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10 Controversial Medical Questions Answered by Dr. Dalrymple

Where do you stand on these challenging ethical and scientific debates?

Theodore Dalrymple


March 15, 2014 - 8:00 am
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From July 2013:


2. Should an alcoholic be allowed a second liver transplant?

Considering the question of how to allocate a scarce resource: human organs.

In private health-care systems, rationing of health care is by price; in public health care it is by waiting lists and administrative fiat. Both have their defenders, usually ferocious and bitterly opposed, but the fact remains that there are some treatments that have to be rationed however much money is available for health care: as when, for example, there are more people needing organ transplants than there are organs to be transplanted. Few people would be entirely happy to allocate organs merely to the highest bidder.

A recent article in the New England Journal of Medicine tackles the problem of allocation of lung transplants. A system was in place in the United States that excluded children under 12 years of age from receiving adult lungs as transplants, an exclusion that parents of a child with cystic fibrosis challenged in the courts. The problem for children under the age of 12 requiring lung transplants is that there are very few child donors, so in effect the system discriminated against them.

The reason for the exclusion was that most children for whom lung transplants are considered have cystic fibrosis, a condition for which the results of such transplants are equivocal given the constantly improving medical treatment of the disease. Moreover, children are especially liable to complications from the procedure, though these can be partially overcome by using not whole adult lungs for transplant but only resected lobes of them.

The American system of allocation of lungs for transplant into adults takes into account various factors, such as years of potential benefit from transplant, the imminence of death without transplant, the statistical chance of success of transplant, and so forth. Ability to pay does not come into it; in other words it is a socialized system, but there is a mechanism of appeal for those relegated to low priority which the more educated and wealthier are better able to take advantage of. No explicit judgment is made about the relative social or economic worth of the individual, however, for that way madness, or at least extreme nastiness, lies. And the authors of the article think that, on the whole, the system works well, for it seems to stand to reason that those who would benefit most should go to the top of the waiting list.

I once had a small transplant dilemma of my own…

shutterstock_92809222 A newspaper in England asked me to write an article, for what for me was a considerable sum of money, to opine that a certain very famous soccer player, who had turned severely to drink after his retirement, should not be given a second liver transplant, the first having failed because of his continued drinking. The player in question was not admirable, but he did say one memorable thing. Impoverished by his habits, an interviewer asked him where all his money had gone. “Wine, women and song,” he replied. “The rest I wasted.”

I told the newspaper that, as a practising doctor, I could not possibly write an article saying that a named person should be left to die without potentially life-saving treatment.

“Do you know a doctor who would write it?” the editor asked.

“I hope not,” I replied.

I was not being quite honest. In my heart I did not think that the man should have a second transplant (in the event, he did get it and, all too predictably, it went the way of the first). It was not only that I did not think he would give up drinking, a matter of statistical likelihood; but I also thought that he did not deserve his second chance, especially if it meant that someone else was deprived of a first. But doctors treat diseases, not the deserts of their patients.

Hard cases make bad ethics.


images courtesy shutterstock /  artjazz / Alex Luengo

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All Comments   (9)
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More than half of these questions would simply go away if everyone (or their family or close friends as needed) paid for their own health care. For the remainder - perhaps excerpting parental responsibility for an obese child - it is sufficient for everyone to have their own opinion and act accordingly.
50 weeks ago
50 weeks ago Link To Comment
There's so much PC BS on most topics that it's startling to hear or read TS, "true speak." Thanks, Doc.
50 weeks ago
50 weeks ago Link To Comment
RE: Obesity & RE:Healthy Diet. I know 17 people with Hypo-Throidism, & most continue to gain weight eating healthy low cal diets with lots of aerobic exercise. I doubt most overweight people have this, but some do have a medical reason for obesity, likely a small minority. Those who simply choose a poor diet likely fall into one of these categories...1) I will eat what I want (needs immediate & constant gratification). 2) Too uninformed (or ill informed) to make intelligent choices. 3) Too poor to buy healthy food (the price, per calorie, of junk food has dropped, while the cost of real food has skyrocketed). If most people would eliminate all processed foods made with white flour & white sugar, & replace that with a MUCH SMALLER amount of whole grains than the food pyramid recommends & eat mostly lean sources of protein + lots of organic produce, they would naturally loose weight. For weight loss to be permanent, you have to make permanent changes!! "Let thy food be medicine & let thy medicine be food"...Hippocrates
50 weeks ago
50 weeks ago Link To Comment
Here in NV our absurd Medical Marijuana laws require a patient to break the law BEFORE they can comply with it. First, you have to break the law & illegally obtain the seeds. Then you apply for a Medical Marijuana card ($50.00), then pay another $50.00 for an "Illegal Contraband Tax Stamp", (no I'm NOT making that up). Then you have to "grow your own". Once "your crop comes in" FINALLY have your medicine. As a patient who laid in bed CRYING AND SCREAMING IN AGONIZING PAIN FOR MONTHS ON END, because pain pills don't work on me, NOT opiates & NOT NSAIDS, I can tell you that "witch hunt" leveled against Medical Marijuana is merely "cover" to TORTURE cancer patients like me. I choose not to break the law, because there's no telling when/who the Fed. Gov't. will turn on next & my Hubby is a legal immigrant, here on a Green Card from I SUFFERED!! The freely available (by RX) dangerous, highly addictive, toxic narcotics & their horrific side-effects they "experimented on me with" are what we should be worried about...NOT a plant that grows out of the ground!!
50 weeks ago
50 weeks ago Link To Comment
With the understanding that people should be free to obtain help for obesity, addiction, and all health issues at any age, but cannot demand that others pay for this treatment (Charity given by others is ok and encouraged), my take is as follows. Let the debate begin.

1. Obesity is neither a disease nor a moral failing
2. Alcoholics should not be denied available medical care
3. Psychiatric illnesses merit treatment as much as physical illnesses
4. Doctors sometimes are guilty of giving pain killers to addicts who con them
5. Elderly should not be denied available medical care
6. Marijuana can be a medicine, with side effects
7. Nutrition is important to health
8. Drug addiction is not like non-addiction illnesses but addicts should be treated
9. Obese children are not victims of child abuse
10. Parents should vaccinate their children
50 weeks ago
50 weeks ago Link To Comment
Interesting that the author chose only one vaccine to discuss pros and cons.
50 weeks ago
50 weeks ago Link To Comment
He must be in on the CONSPIRACY!!!!!!!
50 weeks ago
50 weeks ago Link To Comment
A government funded psychiatrist on an NHS pension in on 'the conspiracy'? No. Not possible.
50 weeks ago
50 weeks ago Link To Comment
Thank you, Doctor, for this thoughtful and objective article. These are two qualities that in tandem are virtuous but rarely encountered today.
50 weeks ago
50 weeks ago Link To Comment
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