Just Allocation of Scarce Medical Resources. Moss and Siegler: “Should Alcoholics Compete Equally for Liver Transplantation?”

Cheers! Hard liquor

Cheers! Your liver on hard liquor

Prelim ESLD (sometimes just ‘liver disease’) ARESLD (sometimes ‘alcohol liver disease’)

The main conclusion Given the extreme scarcity of donated livers, as a matter of general policy, people with ARESLD should be placed lower on the waiting list for livers than those with ESLD.

The main conclusion If we do a first come first served approach, over half of the available livers will be taken by people who could have prevented their livers from failing. This approach is both unfair and could lead to a decline in public support for liver transplantation.

Q: Why are livers an extremely scarce medical recourse as opposed to being a relatively scarce medical resource? Q: Just how scarce are they?

Objection to Moss and Siegler Alcoholism is a disease; thus it’s not true that people with alcohol liver disease could have prevented the destruction of their liver.

Their reply Yes, it is a disease. But alcoholics are responsible for seeking out effective and available treatment and continuously pursuing it their entire lives.

Their reply ARESLD is caused by years of heavy drinking; they have time, then, to seek help. They could have prevented their failed liver in that they didn’t seek (or continuously seek) treatment for their disease.

Another objection There are people who are responsible for their medical conditions (e.g. coronary artery disease, lung cancer) that compete equally (for treatments) with others who have the same conditions but through no fault of their own.

Their Reply But the medical resources needed to treat these conditions (e.g. lung cancer, coronary artery disease) are only relatively or moderately scarce.

Side Bar NOTE: donor hearts are an extremely scarce medical resource [presumably a heart transplant is the only way to treat heart failure]. But patients with heart failure who smoked, had a poor diet, etc compete equally with those who didn’t. Why?

Side Bar There is no clear evidence showing a direct causal link between behavior (e.g. smoking, poor diet,etc) and heart failure. This is not the case with end stage liver disease.

Their Reply Absent extreme scarcity, alcoholics should compete equally with other ESLD patients. --there are other medical resources that alcoholics should (and do) compete equally for (e.g. hospital beds)

Their Reply When it’s impossible for all to be saved, the just course of action is to ensure that people with ESLD compete only amongst themselves. If not, think of the number (say 500) of ARESLD who will be saved. Then ponder the fact that 500 people who had a faulty liver through no fault of their own could have lived instead. Isn’t this unfair to those 500?

Their last point Public support for liver transplantation will decline if we do a first-come first-served approach. How / Why?

Their last point The general public will be unhappy with a first-come first served approach, which will lead to: 1. Fewer people donating livers. 2. More people favoring legislation that will deny insurance companies from paying for transplants.

Exceptions? Do Moss and Siegler make some exceptions for alcoholics? What are they?

Just Allocation of Scarce Medical Resources Cohen, Benjamin, et al. “Alcoholics and Liver Transplantation”

Prelim Cohen and Benjamin hold that alcoholics shouldn’t be excluded from transplants. We can infer that they are for a first-come first-served approach.

The Argument Assume alcoholics are at fault for their failed liver, it doesn't follow that they should be discriminated against when it comes to liver transplants. Why?

The Argument 1.) If we should discriminate against alcoholics for liver transplants, then it's only fair that all others who are also at fault for their own medical condition should be similarly discriminated against when it comes to getting life saving treatments.

The Argument 2.) But determining who is and who is not responsible for their condition is a very intrusive and repugnant task. It would require “vigorous” and “sustained” efforts to find out who was morally weak so as to cause their own condition.

The Argument So, we shouldn’t seek to discriminate against other patients, given the intrusive process of finding out who’s responsible for their condition.

The Argument So we should not discriminate against alcoholics either.

Possible Replies 1. Why think that “vigorous” and “sustained” inquiries into people’s lives is bad given what’s at stake? 2. Why think such inquiries would be “vigorous” and “sustained”? 3. What else is an extremely scarce medical resource besides livers and hearts?

Another consideration by C & B There are people (e.g. many women) who drink moderately, even very little but get ARESLD because they are naturally more susceptible to liver cirrhosis. Seems unfair to discriminate against them. Should they have little to no chance at life because they drank moderately? Moss and Siegler would seemingly say yes.

Questions Is it unreasonable to say that naturally susceptible people should abstain from even moderate alcohol consumption? Should we make an exception for these people?

The medical argument Cohen and Benjamin give a medical argument for why alcoholics should not be excluded from transplant lists. What is it?

The medical argument There’s no evidence to suggest that alcoholics with newly transplanted livers have a lower survival rate than non- alcoholics with a newly transplanted livers. They shouldn’t be excluded, then, on the grounds that their liver could have been put to better use.

The medical argument A case by case approach (whether one is an alcoholic or not) is needed to determine one’s prospects for survival. How would Moss and Siegler likely respond to the medical argument?

Response of Moss and Siegler We agree that the evidence doesn’t show that survival rates for alcoholics are lower than for non-alcoholics (see the beginning of their article). And whether you’re an alcoholic or not, prospects for survival is a good discriminating tool.

Response of Moss and Siegler However, if the medical argument is meant to show that the only discriminating criterion that should be used is prospects for survival, then it clearly fails. For granting the medical argument does nothing to impugn our own moral argument.