Ethics Vs. Ethics
The first in a series of things I’ve been meaning to write about: when one ethical value comes into conflict with another.
We have a bioethics class where we discuss autonomy, nonmaleficence, beneficence, and scarce resources, but I’m not particularly a fan. We can argue this hypothetical case studies presented in class, and see different perspectives, but in the end, the answer always seems to be “it depends on the situation.” It always seems like a cop-out.
In the last week of classes, however, we had a patient come speak to us about his experience as a smoker and lung transplant. The surgeon presented the patient’s history, and told us that there are significantly more people waiting for donor lungs than there are donors available. The patient told us he ended up smoking something like 120 pack years, and was supplemental oxygen for at least 5 years, and *still* kept smoking. The patient eventually stopped, and had one lung transplant. It was a bad pair of lungs–they failed within months–and so he was put back on the transplant list, and received a second set of lungs. (Nothing up to here really gets to me.)
The surgeon presenting the case told us the patient was on immunosuppressive drugs, to prevent the body from rejecting the foreign lungs, and then reminded us that, as a consequence, the body is much more likely to develop cancers and tumors when it is immune suppressed. The patient then told us how he knows he’s at higher risk for skin cancers, that his doctor has warned him, but he doesn’t listen–he just got back from a week in Cancun tanning all day long. Most of my classmates laughed; the surgeon did too. “What a silly, fun-loving, risk-taking patient! Ha ha!”
Maybe I was just in a peevish mood, but it totally rubbed me the wrong way. I mean, here we are, talking about lack of resources for other lung transplants–or hell, lack of resources in general–and we’re encouraging destructive behavior by laughing at it.
I *know* we can’t just tell patients what to do, how to behave, or what to eat. Maybe it’s my lack of experience with non-adherence by patients, but it just seems like totally ignoring the “justice” or “limited resources” ethical value.
You’ve probably thought a lot more about this than I have, but attempts to assign relative values to human life are bound to run into ethical obstacles at many levels. The only role of justice in the situation you describe would apply to the process by which a patient receives a donor organ. So in this case, a waitlist, perhaps prioritized by urgency.
The subsequent use (or abuse) of that organ, however, is squarely at the discretion of the patient. Fairness applies only to its acquisition, not its use. Though shareholders have a right to be outraged at greedy executives who illegally and unfairly steal from the corporate coffers, they don’t actually have any basis for outrage at profligate consumption of fairly earned wealth (however repugnant such waste may seem).
Of course, we are talking about human life here, not money. By a more tangible process, every organ that is given to a patient is de facto denied to another. But I pose this question to tease out the source of injustice: if a patient paid $1mm for the lung – money which perhaps goes towards cancer research or something otherwise beneficent – would it still be unethical (not offensive, but *unethical*) to live in an imprudent manner? Are we offended because a patient does not appreciate his life, or because a patient receives a gift, at the expense of another patient, and does not properly appreciate it?
A final (finer?) point: The scarcity of the resource is a relevant consideration only insofar as people care about justice only when denial is involved. If every person were eligible for a $5 bill dropped from the sky, there would be no discussion of whether it was fairly earned or deserved, because no denial is involved.
I think the better class would have another patient on the lung donor list who’s still waiting for a lung to come in and give the opposing view. Then I’d wonder how many of your classmates would laugh at the first patient’s behavior.
Wasn’t there a similar “controversy” when Mikey Mantel – a long time alcoholic got 2 livers before he died?
I agree with you though and don’t think it has anything to do with being in a peevish mood. It’s just downright wrong – one of those things where there’s good argument on both sides but you know how wrong it is deep down inside.
I’m a card carrying organ donor and I strongly believe in it. I guess being a strong believer means taking the chance and being OK with my organ possibly going to someone who’s going to abuse it.
If a million people believe a foolish thing, it is still a foolish thing.