Transplantation in Alcoholics:

Separating Prognosis and

Responsibility From Social Biases
Peter A. Ubel

any people strongly believe that scarce transplantable livers should not be given to
people with alcoholic cirrhosis. These feelings
often reflect a belief that we ought to hold people
accountable for their behaviors and thus should
not give scarce resources to people who cause their
own illnesses. They may also reflect a belief that
alcoholics will not do well after transplantation and
that we should not give scarce resources to people
who are unlikely to benefit from them.
It is not always easy to tell whether peoples
attitudes toward transplantation in alcoholics reflect the importance they place on prognosis (how
likely patients will be to benefit from transplantation), their responsibility for illness, or the social
undesirability of alcoholism. People may use prognosis (or responsibility for illness) as a way to
justify social undesirability judgments.
This article explores two arguments against
transplantation in alcoholics: (1) that they do not
deserve organs because they are responsible for
their illness and (2) that they should not receive
organs because they are less likely to survive
transplantation. Both of these arguments depend in
part on factual statementsthat alcoholics are
responsible for their illness, and that they do worse
after transplants. Both of these statements are
controversial. Nevertheless, it will be argued that
even if these statements are true, they do not justify
policies that single out alcoholics as less deserving
of transplants than other patients. Instead, denying
livers to alcoholics on the basis of responsibility or
prognosis will be shown to be a result of social
biases against alcoholics. These social biases deserve no role in transplant allocation.

Are Alcoholics Responsible for

Developing Cirrhosis?
Arguing in favor of transplantation in alcoholics is
not a popular position. Public opinion polls show
that most people do not think alcoholics should
receive liver transplants.1 Research we have done
with colleagues supports this finding. When we
asked people to evaluate a number of potential

criteria to allocate the scarce organs available for

transplant, we found that a patients responsibility
for his illness was the second most important factor
in deciding whether people wanted to give them
transplant organs (DeKay et al., unpublished data).
But what does it mean to say a person is responsible
for his or her illness?
Alcoholic cirrhosis differs from many other
behaviorally associated chronic illnesses in that the
disease can be attributed almost entirely to a
persons behavior. Long-term use of large amounts
of alcohol is undoubtedly responsible for many
cases of liver failure. Indeed, in some patients there
is little doubt that alcohol use caused the liver
failure. In contrast, smoking undoubtedly contributes to the incidence of heart attacks, but it is
extremely difficult in particular patients with coronary artery disease to say that they would not have
had heart attacks if they had not smoked. Thus,
even though we can say, for example, that 30% of
heart attacks would have been prevented if no one
in a population had smoked, we cannot identify
which people would have avoided heart attacks if
they had not smoked.
Alcoholism causes alcoholic cirrhosis. Does that
mean that alcoholics are responsible for developing
liver failure? For alcoholics to be responsible for
developing cirrhosis, they must be shown to be
responsible for their long history of alcoholism.
This means that we should be able to determine
that a person is either responsible for becoming an
alcoholic or responsible for remaining an alcoholic
From the Veterans Affairs Medical Center; the Division of
General Internal Medicine and Center for Bioethics, University of
Pennsylvania School of Medicine; and the Leonard Davis Institute
of Health Economics, University of Pennsylvania, Philadelphia,
Pennsylvania.
Dr. Ubel is a Measey Foundation Faculty Fellow and a recipient
of a Health Services Research and Development career development
award from the Department of Veterans Affairs.
Address reprint requests to Peter A. Ubel, MD, Division of
General Internal Medicine, Center for Bioethics, University of
Pennsylvania, 3401 Market St, Suite 320, Philadelphia, PA 19104.
Copyright r 1997 by the American Association for the Study of
Liver Diseases
1074-3022/97/0303-0023$3.00/0

Liver Transplantation and Surgery, Vol 3, No 3 (May), 1997: pp 343-346

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Peter A. Ubel

long enough to develop liver disease. Let us look at

these two issues separately.
It is controversial whether people are responsible for becoming alcoholics. Nevertheless, few
would argue that alcoholics are completely responsible for developing their illness. Most would admit
that factors beyond peoples control influence their
chance of becoming alcoholic, such as their upbringing, chromosomes, etc.
However, alcoholism is clearly related to behavior that people have some control over. Alcoholism, to the extent that it is a disease, is one that
results from decisions people make. Even people
genetically susceptible to alcoholism who are raised
in abusive families by alcoholic parents still make
decisions at some point in their lives about whether
they want to have their first drink. Even when
these decisions are made by 12-year-olds, we hold
them partly responsible for their actions. In short,
although there is reason to think that some people
bear at least partial responsibility for their illness,
there is no consensus about how much responsibility people bear for becoming alcoholics.
Even if people are not responsible for becoming
alcoholics, they may still be responsible for developing liver failure if they can be blamed for
remaining alcoholics. Moss and Siegler, strong
opponents of transplantation in alcoholics, claim
that alcoholics bear no responsibility for becoming
alcoholics but are responsible instead for failing to
get their alcoholism adequately treated.2 They
argue that because alcohol treatment programs
work in 50% to 100% of patients, alcoholics should
be held responsible to get such treatment. We
believe, therefore, that even though alcoholism is a
chronic disease, alcoholics should be held responsible for seeking and obtaining treatment that
could prevent the development of late-stage complications.2
Moss and Sieglers argument is not compelling.
First, although they acknowledge that alcoholism
treatment programs are not 100% successful, they
do not say what should be done about alcoholics
who have sought treatment but have not been
cured. Are alcoholics responsible for developing
cirrhosis if alcohol treatment fails? Second, although Moss and Siegler acknowledge that alcoholism is a disease and that people are not responsible
for becoming alcoholics, they ignore the possibility
that one of the symptoms of alcoholism is that
people deny that they have a drinking problem that

needs treatment. Are these patients truly responsible, then, for not seeking treatment?
It is impossible to know whether any specific
person is completely responsible either for becoming an alcoholic or for remaining an alcoholic. At
best, we can attribute responsibility to alcoholics
for liver disease much in the way we might blame
heredity for causing a heart attack. Well, there is a
30% chance that your heredity caused your heart
disease. Once we acknowledge the impossibility of
saying that any particular alcoholic is 100% responsible, or even 90% responsible, for their liver
disease, the distinction breaks down between alcoholic liver disease and other diseases related to
behavior. Patients who fail to exercise are partially
responsible for their heart disease. Patients with
high blood pressure who do not follow low-salt
diets are partially responsible for developing kidney failure. In the same way, patients with alcoholism are partially responsible for developing cirrhosis.
This leaves us with several ways we could use
information about personal responsibility to decide
how to distribute scarce health care resources. We
could estimate the degree of responsibility specific
people have for their illnesses and factor this in to
allocation decisions. This would be an incredibly
difficult, probably impossible, task. We could come
up with some threshold at which, patients who are
responsible for more than x% of their illness
would get a lower priority in receiving scarce
resources. This would just be a blunter way of
doing the first task, and may not be any easier to
do. Finally, we could entirely abandon allocating
resources according to personal responsibility. This
last option is best because any attempt to base
allocation on personal responsibility is impossibly
entangled with our social judgments about the
desirability of alcoholism.

How Social Biases Influence Our Desire

to Allocate Resources According
to Personal Responsibility
Imagine a study that conclusively proves that
working more than 80 hours per week leads to a
dramatic increase in liver disease, and this liver
disease can be definitively diagnosed by a liver
biopsy. How would this affect what we thought
about whether workaholics should receive liver
transplants? Although it is difficult to predict, it
seems that initially few people would want to deny

Social Bias and Transplantation

transplants to workaholics, especially those who

have been working 18 hours a day trying to
develop programs to provide shelter for homeless
people. On the other hand, once the public became
aware of the association between workaholism and
liver disease, would workaholism be viewed differently? Would workaholism become a vice? Probably not. If people were working long hours to find
ways to exploit their blue collar workers and
increase their companies profits, the workaholism
might be viewed negatively. However, this would
reflect more on judgments about what type of work
people were doing than how many hours a week
they work. The workaholic Mafia kingpin is bad,
while the workaholic Mother Teresa is good.
The point of this hypothetical exercise is to help
us think clearly about judgments we make regarding the importance of responsibility in determining
how we allocate scarce goods. Our judgments are
influenced not only by whether a behavior is
responsible for someones illness but also by what
we think of the behavior. If that behavior is socially
desirable, we will not be inclined to penalize
people for partaking in the behavior. In fact, if the
behavior is socially laudable, we may give people
higher priority in receiving organs. Mother Teresa,
perhaps, deserves top priority so that she can
continue to do the kind of work she does.
Of course, most ethicists would argue that
Mother Teresa does not deserve priority in receiving life-saving treatment. Indeed, early in the
history of bioethics in the United States, national
controversy arose when a committee deciding how
to allocate scarce dialysis machines gave priority to
people who went to church over those who did
not.3 This was uniformly criticized by ethicists and
the general public alike. We should be cautious
about adopting policies that allocate resources on
the basis of peoples responsibility for their illness
because such policies may merely reflect our views
of the social desirability of those behaviors.

The Importance of Prognosis in

Allocating Scarce Resources
One other factor people have said ought to influence transplant allocation policies is the likelihood
that people will benefit from transplant. Indeed, a
number of studies have shown that prognosis is
one of the most important criteria people think
should be used in distributing organs.4-7
Data suggest that carefully selected alcoholics

345

have prognoses as good as that of the average

person receiving a liver transplant.8 Obviously, this
careful selection is a crucial part of the good
prognosis these patients showed. Selection can
include requirements of lengthy periods of abstinence before transplantation, highly developed
social support systems, etc.
Let us assume for the sake of argument that
most alcoholics do not do as well after transplant as
nonalcoholics. Should this influence our allocation? Clearly we need to do more to factor prognosis into transplant allocation. For example, retransplant candidates deserve less priority for organs
than first-time transplant candidates because of
their poorer prognoses.9 To the extent that we can
develop strong predictive models of transplant
success, there may be certain patients who should
be excluded from transplant consideration because
their prognosis is too poor. Other patients, perhaps, should receive lower priority or only be
allowed to receive organs that would otherwise not
be used.
Although prognosis ought to be given more
emphasis in the allocation system, we must avoid
using prognosis as a means of judging the social
desirability of transplant candidates. People will be
more inclined to favor basing allocation on prognosis if they think that prognosis is determined
primarily by behaviors like alcoholism and intravenous drug abuse. We should not single out alcoholics as poor candidates for transplantation without
giving equal attention to other groups of candidates who have similarly poor prognoses.

Summary
The general public does not favor transplanting
livers into patients with alcoholic cirrhosis. This
opinion may reflect a sense that we should not
distribute scarce resources to people who are personally responsible for their illness. It may also
reflect a sense that alcoholism is socially undesirable, and therefore alcoholics should not receive
transplants. This article argues that these positions
do not hold up under scrutiny. The only reason to
give alcoholic patients lower priority for transplantation is if subgroups of alcoholics can be shown to
have unacceptably poor transplant prognoses. However, giving these alcoholics lower priority is justifiable only if it is part of a larger policy that
distributes livers on the basis of prognosis. In the

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Peter A. Ubel

meantime, there is no justification for giving lower

priority to alcoholics for available livers.

Acknowledgment
The author gratefully acknowledges Ellen Wise for assistance in
manuscript preparation.

References
1. Harris L. Making difficult health care decisions. The Loran
Commission. 1987.
2. Moss AH, Siegler M. Should alcoholics compete equally
for liver transplantation? JAMA 1991;265:1295-1298.
3. Alexander S. They decide who lives, who dies. Life
1962;Nov 9:100-106.

4. Ubel PA, Loewenstein G. The efficacy and equity of

retransplantation: An experimental survey of public attitudes. Health Policy 1995;34:145-151.
5. Ubel P, Loewenstein G. Distributing scarce livers: The
moral reasoning of the general public. Social Science
Med 1996;42:1049-1055.
6. Ubel PA, Loewenstein G. Public perceptions of the
importance of prognosis in allocating transplantable livers to children. Med Decis Making 1996;16:234-241.
7. Ubel P, DeKay M, Baron J, Asch D. Public preferences for
efficiency and racial equity in kidney transplant allocation
decisions. Transplantation Proc 1996;28:2975-2980.
8. Cohen C, Benjamin M. Alcoholics and liver transplantation. JAMA 1991;265:1299-1301.
9. Ubel PA, Arnold RM, Caplan AL. Rationing failure: The
ethical lessons of the retransplantation of scarce, vital
organs. JAMA 1993;270:2469-2474.