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Reasoning about justice and resource allocation, avoiding blame-based judgements, and awareness of how allocation actually works.
A structure to build your own answer on — not a script.
Clarify
Decisions aren't made by an individual doctor choosing between two people; national allocation systems use clinical criteria (need, likely benefit, urgency, matching).
Principles
Justice (fair allocation of a scarce resource), beneficence (maximise benefit), non-maleficence (wasting a scarce organ harms others).
The blame question
Is it fair to deprioritise 'self-inflicted' illness? Consider addiction as illness, social determinants, and consistency (smoking, sport injuries, obesity).
Clinically relevant factors
For alcohol-related liver disease, programmes assess the risk of relapse and commitment to abstinence because it affects outcome — this is about benefit, not blame.
Conclude
Allocate by clinical criteria (need, benefit, likelihood of success), not moral judgement.
A strong but not perfect answer. Read the notes to see why it works — then make your own version with your experiences.
I'd start by saying that in reality this decision wouldn't be made by one doctor1 weighing up two people's life choices. In the UK, donor livers are allocated through national systems that use clinical criteria like urgency, the likely benefit and how well the organ matches.
But the underlying question is whether the cause of the illness should matter. I don't think we should allocate organs based on blame. Alcohol dependence is an illness, often linked to genetics, trauma and social circumstances — the Marmot reviews show how strongly behaviours like drinking follow deprivation. And if we deprioritised 'self-inflicted' disease, it's hard to know where to stop2: smokers, people injured playing rugby, people with type 2 diabetes. That would be inconsistent and would undermine the principle that care is based on clinical need.
What can legitimately matter is the likely benefit. A donor liver is scarce, so justice means using it where it will do the most good. For someone with alcohol-related liver disease, the transplant team would assess the risk of returning to drinking, because relapse can damage the new liver. That's why programmes usually look for a period of abstinence and commitment to support. That's a judgement about outcome, not morality3.
So my answer is that neither should be automatically preferred because of the cause. It should go to whoever the clinical criteria show has the greatest need and likely benefit — and if the alcohol patient met those criteria, including a low risk of relapse, it would be fair for them to receive it.
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