Transplants and personal responsibility
Whenever we face shortages of particular types of medical care we need to decide how best to allocate those scarce resources. Nowhere is this more acute than in our decisions about who should receive organs for transplant, particularly for life-saving transplants. The problem becomes especially prickly when there arenít enough organs to go around and some patients need transplants because of their lifestyle or behavior.
For instance, the need for a liver transplant can be caused by a variety of factors: congenital problems, disease or, most controversially, by unhealthy habits such as drug and alcohol abuse. In fact, the majority of liver transplants are for Hepatitis C infection (often a result of intravenous drug use) and alcoholic liver disease.
To address the issue of personal responsibility, many transplant programs require that potential recipients of liver transplants be drug- and alcohol-free for a specified period of time before transplant. This requirement often includes the drug methadone, a treatment for heroin addiction. But a recent article published in the Journal of the American Medical Association presented data that requiring a methadone-free period may actually encourage renewed drug use among liver transplant recipients. So how far should we take personal responsibility when it comes to receiving organ transplants? Should smokers be denied heart or lung transplants? Should drinkers be denied liver transplants?
The unknown genetic factor
There has always been a sense that it is unfair to give the same priority to a patient who needs a liver transplant because he abused alcohol as to one who contracts a disease. This is partly because of the concern that the alcoholic will drink away the new liver and effectively "waste" it. But what if we didnít bear complete responsibility for our unhealthy behaviors? Wouldnít that change the way we think about fairness and organ transplants?
As the Human Genome Project starts to supply us with more information about the genetic causes of health, disease, and behavior, we can expect to learn that drug and alcohol abuse have at least some genetic component -- some individuals will be identified as more susceptible to addiction. Any sense that this confers a genetic predisposition to unhealthy behavior starts to make alcohol abuse look much more like other diseases influenced by our genes, and reduces the sense of personal responsibility. This is fine so long as genetic information is used to improve prevention and treatment of unhealthy behaviors. The worry is that such information will also be used to excuse it.
The donor decision
Even if we could find a way to limit transplants for patients whose medical problems are related to their behavior, it is becoming increasingly common for patients to find living donors willing to give all or part of one of their organs. While living organ donation doesn't create the same kind of allocation problems as in cadaveric donation, it raises different concerns. Should an otherwise healthy prospective donor be allowed to undertake the medical risk of donation, when the recipient's behavior contributed to the need for transplant and the same behavior may ruin the donated organ? What if an alcoholic has a sufficient number of friends and relatives willing to donate parts of their livers, so that he can effectively drink his way through a number of donated livers?
The medical profession increasingly will be faced with decisions about who should be allowed to donate organs and who should receive them, whether from living donors or cadavers. We should encourage people to come to the aid of a loved one who smokes or drinks or abuses other drugs, but not by endorsing irresponsible and dangerous behaviors. This problem will go away when we can grow organs in laboratories and provide organs for all who need them -- which may be sooner than we think. But until then we need to realize how little we understand the root causes of behavior, and not take out our ignorance on those who seem to make bad lifestyle choices.
"Ethics Matters" Archive
where you'll find other columns from Jeffrey Kahn
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