ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Saturday, November 23, 1996 TAG: 9611260007
SECTION: RELIGION PAGE: B-9 EDITION: METRO
DATELINE: PHILADELPHIA
SOURCE: RON GOLDWYN KNIGHT-RIDDER/TRIBUNE
Who shall live, and who shall die? What is God's will, and how do we know?
Those issues are in the spotlight among experts on medical-religious ethics after a board of organ-donor experts last week changed their rules for liver transplants. The board assigned top priority to dying patients with the best chance for survival.
The old policy put the sickest patients first in line, regardless of long-term prospects.
The United Network for Organ Sharing said the national policy change had been made on medical, not on lifestyle or moral, criteria. But it means a lower priority for most candidates who have alcoholic cirrhosis or hepatitis and whose overall recovery prospects are poor.
``Any time you make a decision on criteria about who will have access to treatment and who will not, there is a moral dimension to that,'' said Adele Stiles Resmer, a medical ethics expert at Lutheran Theological Seminary in Mount Airy, Pa. ``To say it is strictly a medical decision is mistaken.''
Rabbi Gerald Wolpe of Har Zion synagogue in Lower Merion, Pa., serves on ethics boards at several hospitals and medical schools. He said the transplant rule change was part of a widening national debate on rationing. He said ``downsizing'' throughout the health-care industry means ``we will be hearing much more of this issue.''
But those who stress the moral and religious side of medical decisions do not necessarily quarrel with the new rules if criteria are fairly and evenly applied.
``What you're looking at is the allocation of a rare resource,'' said the Rev. Kevin McMahon, professor of moral theology and academic dean at St. Charles Borromeo Seminary for Catholic priests in Wynnewood, Pa. ``The question becomes one of justice. As long as it is not based on unjust discrimination, it is legitimate.''
McMahon likened the rationing of scarce resources or supplies to the medical triage standard of assessing who is in most urgent need and would most benefit. Such medical criteria, he said, meet the test of Catholic teaching.
Dr. Arthur Caplan, director of the University of Pennsylvania Center for Bioethics, said, ``It is wrong to take sin to the bedside. On the other hand, these policies don't do that. The way bad habits come into play is, it's because people who do those things won't do as well in recovering.''
The issue goes far beyond liver transplants to all organ transplants and rationed care, he said. The wishes of the donors - ``and remember it is a gift, you do so in order to save lives'' - should work in favor of those with the best recovery prospects.
But rationed care will not extend to barring bypass surgery to those who eat meat or lung treatment to those who smoke, he said.
``When you put sin into the equation, the next person caught in the net is you,'' he said, citing skiing, owning a swimming pool, eating dessert or not buckling your seatbelt as health sins.
``If you want to save money in health care, just throw the sinners out of the hospitals. They'll be empty,'' Caplan said. ``All of us are sinners when it comes to our health, except maybe two nuns and a Mormon deacon somewhere.''
Religious leaders surveyed about the new rules note that Catholic, Jewish and mainstream Protestant denominations permit, and encourage, organ donation.
``Evangelicals accept transplants as a good gift of God,'' said the Rev. Dennis Hollinger, a Mennonite and adjunct professor in Christian ethics at Eastern Baptist Theological Seminary in Wynnewood, Pa.
The question of rationing medical care - so controversial in cases of critical and chronic illness - must be asked much sooner, according to several experts. They say the key question is, why all Americans do not have access to full medical care?
``If you are poor and don't have health insurance, you may not get your disease diagnosed until you are at death's door,'' Caplan said.
Said Wolpe, the Conservative Jewish rabbi: ``The immoral element of it is that we should come to a point we have to make these decisions. We're almost forced to make these heart-wrenching decisions because we haven't earmarked for life the resources available in this very wealthy society.''
Said Resmer: ``The Lutheran view is any time you have to look at allocation of organs when you're starting in a society where not everyone has access to basic care, you already have a moral problem.''
Are moral judgments tied to lifestyle ever permitted?
Rabbi David Teutsch, president of the Reconstructionist Rabbinical College in Wyncote, Pa., and a medical ethicist, said Judaism does not shrink from tough choices.
If the issue were strictly economic, he said, ``there is an unequivocal response in Jewish tradition: we have an overwhelming commitment to preserve life regardless of expense.
``But that is not the case here,'' Teutsch said. ``You have a resource that is not financial. It is an organ that can only be used once. If it is a question of who receives the gift of life, the question of who deserves it more must inevitably be asked....
``If the only fact you know about two people is one is an alcoholic and one is not, you have no choice'' but to choose the nonalcoholic, he said.
Hollinger, at Eastern Baptist, has a counter view.
``Once we make value judgments based on lifestyle or social position, then we are moving away from the traditional Christian view that we are all made in the image of God,'' he said. But that does not rule out medical judgments.
``In ethics,'' he said, ``we call it the triage situation - who gets the goods when there's not enough for everyone.''
McMahon, at St. Charles Borromeo Seminary, said it was ``legitimate'' to bypass a cirrhosis patient if that person has little chance of full recovery, but he added:
``If you say a bad drinking habit ruined their liver, we don't want to do this transplant because they're alcoholic, that is not right, because an alcoholic can always change, and not abuse the next liver.''
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