- Are Alcoholics Less Deserving of Liver Transplants?
When does behavior trigger a lesser claim to medical resources? When does chronic drinking, for example, mean that one has a lesser claim to a liver transplant? Only when one's behavior becomes a callous indifference to others' needs-when one knows the consequences of heavy drinking and knows that by drinking one may end up depriving someone else of a liver.
As many studies show, Americans tend to think that an illness has a morally weaker claim to medical care when it is caused by personal conduct that is known to put health at risk. More specifically, many Americans believe that health-risky conduct can make for a significantly weaker claim to scarce medical resources. According to one study, for example, "respondents were 10 to 17 times more likely to allocate liver transplants or asthma treatment to patients they deemed not responsible for their illnesses than to patients they deemed responsible for their conditions."1 My goal in this essay is to see if there are conditions under which this belief may be justified. I want to see where-if anywhere-this belief touches defensible moral ground.
Broadly speaking, one could examine two different issues. When, if ever, is it morally appropriate to make some agents pay at least part of the extra cost of medical care for illness that is due to their voluntary, health-risky conduct? And when, if ever, is it morally appropriate to make it more difficult to gain access to medical resources-and so in effect sometimes to deny access-for illness that is due to an agent's voluntary, health-risky conduct?
The question of when to impose financial costs on health-risky conduct is important, and will become increasingly so as we learn more about our own role in our own ailments. However, rather than try to find criteria for when it would be proper to impose financial costs on agents-a task likely to be burdened by citizens' conflicting beliefs about which activities have significant social value-I will focus on the perhaps more dramatic issue of when voluntary conduct should trigger a lesser claim to medical resources. As my paradigm example, I will look at alcoholics and liver transplants. This sort of case is [End Page 41] widespread and presents comparatively few epistemic problems-it occurs reasonably frequently, and frequently it is sufficiently clear that the patient's liver disease is in fact due to drinking.2
My analysis will suggest that there are indeed conditions under which it would be justified to give an alcoholic a lesser claim to a transplant, but that at present very few cases would satisfy those conditions. I don't want to blink the fact that when those conditions are satisfied, my claim is that we are justified in putting a desperately ill person in an even graver medical position on the ground that his past conduct was morally lacking. This may seem to border on the cruel, yet in some cases it will be justified. Nevertheless, the central claim of this essay is that in the great majority of cases, at least at present, it will not be justified.
An agent's conduct can make him morally vulnerable only if that conduct is in fact voluntary. Throughout, my analysis assumes that the conduct in question is sufficiently voluntary. I leave to others the task of determining what that amounts to.3
Conduct and Responsibility
Let's take Jane as our first example. Let's assume that her long-term drinking was sufficiently voluntary (whatever we decide that means).4 And assume, too, that it is sufficiently clear that her drinking ruined her liver. It might be urged, now, that Jane should bear the consequences of her conduct, meaning that she should be penalized by moving her lower down on the waiting list for liver transplants. This claim has in fact been made by a number of writers.5 I quote from Walter Glannon's formulation:
[The alcoholic] will have a weaker claim to receive a liver than someone whose end-stage liver failure is beyond his control and thus contracted through no...