Heavy drinkers should be denied liver transplants

An important problem that many coutries face is the serious shortage of liver transplants. Many people are unable to use the advances of modern medical technology because of the unavailability of livers. According to the United Network for Organ Sharing, more than 17 000 people in US are currently waiting for a liver transplant.

Meanwhile, almost half of the situations where it is necessary to transplant a liver is caused by the alcoholic liver disease. This situation has raised many eyebrows and it is a wide-spread view that giving transplants to alcoholics is unfair and inefficient. This is an issue that we will try to resolve in this debate.

Heavy drinkers should be denied liver transplants

Yes because... No because...

Our model

There are not many things that should be said about our model. Most countries in the world are currently using some principle according to which they distribute livers for transplantation. It is mainly a queue-based system. We are proposing not to include alcoholics in these queues.

We acknowledge that sometimes it may be complicated to draw a line between alcoholics and other human beings. However, we believe that for alcoholism, as any other disease, there is a set of symptoms that professional doctors can use to decide whether a person is an alcoholic or not. We would urge the honourable opposition to focus on the core points in this debate.

We appreciate the simplicity of the proposition model and would also like to propose a similarly simple model. We, the opposition, recognize that in the earlier days of liver transplants, alcoholics were refused transplants, and we think this policy was overturned for a good reason—because the policy of the status quo is better. We do not think a blanket policy effectively giving all alcoholics with ailing livers a death sentence is fair, nor humane. Instead, we will give all alcoholics a chance to get liver transplants according to standard procedure currently in use (medical professionals assess how much the patient needs the organ and places him/her on a waitlist, in case of alcoholic patients, they follow a six-month abstinence period before surgery etc.), and incorporate sobriety and recovery programs into the post-surgery treatment, as done in places such as California in the status quo.1 In the status quo, people who are known to have little to no chance of living following a liver transplant regardless of the reasons for their liver disease are not given transplants, and we will like to keep that rule intact as well. Bear in mind that we will NOT, unlike the proposition, deny people transplants based on past alcoholism, but instead shall place faith in their futures.

1http://www.cpmc.org/advanced/liver/patients/topics/transplant.html#Evaluation%20Process).

Heavy drinkers should be denied liver transplants

Yes because... No because...

Why our plan achieves efficiency

We believe that public policy regarding a distribution of a scarce resource should always be guided by two most important principles. Firstly, the distribution should be as efficient as possible; secondly, the distribution should comply with the conception of fairness and justice. These aims tend to be somewhat contradictory, but we believe that the model that we have proposed reconciles both of these ideals.

So our burden of proof in this debate is to show why our model is efficient and why it achieves the fair distribution of resources. In this argument we will show why it is efficient.

In general, we believe that governments always have a mandate to be utilitarian, i.e. strive for biggest possible good in the society. Why is that? Well, state ideally is a social construct designed to achieve the biggest possible good/happiness/utility etc. It would be a bit awkward if people would not require the government to do that. Of course, these positive aims can also include ethical considerations or other things - the utilitarian government framework does not require us to become ruthless pleasure seekers.

Of course, we can all agree that there are some problems with the utilitarian doctrine. For instance, it usually is hard to agree on what is the "good" we should strive for. However, we believe that our moral intuition can help us in this task. For instance, most of us who do not have psychopathic tendencies would agree that death is preferrable to non-death. Most of us would also agree that one death is preferrable to two deaths of human beings. We strongly believe that these beliefs have universal moral value and always should be encorporated in government policy.

We will be operating under these reasonable assumptions about what is good and what is not in the following argument.

We have no doubts that giving livers to alcoholics is a waste of resources and prevents us from saving lives of other citizens. Why is that so? Well, we believe that is clear that if a liver is given to an alcoholic and he is often not saved anyway (as we shall see in a moment), we have wasted an organ that could be used to save another, equally valuable life instead.

So why is our model the best way to distribute livers efficiently? There are three mechanisms through which this efficiency is achieved:

(1) The chances of a successful transplantation are lower for alcoholics

A very important factor influencing the success of any transplantation is the way the body of the patient responds to the new organ. It is crucial that no complications arise; otherwise, the procedure is likely to fail.

Unsurprisingly, these risks are higher for chronic alcoholics. Firstly, alcoholics usually have other alcohol-related disorders, like chronic pancreatitis [[http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/]] and cerebral atrophy [[http://www.alcohol-drug.com/neuropsych.htm]]. Secondly, alcoholics very often have nutritional deficiencies [[http://www.about-alcohol-facts.com/Alcohol_Nutrition_Facts.html]] that strongly complicate the transplant acceptance process.

All of these aspects show that there is a significantly bigger chance of a failed operation and recovery process, thus wasting organs that could be used to save other patients.

(2) There is a significant risk of a relapse of alcoholism, thus ruining the implant.

It should come as no surprise that alcoholism is a very complicated disease to deal with. Using alcohol for a long time creates both a psychological and physiological addiction, and it is very complicated to supress the desire to drink.

We believe that there is a significant risk that these patients will continue drinking after the procedure. Even though there is a six-month sobriety period before any liver transplantation, empirical evidence shows that heavy drinkers go back to their old ways and start drinking again [[http://psy.psychiatryonline.org/cgi/content/abstract/42/1/55]]. Why is this likely to fail the procedure?

Firstly, all receivers of a liver always face a high chance of getting an infection, so they have to take immunosuppressant drugs that strengthen their immune system. Using alcohol is extremely detrimental for the immune system. It also negatively effects the impact of the immunosuppressant drugs. [[http://www.guardian.co.uk/science/2005/oct/05/drugsandalcohol.medicineandhealth]] Thus alcoholics effectively open themselves up for infections and often ruin the transplant.

Secondly, if alcoholics start drinking again, it can once again lead to the alcoholic liver disease and other alcohol-related disorders. This would once again put the burden on the health care system and maybe even generate the necessity for another transplant.

On the other hand, if we reject giving transplants to alcoholics, they could be assigned to patients with much bigger probability of survival after the operation, thus achieving distributional eficiency.

(3) The plan sends a message about the use of alcohol & deals with the moral hazard.

Finally, we believe that this plan sends a very bold message that heavy use of alcohol is something very negative and undesirable. It sends a clear signal from the government about the detrimental effects of alcohol use. We believe that government can influence its citizens in this way.

In addition, it would simply deal with the moral hazard that sometimes is prevalent in the behaviour of individuals. At the point when they are not yet addicted, this plan can act as an active deterrent for people to take up drinking, since they will know that the downside of this decision will be faced by themselves.

We think these two effects are likely to decrease the overall amount of alcoholics in the society. Why is that efficient? Well, less health care resources will have to used to cure alcohol-related disorders. Also alcohol has other negative externalities that would be prevented. This is definitely beneficial for society.

We have three points of refutation against the proposition’s argument for efficiency.

Government responsibility and Utilitarianism

We think the proposition’s idea of government responsibility is rather simplistic. We don’t think the primary definition of a government boils down to “a social construct designed to achieve the biggest possible good/happiness/utility.” This can be an entire new debate, but we think that social contract theorists such as Hobbes, Rousseau, and Locke agree that the primary government responsibility is to protect the lives of its people—the government is given sovereignty specifically with the purpose of ensuring that the people can live in relative peace, enjoying property rights. The issue of providing happiness and utility is completely different from those basic responsibilities. People did not come up with governments with the expectation that they would provide happiness or even utility. So we don’t think a government is upholding its primary responsibility to fairly protect the lives of its people when it designates, according to random criteria (as we will prove later), who is to live or who is to die.
But even if we agree with this rather spurious concept of government, we definitely don’t think that denying alcoholics and ex-alcoholics who may be on their way to recovery but damaged their livers already a second chance is the best way to maximize utility. The proposition makes an unsubstantiated assumption when they say they can save two people instead of one people when we give a liver to a non-alcoholic. In cases of diseases such as hep-b which have a high rate of reinfection, the survival rates post-surgery can be lower than the equivalent for alcoholics, and many alcoholics successfully recover to live healthy lives—we will elaborate on this point further on later, of how in purely counting lives saved the proposition does not win this debate. But finally we also think that utilitarianism is a cruel principle to apply when we make decisions about human lives. We don’t think we should be doing moral calculus adding up years or making prophesies about chances of survival when a dying man is in desperately in need of help—which is why we want to stick with the form of government which truly cares about the needs of its people by giving to those who need it most, based on a waitlist. All lives are equal, and we think we should not be discriminating based on past mistakes, age or any other criteria such situations.

Chances of a Successful Transplant/Danger of Relapse

The argument that alcoholics are prone to other diseases, and therefore should be denied transplants are fallacious for several reasons.
Firstly, just because alcoholics have a heightened chance to get other diseases, it doesn’t mean all alcoholics have all the listed diseases. In many cases alcoholics get successful transplants.
Secondly, according to that logic obese people or people with other non-alcohol related complications should all be denied transplants as well, because they have low chances for successful transplants. Obesity, which can be another cause of liver failure (as will be elaborated later on), also causes other complications such as cancer, heart failure, and high blood pressure 1
But thirdly, if we’re looking at purely the chance of survival post-surgery, we should be denying liver transplants to people suffering from other non-alcohol related liver diseases such as chronic HBV infection which very often re-infects the newly transplanted organ.2 The idea that transferring livers to alcoholics shall fail was largely unsubstantiated by the proposition and fails to take into other factors that can contribute to liver disease.
The proposition would also have you believe that alcoholics will relapse—please read the source that the proposition kindly provided for us, which says that “Thirty-eight percent of the patients consumed any alcohol after transplantation” We think it’s unfair that the proposition says, based on this evidence, that all alcoholics will probably relapse—the sixty-two percent obviously succeeded in refraining from drinking again, and nowhere does it say that the thirty-eight percent drank to the extent they damaged their new livers again. This is what we actually gather from the BBC: “Mr Forsythe said the chances of a patient returning to dangerous levels of drinking following surgery were low. Around 15-20% of patients do drink following surgery, but only about 2% of these do so at levels which could damage their new liver” 3. So, it’s evidently unfair and outrageous to give up on 98 percent because of the 2 percent, and we are optimistic we can help the 2 percent as well with post-surgery procedures. We would also like to draw your attention to the proposition’s stunning analysis in their final argument: “We consider a significant influence of addiction to alcohol. To deal with it there are certain programs, such as Anonymous Alcoholics, which have proven to be pretty successful ones. So, even if a person has become addicted to alcohol, he could still cure from this addiction and prevent the liver disease from happening.” Precisely that is why we believe that if these people can so successfully cure addiction before they get liver disease, they can also cure addiction after the trauma and shock of a transplant as well. In other words, addiction is curable; it is not a fault that just cannot be undone.

Social message

Public advertisement campaigns exist for sending social messages—it is not necessary to give up on all the alcoholics just because we want to send out a good message. We also don’t think this will be a strong deterrent, since we don’t think people generally think, “OK, if I ruin the liver I have by becoming an alcoholic, I can just get a new one, so I’ll just go ahead and drink one more get it.” People rarely think about their chances of getting liver transplants before they become alcoholics, so in reality not giving livers to alcoholics does not send a proper message deterring potential alcoholics.

1http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/bariatricsurgery/bariatricSurgeryObesityHealthEffects.html
2http://www.cpmc.org/advanced/liver/patients/topics/transplant.html
3http://news.bbc.co.uk/2/hi/uk_news/3064167.stm

Heavy drinkers should be denied liver transplants

Yes because... No because...

Why our plan achieves fairness

One of the government’s roles is to distribute the welfare fairly. It is the government’s burden to help every citizen who is in a disadvantageous position. Thus it would be only fair if people who get sick could get the treatment at hospital.

On the other hand we believe that if there is no possibility to help every person in disadvantage, some requirements should be put. We believe there is a crucial difference between a person who is sick with flu getting his treatment in hospital and an alcoholic getting his kidney transplant. And we believe that people should be judged on their merits when the circumstances require so.

The argument is divided in two parts. First we prove why judging upon merit is fair in some cases, secondly we take a look on the nature of alcoholism and what is the proportion of individual’s fault in becoming one.

(1) Judgment upon merit

Justice is an ambiguous concept and debates about what is “fair” seem to never end. One of the definitions one could give to fairness is that all people should be given an equal right. However, in some cases there is no possibility to do so. Imagine a situation when we have one liver and two patients applying for a transplant. One of them is 50 years old and has been a heavy drinker for 20 years, which caused his liver disease, the other one is a young healthy man who has been doing sports all his lifetime and is concerned about his health condition, but got the liver disease because of bad genes. If we think in terms of fairness in this situation we have to provide them with an equal right for this liver. We cannot cut it in halves, thus the best “fair” decision we could make is to provide them with equal chances of getting the liver, i.e. to flip a coin. Although this is just, it is arguable whether the best outcome has been achieved.

First we see that a young healthy man has more chances to survive after the operation, which is brought in details in our first argument. Secondly, we believe that it was mostly the fault of alcoholic himself in getting the liver disease, thus it could have been prevented if he had been more concerned about his health. This leads us to the concept of judgment upon merit, thus taking into consideration the fault of a person in getting to the disadvantageous situation he is now.

There is a fundamental difference between getting flu and being treated from that and getting a liver disease because of alcoholism. In the case, a patient’s fault is negligible. For most it is his decision not to wear a scarf, otherwise it is mostly bad luck. In the second case it is mostly a decision of an individual to drink heavily and thus getting the liver disease. We believe that since the resources for treatment are scarce, it is fair to treat in the first place those who got the disease because of bad luck or bad genes, denying them who were responsible themselves in getting the disease.

People know that if they drink they get the liver disease, thus they are aware of these consequences when they make the decision to drink. In this case the disease is preventable, while in the case with bad genes it is unpreventable. If a person likes fast driving he is taking the responsibility for the possible consequences of his actions. Insurance companies deny fixing a car after a driving accident caused by the driver. Government in some cases could deny in providing the treatment for free after an accident which was caused by speeding. This is done because these people break the duty of care, break their responsibilities and take actions being aware of all the harmful consequences.

Moreover, if the government gives liver transplants to alcoholics it takes away it from other people. The government could try to distribute welfare in such a way that all citizens achieve the same satisfaction, thus all in need of treatment get the treatment. But it will sufficiently harm other people, since the government will end up in wasting scarce resources on people who don’t maximize their utility from these resources, people who waste their liver on heavy drinking.

But there is also another approach. The government tries to equalize endowments given to people at the initial stage, and then it is up to individual’s decision how to maximize utility from that. In such a case an alcoholic initially has a healthy liver and could prevent his disease, but a person with bad genes initially has an unhealthy liver and his disease is unpreventable, thus their endowments are not equal. It is the duty of government to equalize their states by giving a liver transplant to the person with bad genes, thus giving him a priority over the alcoholic.

One could say that being first in the waiting list is the fair criteria. However, we argue about whether to put heavy drinkers on this list at all. By putting them on the list, resources are taken away from other patients, thus the distribution occurs at the moment when it is decided whether to put a patient on the list. In the United States there are about 17,000 people waiting on the list, and the median time for waiting in 2006 was 321 days.[[http://www.livermd.org/waiting.html]] This illustrates the scarcity of the resource and makes the question of who should be given the liver inevitable.

(2) How the choice of becoming an alcoholic is made?

Some might argue that if we judge upon merit, we consider that all alcoholics have made the decision to become one only by themselves, thus no external factor was involved. Now we will try to get to the nature of alcoholism and identify any mechanisms how people become alcoholics.

First people are most likely to drink for fun. It is a clear situation of free choice and no external factors are involved. Then there are people who drink to support community around them: friends, relatives, colleagues etc. While in this case there is an external factor involved to some degree, we believe it is still not worth arguing that the decision is mostly a matter of the individual.

The next group of reasons for drinking we see is external community (bad neighborhood, alcoholic families etc.) and moral trauma or depression. In the first case while the external factors could put a significant pressure on the individual, so he starts drinking, it is still his free choice. To make an analogy: there is no such justification for committing a crime as pressure from external community. Also bad neighborhood of a convicted person is not a justification and by no means could reduce the punishment, since committing the crime was still a free choice decision. We believe that the same mechanism is applicable here. In the second case, people could seek for a fast solution in alcohol after they were exposed to a serious moral trauma. The proportion of individual’s decision is still pretty high, because, first of all, drinking is not the only solution and there are other means of dealing with depression; secondly, after the time has passed and the trauma has become less harmful, a person could abandon drinking.

We consider a significant influence of addiction to alcohol. To deal with it there are certain programs, such as Anonymous Alcoholics, which have proven to be pretty successful ones. So, even if a person has become addicted to alcohol, he could still cure from this addiction and prevent the liver disease from happening.

To sum up, we believe that when resources are scarce, it is acceptable to distribute them fairly upon merit, which allows punishing alcoholics for not taking care of their liver and giving priority to those who have the disease because of external factors. We see the decision to drink as a free decision made by an individual after a certain cost-benefit analysis, thus he is the one to take responsibility of all the consequences. Even if a person has become alcoholic due to external factors, he could still get rid of his addiction, thus preventing the liver disease. For all these reasons, we are proud of proposing the plan.

We on the opposition are slightly confused about what the proposition means by “merit.” If they mean we should give people organs based on the decisions they’ve made in life (have they played sports, how much vegetables they ate, how much they drank) we think that not only is this completely arbitrary/difficult to measure, but also unfair—we will argue later that we should give according to necessity, that it is just to give to the people who need the most. But let’s examine their merit point anyway.

A. Young sports player vs. Old Addict

We think this is an incredibly simplistic approach to a complex problem. There are plenty of young alcohol abusers (refer to cited BBC article) who have ravaged their livers at an early age, and old people who are experiencing liver failure simply because they have used their livers for a long time.1 So we don’t agree with the fictional dichotomy that the proposition presents us. But even in this case, we think that if the old addict is closer to death and more diseased than the young sports player, we should give the old addict the liver, because chances are the young sports player can wait for a new liver. We need to give to the people who are most in need, and if both are in equal need, the one who got on the transplant list first. We think it’s ageist and discriminatory to give the liver to the young sporty boy.

B. Blame the Alcoholic

We are indignant about this argument because we don’t think placing blame is so simple as the proposition would have you believe. Firstly on the point that alcoholics aren’t born with “bad genes” and they are purely to blame. This is just not scientifically true. We the opposition don’t like the term “bad genes” but we do think that scientific evidence shows us that a sizeable number of people are born with strong genetic predispositions to alcoholism. According to the kind researchers at the University of Kent, “Genetic effects from the aldehyde dehydrogenase gene localised on human chromosome 12 have been shown to have a major effect on the development of alcoholism in Far Eastern populations” 2 . Also, some people may have just been born with weak livers, which was damaged with light degrees of alcoholism, which again may be attributable to luck. While the proposition tries to preempt our argument saying that drinking is a personal choice and not the government’s fault, we think that to an extent the government does share a responsibility if it fails to educate children about alcohol properly and leaves children in negligent families to copy the behavior of their parents, namely binge-drinking. And even if it isn’t the government’s fault, again, we think people are sufficiently punished for the choices they made when they suffer (and they do suffer) from liver diseases; the question is whether we will help them overcome the disease rather than let them pay with their lives for these mistakes. We also think the government, with the modern concept of a welfare state, tries its best to help people when they make bad decisions.

C. “A Waste of Liver”

The proposition frames its case arguing that the alcoholic, who made bad choices, is stealing the liver from the healthy sports player who had bad luck. We showed you in the previous argument that the alcoholic is not always an alcoholic because of bad decisions, but also because of genetic predispositions and bad luck (meeting irresponsible parents, etc). But we also think that other people with liver diseases aren’t complete victims of bad luck either, which makes it difficult for us to call them completely faultless in comparison to alcoholics. Let’s have a look at other causes of liver disease. One, there is obesity, which causes Non-alcoholic Fatty Liver Disease and other forms of Hepatitis. In these cases, of course, the government didn’t force people to live with unhealthy diets either, and the disease was a consequence of bad habits; bad habits that the people knew very well would bring consequences. Two, unprotected sex, use of unclean needles, lack of sanitation and sharing of bodily fluids can all be causes of Hepatitis, according to the NHS 3 . So we don’t think we are necessarily stealing a liver from these people. We make bad decisions in life, all of us do, and sometimes they translate into diseases. No scientific device in the world can measure who is to blame to what extent for his or her disease, since a lot of these bad habits can be mixed and contribute to different extents. There are a constellation of complex reasons associated with liver diseases—bear in mind, also, that scientists can never pin down a single “cause” for liver disease, but use the word “correlation,” because that’s really all it is, a correlation—nobody can prove that alcoholism is what solely and directly caused liver disease, only that there is a correlation between drinking and suffering from liver disease. We think the best idea is to save the person who is on verge of dying, and then look for a liver for the person who has a chance of living a little longer. Thus our model based on need.

1.http://news.bbc.co.uk/2/hi/uk_news/england/london/8159813.stm
2.http://kar.kent.ac.uk/16825.
3.http://www.nhs.uk/Conditions/Hepatitis/Pages/Introduction.aspx

Heavy drinkers should be denied liver transplants

Yes because... No because...

Why our plan achieves efficiency #2

In this argument we will respond to some of the criticism as well as offer an additional mechanism through which our plan ensures efficient allocation of liver transplants.

Let's start with our response to their rebuttal:

(a)

The opposition accused us of being brutal utility-maximizers. We believe that this disagreement is a semantic one. We never said that our definition of utility includes only base pleasures like sex, food etc. We simply stated that, given that we know what we want, we should strive to maximize it. These aims obviously can also include protecting citizens. We already aknowledged the problems with agreeing on what these desirable ends should be and presented reasons why saving lives should be important. There is no real disagreement here.

The opposition agrees with us that protecting lives of citizens is an end we should strive for. We believe that then they should agree with our plan. After all, the transplants are scarce. If a liver is given to an alcoholic, another person in the queue dies and maybe also alcoholic dies. If liver is given to someone else, that person lives and alcoholic dies. There is simply is no way of saving everyone with the available technology and current rates of transplant donation (more about that later), so government has to make a painful choices about the most efficient distribution of livers.

(b)

The opposition noted that the study we quoted finds that 38% of alcoholics use alcohol after transplantation and also provided some other statistics. We agree that there are studies with different findings regarding relapse of alcoholism. That is not surprising. The most important point is that there still is an important proportion of alcoholics who start drinking after the transplantation. Even if it is one person in ten, it is still a lot. We have shown how consumption of alcohol can often lead to lethal consequences after the operation.

Why is that bad? Because even if the number of alcoholics who start drinking is not overwhelming, it still means deprived opportunity to live for people who have made the right choices in their life. Meanwhile, the recipients of the liver squander their opportunity as well. We find this absolutely unacceptable.

(c)

The example of obese people was not used appropriately. There is a far stronger causal link between being an alcoholic and failed transplantation/recovery process than between being fat and failed transplantation/recovery process. If our aim is to distribute as efficiently and justly as possible, this distinction is very important.

(d)

We never that all people are perfectly rational and always take availability of transplants into account when going on with drinking. However, it is clear that our plan sends a clear negative message about the use of alcohol. Even if people do not care about transplants, their desire to conform socially means that the costs of drinking will go up. Attitude of their fellow citizens will make them understand that drinking is a very bad decision.

Finally, our fourth reason why our plan achieves distributional efficiency:

(4) It will increase the level of organ donation

Both sides in this debate agree that is unfortunate that we have so few livers that can be used for transplantation. Currently, very few people decide to donate their livers - a pitiful state of affairs. It does not have to be that way.

There are many reasons why people do not decide to give their organs for transplantation. We believe that one of the important factors (although not necessarily the most important one) is the recepient of the transplant.

People like helping others who share their genes, worldview, ethnicity, nationality and other things. This is a basic aspect of group psychology. Some people think it is unfortunate; however, that is the way human beings are wired up. According to the United Network for Organ Sharing, most living organ donors are family members of the recipient [[http://www.unos.org/news/newsDetail.asp?id=163]].

We believe that many potential donors are not agreeing to give away their liver precisely because it can received by a person the donor is not fond of. It is no surprise that there are many people who dislike alcoholics, think it is their own fault and would not want to give away their organs to help them. This is particularly true when consenting to donate a liver - after all, heavy drinkers represent a big proportion of the current recipients of livers.

If people know that their livers will be received by people who are not alcoholics, the level of donations is likely to go up.

Why is that efficient? Well, because it will help us to solve the disgraceful mismatch between people who have organs and can give them away with little cost (for instance, after death) and people who desparately need these organs to stay alive. Of course, alcoholics as a group will be significantly worse off; however, we are ready to accept this if it helps us to save the lives of all other people.

The proposition has shown remarkable clarity in spreading out their arguments. The opposition appreciates this, but unfortunately cannot accept any of the arguments.

(1)
“If a liver is given to an alcoholic, another person in the queue dies and maybe also ex-alcoholic dies. If liver is given to someone else, that person lives and alcoholic dies.” A direct quote was taken from the proposition side here. This is the cornerstone of all the proposition side’s arguments in this round. We the opposition seriously question the validity of this dangerous assumption.

The fundamentals of the proposition assume two things, two wrong things. 1) All non-alcoholics never die after a liver transplant. 2) Every person’s urgency and need for a transplant are exactly the same. Both are untrue.

There can be absolutely no foresight whatsoever what a non-alcoholic, or an ex-alcoholic, for that matter, may do after a liver transplant. Non-alcoholics can smoke, non-alcoholics can turn into ex-alcoholics (if not, why would there be any ex-alcoholics in the first place?), non-alcoholics can start marijuana. The chances of an ex-alcoholic harming himself and a non-alcoholic harming himself are practically the same, as the opposition sees it. The survival rate for non-alcoholics after a transplant is 90%. The survival rate for ex-alcoholics after a transplant is 85%. We see practically no difference in these statistics; not a lot of people receive liver transplants in the first place, which renders a 5% rate to practically nothing. Thus the first assumption of the proposition is false.

Moreover, every person’s urgency and need are different. In many cases, the ex-alcoholic is in a much more desperate situation than the non-alcoholic; and vice versa. The opposition disagrees with the proposition when it argues that an ex-alcoholic, minutes away from death, should be ignored for a non-alcoholic with ten years left on the clock. Borrowing the proposition’s words, we aim to maximize the protection of citizens. We are sure that maximizing such protection comes with need-based transplants, not merit-based transplants.

(2)
The point of banning alcoholics from the pool of liver transplant receivers increasing the level of organ donation is ludicrous. First of all, not one piece of evidence was given to support this outrageous claim. Throwing out such a controversial viewpoint without proper substantiation is not the best of argumentation. Second, the line of logic is flawed. We the opposition support the contrary opinion. Many potential donors do not agree to give away their liver because of personal qualms or because they are uninterested, not because of whom is it going to go to. The proposition is making a grave mistake if they think that alcoholics are separated with the rest of society. Alcoholics are fathers, mothers, sons, daughters, uncles, grandparents. Excluding people just like us from a chance to save their lives will be viewed as not appropriate, but rather cruel and dastardly. If people would love not giving their organs to alcoholics, why in the world does society use taxpayer money for criminal reform? People believe in values, people believe that all humans deserve equal rights, people believe that everyone needs a second chance; people believe that denying the right to live based on a past lifestyle is downright disgusting. The proposition portrays people as cold and calculating. The thing is, you don’t donate your organ with a cold and calculating mind. You donate it out of the goodness of your heart. The notion of entirely denying some people with a certain lifestyle from the warmth of your love is simply not understandable.

http://www.cpmc.org/advanced/liver/patients/topics/transplant.html#Evaluation%20Process http://www3.interscience.wiley.com/journal/119977720/abstract?CRETRY=1&SRETRY=0

Heavy drinkers should be denied liver transplants

Yes because... No because...

Summary

We quote “we are talking lives here”. Yes, we are, but unlike the opposition we believe that there are some things more general, not only tons of insignificant facts that don’t contribute to the debate. With all due respect to the opposition we believe that the opposition’s argumentation was weak and in the summary, we will try to prove why giving 1st chance to people is more important than giving 2nd chance to those who destroyed their life because of their past lifestyle.

The opposition has all the time been wining that they “value lives of people above everything”. Yes, we too. The opposition should understand that it is impossible at the moment to save everybody. If you save an alcoholic, because a young sporty guy could wait, you could get the situation where the young guy is not sporty anymore, since his disease progressed to the extent that a transplant won’t help him. The alcoholic lives while the young man dies. The opposition thinks that it is fair, we don’t.

The point is that even if at the moment a young guy could wait, no one is sure whether he will get his liver, since the number of organs available fluctuates all the time. Look at this story. [[http://www.guardian.co.uk/society/2009/sep/13/organ-donation-transplant-waiting-list]] Initially everybody thought that it will take him only 3 months of waiting, since in his blood group the donation rate was high. Unfortunately, the rates of donations have unexpectedly dropped, so now after 7 months no one is sure whether he will get his organ. We propose to give first of all organs to non-alcoholics and then see if we could treat alcoholics. This is both efficient and fair.

In our summary, first of, we will clarify the misunderstandings about our model and explain why the Status Quo is inefficient, afterwards, we will argue (1) whether alcoholics were responsible for their actions, (2) how efficient is it to give organs to alcoholics and, in the end, (3) is the government the one to decide.

First, let’s clarify the plan and model. It is no doubt that the liver transplants are scarce resource, which requires a different plan than the Status Quo, since more than 2,000 of people are dying while waiting for their liver each year in the US alone [[http://www.ustransplant.org/csr/current/fastfacts/datatour.aspx]].

The opposition brought up a point that our plan is arbitrary because we do not include smokers and drug addicts, but again we have to clarify that under the Status Quo doctors have the right to deny liver transplants for people, for example with Hepatitis B, so that they make sure that the chances of survival are higher. And even if it wouldn’t be under the plan, the statistics shows that alcoholics are significantly better represented in the waiting list comparing to people with obesity. In the end, the opposition didn’t give us any reference on how fat people or smokers get the liver disease. We assume that it is because there is no such mechanism.

The opposition argues how hard is it to determine who is/was an alcoholic. Even though we have to repeat ourselves, there are various measures how to do it – social stability, employment records, psychological and physical tests which can clearly provide data about the history of the individual.

(1) Are alcoholics responsible for their drinking problems?

As the key group of this debate is alcoholics, once and for all we have to clarify how responsible they are. The burden of proof for the government was to provide evidence that alcoholism was because of individual’s lifestyle and even if there were any external factors they could have been overcome.

First, as opposition didn’t refute our point in the argument of fairness, we can surely state that the significant amount of alcoholics started to use alcohol because of their free-will, and doesn’t matter whether they started doing it at age of 14 or 41, because the government did all the preventive functions: educating in schools, advertisement campaigns etc. Meanwhile we don’t deny that it is the government’s role to help them as much as possible to get rid of their addiction. And the government does it, take a look at Anonymous Alcoholics. Speaking about the external factors, as the opposition didn’t find it enough important to rebut, we believe that none of the surroundings could be a sufficient reason to be an excuse for being alcoholic, because it was both free choice and it is not enough justifiable as provided in the analogy of committing a crime because of a bad suburb. Similarly with genes, a person who is sick should seek for help from AA before the problem gets too serious. Anyway, as we provided in our reference, there is even no clear link proven between genetics and alcoholism.

The opposition argued that people don’t think prior the problem occurs. We don’t think that it somehow could decrease the responsibility of alcoholics because similarly you don’t get a lower sentence just because you didn’t know that killing 10 people will end with the imprisonment. We believe that there is enough information provided about the bad consequences of alcohol. After all, on each bottle of alcohol there is written with bold letters: “The usage of alcohol damages your health”.

Because of all these reasons, we believe alcoholism was a fault of these individuals and even if there was an influence from external reasons, it could have been prevented if a person wanted to.

(2) Is it efficient to give livers to alcoholics?

Even if we know that alcoholism was a fault of these individuals, would it impact the results of surgery and how likely a person would stop drinking after the surgery?

Chances of survival. Both sides agreed that if a person was an alcoholic, it decreases the chance of successful surgery. In the doubtful statistics the opposition has found and to which it gave a failed hyperlink, there was written that alcoholics have 5% less chances of surviving. Even if it is only 5%, on the proposition side, we believe that it is enough to give livers to non-alcoholics. Even if the opposition argues that this percentage is not enough significant, we have to take into consideration how the liver is used afterwards. The data shows that 38% of alcoholics who had liver transplantation started using alcohol. Even if there were only 1 in 10 people starting to use alcohol again, it is clearly too many. We on the government side believe that each life is valuable, but if there is a better chance of allocating the resource, so that it could save 5% of patients more, we go for it. At least, while there 2,000 people dying each year while being on the waiting list.

Assumption that those who will drink afterwards, most probably, will drink not as much to damage the liver again, we find silly. You don’t have to be a PhD in medicine to know that it will damage the liver anyway. Especially, if there is a high probability that the liver might not suit the person, alcohol will definitely increase the chance of failure. Also, we pointed out that drinking alcohol after the operation not only damages the liver, but has a harmful effect on the immune system of the body, which is crucial for a successful operation.

On the point about the evaluation of patients. We don’t buy that 6 month period of sobriety anyhow could decrease the blame of destroying the liver. What we are arguing is not for how long a person was sober but what was the reason to get the liver failure.

To sum up, we believe that it is by no means more efficient to give a liver to a person who has a higher possibility of survival, and even if under this plan we undermine any rights of alcoholics, it is very important to use the scarce resource in the best way possible taking into account even 5% difference.

(3) Is it justifiable for the government to prevent alcoholics from entering the line?

If we have clarified how alcoholics are responsible for their actions and how inefficient it would be to give transplants to them, is it still justifiable for the government to choose what’s the best for the whole society if clearly one group gets worse off?

We are very glad that the opposition brought up the point of who should be given a liver – is a 2nd chance for alcoholic better than a 1st chance for a person with an inherit decease? We do agree that lives should be treated equally if everybody had the same opportunity initially. But we believe it is fairer to give a chance for a person that didn’t have any opportunity before and didn’t damage his own health on purpose. Thus, it is fair to give livers to non-alcoholics.

The opposition believes it is unethical that somebody has to prove they deserve a transplant. On the government’s side we believe that it is ethical to save as many lives as possible and if the resource is scarce, we save those who have a higher possibility of survival. We don’t think that patients have to prove anything and nowhere in our plan or arguments we stated it. But we believe that each and every person has to be suitable for the surgery. However, we see that already under the Status Quo in California, which was given as a counter-plan from the opposition, doctors evaluate candidates in some cases based on their socio-economic group. We believe that if it is allowed, there is nothing wrong to evaluate based on the past decisions made.

Besides these three clash points we believe this plan introduces several benefits that were never really tackled.

The plan will send a clear message that alcoholism is inherently bad and will increase the costs of using it, which is desirable for any government. First it shows that the government doesn’t like alcoholics. Secondly, it once again reminds alcoholics about problems they could possibly have in the future. Thirdly, it deals with the issues of moral hazard alcoholics could have under the status quo.

Also, we believe that organ donations will increase. Even if the majority of people give their livers because of other reasons, one saved life is better than nothing. Such plan could increase the number of livers donated, because a person donating his liver will be sure that it is going to be received by an unlucky patient really in need, not an alcoholic that had been drinking for decades ruining his own organism. In any case, there is no reason that this plan will decrease the number of donors, so in that sense it could only bring benefits.

And the last, but not the least: doctors. As provided in the evidence in the USA and the UK doctors already have to decide which surgery would be too expensive or too unlikely to succeed. Our plan would only decrease the hard times for doctors as it would ease their decision upon preventing alcoholics from having a surgery.

Overall, we think that denying livers to alcoholics and giving them to those with bad luck is both efficient and fair. Even if it is only by 5% more efficient, we go for it. No doubts it is fair, since alcoholics are responsible themselves for their harmed livers. Moreover, this plan also brings some additional good effects. For both these reasons we beg you to propose the motion.

Heavy drinkers should be denied liver transplants

Yes because... No because...

Benefit of Need-based Distribution

While the proposition plan simply calls for a blame game on the patients with their lives at stake, opposition provides a plan that saves lives to the maximum. As in the status quo, the 100,000 patients on the waiting list will be prioritized by the urgency or the need for a transplant. The patients’ medical situation is assessed by the doctors and transplant coordinators with strict standards for categorization and prioritization.1
This need-based system is crucial in the aspect that liver transplant, like any other organ transplant, has its success determined by the timing. If transplants are not operated for the patients before cirrhosis completely overtakes the liver – an organ that exercises tremendous influence over the human circulatory system – the life expectancy of the patients are to drop drastically. However for those patients that do receive an organ transplant, nearly 90% percent live for more than a year and 80% lives for more than 4 years. And even in case of alcoholic patients the survival rate for more than 10 years is 85% - exhibiting small difference from that of normal patients.2 So, in the end, it all comes down to the question of the need. And we the opposition simply cannot forego the instances where alcoholic patients are neglected of their right to life because of abstract distrust of the addiction’s curability

1http://www.unos.org/ http://www.cpmc.org/advanced/liver/patients/topics/transplant.html#Evaluation%20Process
2http://www3.interscience.wiley.com/journal/119977720/abstract?CRETRY=1&SRETRY=0

Heavy drinkers should be denied liver transplants

Yes because... No because...

Disastrous Impact on Other Transplants

Although in this debate we are solely focusing on the issue of liver transplant on the alcoholic patients, we also have to keep in mind of how the effectuation of this policy can impact other sectors of transplantation. Once this blame game is started on all patients for the supposedly "explicit" harms that they have brought on themselves, so many patients in dire need will be prone to denial of life. According to the logic of the Proposition, smoking and obseity, for example, could be identified as those harms that patients have been simply "irresponsible" with and lead to a denial of heart, lung, or kidney transplant. Meanwhile, once the need-based distribution system is kept, we do not have to waste any lives of the patients and also governmental effort on playing the blame game on questionable grounds.

Heavy drinkers should be denied liver transplants

Yes because... No because...

The Responsibility of Those in the Medical Profession

The duty of a doctor is to save people who are in life-threatening situations, and not discriminate based on lifestyles. According to the ethical guide for doctors in the UK, which has replaced the Hippocratic Oath in modern-day UK— point 25 reads “Doctors must not allow their views about, for example, a patient's age, disability, race, colour, culture, beliefs, sexuality, gender, lifestyle, social or economic status to prejudice the choices of treatment offered or the general standard of care provided."1 In other words, according to principle, doctors should not have discretion upon such matters and they should simply carry out the responsibility of an doctor whose job is to save lives not to judge them.

http://www.gmc-uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp#Non-discrimination

Heavy drinkers should be denied liver transplants

Yes because... No because...

The ethics of need-based and merit-based organ giving

Already under the status quo doctors carry out an analysis before they make a decision whether to try an operation or not. There are cases when patients are hopeless and an operation won’t help them anyway. By denying them doctors save valuable transplants for other patients that are more likely to succeed with their operation. The opposition today is stating that the need-based criteria is the only one in deciding who to give a transplant. Well, no. There are other factors included in the process of evaluation. Let’s take a look at the system implemented in California to which the opposition has referred in their counter-model and see what are these criteria.

First it states that liver transplants are given to those patients that obtain maximum benefit from the procedure. Thus, it already implies the utilitarian approach. Then there is a list of diseases that qualify for having a transplant. There is also a part called “Contradictions to Transplant” where it is written in which cases doctors absolutely deny patients in having a transplant. This includes usually diseases or processes that significantly decrease the chances of a successful operation. And, among others, it includes “Active alcohol or substance abuse”. There are also “Factors that increase the risk of liver transplantation”, and these include “Advanced age”, “Chronic hepatitis B”, “Severe malnutrition” etc. It is not necessary that an operation will definitely be unsuccessful if a patient qualifies in one of these groups, but these factors decrease the chances of success and increase the costs of the operation. Doctors have a right to deny referring to these criteria to save valuable transplants for other patients and to save money, because operations to other patients will be cheaper. Thus, it implies the utilitarian approach.

There is a set of criteria used specifically to evaluate alcoholics. A patient with alcoholic cirrhosis will undergo a special scrutiny. The idea is to search for indicators for continued sobriety following the operation. And the criteria used are previous social stability, employment record and psychiatric status. This is a case of direct evaluation of patients in the counter-model our opposition has brought up. [[http://www.cpmc.org/advanced/liver/patients/topics/transplant.html]] We see that this model allows direct discrimination based on social status and employment, and this proves that necessity is not the only criteria used. In fact, such questions as “What’s the point of giving this man a new liver when he’s an alcohol addict who will probably relapse?” are already asked. And they are asked by the group of doctors including surgeons, psychiatrists, social workers, dietitians.

Referring to the Hippocratic Oath and other ethical guidelines we see that our plan simplifies lives of doctors, and takes away the burden of deciding and guilt of denying from them. Doctors evaluate patients even now, and the doctor facing a case of alcoholic cirrhosis should make a difficult ethical decision. On the one hand he has to help as many people as he could, but on the other if he helps this alcoholic, who is guilty in his disease himself, he is taking away chances of helping others. Other patients will have to wait for a new transplant, and there is a possibility that they die before they get a new organ. In the United Kingdom the burden of the decision whether to give a patient a liver is also lying on doctors. They have some guidelines and they are much wider than to give an organ to patient who needs it the most. [[http://www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/liver/national_protocols_and_guidelines/protocols_and_guidelines/adults.jsp]] We see it only as a benefit of our model if we take away the burden and the guilt of denying from doctors and pass it in the form of legislation.

To sum up, we see that under the status quo doctors use several criteria in deciding who to give a new organ, not only the necessity. If it is allowed to use socio-economic status in this process, we see nothing bad in using the past behavior as a criteria. Our plan doesn’t contradict the general ethic guidelines used by doctors, but it takes away the burden of difficult decision making process from them and passes it on the legislation in the case of alcoholics. And the state has such a right, since organ transplants are treated as a national resource in most of the states. [[http://www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/liver/national_protocols_and_guidelines/protocols_and_guidelines/adults.jsp]]

The status quo is that people are given organs according to their needs; in other words, first come, first get. However, the Proposition has proposed that we change this into a merit-based system where the doctors consider the conditions of the patient and carry out the surgeries accordingly. Now, we must ask one question to ourselves: do doctors really have the right to analyze their patients’ history before carrying out surgeries? The opposition’s answer to this is a resounding “no.” What doctors do in this society is to help those that are in need of medical assistance. Simply rejecting a patient and his rights to receive medical care just because of what he has done in the past is an illogical stance to take.
The Hypocratic Oath clarifies that doctors will “never do harm to anyone.” By having these doctors do nothing in face of a dying patient, the Proposition is essentially forcing these doctors to breach the most basic promise that he makes as a professional physician. (http://www.cirp.org/library/ethics/hippocrates/)

The proposition’s case of “merit-based” organ transplants is very troubling because it implies that the doctors will be asking several questions when allocating life-giving organs to patients. Before giving organs, under the proposition model, doctors will have to ask, “What’s the point of giving this man a new liver when he’s an alcohol addict who will probably relapse?” or “Does this man really deserve a liver when he’s brought this upon himself?”

The core problem with this kind of approach is that it is fundamentally against the duty of those in the medical profession. Currently most medical professional swear to some kind of modern-day ethical guideline that has replaced the Hippocratic Oath; for instance, in the United Kingdom, doctors use the General Medical Council’s Guidance for Doctors, in which it says under article 25 that “Doctors must not allow their views about, for example, a patient's age, disability, race, colour, culture, beliefs, sexuality, gender, lifestyle, social or economic status to prejudice the choices of treatment offered or the general standard of care provided,”— in other words, the duty of a doctor is primarily to care for sick people, not to be splitting hairs about who is to blame
(http://www.gmc-uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp#Non-discrimination
). They definitely do not retain the right to withhold or change treatment because of the patient’s prior lifestyle (and drinking is a lifestyle). While doctors may make scientifically based decisions, as in the status quo, and not go forth with treatment if he is absolutely sure that having a transplant will not help the patient at all and maybe cause death, he cannot have the right to withhold treatment simply because the patient made a bad life decision in the past, or because he thinks that the patient will never be able to recover from an addiction. The fundamental notion established under the Hippocratic Oath is that a doctor ought to help people in need.

That is why we want a need-based system; we do not want to force people to have to prove that they deserve organs or deserve help, or that their lives are more valuable than others. When there is a dying man in need, we do not calculate whether he was to blame—we try to help them. Thus we want to retain the queue system we have; those who are in life-threatening situations and need help will get in line, and shall get help accordingly.

Heavy drinkers should be denied liver transplants

Yes because... No because...

The proposition model is arbitrary and dangerous

In the beginning we would like to mention that according to your lovely counter-plan (the procedure used in the state of California), Hepatitis B could be the reason to deny a liver transplant. [[http://www.cpmc.org/advanced/liver/patients/topics/transplant.html]]

We believe that giving a person a second chance to live is great, but giving him the first is even better. We would like to give priority to those that never had a chance to live fully with a healthy liver, rather than to those that had it initially, but wasted their organ behaving irresponsibly. If we had enough transplants for all patients, we would be happy to give them to everybody in need. Unfortunately, transplants are a very scarce resource. We could give first a transplant to a person who is more in need, but there is a substantial risk that the next person will die before he gets his transplant.

Returning to the case of an old man and a young sportiest. Imagine that an old alcoholic needs a transplant more urgently. According to the opposition he should be given a transplant, but there is a high risk that the operation will fail because he has other diseases, malnutrition, advanced age, which are all criteria used already by the commission to decide whether to put a patient on the waiting list. Moreover, there is quite a high risk of relapse. According to the statistics we have given before there were cases of alcoholic relapse in the first three months. Also 38% of drinking patients after an operation is a quiet high percentage we believe, since it shows only cases during the follow-up procedures. It should be not a surprise that constant control deters previous alcoholics after the operation. Unfortunately, no statistics could tell us what the rates after the follow-up period finishes are, but we could reasonably guess that they could be much higher. [[http://psy.psychiatryonline.org/cgi/content/full/42/1/55#SEC1]]

So, we give a transplant to an old alcoholic, because we believe that a young guy could wait for the next liver. Unfortunately, rates of donations have decreased, and he dies before he gets a new organ or his disease progresses so much that a transplant cannot help him anymore. We have saved an old person who could live for 3-5 years more if he doesn’t relapse, but we have sacrificed a person who could have lived for a longer period following an operation or even the whole normal life. Moreover, we have saved a person who was guilty himself in his disease, but sacrificed the one who just had a bad luck. We believe that this is neither an efficient or fair outcome.

Concerning the complexity of determining the cause for a liver failure, we challenge the opposition’s idea of correlation. When there is a strong correlation between A and B, that most likely means that A causes B. If the mechanism how A causes B is found out and proved then this is called not a correlation, but a causation. The mechanism how alcoholism causes a liver failure is definitely not new and could be called a causation rather than a correlation. [[http://www.liverfoundation.org/education/info/alcohol/]] Otherwise, there wouldn't even be a term "Alcoholic liver disease." Moreover, alcoholism is proved to be the most popular reason for a liver failure. [[http://www.britishlivertrust.org.uk/home/the-liver/liver-transplantation/a-history-of-liver-transplantation-and-current-statistics.aspx]] Such statistics shows us that there are techniques and criteria to establish the cases of alcoholism and that alcoholism is a reason number one for liver diseases.

We haven’t heard about such strong correlation between overeating and a liver disease. We would be grateful if the opposition tells us something about it.

Also even if we believe that in some cases alcoholism could be partially caused by irresponsible parents or genetic predisposition, we say that it was still the choice of an individual to start drinking. First in this case the term correlation is definitely a better one, because it has still not been proven that alcoholism could be caused by genetic predisposition. There is some empirical data, but additional research in this field should be made to reveal mechanisms and to call it being true. [[http://alcoholism.about.com/od/genetics/Genetics_of_Alcoholism.htm]] Even if this was true, if a person understands that he has a genetic predisposition towards alcoholism and catches himself on a though that he is becoming an alcoholic, he could sign to Anonymous Alcoholics and try to cure his predisposition. It was still his decision to start drinking and not to cure his addiction when it developed. That is why it is mostly him to blame for the disease. However, in the case of some other liver disease cases it was mostly bad luck, thus the person is less to blame.

We have read an article at BBC News about a young guy that died because he was refused in liver transplant. We say that it is sad. But this precedent has sent a bold message that alcoholism is something unacceptable in our society and it is something that could undermine it. Even if a person doesn’t think in a manner “Ok, I will drink, but then receive a transplant”, it still sends a message that alcoholism is inherently bad.

Also if we speak about the level of guilt in receiving Hepatitis because of drinking from the same bottle and alcoholism, we see that the level of guilt in a liver failure as a consequence of alcoholism is much higher. Although the decision to drink from the same bottle was also made by an individual, it was just a one decision. However, developing alcoholism is a set of many decisions made by an individual. A person can’t become an alcoholic because he tried a beer once. He has to drink constantly for a substantial period of time in order to cause a liver failure, thus it is a consequence of many decisions made by an individual. We believe that in the case of one decision made that led to the liver failure the level of guilt is lower than in the case of many decisions. Decisions to start drinking, many decisions to continue drinking from the bottles labeled “Alcohol is bad for your health!” and decisions not to treat the addiction are all parts of this huge set that represents the route chosen by the individual. Thus the degree of guilt in this case is very high.

Overall, we believe that we should give a chance to live first to those that never had it. Secondly, we see evidence that alcoholism is a reason for a liver failure in most cases, and we have a set of criteria to determine it. Then even if person has a genetic predisposition towards alcohol, it was still his decision to start drinking. Lastly, the decision to drink from the same bottle that led to Hepatitis was a decision taken once, but the decision to become an alcoholic that led to a failed liver was a set of many decisions made by an individual. Thus the degree of guilt in the first case is lower than in the former.

Conditions cannot be clear-cut in medical fields, especially when it comes to life-and-death issues. The same applies to these heavy drinkers; the problem is that once these people are restricted from receiving liver implants, the same standards must be applied to other patients as well. For example, what about people that have problems because of smoking or excessive consumption of fatty foods? Or what about those who inherited genetic problems related to the liver, such as Hepatitis B? Should these people be denied of implants as well? The fact is that some of these people have a higher chance of recurrence and a less chance of recovery. (http://www.nlm.nih.gov/medlineplus/hepatitisb.html)

As established in the first argument, the proposition’s model basically brings in all the questions of whether a patient should be given a second chance to live, based on their lifestyles (and the impact it had on the disease) and presumed capacity to kick addictions. We think such judgments are extremely arbitrary and unclear to base life-saving decisions on, considering there are so many other factors that influence diseases.
Bear in mind that alcohol is not the sole cause of liver failure; as stated in the rebuttals, other irresponsible behavior such as smoking, overeating, unprotected sex and the sharing of needles all can be reasons for liver diseases. According to the proposition, it would only be fair then that we deny liver transplants to all these people as well, and we think that would be exceeding inhumane, to deny all these people organs that could save their lives because of decisions they made in the past. If unhealthy irresponsible behavior should be grounds to knock people off transplant waiting lists, we wonder where we should be drawing the line at all.

We challenge the proposition to show us how exactly we are to draw the line between those who are completely innocent in face of their diseases, and those who are not. According to this line of reasoning, we should deny not just livers, but all sorts of other organs as well to patients who are obese or drink too much or smoke too much because it’s presumably their fault. Given that we cannot cleanly divide those who got a disease because of “bad luck” and “bad genes” we don’t think we should let such simple criteria determine whether one is to live or die; we’d rather over-include people when we give help, rather than exclude them.

Establishing this kind of precedent in medicine, that those who are supposedly to blame for their diseases should be taken off the transplant list, allows for a much greater population to be often quite unfairly be deprived of their chances of getting transplants as well.
Please remember the complexities that we mentioned earlier in our refutation (the complexities in the reasons for liver disease and alcoholism) when you are judging this round and this argument.

Heavy drinkers should be denied liver transplants

Yes because... No because...

Last Rebuttal 1: On Status Quo and Ethical Issue

Well, there is not too much to answer. Everything pretty much was already said before. But, anyway, few points of clarification.

First what are the sources of the statistics of 85% and 90% survival rates? If the opposition is talking about their very first point then we feel a little bit betrayed, since they kindly asked us to ignore this point claiming that they cannot delete it. If you give such statistics reference it. Otherwise it seems counter intuitive. Moreover, if we take a look at their quote when these rates appeared, we could see just a clear flaw there. Quoting: "However for those patients that do receive an organ transplant, nearly 90% percent live for more than a year and 80% lives for more than 4 years. And even in case of alcoholic patients the survival rate for more than 10 years is 85% - exhibiting small difference from that of normal patients." How come 80% of all patients live for more than 4 years, but 85% of alcoholics live for more than 10 years. There is a clear mistake. Unfortunately, the link referencing this source doesn't work.

Secondly, we deny livers to alcoholics not only because they "brought the disease upon themselves", but also because giving it to a non-alcoholic is more efficient. Even if we believe in the difference of 5% it is good enough to make a decision who gets the scarce resource. So, we will deny livers to alcoholics because of efficiency and fairness. This is also the answer to the point about relapse.

Once again about the Hippocratic Oath. By the way the Hippocratic Oath claims "never do harm to anyone", which is nothing to do with the discrimination based on the previous lifestyle. The discrimination point is the product of ethical guidelines doctors have in the UK, which were developed as all the laws and could be changed. Anyway, we believe that no breaking of the Oath or any other ethical guideline is involved, since doctors allocate the scarce resource in the most efficient manner, and if non-alcoholics survive in the 90% of cases, while alcoholics only in the 85%, it is the best of doctors to cure non-alcoholics first. They already make such decisions and deny to those whose treatment possibility is doubtful, so they already discriminate. And as we pointed out in California (which laws the opposition brought as a counter-plan) it is allowed to discriminate based on socio-economic status. We see no problem then to discriminate also based on the past experience. Anyway, the doctors won't break the Oath, because the law will prohibit them from giving a transplant to an alcoholic, since the government believes that people have to pay for their mistakes. In such a way this burden is completely removed.

From the previous speech written by the Proposition, we on the opposition figures that they are having difficulties differentiating the status quo and what they are proposing. Already in the status quo, we do have guidelines that designates certain standards for a successful operation. And as we have stated before, in case of alcoholism, the patient has to remain abstinent for at least 6 months to be legible to a transplant. This is a basic requirement for the sake of successful surgery. On the other hand, what the Proposition has been proposing today is that the doctors will deny the transplants to all of those who have a record of alcohol abuse and thereby “brought the disease upon themselves” (as they would like to believe.) With that clear distinction in mind, we on the opposition sees that the Propositions point on how their policy is a just another part of criteria already taking in place is invalid.

Also we would like to point out that in the status quo, liver transplants are not given to the alcoholic patients who have been drinking to excess in the past 6 months, because the doctors sees that it is a proven fact that liver transplants will not work on those patients who simply cannot refrain from drinking even when they are about to get a transplant. This is a given fact for sure. However, as we have mentioned again and again, the Proposition is assuming that “giving this man a new liver when he’s an alcohol addict ‘will probably’ [lead to] relapse.” And from their statistics we see that 38% of the alcoholic patients may drink after the surgery while the other 62% does not. Even for those alcoholic patients who continue to drink after surgery, they do not drink to the point of critically stressing their liver because from what we figure they survive just as long as any other normal patient who has received the surgery.

Now on an ethical note, the Proposition argues that the modern day Hippocratic Oath – in link with utilitarianism - can be used as an excuse for denying the rights to life on certain patients. We see that they would even like to use it as a societal institution that can do the moral calculus for the doctors. However, the reality is that making the final decision on whether or not the patient will be able to survive and how much the “blame” is to be placed on is fundamentally made by the doctors. It is a burden that they cannot simply be dismissed from. In light of that, we have to reminded of the fact that in this situation, doctors can never have the full assurance that an alcoholic patient who has not drank for the past 6 months will not be able to survive the surgery. Only the facts proving the contrary continue to surface. Thus under the ethical guidelines that binds all doctors, they are required to carry out the treatments in the best interest of the patients.

In the end, it all comes down to the question of whether or not there is a chance these patients can survive. As the Proposition has partially agreed and we on the Opposition has continuously pointed out, it is becoming more and more apparent that these people do survive and live a healthy life ever after. And under that factor, we firmly believe that no doctor has the right to deny the patients’ privilege to life.

Heavy drinkers should be denied liver transplants

Yes because... No because...

Opposition's rebuttals to the Proposition's rebuttals

We didn't get the first paragraph. Sorry. The only thing we got from it is "when doctors don't have the right to make a choice in the first place...". Well, just in the previous point you told yourselves: "However, the reality is that making the final decision on whether or not the patient will be able to survive and how much the “blame” is to be placed on is fundamentally made by the doctors. It is a burden that they cannot simply be dismissed from." Please, be consistent with your speeches. Otherwise, it is hard to understand.

Yeah, we agree we are talking lives here. However, on the side of the government we are weighting this thing up to achieve the best result, while the opposition simply is shouting about how much they value lives. Look at this data. [[http://www.ustransplant.org/csr/current/fastfacts/datatour.aspx]] It shows that there is a great mismatch between the number of livers available and the number of patients in need. It also shows that more than 2,000 people die every year while in the waiting list. On the side of the proposition we believe that these 2,000 people should be alcoholics, since they are the ones to blame for their disease, while non-alcoholics that were unlucky to get the disease should get their livers first. It will be more efficient (even in the doubtful case of 85% versus 90%) and fair at the same time.

Once again about alcoholism causing liver disease. Come on. We gave you references. Here you are once again. It is clearly written there "Alcohol was the highest cause for a liver transplant with 652 transplants (following a standard six months abstinence period)." [[http://www.britishlivertrust.org.uk/home/the-liver/liver-transplantation/a-history-of-liver-transplantation-and-current-statistics.aspx]] And here all the mechanisms are explained. [[http://www.liverfoundation.org/education/info/alcohol/]] However, when we asked to give references on effects of cigarettes or fatty food on the liver disease, we got none. It is because the causation there is much weaker. Please, when you claim anything scientific, which couldn't be described by simple logics, make references. Otherwise, such quotes about alcohol causing the liver disease as "nor is it a much more detrimental factor than other factors", don't sound really valid.

And finally, about the mistakes made over time and one mistake versus thousands of them. Your favorite California medical center for liver transplantation already analyses the psyche of their patients to make sure that they don't relapse. We clearly described the mechanics how we see such a decision-making process. In the case of Hepatitis because of one sexual act when one decision was made, and in the case of alcoholism when plenty of decisions to drink and not to stop were made. Yes, we see the fault of the patient higher in the second case. You didn't provide any substantial refutation, except of saying that we will be "considering the socio-economic background and the past psyche of the patients before deciding on whether they would allow doctors to perform liver transplants". Yes, we could to that. Under you sweet counter-plan it is already done. I would suggest you reading what is written in your counter-plan before proposing it.

[Rebuttal to Rebuttal]
On our policy, which is basically maintaining the status quo, the Proposition argues that this is a utilitarian policy in the sense that it leaves some people out. However, the Proposition made an assumption, which was that “Doctors have a right to deny referring to these criteria to save valuable transplants for other patients and to save money, because operations to other patients will be cheaper.” Now, is the Proposition justifying the trade-off between cost and human life? This is something that simply cannot happen in modern society, especially when doctors don’t have the right to make a choice in the first place, as the Opposition has been continuously arguing.

On our reference to the Hippocratic Oath, the Proposition said that this is merely removing the burden of hard decisions to the government. However, the problem is that we are talking about human lives here. As the Proposition so kindly pointed out, a few months can be the difference between life and death for some of these patients. Taking into account the bureaucratic system of today’s government, there is little doubt that this shift of burdens will come at the cost of quite a few human lives. Because the Opposition values human lives above anything else, we cannot tolerate the denial of certain patients over others.

Now, the Proposition seems to believe that in the example of the old man and the young sports player, the old man should be negated in the doctors’ waiting list because alcoholics are not going to be fully healed anyways. However, who says so? The fact of the matter is, 85% of alcoholics that receive liver transplants survive and live for an extended period of time. This number is only slightly less than the survival rate of normal patients; in other words, alcohol problems cannot be a justification for the discrimination between patients.

Also, the Proposition committed the logical error of assuming that alcohol addiction is the dominant cause of liver disease, which is not true at all. Besides alcohol, so many other factors, ranging from consumption of fatty foods to smoking, contribute to liver disease. What are the standards that are to be applied to these people? The Proposition has not made this clear at all, which means that even if this policy is to be applied it would only bring about confusion.

The final rebuttal was centered on how individual mistakes made over a course of time are worse than one-time mistakes. However, we are talking lives here. The Proposition must have all the time in this world to be considering the socio-economic background and the past psyche of the patients before deciding on whether they would allow doctors to perform liver transplants. We as the Opposition value human lives above the question of whether a transplant is valid or not, especially when it has been proven that alcohol is not the sole factor of liver disease, nor is it a much more detrimental factor than other factors.

In all, the Proposition argues for what they think is human lives, but what actually is the validity of liver transplants. On the other hand, the Opposition is the one that is being realistic and effective at the same time in the sense that it is sticking to the status quo, which saves more lives than the proposed policy of the Proposition.

Heavy drinkers should be denied liver transplants

Yes because... No because...

[Summary]

We the opposition shudders at the thought of the world being so bitterly utilitarian that we would deny people a right to live because of one reason and one reason only. That they drank a certain legal beverage which is integrated into the very basic lifestyles of our society; that they have 5% more chance of dying than people that do not share their lifestyles. We the opposition shudders at the notion that they must pay for their first innocent gulp of alcohol with a slow, painful death that can be averted at will. We the opposition is especially horrified that a government, built meant to protect the people’s lives, might turn to it-is-your-fault discrimination on matters of life and death. Ladies and gentlemen, we the opposition truly believe that the policy of denying past alcoholics liver transplants is deeply shameful and essentially meritless.

Although there were many enlightening points, there were two main clashes in the debate, and the opposition would like to summarize the debate accordingly.

1) Will this policy lead to saving many more lives?
2) Should organs be distributed according to need or according to merit?

First, will this policy save many more lives? The proposition argued yes with a two-pronged approach. The proposition has argued that many alcoholics are prone to relapsing into their old habits, thus excluding them entirely from distribution will save much more lives. However, the opposition has given statistics that show that actually, the survival rate of past alcoholics and nondrinkers almost equal each other. The proposition then argued that excluding alcoholics from the recipient pool will foster liver donations. Yet the opposition pointed out that this argument was one gigantic assumption, and that people kind enough to donate their organs would definitely not want their organs distributed discriminatingly.

Second, should organs be distributed according to need or merit? The proposition says that past behavior should be taken into consideration when deciding to give a man a chance or not. We the opposition see that the policy proposed is not “taking past behavior into consideration”. It is rather ignoring all the desperateness of the patient and sanctity of human life, based on whether a person drank or not. No one should play the game of moral calculus on matters of life and death. The opposition understands that we should not bury a man just because he used to dig his grave in the past. We believe that making certain mistakes in how much to drink in your past is too little a crime to deny life. We believe that making legislation, instead of human doctors, deal with the question of whether to save a man or not is not efficiency, but cowardice.

For these causes, ladies and gentlemen, we are proud to oppose the silent neglects and murders that will take place under the government resolution.

Debates > Heavy drinkers should be denied liver transplants
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