So who gets the liver?
At the end of his address at the National Undergraduate Bioethics Conference, Dr. Daniel Wikler posed a tough question to the audience. Two people need a liver transplant, one who is blind and one who is not. If there is only one liver available, who should receive the transplant?
According to a global health mantra, the sighted person should receive the transplant. This would amount to progress in global health, a small reduction in the burden of disease: A population of equal size that has one less person suffering from blindness is a healthier population.
Something about this answer feels repugnant, even for many who agree with the logic. There is no clearly desirable outcome in this situation. A human being will die regardless of the decision that is made. When facing such circumstances, perhaps the best we can do is to seek the lesser evil.
How would you decide who gets the liver? Save the blind person or the sighted? Or flip a coin?
–Kavin Sundaram
March 15th, 2009 at 9:33 am
I would give it to the sighted person and let the blind person die. But I don’t see a clear way to translate this into policy. Try to imagine a real-world situation where such a policy would have no negative side-effects. Why stop at blindness? When deciding between the lives of two people who are the same in every way except one inch of height, the same logic applies: Kill the short guy. After all, the slightly taller person will be able to reach the top shelf in the grocery store to help others get food. Or how about two people, one of whom tells slightly funnier jokes? The difficulty of translating these thought experiments into real-world policy is that no two people are ever identical except for a single characteristic. We differ in infinite ways. How should we weigh the relative importance of those differences? The best thing to do, in the real world, is to flip a coin.
–John Bohannon
March 15th, 2009 at 11:01 am
I’m in agreement with most of your post, John. However, why the coin flip? I’ve never been impressed by the morally palatable veneer of controlled chance. Yes, it forces us to divest our own interests from the decision making process, but it doesn’t supply any better of a justification for action. Normally we feel that people *shouldn’t* suffer on account of chance. What (besides moral-psychology quirks in us) makes this case any different?
March 15th, 2009 at 12:32 pm
Imperfect information. That’s what makes it different. Imagine the same life-saving liver dilemma. But now it stipulates that “one of the two people contributes slightly more to the global burden of disease than the other, but there isn’t a clear way to determine which it is.” Wouldn’t you flip a coin in this case? That’s the real world.
–John Bohannon
March 16th, 2009 at 7:22 am
Ah, well – the pragmatics of the situation are one thing. But suppose we’re *really interested* in the “extrapersonal moral truth” of the matter as to which action is right – assuming that there is such a thing. Which is to say, we want to know what we *should* do, not just the best thing to do given the information constraints. Now the case you gave resigns us to an arbitrary choice by stipulation, rendering the moral fact of the matter flatly beyond our reach. But in the former case? Can’t we start trying to determine just which of them it would be “better” to keep alive? Or, phrased more carefully, in the first case does the theoretical (however remotely so) possibility of arriving at the truth obligate us to resist the cop-out of the coin flip?
March 16th, 2009 at 7:41 am
No, you’re right. I do believe that we are obligated to save the sighted person and let the blind person die–in the idealized case. I just wanted to add my real-world policy point to the discussion to point out that this answer of mine does not lead to an obvious real-world decision. It should guide policy (assuming the policy-makers agree with me) but that doesn’t make it easy to implement. What about the case of the two people who need a liver, identical in every way except that one tells funnier jokes? Is there a threshold of utility difference, below which a coin-toss is the better answer? My intuition: there is no threshold (in the idealized case). You should always kill the guy with mediocre jokes.
–John Bohannon
March 16th, 2009 at 3:25 pm
Talk about the quintessential bioethics question!!
I hate to to say it (I really hate to say it!) but it does make more sense in a Darwin world to give the liver to the person who will better our evolutionary progress.
However…
Where do we stop? Let’s forget UNOS all together and say, maybe the person who is more kind should get the liver. Or, the person who is prettier. Or maybe even the person who is smarter. These all seem to have the same justification as sight. It’s the age-old question… where do you draw the line?
March 17th, 2009 at 2:36 pm
Just in case you are dying to see Wikler’s video on 200 kidney donations video:
http://fliiby.com/file/70866/f07o0egn1a.html
March 27th, 2009 at 5:29 pm
This is what bioethics is all about. Should the blind man, who has suffered all his life with a disability, suffer and die more because of a defect he couldn’t have helped in the first place? If it were my decision, the blind man has suffered enough and I would in fact give him the liver. The fact that he is blind and sometimes considered less useful in our society shows how we want to eliminate all those different than “normal”. Plus, the man with vision may be able to find another liver easier than he thinks.
April 17th, 2009 at 8:13 pm
Interesting comments. I find it interesting that the presumption is that the sighted person should get the organ because he would contribute more to the global community. What if the sighted patient is a derelict and the blind man is governor of New York? Does that change the answers? How about a Solomonesque approach: split the organ and give a portion to each recipient. The liver is a multi-lobed organ of which we only require a portion.