Tuesday, April 03, 2007

WHO GETS A SECOND CHANCE?



If we were given the power to stipulate what criteria should be applied to decide which applicant would get an organ transplant, it would be a most difficult task. Who are we to decide who lives and simultaneously, who dies? Who deserves to live is not the only question but who should live should be considered as well? The person who pulls the trigger out of instinct to survive has an excuse. The defendant, who in an excited reflex causes another person’s demise, has a reasonable belief of danger or harm and used only necessary force, may have a valid justification. But the one who contemplates the condition and premeditates the result is either a killer or a giver of life or both as in this case. Consider that all applicants must have the organ transplant to survive and that one must select three out eight factors. This makes the decision an excruciating ethical dilemma or simply something that must be dealt with cold, hard, practical reasoning.
Our choices include:
A. Quantity of and quality of life expectancy with transplant (age plus prognosis).
B. Order of application
C. Ability to pay
D. Social worth/contribution potential
E. Need (other than medical)
F. Fault (e.g. personal responsibility for condition—self abuse or victim)
G. Dependence of others
H. Equality
My gut reaction is to grant the application based first on equality, second on quantity/quality of life expectancy with transplant and third on the fault of the applicant. My committee (including myself) decided that three factors were not enough. We determined to give preference to quantity/quality of life, second to fault, and third to dependence of others on the applicant and finally to the order of application. What made me change my mind? Why? or did I? The reality is that these decisions are made based on consensus and they do not necessarily reflect each person’s views. Compromise is the first order of business because time is of the essence. The implications are very troublesome and I can only ascertain the reasons for the results by analyzing the process.
How did we define each factor? We considered the quantity and quality of life based on age, physical condition and the lifestyle of the applicant as best examined under the circumstances. We felt that even if a young, otherwise healthy female would live longer than an elderly male, if the female is serving a long prison sentence, then the elderly male would benefit more from the procedure. We also considered that a child would most likely live longer but the conditions of his life could make a difference. Other aspects like other physical or mental disabilities and external factors that constitute “quality of life” should be considered such as: dire surroundings, despair, penury, destitution, drugs, poverty, no parents, ward of the state, no emotional support. These factors are all troublesome and bring up serious controversy leading to gridlock in reaching consensus. Personally, I feel strongly that all individuals can overcome their conditions and that great persons have emerged from dreadful circumstances. However, the organ transplant decision must be made primarily based on present conditions, or do they?
Our committee then decided that it would be easier if we started by eliminating those factors that we felt should not play a decisive role. Those factors include the ability to pay, and the social worth / contribution potential of the applicant. These are both totally feasible independent factors but when submitted for a vote, they were surprisingly selected as non-decisive by most members of the committee. I then realized that it is only fitting to take into account the primer on ethics that our committee had just been exposed to prior to our meeting. That primer was made by Doctor Michael Sandel, an expert on complex issues who explained much on the roots of our decisions.
Mr. Sandel explained that ethics can be explained by three different schools of thought: utility, rights and virtue. The title of his lecture was “[a] primer on ethics from the late philosophers to everyday life.” The lecture went on to explain the concept of Utility or Utilitarianism as expressed by Jeromy Bentham (the way of utility), who defined utility as “the greatest happiness of the greatest number”, and called this the criterion for ethics (utilitarianism). Bentham also explained that “Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think...” (Ch. I, p. 1, The Principles of Morals and Legislation, 1789).
Mr. Sandel mentioned that Bentham’s idea was a very straightforward concept in that the right thing to do is to do the greatest good for the greatest number. The concept of pain and pleasure and cost/benefit analysis was brought up. Everything we do should maximize the balance of pleasure over pain for the community as a whole. The individual moral life and the legislators must base their decisions with this concept in mind. Michael Sandel then explained that there are two things that are wrong with this concept. One is that it doesn’t respect that we are not just a collection of desires and interests, we are individuals. The other is that it disregards fairness as an essential part of justice and treats injustice as a necessary evil to obtain the greatest happiness for the greatest number.
This line of thought slightly resembles the law and economics schools of thought were well-known legal professors including Beckner and Posner who explain that legal decisions should be based on pragmatic reasoning. The concept has been utilized to persuade politics, schools, students and jurists in all branches of law so that the results are principally practical regardless of ambiguous considerations. In our case, we must consider whether or not it causes us pain or pleasure to award the organ to one person over the other and if the majority of those affected benefit most.
To apply utilitarianism to our case study on transplants, one would expect to find the exact two factors that our committee discarded: ability to pay and social worth/contribution potential at the top of the list. For one, the ability to pay puts the market forces at play. If the patient has the funds to pay, then the circumstances that enabled the individual to acquire the funds are rewarded and encouraged. If we encourage capitalism, we foment competitiveness and create an environment which is conducive to the most good for the community. We are all better off if we all strive to the best of our abilities and to obtain the rewards of greater efforts. This is the way of the world; even so-called communist countries are governed by cold, hard cash like China. The one with the most bucks makes the decisions and the rest pay to see it happen. In some societies, like ours, magnates are idolized like Donald Trump or Bill Gates and what they say, goes.
The ability to pay as a ticket to organ transplant surgery is undoubtedly a primary method of selection in today’s world. Organ transplants and medicine in general is very expensive. I am sure that it takes hundreds of thousands of dollars to have the capacity to perform them. Furthermore, it must cost tens of thousands to select those most able to withstand the procedure. One can make the argument that if taxpayers bear the burden to provide those less able a possibility to get a second chance at living, those resources could best be used in other types of care for a larger number of patients. One transplant surgery can cost what thousands or millions of vaccinations cost. How much is a person worth? We can look at life expectancy, earning capacity, loss of affection, companionship, and consortium and even expected tax payments. This method may seem fair to some but it is not necessarily just. It fails to take into account many factors that enable some individuals to amass fortune that are beyond their own capacity. One of those is being born at the right place and at the right time. Legacy money is very real and has nothing to do with deserving it. Societal factors also play a large part when they deter the advancement of some and promote that of others. Is it the child’s fault that she was born without the proper nutrition or educational environment? It might be more meritorious and fair to award the benefit to those whose individual value is accounted for.
This sort of thought applies to social worth/ contribution potential as well. If we apply the utilitarian methodology, these individuals would be selected because their survival would benefit society as a whole. This is probably unfair as well, like when we see famous individuals that are saved and used as “poster patients” to attract more donors or to generate publicity for the medical institution that performed the transplant. Another type of patient is the one that shows promise of contributing to society by contributions such as scientific findings or inventions that could possibly save a lot of other people. It is a calculated gamble being made in that the organ should be given to someone who would most likely recover and continue to contribute disproportionately to society. Will the individual be able to recapture her abilities after the procedure? What is the merit of one individual worth to us a whole? Does a famous person have more of a right to live than someone who has simply led an exemplary existence? All these questions lead to discussion and to non-objective measurements because we cannot truly say that a smart person has more of a right to live than a good person.
Mr. Sandel also touched on ethics based on rights. The basic human rights concepts discussed by his primer are based on Emmanuel Kant’s studies where each person as a moral agent can act autonomously. There are fundamental rights where certain things are simply wrong. He used the example of using the town drunk as a scapegoat to prevent a riot being completely unacceptable. The riot would likely cause more damage and maybe even more lives but in the end, killing one person for the good of others is still undeniably wrong.
Mr. Sandel then raises the issue of the categorical imperative. Kant is known for his theory that there is a single moral obligation, which he called the “Categorical Imperative”, and is derived from the concept of duty. It is from the Categorical Imperative that all other moral obligations are generated, and by which all moral obligations can be tested. Humans are not only valuable as means but also as ends in themselves, (Kant’s Foundations of the Metaphysics of Morals (1902)). In order to fix the defect in utilitarianism, we must treat each other with respect. We are not simple tools to be manipulated. The individual is worthy of respect and whatever is prized by an individual’s ethics need not be judgmental; it needs to be based on basic rights. Therefore, we shouldn’t impose any particular way of thought; we should expose our views and respect each other’s opinions.
However, this approach is also flawed because when we apply it in practice we are unable to reach a decision as to who will benefit from the organ transplant. Because everyone has intrinsic value and is deserving of life, how do we attribute who is more deserving than others or who should ultimately get the organ? The concept creates more of a challenge than a solution when applied to our case. Judgments in or about virtue come into play and those are made subjectively, thus up to individual discretion lending itself to unfair partiality.
The third line of reasoning is based on virtue. Societal roles and expectations all relate to the pursuit of excellence. Based on the teachings of Aristotle, virtue isn’t about maximizing pleasure, it is about learning. We are misled into believing that we should seek a balance between pain and pleasure. If we are to find the true meaning in our lives, we need to look at happiness as an activity of the soul in accordance with virtue. We must learn to take pleasure in the right sorts of things. We also learn everything by doing; repetition and practicing improvement are basic to acquiring virtue. Practice leads to learning what our role is designed to be which is what we are best capable of being. Doing what is right and avoiding what is wrong will ultimately make us virtuous. We must resist at all cost the tendency to be mediocre. We cannot settle for being less that our optimum potential without even questioning ourselves. We must base our lives on doing what we are designed to do, our essence in being, and apply it to our constant decision-making.
Learning to discern what the right decision is may only come from doing. It needs to be learned by cultivation. Kant would disagree in that his concept of ethic is built into the individual and doesn’t need coaching or training. An ethical life is acquired by conscious selection of ethical choices. The one factor that needs to be present is “polis,” we can’t live it by ourselves like Robinson Crusoe in an island somewhere and cultivate virtues. The highest earthly goods, which are core to human beings, are actualized through participation in social practices. The tired argument on the idea about whether the leaf that falls in the forest really exists comes to mind. Does the leaf really fall if there is no one there to see it? Or does the human being exist only through the interaction she has with others? Only by living with others can we fully realize our capacity, our human nature.
The Greek word “Telos” is used to define an end/goal/purpose that for humans is only realized in community through the laws and civic life. How do we apply these concepts to the case at hand? If we base our decision on virtue, on the interconnectness of the decision-maker and the beneficiary of the organ transplant, we should take into account not only the virtue of the decision-maker(s) but also the recipient’s own virtue. In all the years we have had of organ transplants, certain protocols have been followed. They have been modified based on what works and what doesn’t. The problem is that there is no universal, agreed upon, system for deciding who gets a second chance. We once again answer the question in the negative and decide who doesn’t deserve a second chance.
The person that has failed to secure a right to be included because of her own fault, such as lung cancer from smoking, or liver damage from drinking alcohol, or some other self-inflicted damage, does not deserve to be considered until all others have their chance. The same is true to the individual whose own acts have resulted in the deprivation of life, liberty or happiness. That person has showed a lack of virtue by the way her life has been lived. One thing I might add is that in order for a person to become a beneficiary, that person must have been listed as an organ donor herself prior to the need for the transplant. The virtue of generosity is proven and there are practical benefits as well. This would ensure that the person is part of the whole and that she is not there only because of need. Instead, she is willing to share of herself and is a deserving part of the community. After all, the donor community is sharing its’ very self, in the form of its members’ organs. The ultimate purpose is to save another’s life by giving one’s organs upon one’s passing and sometimes even when still alive, and that is an act of love.
Back to the teleological concept, we find controversy in that the purpose of the organ should be to benefit the one who would benefit most from it. Who should get the best flute? The best flute player of course. This is so because that is what the flute’s purpose or goal was intended to be, to be played the best possible by the best possible player. One may argue that flutes are not made only for good players but for others to learn how to play also, but does just anybody get the best flute? How could we determine who will be the best player or the best survivor if she is not given the chance? By the way, if everyone would gain by only enjoying the best flute playing, then utilitarians would be happy, but it would be a close to flute-less world. What then, is the purpose of the donor system? Well, to save lives of course. What then, is the essential nature of organ transplants? To give another person the second chance to live and that the person is not just who needs it but is the ideal candidate. The ideal candidate is what the debate is all about. Should we not look at first come, first served as a fair method of providing that chance? We should and we can but let’s look at our alternatives again.
In conclusion, there are basically four different approaches that can be chosen. The “utilitarian/economic” approach would rule where the most win or when the market forces are used to make the choice. The more the patient can pay, the higher the chances of obtaining an organ. In theory, the more the value of that individual, the more chances that the person will be considered worthy based on popular opinion. The “rights” approach would result in constant negotiation and manipulation to decide who is most deserving. The committee will inevitably favor some applicants over others based on what they perceive to be the most important rights. Some would choose the persons who have more people dependant on them, (more aggregate rights) presumably parents. Some will simply choose the ones who they perceive as in most need because we all have the right to live. Who is to rank the value of need? Is spiritual or emotional need capable of measurement? I very much doubt it. Who has more rights to get a second chance at life? Third, is the “virtue” approach where the patient is evaluated based on the ultimate purpose which is to save lives that will save lives and arguably that will be most deserving by the way they carry out those lives.
I look for the answer in my original, visceral reaction to the question. I would probably vote that equality should be number one because it takes away all subjective measures and possibilities for corruption or favoritisms. It is true that some would argue that it makes the sanctity of life seem trivial, but it also means that everyone gets a fair second chance at life. This would result in a form of lottery where the recipient gains an organ solely by luck or fate. I believe in serendipity, fate and destiny and most of all, I believe in a higher power who gives us freewill to decide and let’s us live up to our decisions. If we give the first assessment based on equality, I believe we may not be leaving it up to chance at all.
Secondly, I had chosen to make the second criteria quantity and quality of life. I still believe that it should be medical experts who decide what the probability of success for the patient should be; there is absolutely no sense in throwing away a life when the recipient has little to gain from the second chance. After that, I would choose to base the decision on fault. The person who has made a decision to not take care of her own life should not be given a second chance over the person who has taken all appropriate measures to value her own life. I would insert a clause that those who have volunteered to become organ donors should be the only ones eligible to receive them regardless of any other factor. This seems fair to me and besides, it is as a way to increase the number of organ donors so that more people can benefit from the practice. In the end, after the aforementioned criteria are taken into consideration, the individual who comes first gets first service and stands in front of the line for the new organ.
In sum, a lottery should be given to all applicants first; those who are medically and objectively in the best positions to make best use of the organs go to the next round. Those whose own fault it is to be in the position of needing the organ, have made wrong decisions or have chosen to be selfish with their own organs get excluded. Out of those who are left the one who applied the earliest gets the procedure and with it, the obligation to make the most out of the second chance at life.
I realize that this method has a lot of flaws and that we can argue the merits ad nauseam, but if the decision is made in case I need an organ transplant after an accident on my way home; I think I would like to have a second chance based on those reasons. Come to think of it, reflection alone gives me a de facto second chance so that I may do my best with whatever life that I have left. What about you? Do you deserve or should you be given a second chance? That is the critical question.

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