Background:

Janet is a middle-aged single mother of two children with a serious drinking problem. After being discharged from the hospital where she was treated for injuries incurred in a traffic accident just three months prior, Janet has been readmitted for high blood potassium levels indicative of impending renal failure. In order to live, Janet requires long term dialysis. However, both of the tertiary care hospitals offering long term dialysis do not have any open dialysis machines. Her physician argues Janet’s case, but is met by heavy opposition. Both hospitals refuse to consider Janet’s case because of their “first come, first served” policy.

Discussion:
The moral principles at play in this distributive justice case are non-maleficence and justice. If we fail to treat Janet’s high potassium levels, we greatly increase the risk that her heartbeat will stop. Since we are not informed of alternative options for lowering her potassium levels, refusing Janet dialysis is effectively sentencing her to death. Therefore, if the tertiary care hospital does deny her access to the dialysis machine, the principle of principle of non-maleficence is being violated. If we treat Janet at the expense of other patients already on dialysis, we are also violating the principle of non-maleficence. Since doing harm is unavoidable in this case, we must turn to the principle of justice to make the most moral decision. In order to reach the most fair decision in this situation I will first determine Janet’s eligibility and then her perceived societal worth. If these exceed other patients’ eligibility and worth I would argue that the most just thing to do would be to allow Janet to take one of those patient’s places at the tertiary care hospital.

In the third edition of Well and Good, it is suggested that eligibility for having access to a scarce medical resource should first be established according to the following factors: constituency (proximity to the resource), the progress of science (research interests of the hospital), and the prospect of success (amount of benefit) (Thomas and Waluchow). As stated in the dialysis machine shortages case, the two tertiary care hospitals that Janet’s physician was attempting to negotiate with were both “geographically accessible.” Since no research on dialysis patients was mentioned, we can assume that the progress of science was a negligible factor. Janet’s physician also seems pretty confident that his patient has great promise of long-term benefits. Therefore, we might also assume that her prospect of success was pretty high, perhaps even higher than some of the current patients in the two tertiary care hospitals.
Since there is not enough of the medical resource after applying the eligibility criterion listed above, Thomas and Waluchow advise that one must then select individuals based on their “worth.” In Well and Good, the authors suggest that this “worth” is determined by the individual’s family role and contributions to society (Thomas and Waluchow). Although I would argue that Janet’s role as a single mother of two should factor into the assessment of her worth, in order to protect members of society that are mentally or physically handicapped or socioeconomically disadvantaged (like Janet, who is on welfare), I believe that it is important to also consider an individual’s vulnerability when establishing worth. Basing worth solely off family role and contributions to society effectively excludes the aforementioned populations who may not have access to the same resources that able-bodied, able-minded, financially stable individuals do. Without these resources, individuals in these groups in many cases do not have as many or as great of opportunities to contribute to their communities.  Yet another factor that must be taken into consideration is whether or not a patient’s behavior may be exacerbating the illness. As was mentioned previously, Janet is a heavy drinker. According to the National Kidney Foundation, chronic drinking can decrease the kidney’s ability to filter blood, and can cause liver disease and high blood pressure which, both of which can lead to kidney disease (National Kidney Foundation). Although it is difficult to discern just how much of Janet’s kidney damage can be attributed to her drinking, considering she had previously experienced kidney failure after sustaining injuries from an automobile accident and had never quite fully recovered, if Janet continued to drink heavily after returning from her first hospital visit, she at the very least increased her risk.

In any case, I believe that the tertiary care centers’ decisions to provide patients with dialysis on a first-come, first-served basis is morally wrong when applying the moral principle of justice. Although it would be arguably more difficult to take away care from someone with a poorer diagnosis than to deny it from them in the first place, when medical resources are limited, I believe that those resources should be allocated to individuals who have the greatest prospects of success. If we assume that all individuals all have the same prospect of success however, I would argue that the tertiary care centers should grant access based first on the individual’s family role and then, if there are still not enough resources available, degree of responsibility for ailment. Applying this to Janet’s case, I would argue that the tertiary care center should bump an individual with a poorer prognosis than Janet and, if there are none, bump an individual who is not providing for a family. If, by some chance, there are no individuals who have poorer prognoses or who do not have children or other individuals that are dependent upon them, I would make Janet wait on the tertiary care dialysis list.

Sources:

“Alcohol and Your Kidneys.” – The National Kidney Foundation. N.p., n.d. Web. 16 Apr. 2015.