Who Deserves to Get New Organs?

July 09, 1995|By HENRY SILVERMAN

Should people who are responsible for their diseases receive the same consideration for organ transplantation as those who develop diseases through no fault of their own?

Debates about making people suffer the consequences of their voluntary, unhealthy lifestyle choices recently surfaced when Mickey Mantle received a transplant to replace his liver, which had been severely compromised by years of heavy alcohol abuse. Concern also was expressed that Mr. Mantle, because of his "hero" status as a former New York Yankee star, received special treatment when he received a liver after beingon the waiting list for only 24 hours.

The case of Mickey Mantle raises the troubling and perplexing issue of what should be the ethical criteria by which scarce and precious liver organs are allocated.

It is difficult to develop these criteria for several reasons. First, compared to other life-saving therapies, such as mechanical ventilation and dialysis, which may become relatively scarce due to health care reform, the supply of livers represents a naturally occurring, scarce resource in which the supply lags far behind the demand. Hence, unless we decide to ban liver transplantion, which seems unlikely, tragic decisions concerning how to allocate these organs must be made.

Second, criteria by which to allocate organs for patients with liver diseases are especially tragic, since in contrast to patients with end-stage renal disease, who may rely on dialysis while waiting for a kidney transplant, those in need of a liver have no alternative treatment: For them, the lack of an available and suitable transplant organ spells almost certain death.

Finally, another consideration that may be relevant is the extreme costs associated with liver transplantation.

For example, a kidney transplant may cost around $40,000, a heart transplant about $120,000 and a liver transplant in the range of $200,000 to $300,000. Thus the dire, absolute nature of donor liver scarcity coupled with its high costs mandates that the distribution of livers be based on unusually rigorous criteria -- criteria that may not be required for the allocation of most other resources.

What would be a fair, equitable, and efficient allocation policy for liver transplantation?

At first glance, a random procedure, such as a lottery, might seem attractive. In such a case, each person is treated as having equal value. Everyone in the patient pool has an equal chance of receiving scarce medical resources. Such policies are impartial, since all patients have an equal chance at selection, regardless of race, color, creed, notoriety or financial status.

Although a lottery treats everyone equally, it does so in the abstract and ignores other values that may be important to society. For example, due to the scarcity and costs of liver transplantion, maximizing medical outcomes might seem to be a worthygoal and, therefore, scarce and precious livers should be allocated to those individuals who have the best chance for survival.

Social circumstances

However, this utilitarian concern with best outcomes invites the problem of subjectivity, as one needs to define the determinates of benefits, e.g. probability of success, length of extended life with the transplant, or quality of life. A maximizing strategy also has the potential to be unfair to certain groups of individuals, as many determinates of medical success depend on social circumstance. For example, an exclusive focus on maximizing medical benefits might exclude the poor and disadvantaged because health and socio-economic status are highly interdependent. Hypothetically, any number of social characteristics might be shown to predict successful transplantation-- educated people might do better than those with a poor education, younger persons better than older ones and rural people better than urban dwellers. Hence any social criteria could be turned into medical criteria if they predicted the chance for a successful transplant.

Alternatively, an allocation policy can be guided by a principle of justice or fairness, a goal that sometimes competes with that of the best outcomes. Common to all theories of justice is the requirement that peoplewho are equal in relevant respects should be treated equally and people who are unequal in relevant respects should be treated unequally. But this statement is abstract as it provides no criteria for determining when two or more individuals are in fact equals.

However, one principle that might specify a relevant characteristic for equal treatment is the principle of need, i.e. distribution of medical resources should be based on need. With regard to liver transplantion,this concept of fairness entails that organs should be allocated to the patients who have the greatest need, in other words, those patients who will die shortly without transplant.

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