not give it to someone 80 rather than chuck it in the bin?
This is also where history comes into play. Someone who quit smoking 10 years ago and hasn’t relapsed since should, in my opinion, be treated equally with someone who never smoked because the ex-smoker has demonstrated the ability to not engage in damaged behavior. Likewise for former drinkers - if you’ve been dry for X length of time then your history shouldn’t be held against you.
And now we’re back to the problem of “has a history of heavy drinking but stopped last week when handed a terminal diagnosis”.
[emphasis added]
We have no such screening tool. It sure would be useful, but it doesn’t exist. We can quote odds and statistics, but we have no way to know who can and can’t truly alter their behavior in advance.
Or there is something else going on with the patient that the news media, and by extension us, does not know or have access to. Or the reporter got it wrong. Or the wife got it wrong.