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If alcoholism is a disease, rather than a moral failing, why should the afflicted be denied useful medical care - even if the scarcity of livers means that helping an alcoholic means not helping someone else?Here before you is a young child, born with a defective liver, and an alcoholic, who destroyed his liver in years of heavy drinking. A liver transplant is the only hope. You've got only one liver. Who gets it? Who dies?

This looks like an easy question. I suspect 99 percent of Americans, including 99 percent of alcoholics, would say: Give it to the kid.But the question is getting harder, and the answer goes beyond the esoteric world of liver transplants to take in some very large issues: How do we allocate health care when scarcity is the reality? Can we hold people responsible for behavior that leads to health problems?

Till now, few alcoholics have been given new livers because doctors believed they were unlikely to benefit: Alcoholics wouldn't survive a transplant, if they did, they wouldn't be responsible enough to take the daily medications essential to surviving. Or they'd start drinking again and ruin the new liver.

But a 1988 study by Dr. Thomas E. Starzl at the University of Pittsburgh found that a small, perhaps unrepresentative sample of alcoholics who did get new livers were as likely to be alive a year later as non-alcoholic liver recipients. Most stayed sober.

As a result, Medicare is expected to start providing coverage for liver transplants, which cost about $200,000, for non-drinking patients with alcoholic cirrhosis.

If alcoholism is a disease, rather than a moral failing, why should the afflicted be denied useful medical care - even if the scarcity of livers means that helping an alcoholic means not helping someone else?

In the March 13 issue of JAMA, the Journal of the American Medical Association, medical ethicists debate the question. Alvin H. Moss and Mark Siegler of the University of Chicago's Center for Clinical Medical Ethics argue that alcoholics should go to the bottom of the waiting list:

"Given a tragic shortage of donor livers . . . we suggest that patients who develop ESLD (end-stage liver disease) through no fault of their own . . . should have a higher priority in receiving a liver transplant than those whose liver disease results from failure to obtain treatment for alcoholism."

Carl Cohen and Martin Benjamin, of the ethics and social impact committee of the Transplant and Health Policy Center in Ann Arbor, Mich., argue a somewhat different point - should alcoholics be categorically excluded for transplants? - and answer no:

"People who are sick because of alleged self-abuse ought not be grouped for discriminatory treatment - unless we are prepared to develop a detailed calculus of just deserts for health based on good conduct," they said.

Liver disease kills roughly 65,000 Americans every year; the majority have been heavy drinkers for decades. Only 2,000 livers are donated for transplant, and 90 percent go to non-alcoholic patients. If alcoholics get equal consideration, Moss and Siegler say, 30,000 more people could compete for those 2,000 livers.

They don't argue alcoholism is not a disease. They say, in essence, it's not your fault you're an alcoholic, but it is your fault if you haven't gone to Alcoholics Anonymous, which is free, or some other source of help, to deal with your alcoholism before it destroys your liver.

Both sides in the debate agree that lots of people contribute to their own ailments and that ideally care should be based on whether it will do any good, not whether the patient has been good.

Cohen and Benjamin observe: "Accident victims injured because they were not wearing seat belts are treated without hesitation; reformed smokers who become coronary bypass candidates partly because they disregarded their physicians' advice about tobacco, diet and exercise are not turned away because of their bad habits.

"But new livers are a scarce resource, and transplanting a liver into an alcoholic may, therefore, result in death for a competing candidate whose liver disease was wholly beyond his or her control."

Because of this scarcity, Moss and Siegler reject "first-come, first-served" allocation.

Cohen and Benjamin are extremely reluctant to make this kind of moral judgment, worried about slippery slopes, afraid of being forced to decide whose life is more worth saving. Is this transplant candidate the mother of five, while that one has no dependents? What if the mother of five is an abusive mother, while the single candidate is a creative artist? A good artist?

Some alcoholics are good people, with much to contribute to their families and communities; others are bums. For that matter, some people who have liver disease through no fault of their own may have other faults.

But our instinctive sense of fairness says: The guy who had a good liver and wrecked it shouldn't get in line ahead of someone who never had a good liver to begin with.

Indeed, Moss and Siegler's final argument is political. The majority of people in need of new livers are alcoholics. If they get the majority of transplants, the procedure will be seen as a very costly second chance for alcoholics, and it will lose support, funding and livers.

In a 1987 Lou Harris poll, the public gave the highest health care priority to saving premature infants and cancer patients; patients with alcoholic liver disease ranked at the very bottom.

Cohen and Benjamin don't deny the point. "One can imagine the effect on transplantation if the public were to learn that the liver of a teenager killed by a drunken driver had been transplanted into an alcoholic patient."

In their view, however, bowing to this pragmatic reality is unjust and immoral.

I think they're afraid that if the commandment to love thy neighbor as thyself is made conditional, it will be easy for society to abandon responsibility for its less popular members.

Still, I end up where I started: Help the kid first.

Sometimes it is both possible and necessary to hold people responsible for their behavior. Sometimes there can be no second chance.

(Joanne Jacobs is a member of the San Jose Mercury News editorial pages staff.)