“Need a New Liver? Drinkers to the Back of the Line” Lesson Plan

Abstinence/Abstain 

In the treatment of substance use disorders, abstinence is the act of not using addictive substances (for example, not drinking any alcohol) as a way to recover from the disorder and avoid its consequences. In contrast, other recovery methods might include harm reduction, in which a patient might still use the addictive substance, but in ways that reduce its potential to cause harm (for example, drinking less without complete abstinence). 

Allocate 

To distribute according to a plan based on clear rules and principles. 

• Livers are currently allocated to the sickest patients, who are at the highest risk of dying if they do not receive a transplant. 

Eligible/Eligibility 

Qualified and meeting criteria for being chosen. 

• In most transplant centers, people who have a history of heavy alcohol use and need a liver transplant are not eligible for one until they abstain from alcohol use for six months. 

Stigma 

A set of negative or unfair beliefs that a society or group of people have about something. Stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual from a benefit or service. 

Utilitarianism 

An ethical theory that holds that moral decisions should be made with the aim of providing the maximum benefit for the maximum number of people, while minimizing harms. 

Additional Terms Adapted from the OPTN’s Ethical Principles in the Allocation of Human Organs 

For use in the Sample Activity: Policymaking Simulation 

The Organ Procurement & Transplantation Network (OPTN) is an organization that oversees and connects all organ donation and transplantation efforts in the United States. It is a partnership between the US Department of Health and Human Services Health Resources and Services Administration (HRSA) and a private non-profit organization, United Network for Organ Sharing (UNOS). The OPTN has adopted ethics principles to inform their work and UNOS’ work. 

Justice 

Fairness in the distribution of benefits and associated risks or actual burdens or harms. 

Respect for Persons 

In healthcare, honoring patients’ rights to control their own lives, bodies, and health. 

Utility 

Providing the maximum benefit and minimizing harms for the maximum number of people (sometimes written as “the greatest good for the greatest number”). See also utilitarianism

(sample answers provided in italics) 

• Why wasn’t Jamie Imhof eligible for a liver transplant?
  • Jamie Imhof needed a liver transplant because her liver was failing. However, she was not eligible because of a rule that hospitals have traditionally followed. The rule says that patients whose liver failure is due to heavy alcohol use are not eligible for a transplant until they show that they can abstain from drinking alcohol for 6 months.  

• What is the 6-month rule and why does it exist?
  • The 6-month rule is an informal rule that has been used by hospitals to decide who is eligible to receive a liver transplant. Patients whose liver failure is due to heavy alcohol use are not eligible for a transplant until they can show that they have abstained from drinking alcohol for 6 months.
  • It is part of a system for allocating livers to people who need a liver transplant. This system considers many factors and tries to allocate organs fairly and in ways that save the most people. 

• Dr. Andrew Cameron says the 6-month rule is based on stigma, not science. What is stigma? Can you identify evidence from the Episode to support Dr. Cameron’s claim of stigma? 
  • See Vocabulary for a definition of stigma
  • Research has shown that patients who have liver transplants because they have liver disease caused by heavy alcohol use have the same rates of success as those who receive liver transplants for non-alcohol related reasons. They are also likely to stay sober after their transplant, debunking the assumption that they would likely continue to drink and eventually need another liver. Survey research has shown that getting rid of the 6 month rule would not change people’s willingness to become organ donors, debunking another assumption.  

• What evidence is presented in the Episode that challenges the assumptions of the 6-month rule?
  • Surveys of the public have shown that getting rid of the 6-month rule would not affect people’s willingness to become organ donors
  • Studies of patients who received liver transplants after heavy alcohol use have shown that their success rates are not different from other liver transplant patients 
  • Studies of these patients have also shown that many go on to stay sober 

• Was there a time in your life where there weren’t enough resources to go around? How was it decided who would get the resource and who wouldn’t? Or, how was it decided who would get the resource first, and who would have to wait?
  • Possible examples: the last slice of pizza; concert tickets; a ride in someone’s car 

• Besides donated organs like livers, what other scarce resources can you think of that we as a society have to allocate fairly, deciding who gets the resource and who doesn’t, or who has to wait?Possible examples:
  • PPE (personal protective equipment, like gloves, and safety glasses), ventilators, hospital beds, vaccines during the COVID-19 pandemic; fresh water, food, and other basic necessities in the aftermath of a hurricane, floods, or other natural disaster. 

• What factors should be considered when evaluating someone’s place in line for a liver transplant? Which factors are not okay to consider?
  • Possible examples: severity of disease/urgency, a “good match” (likelihood the surgery will succeed), the availability and effectiveness of alternative treatments, side effects and quality of life, genetics, age, health insurance status, housing situation, social support/relationships, income, employment, intelligence, time on the waitlist, and others. 

• The Organ Procurement and Transfer Network (OPTN) has developed allocation guidelines that are followed by US organizations involved in organ transplantation. The OPTN guidelines reflect three ethical principles: utility, justice, and respect for persons. Consider the “6-month rule” as it relates to these principles.
  • Utility: Does this policy maximize benefits? Does it result in the most good for the most people? Does it minimize harm? Does it result in fewer deaths? Does it result in less suffering? Who benefits from this policy? Who is harmed?
  • Justice: Like the previous question– are the factors that determine someone’s eligibility ethically acceptable– are they fair? Do they result in the fair allocation of a lifesaving scarce resource?
  • Respect for persons: Should people get to decide who gets their donated organ? For example, could someone say that they don’t want their liver to be given to someone who needs a transplant due to alcohol use. What if they won’t donate their liver without conditions?  

• How should public opinion inform the 6 month rule? If the survey data said the opposite– that people would not donate organs if they went to people with alcohol use disorder– is that a good reason to keep the policy?  

• Can you think of other health conditions that are associated with stigma? What do you think are the impacts of stigma in those contexts?
  • Possible examples: substance use disorder, HIV/AIDS, sexually transmitted infections (STIs), mental illnesses, anxiety, ADHD, Down Syndrome, autism, use of assistive devices like wheelchairs or hearing aids, and others. 

Description:

This exercise is a truncated simulation of the policy development process from UNOS’s “How We Develop Policy.” The exercise also considers the OPTN’s “Ethical Principles in the Allocation of Human Organs.” Both can be found in Additional Resources. 

The class will be split into groups of 6-7 students. Within each group, students will role play different stakeholders with different interests. Each group must discuss and choose one of three proposed organ allocation policies. The class can consider different perspectives, identify ethical tradeoffs in each policy, and justify their choices to the class. Then, the groups will apply the policy they chose to a hypothetical scenario and explain their reasoning to the class.  

Instructions: 

Before the exercise: 

• Students should listen to the Podcast Episode. 

• Students should be familiar with the Vocabulary list above.  

• Teachers should print Lesson 3 Handout – one copy for each group of students.  

• Optional: teachers can provide name tags and students can write their roles on the nametag.  

Assign Roles (can be done in class or before): 

• Split the class into groups of 6 or 7 students. Within each group, individual students will represent certain stakeholders:
  • Policymaker
  • Bioethicist
  • Healthcare Worker
  • Health Economist
  • Potential Organ Donor
  • Family Member of a Child with a Rare Congenital Liver Disease*
  • Family Member of a Patient with Liver Disease Caused by Alcohol Use

*In groups of 6, one of these two roles can be represented and the other omitted

• Give students a handout designating their role and a name tag (optional) where they can write their title. Students should read the handout without sharing the contents with other group members.  

Scenario 1: 

• Give each group one copy of the Scenario 1 handout. Group members should take 2-3 minutes to make a decision for themselves, in their assigned role. Then, each group should deliberate and reach consensus on which policy their group would choose, for liver allocation.  

• The policymaker of each group can report to the class which policy was chosen by their group, and provide a brief justification based on the OPTN ethics principles (utility, justice, respect for persons).  

Scenario 2:  

• Give each group one copy of the Scenario 2 handout. Students should discuss how to apply their chosen policy to the scenario and reach consensus about which patient the group would choose to receive a transplant.  

• The policymaker of each group reports the group’s decision to the class, with a brief explanation of how they applied the group’s selected policy to make the decision.  

Organ Donor Reflection & Class Debrief: 

• Finally, the Potential Organ Donor of each group can reflect on the process and their observations with the class.  

• After the Potential Organ Donors have each shared, the discussion can be opened to the entire class. 

1. ELA writing assignment:  Identify a health condition or other characteristic that is associated with stigma. Research the history and context of the condition or characteristic and identify the outcomes or consequences of the stigma. Make suggestions for how these outcomes could improve and how stigma might be reduced. 

• Potential examples include: addiction, mental illness, HIV/AIDS, Down Syndrome, users of assistive devices (hearing aids, wheelchairs), smoking, obesity, sexual orientation, gender identity. 

• See Additional Resources for more information and guidance for students 

The God Squad, playing god?, Episode 10, Season 1, Johns Hopkins Berman Institute of Bioethics, 2024

“The God Squad” Episode Guide

The Organ Procurement & Transplantation Network (OPTN) is an organization that oversees and connects all organ donation and transplantation efforts in the United States. It is a partnership between the US Department of Health and Human Services Health Resources and Services Administration (HRSA) and a private non-profit organization, United Network for Organ Sharing (UNOS). The OPTN has adopted ethics principles to inform their work and UNOS’ work.

Organ Procurement & Transplantation Network  

Ethical Principles in the Allocation of Human Organs, OPTN, 2015. 

United Network for Organ Sharing 

How we develop policy, United Network for Organ Sharing (UNOS). 

For use in the Research & Writing Activity 

Stigma and Discrimination Research Toolkit, National Institutes of Mental Health. 

New US liver transplant policy raises cost and equity concerns, according to new study, CNN Health, May 2024. 

Johns Hopkins Study Reveals Racial and Socioeconomic Disparities in Liver Transplant, Johns Hopkins Clinical Connection, April 2024. 

In the quest for a liver transplant, patients are segregated by prior alcohol use, NPR, October 2021. 

Johns Hopkins Among Few in U.S. to Offer Early Liver Transplants for Patients with Alcohol-Associated Liver Disease, Johns Hopkins Inside Tract, April 2023.