This column was originally published in Yiddish at the Yiddish Forward, and is published here in translation by arrangement with them.
Dear Dr. Berger,
What are the ethical arguments for and against providing an alcoholic with a liver transplant?
Robin Katcoff, Baltimore, MD
Dear Ms. Katcoff,
You have a very serious question, one of the deepest in medicine. Is a sick person guilty of being ill? Fault is, of course, a moral concept. A basic principle is that the sick are not guilty of their illness. Once you start blaming the sick, where does it end? "You have diabetes because you snack too much"; "You broke your leg because you’re a terrible football player"; "You’re depressed because you lost hope too quickly." Hard to say who is not guilty. It is better to say that everyone gets sick, nobody is guilty and our work as doctors is only to treat as far as possible.
Your example is on point. On the one hand, it is not only cruel, but also stupid to say that an alcoholic should not receive a liver transplant. Liver transplants are for those who no longer have a functional liver, and alcohol is a very common cause of liver failure. (Should you, for example, also blame those who have harmed their liver with too much Tylenol?)
On the other hand, however, you can understand the downsides of distributing livers completely equally. Particularly in the United States, there are not enough organs to transplant.The supply doesn’t match demand. Thus we have to make sure that the recipient can be helped by the organ. For example, a transplanted liver would likely not be of much use for someone with a terminal disease. If a patient cannot be helped by a transplanted organ because of active alcohol use, or the damage that alcohol has already done to the liver, than transplant might not be effective. (This ignores, of course, the social environment which can increase the risks of substance use, and the frequent difficulties in the path of those who seek treatment.)
The criteria for the distribution of transplanted organs are among the most controversial in bioethics. There is no easy answer.
Dear Dr. Berger,
Why do hiccups come in waves? I don’t hiccup for forever and then they come on for weeks at a time.
Miriam Avins
Baltimore, MD
Dear Ms. Avins,
There are many reasons for people to hiccup, from the trivial to the Important. Eating too much, stress, anxiety, or drinking alcohol or soda can produce hiccups, as well as sudden changes in the temperature or swallowing air when chewing gum or sucking on candy. Such hiccups, generally speaking, last only a day or two.
Hiccups that last more than two days may be due to an inflammation or injury in nerves which serve the diaphragm, the muscle which controls the pressure in the chest (thorax). A growth in the neck, a hair, or anything else that touches your eardrum can affect the nerve. More common reasons for such hiccups can include sore throat, laryngitis or heartburn (acid reflux may cause hiccups).
More serious matters, for example, strokes or brain infections can also result in chronic hiccuping. Long lasting bouts of hiccups might also be due to ingestion of alcohol, anesthesia or its after effects, diabetes or other diseases. Emotional factors and surgeries are also linked to hiccups.
Hiccups can bother the hiccuper - or the person who has to listen to them. May you see a quick end to them!
Dear Dr. Berger,
What are the ethical arguments for and against providing an alcoholic with a liver transplant?
Robin Katcoff, Baltimore, MD
Dear Ms. Katcoff,
You have a very serious question, one of the deepest in medicine. Is a sick person guilty of being ill? Fault is, of course, a moral concept. A basic principle is that the sick are not guilty of their illness. Once you start blaming the sick, where does it end? "You have diabetes because you snack too much"; "You broke your leg because you’re a terrible football player"; "You’re depressed because you lost hope too quickly." Hard to say who is not guilty. It is better to say that everyone gets sick, nobody is guilty and our work as doctors is only to treat as far as possible.
Your example is on point. On the one hand, it is not only cruel, but also stupid to say that an alcoholic should not receive a liver transplant. Liver transplants are for those who no longer have a functional liver, and alcohol is a very common cause of liver failure. (Should you, for example, also blame those who have harmed their liver with too much Tylenol?)
On the other hand, however, you can understand the downsides of distributing livers completely equally. Particularly in the United States, there are not enough organs to transplant.The supply doesn’t match demand. Thus we have to make sure that the recipient can be helped by the organ. For example, a transplanted liver would likely not be of much use for someone with a terminal disease. If a patient cannot be helped by a transplanted organ because of active alcohol use, or the damage that alcohol has already done to the liver, than transplant might not be effective. (This ignores, of course, the social environment which can increase the risks of substance use, and the frequent difficulties in the path of those who seek treatment.)
The criteria for the distribution of transplanted organs are among the most controversial in bioethics. There is no easy answer.
Dear Dr. Berger,
Why do hiccups come in waves? I don’t hiccup for forever and then they come on for weeks at a time.
Miriam Avins
Baltimore, MD
Dear Ms. Avins,
There are many reasons for people to hiccup, from the trivial to the Important. Eating too much, stress, anxiety, or drinking alcohol or soda can produce hiccups, as well as sudden changes in the temperature or swallowing air when chewing gum or sucking on candy. Such hiccups, generally speaking, last only a day or two.
Hiccups that last more than two days may be due to an inflammation or injury in nerves which serve the diaphragm, the muscle which controls the pressure in the chest (thorax). A growth in the neck, a hair, or anything else that touches your eardrum can affect the nerve. More common reasons for such hiccups can include sore throat, laryngitis or heartburn (acid reflux may cause hiccups).
More serious matters, for example, strokes or brain infections can also result in chronic hiccuping. Long lasting bouts of hiccups might also be due to ingestion of alcohol, anesthesia or its after effects, diabetes or other diseases. Emotional factors and surgeries are also linked to hiccups.
Hiccups can bother the hiccuper - or the person who has to listen to them. May you see a quick end to them!
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