Alcoholism is defined as an addiction to alcohol consumption, resulting in the dependence and eventual abuse of alcoholic drinks. Alcoholism is associated with many short and long-term health problems, the most severe of which being alcohol-related end-stage liver disease. Alcohol liver disease (ALD) has a very rapid onset and while most drinkers don’t ever really damage their livers, research has proven that after a certain limit, the liver will be damaged, sometimes irreversibly. One of the more serious outcomes of ALD is alcoholic cirrhosis of the liver, which is an irreversible condition brought about by acute scarring of liver tissues. Liver transplants are often the only viable survival option for patients with cirrhosis, but as with most organs, the demand exceeds the supply available and this leads us to the debate on the allocation of such scarce resources [1].
Whenever we’re allocating scarce resources, there are many factors to take into account and it makes sense that society allocates the resources on the basis of whatever generates the greatest return [2]. This essay will work on delineating the two major facets of this controversial topic, the medical considerations, along with ethical/moral concerns; and whether they justify giving alcoholics a lower priority when allocating deceased donor livers for transplant (LT).
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In order to understand the medical ethics involved in this issue, we must first grasp how the current allocation system for liver transplants is structured. Alcoholics compete with patients who have chronic hepatocellular diseases, chronic cholestatic liver disease and end-stage chronic liver disease. There are specific requirements and thresholds each potential transplant recipient must meet before they can be considered for a transplant [3]. The most common scale used today is the MELD (Model for End-Stage Liver Disease) system, which serves as an effective indicator for how urgently a patient needs a transplant. As of 2002, a patient’s MELD score has been the principle determinant of priority for a liver transplant. Whenever an organ is available, it is typically offered to the patient with the highest MELD score and a compatible blood type in a specific region [4].
However, this applies for patients who are already on the waitlist. Most transplant centres require alcoholics to have a sobriety period of at least 6 months, to be considered eligible for transplant [4]. However, there is mounting evidence that contradicts the 6-month abstinence period, which justifies the actions of transplant centres who have moved to dismiss the abstinence period as a requirement for LT [4-6]. Patients with ARESLD are often placed under more scrutiny compared to others that are deemed suitable for LT, because in order to be transplant eligible, not only do they have to have a high MELD score, they also had to have to adhered to the 6-month abstinence period [4].
The abstinence period was introduced on the basis of two concepts - the abstinence period allows for the gradual removal of alcohol from the liver and will possibly allow the liver time to regain some function; perhaps even enough to not require transplantation anymore. In addition, the sobriety period also ensures that the patient is able to abstain from alcohol and drug-free for a relatively long period of time [4].
The 6-month abstinence period is an ineffective measurement of relapse risk and because the abstinence period hasn’t been found to successfully correlate with reduced post-transplant relapse rates [4]. Moreover, one could argue that the sobriety rule is also ethically suspect when involving patients who suffer from more life-threatening diseases that could be exacerbated in this additional waiting period, because they could die before they reach the end of the 6 month period [5], thus violating the medical principle of non-maleficence (do no harm). By discriminating against those with a specific class of disease (ARESLD), we violate the ideals of medical justice and by withholding medical treatment that could be potentially life-saving, health professionals also disregard the medical ethical consideration of beneficence by failing to provide medical assistance [5-7].
We’ve now discussed the hurdles an alcoholic must go through in order to qualify for and eventually receive a LT; what about the success rates post-transplant? ALD transplant recipients have approximately the same patient and graft survival rates as non-ALD LT recipients, and data has shown that alcoholics actually have improved survival outcomes in comparison with transplant recipients who suffer from hepatitis C [4,8]. In addition, there are also lower rates of relapse among ALD LT recipients than originally thought, although this could be a result of confounding arising from the various definitions of relapses among individuals and a general reluctance among recipients to disclose any alcohol abuse for fear of being deemed ineligible for LT [4].
Now that we’ve explored the medical considerations to be taken into account, we will evaluate the moral concerns involved in this topic. The major ethical argument against LT for alcoholics, or the main argument for deprioritising alcoholics for LT is that their condition is a consequence of their own making, as a result of their actions and choices [9]. The problem with this outlook is that not only does it dismiss the fundamental concept of each person’s bodily autonomy (defined as the right to self-determination and governance over one’s own body) and the fact that health professionals are required to treat all patients equally regardless of their choices, it ignores the fact that alcoholism is a disease, like any other addiction. In the medical community, it should be unethical to use different criteria in evaluating patients for the same resource (in this case livers) [5,9].
The general view on alcohol as a socially disparaging behaviour distorts the perceptions of what is a disease into a medical condition that appears voluntary. Alcoholics, like most addicts are usually only diagnosed once their alcohol abuse has developed into a serious problem. The defining symptom of an addiction is a loss of control, and continued substance use regardless of any harmful consequences. Telling an alcoholic to simply stop drinking would be the equivalent of telling someone suffering from anxiety to depression to “calm down” or “be happy” [9].
Nonetheless, respecting people’s individual autonomy doesn’t exempt them from being responsible for the consequence of their own actions and choices [10]. One could argue that deprioritising alcoholics is a suitable form of retributive justice, which means that the solution to a problem should take into account any possible wrongdoing or harmful actions from an individual [3]. In this case, we would give alcoholics lower priority for LT because they “chose” to drink regularly even when there were treatment options available and developed liver disease to the point where a LT is necessary as a result of their own negligence [3,10].
A notable 1992 paper published by authors Moss and Siegler reflects this [10], by saying that alcoholics themselves shouldn’t be blamed for being addicts, but ALD patients who haven’t sought treatment for their addiction are personally responsible for their liver failure. They say that “Although alcoholics cannot be held responsible for their disease, once their condition has been diagnosed, they can be held responsible for seeking treatment and for preventing the complications of [alcohol-related] ESLD.” Moss and Siegler base their arguments on the principles of justice and autonomy too. They argue that although justice mandates similar outcomes for relevantly similar cases, there is an ethical difference between a non-alcoholic liver patient and an ALD patient who has not sought treatment because one had a certain extent of control on the outcome and severity of their disease while the other did not. Moss and Siegler believe that this argument is especially relevant in the context of scarce but life-saving resources like organs, and that the conditions of scarcity justify the differing treatments of individuals with the same disease [10].
However, there are several problems with this perceived causal relationship between alcoholism and liver disease. The diagnosis of alcoholism is not always simple or straightforward; and as like with most addictions, there is a spectrum of addiction and for the majority of alcoholics, they’re usually only diagnosed once their addiction has evolved into a serious problem [9]. Consequently, we can’t assume that all ALD patients were aware of the extreme consequences of their actions and were properly diagnosed as alcoholics or were advised to pursue substance abuse treatment [10].
In addition, although Moss and Siegler acknowledge that alcoholism treatment programs are not always 100% effective, to what extent are alcoholics responsible for developing ALD if their alcohol treatment fails? It is almost impossible to accurately and fairly determine the subclass of ALD patients who are directly and personally responsible for their condition [11]. In fact, we can relate alcoholism and liver disease in the same way we can blame hereditary traits and lifestyle for a heart attack. Patients who have high cholesterol and fail to improve their diet and/or exercise are also partially responsible for their heart disease and patients who have high blood pressure who fail to adhere to low-sodium diets can also be deemed partially responsible for their kidney failure. In addition, unlike these other diseases and medical conditions, yet another symptom of addiction is a perceived sense of control where the addict falsely believes that they can “stop whenever they want”, thus delaying their acceptance of the problem and their subsequent search for substance abuse treatment [11].
Moreover, it can be difficult to determine the extent of a person’s autonomy in seeking alcohol treatment and as a result we shouldn’t be quick to pin the blame on them for the eventual consequences of their addiction, especially when 90% of alcoholics don’t develop ALD [10]. This is especially relevant in today’s society where not only is alcohol widely available and accessible, even for those from lower socioeconomic groups, but alcohol consumption is normalised in media and culture [10].
By using ‘personal responsibility’ as a criterion for transplant eligibility and priority, health professionals and ethicist are subjecting alcoholics to a harsher standard of criteria compared to other candidates for LT. The imposition of the 6-month abstinence period as an additional requirement for transplant eligibility for alcoholics means that medical professionals are allowing the patient’s autonomous choices to eclipse their MELD score (and therefore the urgency of a transplant). This disparity is consistent with society’s general view of alcoholism as an undesirable behavioural trait that makes someone less worthy of equal treatment [5].
In his chapter on “Transplantation in Alcoholics: Separating Prognosis and Responsibility From Social Biases”, Peter Ubel provides an effective thought experiment where he emphasises the importance of how the perceived social desirability of certain behaviours can influence our judgements. For example, he asks if in a hypothetical example where workaholism was linked to increased liver disease, would workaholism be viewed differently and would we judge people based on the type or work they do i.e. a “Mafia kingpin” workaholic would be viewed as ‘bad’ while a workaholic “Mother Teresa” would be ‘good’ and beneficial to society [11].
With this example, Ubel shows how our judgements are influenced not only by whether a practice is responsible for someone’s condition but also by what we think of that specific practice. If the behaviour being judged is socially laudable, we’re not inclined to punish people for engaging in it, but rather, reward them. On this basis, one could argue that ‘heroes’ like Mother Teresa deserve the highest priority for an LT, just so she could continue with her socially beneficial work. However, this sort of prioritisation caused controversy in the early history of bioethics in the US, where a medical committee decided to allocate scarce dialysis machines based on whether people went to church or not [11]. Allocating scarce resources based on perceived social benefit should be completely unethical, as not only would what is seen as desirable reflect the standards of a specific time or place, it also goes against the official United Network for Organ Sharing’s (UNOS) framework for allocating human organs and tissues [10].
In conclusion, by exploring the specific arguments for alcoholics receiving lower priority for LT, I have shown how these stance is unjust because for the most part even when alcoholics fulfil the medical requirements to be transplant eligible, they have to undergo further scrutiny compared to other LT recipients as a result of how society perceives alcoholism as socially unacceptable. Consequently, it is not fair to deprioritise alcoholics in virtue of their alcoholism as they are already disadvantaged in terms of their ancillary eligibility requirements. In addition, we have shown how using personal responsibility as a basis to discriminate against alcoholics is unfair because it is difficult to determine the extent to which a person is responsible for their medical condition.
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