Saturday, August 20, 2016

Liberalism, Alcoholism, and Liver Transplants

Tyler Cowen suggests that this abstract of an article in Bioethics is a good reductio of what liberals believe:
Some philosophers and physicians have argued that alcoholic patients, who are responsible for their liver failure by virtue of alcoholism, ought to be given lower priority for a transplant when donated livers are being allocated to patients in need of a liver transplant. The primary argument for this proposal, known as the Responsibility Argument, is based on the more general idea that patients who require scarce medical resources should be given lower priority for those resources when they are responsible for needing them and when they are competing with patients who need the same resources through no fault of their own. Since alcoholic patients are responsible for needing a new liver and are in direct competition with other patients who need a new liver through no fault of their own, it follows that alcoholic patients ought to be given lower priority for a transplant. In this article, I argue against the Responsibility Argument by suggesting that in order for it to avoid the force of plausible counter examples, it must be revised to say that patients who are responsible for needing a scarce medical resource due to engaging in behavior that is not socially valuable ought to be given lower priority. I'll then argue that allocating organs according to social value is inconsistent or in tension with liberal neutrality on the good life. Thus, if one is committed to liberal neutrality, one ought to reject the Responsibility Argument.
I probably would not endorse all the arguments in this piece, but I confess skepticism about the argument that good people ought to get priority over bad people in receiving organ donations. Who makes these rules? What will the rules be? Perhaps a murderer on death row ought to get a lower priority, but what about a former small-time burglar? A former soldier or policeman for a despotic regime like Saddam Hussein's? A former cop who was fired for using excessive force too many times? And what about other considerations, like, should a mother of young children get priority over a single man? Etc.

And this gets indirectly to how I feel about any argument that focuses heavily on individual responsibility: the circumstances of life are just too complicated for us to judge every person and say who does and does not deserve a decent job or decent housing or whatever. (Or to be a billionaire.) I am comfortable with setting up a limited number of clear laws and punishing people who transgress them, but beyond that judgment about who is "deserving" become ever more arbitrary.


G. Verloren said...

I feel that the "Responsibility Argument" doesn't need to involve any value judgements beyond the simple fact of personal responsibility.

Compare to something like car insurance. We don't charge "good" people less and "bad" people more - we simply base rates on what the likely odds are of a given individual costing the insurer money. You could be a convicted violent felon with a history of psychosis and drug abuse, but so long as you're a safe driver who drives an inexpensive vehicle, you're going to pay a lot less on your insurance than a living saint who routinely totals luxury cars - and that's perfectly fair. There's no need to drag in other valuations beyond the simple fact of how likely you are to cause damage to vehicles and property.

Similarly, I feel one of the few relevant issues in terms of who receives a liver transplant should be the question of how likely an individual is to cause damage to that liver. Simply put, an alcoholic is vastly more likely to destroy a new liver than other people. Just as it doesn't make sense to give an organ transplant to an elderly patient nearing death over a child, it also doesn't make sense to give a liver to a drunkard over a teetotaler.

Almost all other valuations need not be made, I feel.

pithom said...

For once, I am in concurrence with the opinion of Verloren.

Shadow said...

Perhaps we should use credit scores?

I'm in complete agreement with John. This isn't just a value judgment; it's an ethical dilemma we cannot solve. First come, first serve. I see no reason why a child should get an organ over an elderly person. Why is a life that will likely last longer, even much longer, than another worth more? If you can't get on an organ list because of your age (or for a few dozen other reasons), that's forced euthanasia.

The only satisfactory solution is to supply the demand. Better get moving on cloning organs in vats.

Anyone see the movie In Time?

G. Verloren said...

@Shadow Flutter

Forced euthanasia? That's absurd!

If a restaurant runs out of tables and gives priority to those with reservations, is that discrimination? If a store lacks sufficient supply of a popular product and gives priority to those with pre-orders or layaways, is that theft? If a hospital runs out of painkillers and has to reserve them only for the most severe cases, is that torture? If a boat sinks without enough lifeboats on board, and the choice is made to give the space to women and children, is that murder?

No, of course not! Don't be ridiculous.

Besides - if we go with your line of thinking, there isn't any available choice which isn't "forced euthanasia", because no matter what we do, there still aren't enough livers to go around.

And why is it forced euthanasia when the system you don't favor is in play, but is somehow isn't forced euthanasia the moment your preference is used instead? Someone still dies either way. How is choosing which person gets an organ transplant any less moral than leaving it to what is effectively random chance in a first come, first serve situation? You're favoring a completely arbitrary solution over an imperfect yet morally-grounded and utilitarian one.

Scarcity forces us to make the best of suboptimal situations, but we're stuck with it for the time being. Just because we can't have a perfectly satisfactory solution doesn't mean we can't settle for the generally most satisfactory solution available.

Why should we value a child's life over that of an elder? Because the elder has already lived a lifetime, and the child hasn't. If we have no choice but to choose one of them to be deprived of life, how can we possibly value the few remaining years of an elder over the entire remaining lifespan of a child?

The same reasoning applies to liver transplants. How can we possibly value saving the life of an innocent less than we value saving the life of someone who effectively killed themselves through self destructive behavior - and who is also overwhelmingly likely to continue to do so, making the transplant effectively a colossal waste?

Shadow said...


I think part of the problem is found in your analogy comparing human life (and organs) to the availability of restaurant equipment. From the moment we could reliably replace organs with others while knowing we have insufficient supply to meet demand, we have had a decision to make. So we — some committee(s) actually — developed a process richly embedded with value judgment criteria to determine who lives and dies, and it’s those value judgments (moral judgment really) that makes it forced euthanasia.

I suggest first come, first serve precisely because such a policy removes value judgments from the decision, and therefore is not forced euthanasia. Yes, there will still be the same number of deaths, but we will no longer be deciding whose lives are more valuable. First come, first serve also has the advantage of being resistant to the slippery slope so many of John’s examples are prone to.

Your last two paragraphs are laden with value judgements masquerading as truths — child’s life over elder’s life, a longer lifespan over a few remaining years, the innocent over the not so innocent (those practicing self-destructive behavior), all begging the questions When is a few remaining years too few? How old is too old? What’s the cut-off age? What is innocent?, What is self-destructive behavior? When is it too destructive? Committees, statistics, probabilities, and predictive models all designed to produce the best outcomes based on value judgment after value judgment, but also serving (whether intended or not) to distribute responsibility across so many that no one person feels too responsible. And besides, we have data to back it up. But in the end it comes down this: one liver and two patients, one closer to death than another, two families surrounding hospital beds watching the clock tick, and we choose to give the liver to the one not closer to death because our process has decided who lives and dies.

However, I do understand how difficult, and at times personal and emotional, such decisions can be. So I accept other points of view, even sympathize with the reasoning and emotional discomfort. I’m certainly not the arbiter of truth, and I could be wrong. I feel my way through this as much as I reason through it, so I won’t be calling your position absurd or ridiculous. But I do wonder how some people can be so certain about such things. Like I said, the only good solution to this problem is to increase supply to meet demand.