BY KATE HSU
Did you know that 13 people around the world die each day while waiting for organs?
With more than 48,000 organ transplants being performed in 2024 alone, it is clear
that organ transplants are important in the field of medicine as, in extremes
measures, they may save someone’s life (HRSA, 2025). There are organ shortages
globally, which in turn poses ethical question as to how these organs should be
allocated. Should lifestyle like smoking, drinking and lack of exercise determine
whether one should get an organ? This raises a lot of complex questions such as: Is
it fair to use lifestyle as a determinant? Should organs go to those who will benefit?
Are some health behaviour choices avoidable?
This essay will explore the medical ethics and social context of this debate and focus
on liver transplants, due to the strong correlation between liver failure and
preventable lifestyle related diseases, such as cirrhosis and non-alcoholic fatty liver
disease (NAFTD) along with the rapid increase in liver disease cases related to
alcohol in the UK (British Liver Trust, 2023). A variety of different perspectives and
factors will be discussed: whether choosing based on lifestyle is a better use of
scarce resources or discriminating vulnerable people. Through thorough analysis,
medical and ethical consideration and outcomes, this essay will evaluate the extent
to which lifestyle should affect a patient’s place on the liver transplant list.
Ethical principles
The four core medical ethics principles: beneficence, non-maleficence, autonomy,
and justice, all play a fundamental role in guiding decisions when it comes to organ
transplants, especially when considering whether lifestyle should be a determining
factor. Beneficence is the principle of acting in the patient’s best interest, therefore if
a transplant can save someone, it should be done. (ScienceDirect, 2024a). However,
if a patient has a history of alcohol misuse, this places the new organ at risk of
damage or failure, therefore beneficence may be undermined as long-term outcomes
could be bad. Non-maleficence, also known as “do no harm,” further complicates this
dilemma. If a transplant is given to someone likely to relapse to harmful behaviours,
it may not only harm the patient receiving the transplant but also be a loss of an
organ that could have been used to save another life (ScienceDirect, 2024b).
Autonomy means patients have the right to make their own medical decisions,
suggesting that people should not be denied treatment purely based on their past
choices (The Medic Portal, 2024). However, issues can arise when it comes to
autonomous decision-making, such as choosing not to give up alcohol, which may
lower the success rate of a transplant which again could be another organ not being
used to its fullest potential. Justice is the principle of fairness, which also raises
questions: is it fair to prioritise patients who live “healthier” lives, or are there other
factors and broader contexts, like poverty, mental health, or addiction that may have
shaped a person’s behaviour (The Medic Portal, 2024)? Ethical theories offer
different interpretations and perspectives on this dilemma. A utilitarian or
consequentialist approach would prioritise patients who have the greatest chance of
survival or long-term societal good, such as those who are more likely to stay sober
and live longer post-transplant (The Medic Portal, 2024). In contrast, deontological
ethics argues that outcomes should not override moral duty. This means that all
patients should be treated equally regardless of their past actions (The Medic Portal,
2024). This view rejects the idea of “deservingness” and opposes punishing
individuals for lifestyle-related illness.
Medical considerations
Outcomes of medical procedures are a critical factor when determining a patient’s
position on the liver transplant list, and lifestyle-related behaviours can influence the
success of the transplant. For example, studies of Alcohol-Related Liver Disease
(ARLD) have shown that relapsing back to alcohol usage after transplantation can
damage the new liver and increase risk of death, therefore reducing long-term
outcomes and potentially a waste of a liver (NHSBT, 2024a). To reduce this risk,
many liver transplant centres require patients with ARLD to complete a six-month
sobriety period before being listed. This shows the patient’s commitment to recovery
and therefore reducing the likelihood of relapse (NHSBT, 2024b). The same applies
to obesity and Non-Alcoholic Fatty Liver Disease (NAFLD). Obesity can increase risk
of other diseases like diabetes or cardiovascular disease which can lower survival
rates and increase risk of graft failure (Liver Foundation, 2024).
A very vital consideration with transplants is organ rejection, which is more likely if
the patient doesn’t stick to the strict medical regimes post-transplant. Patients must
take immunosuppressive medication consistently to reduce the risk of rejection. Of
course, there is no way to fully prevent rejection but there are many measures that
can be taken to lower the chance. Those with chaotic lifestyles or substance misuse
histories may struggle to adhere to these regimes (MedlinePlus,2024). In fact, non-
adherence is one of the leading causes of transplant failure. Therefore, the selection
process usually includes psychosocial assessments to ensure that all bases are
covered, including any addiction recovery progress, stability and support networks, in
order to predict whether a patient will likely follow through with post-operative care
(NHSBT, 2024b). Medical professionals argue that these evaluations assess current
and future reliability rather than punishing past behaviours. Patients who
demonstrate genuine behavioural change may still be prioritised over those who
don’t, as long-term outcomes depend more on future compliance than past mistakes
(British Liver Trust, 2024).
To be eligible for liver transplants, there is a strict criterion that must be followed, for
example, conditions like acute liver failure, chronic viral hepatitis, autoimmune liver
disease and liver tumours all follow the NHS guidelines (NHSBT, 2024b). When a
patient is diagnosed, they are referred to a Specialist Liver Transplant Centre, where
they use scoring systems like the MELD (Model for End-Stage Liver Disease) or the
UKELD (UK End-Stage Liver Disease) which assess urgency and survival likelihood
(Organ Donation NHS, 2024). MELD looks at how well the kidneys and liver are
working by calculating using factors like bilirubin, creatine, and INR levels to estimate
the risk of death within 90 days without a transplant, while UKELD does the same
but includes sodium levels in blood (Organ Donation NHS, 2024). At the end of the
day, the best outcomes and compliance play an important role in priority decisions
and even though lifestyle is not judged morally, its medical consequences are
important in deterring who will benefit the most from an organ.
Wanman