Friday, March 23, 2007

Applying the Principle of Desert to Organ Allocation

Here is an essay I wrote last semester for my USP bioethics module. It is somewhat long (at 3K words) so read only if you have the time.

Applying the Principle of Desert to Organ Allocation

Organs are commonly allocated on the basis of need, meaning that priority in allocation is usually given to those who have the most urgent need for the organ. While the principle of need appears to be a reasonable method by which to allocate organs, such a method is, by itself, insufficient, since we would not want to allocate organs solely on the basis of need. Additional principles must be used to supplement the principle of need. I believe that one such principle is that of desert, and in this essay, I will discuss how the methods of organ allocation can be modified with the inclusion of this principle of desert.

Before I begin the main part of my essay, it is first necessary to examine the principle of desert itself. In simple terms, desert rewards those who are deserving. We can see many examples of this in daily life, such as when we pay someone according to the amount and quality of work he does. However, desert can also involve punishing or penalizing those who are undeserving. Again, examples of this are common, such as when we sentence a criminal according to the severity of his crime. Evidently, desert seeks to give people what they deserve, be it reward or punishment, on the basis of their merit or demerit.

There is also another relevant distinction which comes into play when we try to apply desert to organ allocation. The two examples given previously are essentially non-comparative in nature, meaning that what people deserve is only dependent on their own behaviors and characteristics, and not dependent on the behaviors and characteristics of other parties. For example, if a student answers five questions correctly out of a ten question test, he deserves to get fifty marks, and he would still deserve fifty marks no matter how well or badly the other students do. However, desert can also be applied comparatively, meaning that what people deserve is dependent on their relative merit as compared to other people. To reuse the example of the student, we might want to award a grade of A to him, not because he scored fifty marks, but because he scored higher than his peers. Similarly, when distributing a scholarship, each candidate might himself be qualified, but we would need to compare each candidate against other candidates in order to see who most deserves the scholarship. From this example, it can be inferred that comparative desert is relevant when the reward (or punishment) is itself in short supply, as it is with donor organs.

Having given a short description of the principle of desert, we can now attempt to apply the principle towards organ allocation. As stated previously, desert rewards or punishes people on the basis of their merit or demerit. Here, we need to answer two questions. First, upon what criteria should we judge merit or demerit? Second, what should be the reward or punishment for such merit or demerit? I will attempt to reason out the answers to these questions by considering two scenarios. Each scenario will involve two people who require organs, and for simplicity’s sake will be identical in every aspect (for example, in need) except for the criterion which I will be examining.

The first scenario involves person A, who is a registered organ donor , and person B, who is not an organ donor. Given that there is only one organ for transplantation, is there any reason to give the organ to any specific person, or are there no morally relevant reasons for a choice to be made either way? In this scenario, I believe that most will choose to assign the organ to A. Why is this so, and is this choice based on a morally relevant reason? I believe that there are at least two relevant reasons. The first and weaker reason is based on the idea of rewarding virtue. We would like to grant the organ to A because in his prior act of pledging an organ, he has reflected the virtue of altruism, and altruism is worth rewarding. Of course, I find this reason as being less strong because in some cases, organ pledgers might be drawn less by altruistic virtues than by self interest. This concern is especially valid if we begin to reward organ pledgers with priority in organ allocation. The second and stronger reason is that of reciprocity. Because of person A’s prior act of pledging an organ to the society, as a society, we are compelled by reciprocity to grant him an organ if he is in need of one. This reason is stronger because even if people pledge organs out of self interest, the principle of reciprocity is still applicable.

The second scenario again involves a person A, who experienced organ failure as a result of his habitual heavy drinking. Person B also experiences organ failure, but this is attributed to natural factors not within his control. Again, is there any reason to give one person the organ? I think that most will choose to grant the organ to B. There are again at least two reasons for making this choice. The more obvious reason is utilitarian in nature. We might want to deny A the organ because he might continue with his drinking habit even after an organ transplant, and possibility need another transplant later on. We would prefer to give the organ to B, because he could make more use out of the organ. Utilitarians would grant B the organ because the organ would have greater utility. However, this reason tends to be weaker, because it is not always true that A would continue with his drinking habit- if he does quit his habit, this renders both A and B equal on utility. The stronger reason is based on the idea of personal responsibility. We might deny A the organ because he is responsible for his organ failure, and hence is less deserving than B who experiences the same predicament through no fault of his own. Of course, some may question the grounds for penalizing someone for their lifestyle choices, but I will address that concern in a later paragraph.

Through the previous scenarios, we have determined that we should give priority to organ pledgers, and that we might want to penalize people whose predicament is in some part due to their own fault. How then do we incorporate these two ideas into a system for organ allocation? I believe this is best done by modifying a method based on need. First, we should classify patients according to categories of need. For example, we might group patients with very urgent need (death in one month or less without transplant) in one bracket, followed by a bracket containing patients with urgent need, then another bracket containing patients with moderate need and so on. Organs would always go to the neediest bracket, and organs will go to the next bracket only if there are no patients within needier brackets. Within each bracket, we prioritize the patients according to our two previous guidelines, giving priority to organ pledgers and reducing the priority of people with self-caused ailments. The exact system of prioritizing within a bracket may be done by a points system, such that we grant organ pledgers a certain advantage in points. Then, we may impose penalties depending on how responsible a person is for his condition. For example, if a person is a smoker, and if smoking is a minor contributing cause of the medical condition resulting in organ failure, then we may impose a slight penalty. Heavier penalties may be imposed if a person is strongly responsible for his ailment, such as if the person’s condition is the direct result of him taking drugs.

This proposed scheme has at least one advantage over allocation methods. The advantage of incorporating desert into allocation schemes is that doing so actually alleviates the problem of organ shortage. This advantage stems from the fact that desert is a principle that rewards and punishes based on certain behaviors or characteristics, which necessarily means that desert encourages or discourages these certain behaviors. In the case of organ allocation, we encourage people to pledge their organs, and discourage people from engaging in risky behaviors . Both work to reduce the organ shortage, one by increasing supply and the other by reducing demand. However, the same cannot be said about other methods of organ allocation. For example, if we were to allocate organs based on the principle of need, and to give organs to those who need it most urgently, we would not be encouraging either organ donation nor would we be decreasing organ demand. On the contrary, it might be argued that allocating organs based on need encourages people to engage in risky behaviors, since they would not be denied an organ on that basis. Similarly, if we were to distribute organs based on social utility, we would be rewarding people on the basis of their social utility. This does nothing towards alleviating the shortage of organs, since there are no incentives to donate nor are there penalties for any risky behavior. In fact, it might also be argued that distributing organs based on social utility encourages people who are socially useful to engage in risky behaviors, since they would have priority in organ allocation. Again, this outcome is most unfavorable, as it conceivably increases organ demand.

Having discussed the moral motivations and the advantages for incorporating desert into schemes of organ allocation, it is now time to consider some possible moral objections to such a scheme. There are a number of criticisms of desert-based allocation schemes, which I will broadly classify under two categories. The first category consists of extrinsic concerns, which are concerns stemming from factors external to the allocation schemes. The second category consists of intrinsic concerns, which are concerns inherent to the organ distribution method itself. I will address the extrinsic concerns first.

The extrinsic concerns revolve about how organ distribution methods incorporating desert might fail given certain external factors. One such criticism argues that rewarding organ pledgers is fair only if everyone was aware of such a choice. However, if some people were not aware of the choice to pledge organs, and if we were to penalize them for this, in effect we would be punishing them for things that are beyond their knowing. In other words, we should not penalize people for their ignorance. In particular, since one of the underlying principles of desert is the idea of personal responsibility, punishing people for what is essentially beyond their knowing seems unreasonable and self-contradictory. I would agree that this criticism is valid. However, I believe that the solution is not to forgo the desert-based allocation method, but rather, to ensure that everyone (or at least a very large majority) is made aware of the choice of organ pledging. In any case, we should broadly publicize the desert-based distribution scheme, as doing so not only addresses this criticism, but also contributes towards increasing organ pledging rates.

The second extrinsic concern takes the form of a slippery slope argument. In our proposed scheme, we penalize people engaging in certain risky behaviors which would contribute to organ failure. Critics would argue that such a desert-based scheme could eventually be abused such that it would become an indirect tool of discrimination. For example, the scheme might be adjusted to heavily penalize homosexuals or minority races. Alternatively, desert-based schemes might also be modified into becoming a method of social control. For example, if the society were to find smoking undesirable, they could modify the allocation scheme to deny smokers priority, regardless of whether smoking had any significant effect on the condition leading to organ failure. However, while I would admit that desert-based organ allocation schemes could be abused, I do not think that this is sufficient reason to reject such schemes. Firstly, desert-based allocation methods can (at worst) only act as tools of discrimination or social control, but they are themselves not the cause of discrimination or social control. Rather than rejecting desert-based allocation schemes, it would be wiser to tackle the root causes that might motivate such abuse. Furthermore, since not everyone needs an organ transplant, organ distribution methods would be extremely inefficient tools for either discrimination or social control. It is highly unlikely, then, that organ allocation would be deployed to such nefarious ends.

Having addressed some extrinsic concerns, I will now address the intrinsic concerns. In a previous paragraph, I have already alluded to the first concern. This first concern asks whether it is right to penalize people for their lifestyle choices (i.e., their risky behaviors). While I am reluctant to actually penalize people for their personal choices, I am led to believe that doing so is fair. I obtained this conclusion by revisiting the scenario posited earlier. If we were to award the organ to person A (who is responsible for his own organ failure), it might be said this is unfair to person B, because B is essentially paying the cost (of being stuck without a transplant) of A’s risky behavior. This runs contrary to the ideas of personal responsibility, where one should shoulder any outcomes of one’s actions. Furthermore, we believe that it is unfair to force one’s burdens (which are due to one’s actions) to an innocent party. Hence, even though we are reluctant to penalize people for their bad lifestyle choices, this is required in order to be fair to other parties.

Another related criticism argues that if we penalize people for some bad lifestyle choices, what is to stop us from extending the principle such that we penalize people for even minimally bad choices? For example, we would not like to be denied an organ just because we do not eat a balanced diet or if we do not exercise on a regular basis. In my opinion, this criticism is partly valid, in the sense that we should not penalize people for minimally bad choices. However, this is still perfectly consistent with the proposed organ allocation method, which penalizes risky behavior according to how much the behavior contributes toward organ failure. Even if we were to penalize minimally risky behavior, the penalty will correspondingly be minimal and thus have little effect on the outcome of the allocation. In fact, if we were to implement the proposed organ allocation scheme, we might want to ignore such minimally risky behavior in our considerations, since there are other more morally relevant considerations (such as waiting list time, number of dependencies etc) which can be taken into account.

The last and most serious criticism stems from criticisms of the principle of desert itself. Basically, desert rewards people who are deserving, and penalizes those who are undeserving. However, desert is also based on the idea that there is a level field for this comparison. For example, in a race, we might award the fastest runner with the gold medal. However, if the fastest runner was later found to have been born with a special gene which greatly boosts his athletic ability, we might be less willing to say that he deserves the medal, since his athletic gene, and not his effort or skill, might be responsible for his win. In our organ allocation scheme, we based the prioritizing criteria on organ pledging and on lifestyle choices. It might be said this criteria is largely level and fair, since both are personal choices within the control of the individual. However, there are two ways in which the criteria might be said to be uneven or unfair. Firstly, there are certain circumstances in which organ pledging or some lifestyle choices are not a matter of personal choice. An apt example can be found in Singapore, where the Human Organ Transplant Act offers priority to organ pledgers (although this is done via an opt-out rather than an opt-in system). However, Muslims, due to religious reasons, are unable to pledge their organs . We might want to question whether it is right to penalize Muslims for something which they have little control (beyond apostasy, which is unreasonable to expect of them). While we might want to reason that the principle of reciprocity still holds, and that it is actually acceptable to penalize Muslims, this conclusion is at best highly controversial.

The second way in which the prioritizing criteria can be said to be uneven is when the person is partly or absolutely incapable of making the requisite personal choices, such as when the person is a child or is mentally disabled. Clearly, these people would fall outside the judging criteria, since they are not responsible for themselves or for their actions. Of course, we could still apply the principle of reciprocity to justify any prioritizing decisions we make against them, but to do so would be callous. Rather, some alternative provisions should be proposed to cover children and the mentally disabled, otherwise we risk disadvantaging those who are the most innocent.

Having discussed a desert-based organ distribution method and some criticisms of such a method, it might appear that while most criticisms can be addressed, some concerns require more attention. In particular, such a scheme might disadvantage people from certain cultures or religions. While this is a valid concern, I am not prepared to dismiss a desert-based organ allocation scheme so readily, because of such a scheme’s intuitive nature (rewarding the deserving and penalizing the undeserving) and also because the scheme would help to reduce the organ shortage. Rather, I would propose incorporating more elements of consideration (social utility, beneficiaries etc) into the scheme, such that nobody would be overly disadvantaged due to cultural or religious reasons. Admittedly, such an expanded criteria would be more complex, but in the interests of fairness this should be tolerated.

In conclusion, although there are some valid concerns regarding the application the principle of desert towards organ allocation, it cannot be denied that desert offers much promise as a priortising principle for organ allocation. Hence, I believe that more attention should be devoted to incorporate desert into a scheme of organ allocation.