This is, especially if you've ever known someone who needed a new liver, a controversial topic. It's a moral dillemma, as on one hand there is the ideal of caring for individuals and alleviating suffering but you have to square that with extremely limited resources (in the case of liver transplants, the data I've seen show that fewer than 2,000 are performed each year while the number of people suffering end-stage liver disease is several magnitudes beyond that number). With the amount of resources dwindling far below the number of patients, it is necessary to determine a sort of scale that will act as a guide for who gets the treatment and who has to die. I don't want to make any bones about this - people die every year waiting for a new liver. Some of those people are young children, some of those people are in their 50's and 60's, and some of those people have never touched alcohol.

As the title of this post suggests, I think that people suffering alcohol-related end-stage liver disease should be allowed to compete equally with everyone else for getting a liver transplant. I think that way, as it seems to claim the alternative has no good basis from a philosophical / moral standpoint and that the medical data (at least the data I've seen) shows relatively similiar post-op survival rates in both groups (alcoholics and non).

I  take it that the popular objection to my position is that alcoholics are morally responsible for their condition. They made the choice to drink, and they were aware that alcoholism could lead to cirrhosis which, in turn, could cause death. In other words, this is the "you've made your bed, now lay in it" argument. But, I also take it that people are only morally responsible for their actions if they act freely and with intent. If someone holds a gun to my head and forces me to take the life of another or they will kill my family, I take it that I'm not on the same moral level as if I were to take the life of another in cold, calculated pre-meditation. The result is the same, but both the level of autonomy and intended results are different. You can probably see where I'm going with this. 

Alcoholism is a disease. Disease significantly undercuts free will. When you're sick, you can't do some of the things you would do otherwise. Conversely, you do engage in certain activites that you wouldn't do otherwise. For example, it's not as though the schizophrenic chooses to hallucinate or the Tourette's patient chooses to have tics. Even if the analogy is not perfect, and alcholics do have at least some level of free will, it's pretty clear that with respect to alcoholism, autonomy is compromised. Subsequently, alcholics are at least not completely morally responsible for the prognosis of the condition.

Some respond to that claim by stating that treatment is available for the disease and that it is the responsibility of the patient to seek it. True, treatment is available - ranging from behavioral interventions such as Alcoholics Anonymous to pharmacologic treatments such as Antabuse. But, as is painfully clear, treatment is not always effective. Relapse is a very real possibility. Should we blame the alcoholic for failing in treatment? Should we blame the cancer patient for chemotherapy that is ineffective?  I think doing so would be patently cruel. 

What's more, insight into one's own condition is often crucial for treatment (especially for alcoholism). If you've known many alcoholics, many of them simply lack insight into their problem - I can quit when I want. I don't have a problem. Hey, I show up for work, don't I? What makes the case more complicated is that alcoholism involves a psychoactive substance that distorts judgement and thinking.  Should we blame the alcoholic for lacking insight into their own condition? Do we blame the depressed patient for lacking insight into what makes her depressed? Of course not.

I mentioned earlier that moral culpability involves two components - free will and intent. I contend that the intent of the alcoholic is not to get cirrhosis (unless it's ala Nicholas Cage in Leaving Las Vegas), but to alleviate symptoms of the disease. That might seem an obvious point, but it's an important one that I want to make clear. For example, say you open a can of soda because you are thirsty and wish to drink it. In doing so, however, you know that after a period of time the soda will become flat and poor in taste. It would be odd of me to ask "Why did you open that can of soda to make it go flat"? You would probably respond by looking at me oddly, then saying "I opened it because I wanted to drink it, not because I wanted it to go flat". I contend this is analagous to alcohol-related end-stage liver disease. The alcoholic does not drink to develop liver disease. The compulsive over-eater does not eat to develop heart disease. Moreover, not everyone who is an alcoholic develops liver disease and not everyone who develops liver disease is an alcoholic. It is false to say that an alcoholic knows she will develop liver disease. It may be a reasonable belief, but it is impossible to know the future.

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