Johnny Concepcion, a 42-year-old man accused of stabbing his wife to death, received a liver transplant at New York-Presbyterian/Columbia University Medical Center in New York, raising the natural question, “WHAT?!!”
Or to be more precise: Wouldn’t it be more ethical to withhold a life-saving liver transplant from such a man, and give the liver instead to someone who isn’t a blight on society and likely to spend the rest of his life in prison?
No.
It’s not even a tough question.
We do not parcel out medical care to people according to virtue or life worth, nor should we. Concepcion, according to the medical profession’s centuries old ethics, requires two qualifications for life-saving medical care: he must be a human being, and he must be in need. Nothing else is germane, and nothing else should be germane.
Concepcion’s situation, admittedly, challenges our ethics, if not our gag reflexes. He has reportedly confessed to friends and relatives that he killed his wife, Jordania Sarita, whom police found stabbed at least 15 times in the home she had shared with him and the couple’s three children. After the murder, Concepcion fled and launched a manhunt by the New York City police. Trapped and knowing he was bout to be taken into custody, he swallowed rat poison. Doctors determined that his liver had failed, and it happened that a perfect donor showed up, saving Concepcion’s life and allowing him to go on trial for murder in August.
Result: public outrage. But under what set of ethical principles would we be able to justify not giving him a liver?
- Argument #1: Concepcion is a killer, and thus doesn’t deserve a liver. Concepcion, in the eyes of the U.S. justice system, is not a killer until he pleads guilty or a jury pronounces him so. The medical profession can’t and shouldn’t be judge and jury. His alleged confession to friends doesn’t make him a murderer either.
- Argument #2: Okay, but if he was a murderer, he shouldn’t get a liver. Why not? New York doesn’t have a death penalty, and he could live a long life in prison. The State penalty for First Degree murder isn’t death by liver failure. We don’t even know if this was First Degree murder. Maybe it was just manslaughter. Maybe it was self-defense, and she came at him with a butcher knife.
- Argument #3: He got a liver that could have saved the life of a more deserving person. Are we now going to arrange organ donor lists according to perceived value to society? Good luck developing that formula. Now doctors or some super-committee are going to measure our past achievements, present value, and future potential to determine where we stand in line for kidneys and livers? Impossible, unfair, and inherently biased. Who is “better,” Noam Chomsky, Rush Limbaugh or Kate Gosselin? Ann Coulter or Keith Olberman? Bernie Madoff or John Edwards?
- Argument #4: Well, what about a special rule for murderers? I’m not comfortable concluding that all murders are necessarily the worst form of human conduct. Charles Manson didn’t actually kill anyone. What about treason? What about polluters? Isn’t the Gulf oil spill worse in its consequences than murder? Should we have an exception for greedy, reckless oil executives? Do they deserve a liver more than, say, a husband who kills his cancer-riddled wife out of love? There is no reason, other than artificial ones, to draw a line at murder. Some of the most destructive people in history never killed a soul.
- Argument #5: All right, but he attempted suicide! Should we give scarce organs to people who have tried to kill themselves? Yet Concepcion had to approve his liver transplant; obviously at that moment he intended to live. We can’t allot organs according to who we think is likely to make the most of their new organ. Lots of people attempt suicide once, and never again. Suicide is a crime, though attempted suicide is not. Why would it be fair to punish someone with death for failing at suicide?
- Argument #6: But this just seems so wrong! It does. That’s the “ick factor” at work: the situation and result seem too strange to be right, yet there is no ethical principle being violated. In such situations the “gut” instinct fails us. Our gut is really reacting to the strangeness, not the ethics.
MSNBC commentator Arthur Kaplan closed his analysis of the Concepcion case with this:
“So what to do? If we don’t want confessed killers or convicted murderers to get transplants, then our legislators should do something about that. At the end of the day if you are furious that Johnny Concepcion is still alive to face trial you should blame politicians, not doctors.”
He could not be more wrong. None of us should want politicians meddling in the medical profession’s duty to save lives, no matter whose lives or what their value, or trust their judgment in deciding who receives life-saving procedures. (The politicians’ likely choice for the top of the list? Why, themselves, of course!) Nobody is so wise, so fair and so prescient that he can discern what a human being will do with a second chance at life. The medical profession, from the days of Hippocrates, understood that the prime directive of all doctors must be to do everything possible and available to make sick people better. The sole requirements are that a patient be alive, and in need.
Johnny Concepcion qualifies on both counts, and it is right to give him a new liver.
Ethics Alarms 
Sounds like a challenge to the purely utilitarian ethic which insists some human lives are inherently more deserving than others. For the sake of argument, would the same conclusion hold if the patient receiving an organ had severe mental impairment? I hope I’m not inviting too much trouble by asking.
Medical ethics certainly does not accept that utilitarian calculation. I’d say the same conclusion would hold if the patient was severely disabled, mentally or physically. The tougher call: what if he has a year to live with the transplant? 6 months?
At least the proposed tougher call comes down to some sort of an ability to medically benefit, rather than an assessment of the individual’s relative worth as a person or human being. I’m not exactly an expert on this, but medically, I’d have to ask if there were other patients with a better post-op outlook. I’d also want to know how much uncertainty is in the projection of six months or a year to live; how likely is he to live longer? However, non-medically speaking, who knows what this hypothetical patient could do with a little extra time. Maybe they’d cure cancer, finish a novel, or simply make amends with family?
This has the exact same logic as “the prime directive” in Star Trek. We admit that we don’t know the consequences of out power over life and death, so we don’t use it to pick “winners” and “losers.” The ethical value: humility.
Whew! Too many issues and choices, I think. So I have to think simply on this.
It seems to me that the minute that organ transplants are placed in some hierarchy based on something other than medical chances for success, we are on a slippery slope (sorry) that is terrifying to me.
Who would make such choices? Felons do not deserve medical care? Which felons? Terrorists do not deserve medical care? Which terrorists? We let the Lockarbie bomber go for “compassionate” medical reasons… but that’s another story.
If we start with felons and terrorists, then where do we go? The 85-year old, otherwise healthy grandmother who has outlived the “standard” life expectancy but needs a kidney and a perfect match pops up in the donor data base? Will some “committee” decide that she’s had a good life, has lived longer than most, and so doesn’t deserve a kidney that may extend her life another three years? What about the hard-drinking but otherwise productive citizen who needs a liver? Will some committee decide that alcoholism is a self-inflicted disease and that therefore this person doesn’t deserve a liver?
Somehow, some way, we need to draw a stronger line at the intersection of politics and the medical profession. Impossible on the policy side, as it is already soaked through with politics and money. But on the front lines, where life and death decisions are made, let the doctors and the Hippocratic oath reign. I don’t know if it’s too late. Hope not.
What will be the utilitarian view of giving liver organ to murderers?