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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12274

Volume 00 Number 00 2016 pp 0–00

WHY ALCOHOLICS OUGHT TO COMPETE EQUALLY FOR LIVER

TRANSPLANTS

ALEXANDER ZAMBRANO

Keywords
transplantation, ABSTRACT
allocation, Some philosophers and physicians have argued that alcoholic patients,
organs, who are responsible for their liver failure by virtue of alcoholism, ought to
alcoholics, be given lower priority for a transplant when donated livers are being allo-
responsibility, cated to patients in need of a liver transplant. The primary argument for
priority 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 respon-
sible 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 competi-
tion 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.

1. INTRODUCTION We as a society must decide how to apportion what few

According to the American Liver Foundation, more
than 6,000 liver transplants are performed each year.1
This number may seem high, but consider that there are
almost three times that many people – roughly 17,000
Americans – still on the liver transplant waiting list.2
Since donor livers are a scarce resource, many of the
individuals on the waiting list will die before a donor
liver becomes available – more than 1,500 people each
year.3 Hence, we cannot avoid the question of allocation.
1
The American Liver Foundation. More About Organ Donation. 2013.
Available at: http://www.liverfoundation.org/patients/organdonor/
about/[Accessed 17 August 2014].
2
Ibid.
3
Ibid.
livers there are, understanding as we do this that the
stakes are literally life and death. Accordingly, it is
morally imperative that we find the fairest and most just
way to allocate livers to our needy patients.
As it happens, many of these needy patients are active
or recovering alcoholics who have caused their liver to
fail by excessive and uncontrolled alcohol consumption.
In light of this fact, a number of philosophers and physi-
cians have argued that patients who have caused their
liver to failure by excessive alcohol consumption should
be discriminated against in liver allocation. More pre-
cisely, they have argued that patients who are responsible
for their Alcohol Related End of Stage Liver Disease
(ARESLD) ought to receive lower priority for liver
transplants when they are competing with patients who
develop End of Stage Liver Disease (ESLD) through no

Address for correspondence: Alexander Zambrano, Department of Philosophy, University of Colorado-Boulder, Hellems 169, 232 UCB, Boulder,
CO 80309, USA. Email: Alexander.Zambrano@colorado.edu

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V
2 Alexander Zambrano
fault of their own.4 Call this proposal the Lower Priority
Policy.
My main goal in this article is to show that we should
reject the most important and frequently cited argument
in favor of the Lower Priority Policy, namely, what I will
call the Responsibility Argument. Before I begin, how-
ever, three preliminary remarks are in order.
First, with respect to how we should understand the
notion of responsibility, proponents of the Responsibility
Argument have largely adopted what has been called the
retrospective account of responsibility, according to
which being responsible for ones medical condition is a
matter of having causal control over the events that led
to the medical condition. For example, having causal
control over the events which lead to my liver failing
include being in control of my initial consumptions of
alcohol, and being generally in control of my subsequent
drinks, especially over a long period of time. Thus, in
this article, when I assert that a patient is responsible for
her medical conditions, I mean roughly that she had
causal control over the events that led to her resulting
medical condition.5
Second, it is important to note that most transplanta-
tion centers and insurance companies require ARESLD
patients who are eligible for transplantation to refrain
from consuming alcohol for a designated amount of time
prior to transplantation. This time frame is usually set
around six months, sometimes even a year, depending on
4
For a defense of the Lower Priority Policy, see A. Moss & M. Siegler.
Should Alcoholics Compete Equally for Liver Transplantation? JAMA
1991; 265:1296–1298; R. Veatch. 2000. Transplantation Ethics, 1st edi-
tion. Washington D.C.: Georgetown University Press: 311–323; W.
Glannon. Responsibility, Alcoholism, and Liver Transplantation. J Med
Philos 1998; 23: 31–49; V. Thornton. Who gets the liver transplant? The
use of responsibility as the tie breaker. J Med Ethics 2009; 35:739–742. It
should be noted that most of these authors also claim that, since deter-
minations about responsibility are quite difficult to make in the case of
alcoholics with ARESLD, the use of lower priority should only be used
as a tie breaker.
5
For a statement and defense of the retrospective account, see Glannon,
op. cit. note 4. and Veatch, op. cit. note 4. Although most authors writing
on the Lower Priority Policy have adopted the retrospective account of
responsibility, there are exceptions. Moss and Siegler, for example, utilize
what we can call the prospective account of responsibility. On this view,
the ARESLD patient is responsible for her ARESLD only if she failed
to seek treatment for her alcoholism; and she is not responsible for her
ARESLD only if she honestly sought treatment and the treatment failed
to curtail her alcoholism. The obvious limitation of this view is that it
fails to have any application in most other cases involving patients who
are responsible for their medical conditions. This limitation is one reason
why I will be assuming the retrospective account of responsibility for the
purposes of this article.
6
For two interesting discussions about the abstinence requirement, see
JE Everhart and TP Beresford. Liver transplantation for alcoholic liver
disease: A survey of transplantation programs in the United States. Liver
Transpl Surg 1997; 3: 220–226; R. Weinrieb et al. Interpreting the Signifi-
cance of Drinking by Alcohol-Dependent Liver Transplant Patients:
Fostering Candor is the Key to Recovery. Liver Transpl 2000; 6: 769–
776.
the medical state of the patient.6 Given this fact about
current medical practice, the cases of interest in this
paper involve currently sober ARESLD patients, not
patients who continue (and will continue) to drink exces-
sively in the future. Ill therefore put to the side the ques-
tion whether active alcoholics should be given lower
priority on the transplant list.
Third, since patients awaiting a liver transplant often
have other, related (and unrelated) medical problems that
would affect their prognosis, it might be suggested that
in many cases, there are purely medical reasons to dis-
criminate against ARESLD patients in favor of other
needy patients whose prognosis is superior. Suppose Tim
is an 80 year-old alcoholic suffering from ARESLD and
terminal lung cancer, and he is competing with Lisa, an
otherwise healthy thirty year-old woman. Lisa is likely to
benefit from the transplant while Tim is not, given his
other health conditions. The fact that Lisa, but not Tim,
will benefit from a new organ gives us a good prima facie
reason to give the organ to Lisa instead of Tim.
Similarly, one might think that there are statistical rea-
sons to discriminate against former alcoholics on the
grounds that they tend to benefit less than non-
alcoholics from liver transplants. However, this turns out
not to be the case. In general, former alcoholics with
ARESLD tend to do just as well as non-alcoholics post
transplantation.7 Thus, my focus in this article will be on
just those cases where there is no medical reason to dis-
criminate against ARESLD patients in favor of other
needy patients.
2. THE RESPONSIBILITY ARGUMENT
Proponents of the Lower Priority Policy have argued in
favor of their proposal by defending one primary argu-
ment, which Ill call the Responsibility Argument:8
(P1) Alcoholics who have ARESLD are responsible
for their medical condition.
(P2) Patients who are responsible for their medical
conditions should be given lower priority for (scarce)
medical resources when they are competing with
patients who are not responsible for their medical
conditions but who also need the same scarce
resources.
7
See P. Burra & M. Lucey. Liver Transplantation in Alcoholic Patients.
Transpl Int 2005; 18: 491–498: 494; A. Anand et al. Liver Transplanta-
tion for Alcoholic Liver Disease: Evaluation of a Selection Protocol.
Hepatology 1997; 25: 1478–1487; T. Gerhardt et al. Alcohol Use Follow-
ing Liver Transplantation for Alcoholic Cirrhosis. Transplantation 1996;
62: 1060–1063.
8
For defenses of the Responsibility Argument, see Moss & Siegler, op.
cit. note 4; Veatch, op. cit. note 4, pp. 311–323; Glannon, op. cit. note 4.
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 Why Alcoholics Ought To Compete Equally for Liver Transplants
(C) Therefore, alcoholics who have ARESLD should
be given lower priority for (scarce) medical resources
when they are competing with patients who are not
responsible for their medical conditions but who also
need the same scarce resources (i.e. liver
transplants).
Most critics of the Responsibility Argument have
focused on the technical problems associated with the
fair and accurate assessment both of a patients responsi-
bility for her medical condition and of the penalties or
burdens that different degrees of misconduct deserve.9
For my purposes, I will assume that we can accurately
determine a patients level of responsibility and establish
which penalties different degrees of misconduct deserve.
As Ill argue, there is a much better, independent reason
to reject the Responsibility Argument.
Before turning to this reason, however, it will be
instructive to consider one exception to the above gener-
alization. Unlike most critics, Ho (2008) attempts to
undermine (P2) of the Responsibility Argument not by
challenging the conception of responsibility employed in
the argument, but rather by suggesting that using patient
responsibility to allocate medical resources would under-
mine the proper functioning of medicine by undercutting
the physician-patient relationship that is so essential to
proper medical care.10 Ho argues in the following man-
ner: To properly treat a patient, physicians often require
all the relevant and sometimes personal information
about a patients lifestyle. But if we begin giving patients
lower priority for healthcare resources if they are respon-
sible for their medical conditions, patients are likely to
start withholding potentially relevant information about
their lifestyles. As a result, physicians will be less effective
at diagnosing and caring for their patients, thus under-
mining the proper functioning of medicine. Therefore,
Ho says, we should not lower a patients priority for a
scarce medical resource on the basis of her alleged
responsibility for her medical condition.
A potentially problematic defect of Hos argument is
that its success depends on the current state of ever-
changing medical technology. Current practice requires
that all candidates for a liver transplant undergo a
biopsy to determine the cause of their ESLD. Since the
9
For example, Cohen & Benjamin (1991) present three technical objec-
tions to using responsibility to determine the priority of alcoholics for
liver transplants: (1) We have genuine and well-grounded doubts about
comparative degrees of voluntariness and, therefore, cannot pass judg-
ment fairly. (2) Even if we could assess degrees of voluntariness reliably,
we cannot know what penalties different degrees of misconduct deserve;
(3) Judgments of this kind could not be made consistently in our medical
system. See C. Cohen, M. Benjamin, & the Ethics and Social Impact
Committee of Transplant and Health Policy Center, Ann Arbor Michi-
gan. Alcoholics and Liver Transplants. JAMA 1991; 265: 1299–1301.
10
D. Ho. When Good Organs Go to Bad People. Bioethics 2008; 22: 77–
83.
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3
biopsy does not definitively show whether the ESLD was
caused by alcohol consumption, physicians require per-
sonal information from patients about their lifestyles and
habits to make a reliable diagnosis. However, it is not
implausible to suppose that, sometime in the future,
medical technology will advance in such a way that per-
sonal information from patients is no longer necessary.
All we would need is to run some tests, without requiring
the patient to divulge personal information to her physi-
cian. If this were to occur, Hos objection would fail
because, on the assumption that testimony from the
patient is no longer necessary to make an accurate diag-
nosis, ESLD patients will no longer be placed in the
uncomfortable position of choosing whether to withhold
information that could result in a compromise of their
care. In contrast with Hos argument, an advantage of
my own argument against the Responsibility Argument
is that it is not vulnerable to the constantly evolving state
of medical technology. Lets now turn to that argument.
3. RESPONSIBILITY AND SOCIALLY
VALUABLE BEHAVIOR
To begin, consider the following case:
Firefighter. After working for five years at a doctors
office, Chuck decides that he would like to have a
career in firefighting. Although his family warned
him about the various health risks of firefighting,
including the possibility of developing several lung
diseases, Chuck enrolls to become a firefighter, even
though he could have enjoyed a less risky profession.
After firefighting for twenty years, Chuck finds out
that he has developed a lung disease due to inhaling
smoke on the job. He now needs a lung transplant
to continue living.
It is both plausible and reasonable to hold that Chuck
should not be given lower priority for a lung transplant
when he is competing with other patients who need a
transplant through no fault of their own. In other words,
despite being responsible for his medical condition, it
would be wrong for our organ allocation system to give
Chuck lower priority for a transplant. One plausible
explanation for our intuition that Chuck ought not be
given lower priority is that, although he is responsible
for his medical condition, the behavior which has led to
his health condition has contributed positively to society;
given that the behavior which led him to need a new
organ has contributed positively to society, Chuck
deserves to be given at least equal priority for a lung
transplant.11
11
One might suggest that Chuck, given his socially valuable behavior,
should in fact receive higher priority for an organ when he is competing
with others who need an organ through no fault of their own. It should
4 Alexander Zambrano
Notice, however, that Firefighter and ARESLD cases
are identical with respect to the fact that both cases
involve patients who are responsible for their medical
conditions and are in competition with others who need
the same scarce resources through no fault of their own.
Since the cases are the same in this respect, then if its
true that Chuck should not be given lower priority for a
new organ despite being responsible for his need, then we
have a plausible counterexample to (P2) of the Responsi-
bility Argument. That is, we have a case in which a per-
son is responsible for needing a scarce resource yet he
should not be given lower priority for that resource when
he is competing with other patients who need the same
resource through no fault of their own. Therefore, the
Responsibility Argument is unsound.
In order to avoid this result, (P2) of the Responsibility
Argument must be revised to avoid counterexamples
such as Firefighter. Presumably, this revision will have to
focus on the supposedly morally relevant differences
between Firefighter and ARESLD cases. Now the expla-
nation of the intuition that Chuck should not receive
lower priority is that he deserves to compete equally for
a liver given his socially valuable behavior. But this sug-
gests that proponents of the Responsibility Argument,
who wish to avoid the implication that patients such as
Chuck ought to be given lower priority, should revise
(P2) of the Responsibility Argument in the following
manner:
(P2*) Patients who are responsible for their medical
conditions due to engaging in behavior that is not
socially valuable should be given lower priority for
(scarce) medical resources when they are competing
with patients who are not responsible for their medi-
cal conditions but who also need the same scarce
resources.
So revised, the Responsibility Argument does not
imply that patients such as Chuck ought to be given
lower priority for scarce medical resources such as a new
organ. Notice also that (P2*) implies that only patients
who have engaged in socially valuable behavior that has
contributed to their medical conditions ought to be
exempted from lower priority. One might, for example,
hold a view on which any socially valuable person who
requires an organ transplant ought to be exempted from
receiving lower priority. According to what Ill call the
Behavior View, a person who is responsible for her medi-
cal condition should be exempted from lower priority for
a transplant only if she engaged in socially valuable
behavior and that behavior led her to require an organ
transplant. On this view, Chuck, the firefighter, ought to
be noted that even if this claim is correct, it is entirely consistent with my
claim that Chuck should not be given lower priority for a new organ.
Indeed, to say that Chuck should receive higher priority for a new organ
entails that Chuck should not receive lower priority for a new organ.
be excused from being given lower priority. Conversely,
on what I will call the Persons View, even if a person is
responsible for requiring an organ transplant, so long as
they are valuable to society in some way, they ought to
be excused from lower priority.
To illustrate the difference between the Persons and
Behavior views, as well as show that the latter is the more
plausible view, consider the following case. Imagine that
Bill is a firefighter but also a heavy smoker who has devel-
oped a rare lung disease due to smoking, which requires a
lung transplant to treat. Suppose that Bill is competing
for the same lung as Robert, another firefighter who also
needs a lung transplant due to inhaling too much smoke
while firefighting. In this imaginary case, it is quite plausi-
ble that Bill should receive lower priority for the trans-
plant than Robert, even though Bill is otherwise socially
valuable. This suggests that the Persons View is false and
that the Behavior View is true. Additionally, the Behavior
View, but not the Persons View, seems to explain our con-
sidered judgment in Firefighter.
Now that I have I argued that adopting (P2*) avoids
counter-examples to the original formulation of (P2), in
the next section Ill present a new argument against the
Responsibility Argument that directly undermines (P2*).
If successful, this argument will show that even a more
sophisticated version of the Responsibility Argument is
unsound.
4. THE SOCIAL VALUE ARGUMENT
(P2*) of the Responsibility Argument entails that alco-
holics who are responsible for needing a new liver should
be given lower priority for a liver transplant because the
behavior which contributed to them needing a new liver
is not socially valuable. The problem, however, is that
accepting (P2*) would morally permit us to create public
health policies that are incompatible or in serious tension
with liberal neutrality on the good life. This is because, if
we implement a policy that allocates organs based on
whether a patients contributory behavior is socially valu-
able, we are favoring one conception of the good life
over another, and this is wrong in a liberal democracy.
What this means is that we can implement a policy that
lowers the priority for alcoholics who are responsible for
their ARESLD only if we are willing to abandon the
notion of liberal neutrality on the good. My argument
against (P2*), then, is a conditional one, namely: if we
are committed to liberal neutrality on the good life, we
have a strong reason to reject (P2*) of the amended ver-
sion of the Responsibility Argument. Therefore, the
Responsibility Argument is unsound. Call this the Social
Value argument. In the next section, I will defend the
Social Value argument and consider various objections
to it.
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 Why Alcoholics Ought To Compete Equally for Liver Transplants
4.1 The argument
In this section, my goal is to show that the Responsibility
Argument is unsound by arguing that, if we are commit-
ted to liberal neutrality on the good life, then we ought
to reject (P2*), and consequently, the Responsibility
Argument itself.
According to Ronald Dworkins classic exposition of
liberalism, liberal or State neutrality on the good life
consists in the supposition that political decisions must
be, so far as is possible, independent of any particular
conception of the good life, or of what gives value to
life.12 He continues:
Since the citizens of a society differ in their concep-
tions [of the good life], the government does not
treat them as equals if it prefers one conception to
another, either because the officials believe that one
is intrinsically superior or because one is held by the
more numerous or more powerful group.13
Two hypothetical examples will aid in clarifying the
notion of liberal neutrality. Consider a state or federal
law that subsidized opera preferentially relative to other
forms of entertainment. Such a law would be incompati-
ble with liberal neutrality because it would be justified
by the State view that some forms of entertainment (and
hence ways of life) are better or superior to others. Or
consider a policy that forces pornographic actors to pay
a higher tax rate, which is justified on the basis of the
State view that pornography is a bad or immoral way of
life. This hypothetical law is also incompatible with lib-
eral neutrality on the good life because it would disad-
vantage a group of citizens on the basis of the States
preferred conception of the good life.
How does the concept of liberal neutrality on the
good life relate to the revised Responsibility Argument?
If we accept the notion of liberal neutrality on the good
life, then it would be wrong for the State to have a pref-
erence for some conception of the good life over another,
and then enforce a policy that is justified by the prefer-
ence for that particular conception of the good life over
others. Similarly, it would be illiberal for the State to
have a preference against one conception of the good life
and then enforce a policy whose aim is to disadvantage,
in one way or another, the people who adopt this con-
ception of the good life.14
12
R. Dworkin. 1978. Liberalism. In Public and Private Morality. S.
Hampshire, ed. Cambridge, UK: Cambridge University Press: 127.
13
Ibid: 127.
14
See R. Arneson. 2003. Liberal Neutrality on the Good: An Autopsy.
In Perfectionism and Neutrality. S. Wall and G. Klosko, ed. Lanham,
Maryland: Rowman and Littlefield Publishers Inc; G. Gaus. 2003. Lib-
eral Neutrality: a compelling and radical principle. In Perfectionism and
Neutrality. S. Wall and G. Klosko, ed. Lanham, Maryland: Rowman and
Littlefield Publishers Inc.
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5
Allocating organs on the basis of social value would
be incompatible with liberal neutrality on the good life
because the State would be preferring some ways of life
to others and then employing a policy that is both justi-
fied by this preference and whose aim is to favor some
ways of life over others. In particular, socially valuable
patients who are responsible for their medical conditions
would be given exemptions to lower priority simply
because the State believes that their behaviors or life-
styles are good or valuable for society. Firefighters or
police officers, for example, might be given exemptions
because their lifestyles are considered good and valuable
for society. Alternatively, other patients, such as alcoholic
patients, who are similarly responsible for their medical
conditions, would be given lower priority just because
the State asserts or believes that their lifestyles are of lit-
tle to no positive value for society. Thus, if one accepts
State neutrality on the good life, then one should reject
(P2*) of the amended Responsibility Argument, and con-
sequently, the Responsibility Argument itself.
This concludes my statement of the Social Value Argu-
ment. Although the argument is simple, it constitutes a
serious challenge to the Responsibility Argument. Let
me now consider some important objections to the
Social Value Argument.
4.2 Objections
The first objection to the Social Value Argument is to
insist that the socially good or socially valuable life is dif-
ferent from the good or the valuable life, and that liberal
neutrality applies only to the latter and not the former.
Thus, we can discriminate against ARESLD patients on
the ground that their behavior is not socially good or
socially valuable and at the same time uphold liberal
neutrality on the good life.
But this objection fails. It fails because it does not
appreciate how a persons behavior is largely a reflection
of her conception of the good or the good life, and that
this behavior will inevitably have implications for society.
Some behaviors or lifestyles, which reflect a persons con-
ception of the good life, will not be considered socially
useful (chain-smoking or binge drinking), while others
will be deemed socially useful (e.g. firefighting). So if a
policy disadvantages a person for having a socially use-
less behavior but helps another person with a socially
useful behavior, the State is thereby discriminating
against certain conceptions of the good life. To see this,
consider the following example. Imagine Bob loves
drinking beer so much that he spends most of his time
binge drinking on his couch. Bob has a particular con-
ception of the good life – he thinks that the beer-
drinking life is the good life. However, Bobs behavior,
which reflects his conception of the good life, is not
socially valuable. Imagine that Bob now needs a liver
6 Alexander Zambrano
transplant because of his excessive drinking, and that the
State decides to give him lower priority for a new liver
because his behavior is not good or valuable for society.
But now consider Bart, a fireman whose conception of
the good life involves serving his community by saving
people from fires. Suppose that Bart develops a lung
condition due to firefighting that requires a transplant to
treat. If the State exempts Bart from lower priority but is
willing to give lower priority to Bob, then it is privileging
Barts conception of the good life over Bobs. In other
words, the State is giving an advantage to one person
(Bart) because his conception of the good life involves
socially useful behavior, while penalizing another person
(Bob) whose conception of the good life does not involve
socially useful behavior. In just the same way, the State
would not be respecting liberal neutrality if it were to
lower the priority of ARESLD patients but also exempt
patients who need the same resources due to engaging in
socially behaviors.
I argued above that ones conception of the good life
is intimately connected with ones lifestyle in the sense
that ones conception of the good life leads one to live a
particular lifestyle. Thus, on my view, if you are disad-
vantaging a person because her lifestyle is not socially
valuable, you are thereby disadvantaging her based on
her conception of the good life.
However, someone might point out that its permissi-
ble or perhaps even obligatory to sometimes disadvant-
age people because of their lifestyles, even if those
lifestyles are a reflection of and caused by a persons par-
ticular conception of the good. For example, we jail
bank robbers and murderers and in a certain sense, we
arent neutral in evaluating their behaviors. Thus, why is
it inappropriate to be non-neutral when evaluating the
behaviors of alcoholic patients who are responsible for
needing a liver transplant?
In reply, its true that in certain cases we can take
actions against people based on whether their conception
of the good life leads to certain outcomes. For example,
a murderer may have a conception of the good life under
which the criminal, murderous lifestyle is a good one.
However, when such a person decides to act on his or
her conception of the good life we are justified in stop-
ping them because their behavior wrongs others or prob-
lematically interferes with their liberty. But this sort of
extrinsic consideration is entirely absent in the case of
alcoholic patients with liver failure. We arent disadvan-
taging alcoholics because they wrong others. Rather, we
are disadvantaging them merely because their conception
of the good life does not lead to or involve socially valu-
able behavior.
However, suppose we granted that one could remain
neutral on a persons conception of the good life, yet still
recognize that her lifestyle is socially beneficial or socially
unbeneficial. Still, we would need an argument that
purported to show that socially valuable behaviors ought
to be rewarded and that socially non-valuable behaviors
ought not be rewarded. Any such argument would face
the following serious difficulty: who should determine
which lifestyles are in fact socially beneficial? If the State
determines which lifestyles have social value (and which
do not), this might be a case of the State imposing its
own values on the general population. Serious problems
also arise if the determinations about social value are left
to the general population. On this proposal, whether a
person gets lower priority for an organ would depend on
whether the majority of society believes that persons
behavior or lifestyle is sufficiently socially valuable. But,
as Stephen Wilkinson points out in a similar context,
this decision process is bound to be arbitrary, discrimina-
tory, and unfair, especially in a pluralistic society such as
the United States.15 Suppose, as was the case many years
ago, that many people viewed homosexual behavior as
both immoral and not valuable. If homosexual patients
needed organ transplants due to their own risky behav-
ior, then whether they received lower priority for trans-
plants would depend on what the general public thought
of their lifestyles. But surely what the general public
thinks about a patients lifestyle should not determine
that patients priority for life saving healthcare, especially
given peoples constantly changing attitudes and their
unjustified and uninformed prejudices.
A third, related objection is that perhaps it is morally
permissible to give alcoholics lower priority since society
must inevitably make allocation decisions about how to
distribute scarce resources, and furthermore, it seems
bizarre to suggest that these allocation decisions should
not be made on the basis of some common good. But
this objection seems mistaken. First, the mere fact that
society might view some occupations or behaviors as
non-valuable (and hence incompatible with the common
good) and then push to make allocation rules that disad-
vantage the people of this occupation (or behavior) is
simply an empirical fact about what can and sometimes
does happen in society. But it doesnt follow from this
empirical fact that people in these occupations therefore
ought to receive lower priority for new organs. Second,
even if it were true that we ought to allocate organs
based on the common good, such reasoning is obviously
open to the tyranny of the majority objection: If a
majority of society believe that X is morally appropriate
or right, then X is morally appropriate or right. But this
principle is problematic. To illustrate, its plausible that
the majority of Americans in the pre-Civil War South
believed that slavery should not be abolished and that it
was a valuable social institution. But from this it doesnt
15
S. Wilkinson. Smokers Right to Health Care: Why the Restoration
Argument is a Moralising Wolf in a Liberal Sheeps Clothing. J Appl
Philos 1999; 16: 259–269.
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 Why Alcoholics Ought To Compete Equally for Liver Transplants
follow that slavery was morally appropriate or right.
Indeed, slavery was a great moral evil.
Perhaps another way to interpret this objection is that
it is asking the following question: why accept liberal
neutrality in the first place, especially when many of us
care about the common good? To fully answer the objec-
tion, then, would require a full-blooded defense of liberal
neutrality, which I do not have the space to do. Further-
more, notice that this objection is compatible with my
original thesis, which is the conditional claim that, if we
accept liberal neutrality on the good life, then we ought
to reject the Responsibility Argument.
A fourth objection is that the liberal State doesnt vio-
late any commitment to neutrality if the policy that
favors a particular lifestyle or conception of the good is
justified in some other way. For example, rather than
employing a policy that gives preference to some group
of people based on a judgment about the value of the
groups behavior, the State might employ policies that
favor lifestyles that are somehow necessary for the proper
functioning of society. For instance, we are not violating
our commitment to neutrality on the good life by imple-
menting a policy that exempts firefighters from lower pri-
ority if the preferential policy is justified by the fact that
firefighters are necessary for the proper functioning of
society. The problem with this objection is two-fold.
First, it is controversial whether firefighters are in fact
necessary for our society to properly function. Many
societies in the past have flourished without them, and
some libertarians have even argued that the State should
not provide State-funded firefighting services to the gen-
eral public. So if there are good reasons for thinking that
firefighters are not absolutely necessary for the proper
functioning of society, then, according to the proposal
embodied in the current objection, the State should not
exempt firefighters from lower priority. And this is going
to be an unacceptable consequence for those who were
originally inclined to accept both the Responsibility
Argument and (P2*).
Second, if we accept that exemptions should only be
given to citizens who are necessary for societal function-
ing, then we have actually just abandoned the social
value criterion expressed by (P2*). The entire point of
framing (P2*) with a social value clause was to exempt
people who have engaged in risky, but socially valuable
behavior. But under the current proposal, we are not
exempting people based on the social value of their
behavior, but rather on whether or not their behavior is
necessary for society to function. And this means that
many patients who are plausibly socially valuable –
although not necessary for societal functioning – will no
longer be given exemptions, were they to be responsible
for needing a scarce medical resource. Thus, what ini-
tially seemed like a plausible way to avoid the objection
regarding liberal neutrality has led the proponent of the
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7
social value criterion to a view that she herself should
reject.
Fifth, consider another possible justification for
employing the Lower Priority Policy that is not based on
the social value of a patients behavior. It is obvious that
a liberal State can permissibly ban or criminalize a
behavior that wrongs others or harms them in unaccept-
able ways.16 Thus, even if some group of people value,
say, physical violence against other people, a liberal State
could justify banning or criminalizing such behavior by
appealing to the fact that it wrongs other people. Apply-
ing this thought to the case of liver allocation, one could
argue that it would not be wrong for the State to give
lower priority to alcoholics since they voluntarily make
the liver transplant waiting list longer, thereby making it
potentially less likely that another needy patient on the
waiting list would receive a transplant. According to this
objection, the State does not violate liberal neutrality in
giving responsible ARESLD patients lower priority
because the policy that gives them lower priority is justi-
fied by the fact that ARESLD patients wrong other
patients on the waiting list.
However, the major problem with this objection is that
socially valuable patients, who are responsible for need-
ing an organ transplant, would also be guilty of wrong-
ing other patients on the waiting list by making it
potentially less likely that these patients receive a trans-
plant. Therefore, this objection would entail the implau-
sible conclusion that socially valuable patients, who are
responsible for needing an organ transplant, should be
given lower priority for a transplant. Consequently,
appealing to the wronging of other patients on the wait-
ing list does not successfully justify giving alcoholics
lower priority and at the same time exempting socially
valuable patients from receiving lower priority.
The obvious reply here is that many patients, including
socially valuable patients, engage in risky behavior for
what many take to be good reasons, and perhaps a
patient shouldnt be penalized if she engages in risky
behavior for good reasons. But this reply is problematic.
We need to distinguish between two relevant senses in
which a reason to engage in risky behavior is a good one.
The first sense in which a person might have a good rea-
son is that her reason for acting is morally justified: if a
persons reason for engaging in some risky behavior is a
good reason, then it is morally permissible or acceptable
for her to engage in that behavior on the basis of that
reason or reasons. A firefighter, for example, may put
himself at risk for the sake of saving a person from a
fire, and his reason for putting himself at risk, i.e. to save
an innocent person, would be morally justified. The sec-
ond sense in which a reason is a good one is that it is
16
J. Feinberg. 1984. Harm To Others. Oxford, UK: Oxford University
Press.
8 Alexander Zambrano
subjectively justified: if a persons reason for engaging in
some risky behavior is a good reason, then that risky
behavior seems to her to be worth pursuing, despite the
possible consequences. For example, an alcoholic may
think that her excessive drinking is justified by the fact
that it will aid her in coping with her stress or that it will
allow her to have a good time with her friends.
Now that we have distinguished the two relevant
senses of a reason being a good one, we can show why
the current objection fails. If we accept the subjectively
justified account, then many (if not all) alcoholics do
have good reasons for engaging in risky behavior. Alter-
natively, if we accept what I called the morally-justified
account of reasons, then the State would be giving lower
priority to people based on whether it finds it morally
appropriate for a person to engage in some behavior on
the basis of a particular reason. For example, the State
could argue that it is morally inappropriate for alcoholics
to engage in excessive drinking because they desire to
cope with their stressful lives. Alternatively, they might
argue that it is morally appropriate for a police officer to
risk injury to herself to help others. But then the State
would be giving people lower priority for liver trans-
plants on the basis of a moral evaluation about their
behavior, and this is clearly wrong. Indeed, Robert
Veatch (2000), a firm proponent of both the Responsibil-
ity Argument and the Lower Priority Policy, has said
that:
It is widely agreed that public health policy will have
a very difficult time getting into the business of pro-
viding moral evaluations of behaviors. In a pluralis-
tic society it is unlikely that we could reach such
agreement in any case. What is at stake is whether
people are responsible for their behavior, and impact
of that behavior on social policy, including organ
allocation.17
Thus, if public health policy should not be made on
the basis of moral evaluations of patient behavior, then it
is wrong for the State to lower patients priority for liver
transplants because it finds it morally inappropriate for a
person to engage in some behavior on the basis of this or
that reason.
Finally, it might be argued that, although the revised
version of the Responsibility Argument entails a rejec-
tion of liberal neutrality on the good life, surely the value
of liberal neutrality can be outweighed by other consider-
ations. Moss and Siegler (1991), for example, argue that
it is appropriate to use the shared mores and values of
the public in deciding on how to allocate livers and other
organs. It is appropriate to do this, they say, because the
public is the main source of livers that are used in trans-
plantation. If the public learns that livers are being
17
Veatch, op. cit. note 4, p. 315.
transplanted to ARESLD patients instead of other
patients who need a transplant through no fault of their
own, they may be reluctant to support liver transplanta-
tion and donation.18 Although accepting the revised
Responsibility Argument entails a rejection of liberal
neutrality on the good life, it may be permissible to give
alcoholics lower priority on account of social value
because giving alcoholics equal priority might actually
lower support for transplantation and organ donation.
Thus, according to the current objection, the fact that
the Lower Priority Policy is incompatible with liberal
neutrality is a bad that is outweighed by the fact that
failing to give alcoholics lower priority would have bad
results for both the public support of transplantation
and the supply of organs.
For starters, Moss and Siegler are right to point out
that public opinion matters and plays a useful role when
trying to garner support for public health policy. The
problem is that the consequentialist reasoning on which
their argument is based could be used to support other,
morally inappropriate policies. Suppose, for example,
that the general view of the public was that they would
donate and support organ transplantation only if prior-
ity for donated organs was given to patients who are het-
erosexual. A policy that discriminated against gay,
lesbian, and transgender individuals would clearly be
incompatible with liberal neutrality. However, one could
argue that, although such discrimination is incompatible
with liberal neutrality, considerations of liberal neutrality
are outweighed by the fact that discriminating against
this group of patients allows us to gain more support for
transplantation and more organ donors. But such a pro-
posal is clearly morally inappropriate. The explanation
of its inappropriateness seems to be that, even if discrimi-
nating against one group results in more donated organs
for everyone else in need, this fact is not sufficient to per-
missibly discriminate against that group, especially when
we consider that their very lives are on the line.
The same reasoning applies in the case of alcoholic
ARESLD patients: If the publics general attitude is that
ARELSD patients should be given lower priority for
liver transplants, yet we have (as I have argued) a strong,
independent reason not to assign them lower priority, it
seems morally wrong to implement such a policy simply
because it would meet the demands of the public and
thereby secure support for organ transplantation.
5. CONCLUSION
In this article I have argued that the Social Value Argu-
ment succeeds and that, therefore, the Responsibility
Argument is unsound. I argued that in order for the sec-
ond premise of the Responsibility Argument to avoid
18
Moss and Siegler, op. cit. note 4, p. 1298.
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 Why Alcoholics Ought To Compete Equally for Liver Transplants
being susceptible to counter-examples such as Firefighter,
it must be revised to stipulate that patients who are
responsible for needing new organs due to engaging in
behavior that is not socially valuable ought to receive
lower priority for a transplant. But accepting this
amended premise entails rejecting liberal or State neu-
trality on the good life. Thus, I argued that, if one is
committed to liberal neutrality on the good life, then one
ought to reject (P2*) of the Responsibility Argument.
Since the Responsibility Argument is the main and
most often cited argument in favor of the Lower Priority
Policy, proponents of the Lower Priority Policy need
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9
either to respond to the Social Value Argument or to put
forth new arguments in favor of their proposal.
Acknowledgements
Many thanks to David Boonin, Dan Speak, Caleb Pickard, Jay Geyer,
Joe Wilson, Anthony Kelley, Philip Choi, Spencer Case and two anony-
mous referees for their helpful comments. Special thanks are due to Eric
Chwang, who graciously read and commented on various versions of
this article.
Alexander Zambrano is a PhD candidate in the philosophy depart-
ment at the University of Colorado-Boulder. His research focuses
on bioethics and, in particular, ethical issues surrounding organ
transplantation.