Aurelia Butler

The magazine’s Ethicist columnist on how to support someone with an addiction problem.My significant other has a friend who is a longtime alcoholic, while also being intelligent, entertaining and conniving. For example, he used to tell his wife he was going to the gym and then head to the bar; before returning home, he’d dampen his clothes in the bathroom to make it seem as if he’d gotten a good sweat on. He was off the radar for a bit, and then we learned he had a liver transplant. After that, he had an episode of hepatic encephalopathy, a brain disorder caused by liver dysfunction. It seems the doctors knew he was still drinking but gave him the new liver anyway and counseled abstinence. A few parties later, he was sneaking vodka, gin and whatever else was around. He lies to everyone and has made his guy friends vow not to tell his wife about his drinking. They’ve made a meager attempt to confront him, only to be assured that he just fell off the wagon and would be good. Just don’t tell the wife!I’m appalled that they’re going along with this. There are a couple of ethical issues here. First, who should decide whether someone is entitled to a transplant? Some hospital systems deny a liver transplant to patients who continue to drink alcohol, and other hospitals don’t. Second, do the friends have an obligation to tell this man’s wife that he’s still drinking? She could insist he leave the house and go to rehab, in which case he might have a chance of living long enough to see his children get married. Some additional context: A friend of mine died waiting for a liver transplant. I am also the child of a lifelong alcoholic. — Name WithheldFrom the Ethicist:There’s more than one morally defensible way of allocating donor organs. In the United States, as in Western Europe, the system emphasizes equity and basically gives priority to patients with the greatest need. An approach that focused instead on efficiency — on getting the maximum use out of donated livers, as measured by ‘‘quality-adjusted life years’’ — might give an edge to people who were younger and otherwise healthier and might work against low-income and minority populations.Organ allocation in the United States is governed by the Organ Procurement and Transplantation Network (O.P.T.N.), whose policies determine the order in which deceased-donor organs are offered; they do not, however, dictate medical practice. So it’s up to a medical center to decide whether or not transplant candidates with alcohol-related liver disease are to abstain from alcohol for some period — six months having long been a typical sobriety window. Some studies indicate that carefully selected patients who aren’t subject to a sobriety window can do just as well as those who are (though the data is hard to interpret because of the ‘‘carefully selected’’ part). And if your drinking has caused a severe case of acute hepatitis that doesn’t respond to medical treatment, you probably won’t survive a six-month waiting period. So the trend seems to be away from requiring an extended interval of abstinence.The point is that the current system for allocating this scarce resource is morally legitimate, whatever trade-offs it may entail; its architects are perfectly aware that many liver recipients will not succeed in refraining from heavy drinking afterward. The fact that this longtime alcoholic has returned to his old habits is distressing. It doesn’t mean that the system isn’t functioning the way it’s meant to.One thing that transplant centers may try to determine is whether patients with an alcohol problem have social networks that could help them stay sober. This brings us to your second question. This fellow’s friends weren’t looking after him when they agreed to uphold this boozy bro code and keep mum. He doesn’t want to die, but he’s drinking himself to death, which means that, at least in this key area, he lacks the capacity for rational decision-making. In a situation like that, it’s more important to attend to his interests than to respect his autonomy. If there’s a chance that his life can be extended by successful management of his alcoholism, and if discussing the problem with his wife will help, thoughtful friends would do just that.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe. More