How Should The Medical Field Handle Patients With Esld Caused By Alcohol Abuse In Regards To Liver Transplants How should the medical field handle patients with end-stage liver disease (ESLD) caused by alcohol abuse in regards to liver transplants This is the issue at hand within the writing of Alvin H. Moss and Mark Siegler, and the collective work of Carol Cohen and Martin Benjamin. Due to the scarcity of livers, the fact that they are a nonrenewable resource, and the expense of the lifesaving liver transplant, guidelines must exist concerning which patients in need of a new liver receive this transplant. Also, many questions are raised concerning patients with alcohol-related end-stage liver disease (ARESLD). Should ARESLD patients receive liver transplants And if so, should they be given the same chance at receiving a liver as those whose end-stage liver disease is not alcohol-related Also, should ARESLD patients be discriminated against More specifically, the issue concerning discrimination towards ARESLD patients is the topic of dispute between the two writings. From the view of authors Alvin H. Moss and Mark Siegler on this issue, they propose that a general guideline in which patients with ARESLD should not compete equally with other candidates for liver transplantation (p. 670). Their proposition provides ESLD patients with a higher priority in receiving a transplant than those patients with ARESLD.

Although their proposal discriminates against those patients whose disease was caused by alcohol abuse, they do not suggest, however, that ARESLD patients will never receive their liver transplant. The authors base their decision on the belief that the circumstances of liver transplantation differ from those of most other lifesaving therapies (p. 670). The unique circumstances they are concerned with are that the donor liver is a nonrenewable, absolutely scarce resource; and that due to the expensive technology involved with the transplant cost containment and public support are two very important factors and are essential to maintain. Moss and Siegler believe that as a result of the nature of liver scarcity, distribution of donor livers to those patients desperately in need must be based on some sort of medically unusual and strict standards.

Receiving treatment for alcoholism is a critical point in Moss and Siegler's proposal. The view towards alcoholism as a disease shapes their opinion concerning the issue of liver transplants. Alcoholism as a chronic disease is caused by both hereditary and environmental factors. By viewing it as a disease, alcoholism differentiates from being a personal bad habit or a moral weakness.

Also, by perceiving alcoholism as a disease it legitimizes medical intervention to treat it (p. 671). Moss and Siegler feel that by accepting therapy for alcoholism, alcoholics acknowledge their disease and accept responsibility for receiving treatment. Treatment received for alcoholism exposes the risks of heavy alcohol consumption to the individual and that with it the risk of ARESLD is increased. The authors note that ARESLD patients which could be acceptable candidates (p. 674) are those who are abstinent as a result of having received treatment. Moss and Siegler believe that because 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 complication of ARESLD (p. 672).

Basing their proposal on the argument of fairness and morality, ESLD patients should have a higher priority in receiving a liver transplant than those ARESLD patients who fail to obtain treatment for alcoholism once they are diagnosed as an alcoholic. They credit their proposal, allocating organs on this basis, in being fair by holding people responsible for their choices, and in this case specifically, refusing alcoholism treatment. They also comment that this situation in discriminating against ARESLD patients who refuse alcohol treatment is unfortunate but not unfair (p. 672). Moss and Siegler state that what is fair need not be equal (p. 672). This is another strong argument supporting their proposal. As already mentioned, due to the absolute scarcity of donor livers, it is impossible to give every ESLD patient a functioning liver.

The fact that some (few) ESLD patients receive livers while others do not presents an inequality. In treating ESLD patients fair, they believe distributing donor livers on a first-come, first-served gives each patient an equal chance, but is not always a fair approach. Instead, they accept the principle that similar cases should be given similar treatment. Applying this principle, Moss and Siegler believe that patients with ARESLD are unequal in relevance to others with ESLD and it is acceptable to treat them differently, since the liver failure of ARESLD patients was preventable.

Public support for liver transplantation and with further research concerning ARESLD patients complete Moss and Siegler's arguments in support of their proposal. The argument here is that when deciding how to appropriately use a scarce and nonrenewable organ, public mores and values should be greatly considered and respected. In referring to liver transplants as a Gift of Life, each liver is considered a national resource for the public good and it should be used in the public's best interest (p. 673). Surveying the public shows that infants and other patients with cancer should be given the highest priorities in regards to lifesaving treatments, while patients with liver diseases caused by alcohol should be given the lowest.

In the eyes of the public, by giving donor livers to patients with ARESLD on an equal basis with other ESLD patients, it would cause an unwanted decline in public support for liver transplantation, support which Moss and Siegler feel is much needed due to the circumstances and nature of liver transplantation. Until research is conducted in order to prove positive outcomes involving ARESLD patients who receive donor livers, or until it is discovered which ARESLD patients have the best outcomes after liver transplantation, the view of the public will remain the same. Because not all patients with ESLD will receive the lifesaving treatment in order to survive, priorities must be established concerning all ESLD patients. Due to the fact that ARESLD patients represent more than half of ESLD patients of 63,737 deaths due to ESLD within the United States in 1985, 36,000 were ARESLD patients (p. 670) the public would not support liver transplantation if ARESLD patients were to receive their equal share (over half) of the available donor livers. Cohen and Benjamin rebut the proposal of Moss and Siegler in several different fashions. They recognize that alcoholic cirrhosis of the liver is by far the major cause of ESLD.

However, ARESLD is unlike any other cause, in that it is brought on by a person's own conduct. Because the question exists whether or not to provide patients with treatment as the result of personal conduct, liver transplantation is distinctly different from other diseases or therapies. In instances other than heavy drinking, a person is not disqualified from receiving desperately needed medical attention based on personal behavior or conduct. Cohen and Benjamin provide the example of accident victims injured as a result of not wearing their seatbelt; smokers who receive treatment despite disobeying their physicians advice; and treatment provided for those who overeat. The authors argue that these examples and those similar are not widely regarded as being morally wrong, although heavy drinking is (p. 675). Alcoholism should not differentiate from these other personal habits or conducts.

Whether alcoholism is a disease or an alcoholic's personal or moral failing, Cohen and Benjamin argue that personal conduct should not be weighed or valued as heavily as it is when concerned with providing needy patients with treatment. To exclude alcoholics from receiving liver transplantation would assume that qualification for a new organ requires some level of moral virtue (p. 676). Patients with ESLD should not qualify for treatment based on their morality, personal habits or conduct. Discriminating against patients with ARESLD based on morality dismisses other patients with other moral wrong-doings and singles out alcoholism.

They argue that should qualification for treatment be conducted in this manner, singling out ESLD patients that are alcoholics, then other moral virtues would require investigation. This would also require that it be discovered which patients have been morally weak or sinful, and that these characteristics be weighed to a certain degree. Cohen and Benjamin strongly believe that if alcoholics should be penalized because of their moral fault, then all others who are equally at fault in causing their own medical needs should be similarly penalized (p. 676). They conclude that to eliminate alcoholics from receiving the same chance at obtaining a donor liver is unfair and unacceptable. The moral misconduct of alcoholics with ESLD does not justify categorically excluding them as candidates for liver transplantation (p. 676). Cohen and Benjamin also present a medical side in their rebuttal to Moss and Siegler's proposal.

The main reluctance when treating ARESLD patients is caused in part by the conviction that they would do poorly after the liver transplant as a result of their bad habits (p. 676). As a result of this belief, ARESLD patients are discriminated against. Due to the scarcity of donor livers, public approval and support would be aimed at providing non-alcohol related ESLD patients with liver transplantation. This conviction, however, is not yet supported by sufficient evidence regarding the post-transplant histories of alcoholics. The concern is whether or not those ARESLD patients will return to their ways of alcohol abuse.

Cohen and Benjamin acknowledge that the return of heavy drinking could ruin the newly transplanted liver, but not for years. The medical issue at hand here is the rate and length of survival among ARESLD patients after receiving a new liver. Sufficient information and research does not yet exist, however, in order to support whether or not alcoholics should be categorically excluded from candidacy consideration. In conclusion, Cohen and Benjamin provide one last argument concerning public response to ARESLD patients receiving donor livers.

Because the public opinion of alcoholics is generally negative, political problems concerning their treatment arise. However, the authors note that not all alcoholics fit the negative stereotype of being morally irresponsible, vicious, or neglectful drunks (p. 678). Their irresponsible behavior should not be defended, but rather it should be noted that not all alcoholics exhibit negative actions. In an attempt to gain public involvement and concern with the care of alcoholics and their just treatment, Cohen and Benjamin explain that approximately one in every ten Americans is a heavy drinker and that approximately one family in every three has at least one member at risk for alcoholic cirrhosis (p. 678).

They believe that a negative public response to transplanting livers into ARESLD patients should not effect the public policy of this manner. ARESLD patients should not be categorically discriminated simply because of the negative response that may result. In response to the work of Cohen and Benjamin, Moss and Siegler would most likely argue that in the case of liver transplantation, unique medical standards and procedures could and should be applied. First, a donor liver is both a nonrenewable and scarce resource, therefore, presenting the medical world with an extenuating circumstance. The number of donor livers necessary for lifesaving liver transplants are few in number in relation to the number of dying or needy ESLD patients. Second, because ARESLD patients make up over half of those patients with ESLD and because ESLD patients acquired their disease at no fault of their own, ARESLD patients should have a lower priority than other ESLD patients.

ESLD patients already have a slight chance at receiving a liver transplant. By adding ARESLD patients into the equation, with equal priorities, it would be unfair to those ESLD patients who had no control in obtaining their disease. Also, Moss and Siegler would present their argument that public opinion and support would be generally aimed towards giving ARESLD patients lower priorities than other ESLD patients. Public support is important concerning an operation such as this. In the eyes of the public, normal ELSE patients seem more innocent and less at fault than ARESLD patients. Until sufficient research proves and displays positive post-transplant results within ARESLD patients, this proposal should remain legitimate and observed.

Government policies should follow the same standards Cohen and Benjamin establish in their attack on Moss and Siegler's proposal. Government policies should be based on the American belief that each individual has given rights and should be treated fairly and equally. To discriminate against some ESLD patients because they are alcoholics is unequal and unjust. If it should be that society is strongly opposed to equal treatment towards all ESLD patients, their view does not justify treating ARESLD patients differently than other ESLD patients. Should society feel this way, it may be brought about because alcoholism is caused by an individual's own actions.

When ESLD is caused by an alcoholic's heavy drinking, it is easily assumed or believed that these people have brought this disease upon themselves and should therefore be given lower priorities in receiving organ transplantation than those who acquired the disease by no fault of their own and with no way of preventing their unfortunate ESLD. The proposal of Moss and Siegler is not only discriminatory, but it seems as though it is a way of punishing ARESLD patients for their previous actions of heavy alcohol consumption. Although liver transplantation is an expensive procedure involving the use of an absolute scarce resource, this procedure, however rare it may be, should not be denied to any patient desperately in need. Criteria and standards should exist when deciding who should become an eligible candidate and who should be first in line to receive a donor liver. However, it is ethically unfair to discriminate towards alcoholics and not allow them an equal chance among this list of candidates. Also, due to the uncertainty and lack of evidence and research associated with the outcomes of ARESLD patients who receive a donor liver, it is unfair to assume that patients without ARESLD are better off than those with ARESLD.

Within both writings it is noted that many patients whose dilemma is caused by a result of their own behavior or conduct receive treatment without discrimination. Within government policy, medical treatment should be administered based on medical needs, not based on infectious and genetic factors or, more importantly, personal behavior. We all partake in a particular activity or behave in a certain manner, whether we realize it or not, that puts our health or bodies at risk. Participating in athletics puts ourselves at risk to sustaining a serious injury, yet treatment to such patients is never denied or questioned because of personal conduct. Because it would be virtually impossible to clearly justify, weigh, or differentiate amongst which personal actions are acceptable and unacceptable, discrimination in treatment based on personal actions is unjust and should not occur. Excluding ARESLD patients from obtaining a fair and equal chance at liver transplantation is wrong and should become government policy.