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Who Deserves to Get New Organs?

THE BALTIMORE SUN

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.

Giving help to those in greatest need serves the ethic of beneficence. Furthermore, saving an endangered life is an important value highly regarded by the human psyche. In essence, people cannot stand idly by when an identified person's life is visibly threatened if effective rescue measures are available. This Rule of Rescue may simply be an emotional reaction, but an emotional response that appropriately facilitates sense of fairness in providing for the needs of others. In essence, the Rule of Rescue informs us that individuals who will die should have a much stronger claim on available resources than someone whose life is not immediately at stake, even if better outcomes could be obtained bytransplanting patients who are less sick.

The United Network for Organ Sharing, which has developed national criteria for allocating livers, subscribes to the Rule of Rescue and thus gives priority to those who are worst off. For example, individuals who are in the highest priority group (Status 1) must be expected to live less than seven days without a liver transplant and be in the intensive care unit. To qualify for Status 2, the patient must be continuously hospitalized in an acute care bed for at least five days or be ICU-bound. Individuals who can be cared for on an outpatient basis are assigned to a Status 3 level.

Not an absolute

The worst off, however, do not receive absolute priority if the success of a transplant will be marginal due to the existence of complicating medical factors. For example, the patient's blood type must match that of the donated liver, and the size of the donated liver must be appropriate for the patient. In these cases, the extent of achieving a successful transplant is such that now the interest in obtaining best outcomes assumes priority over a concept of fairness.

Mr. Mantle's condition placed him in a Status 2 level. He apparently received a transplant while at this level either because there were no other candidates in his region at a Status 1 level or the blood type or size of the liver that he received did not match those who were in his level or in the higher level.

In addition to blood type and liver size, should there be any other side constraints on the Rule of Rescue? For example, should some social worth criteria be used either to give individuals preferential treatment or to exclude persons from the waiting list?

Unlike blood type and liver size, which are neutral factors, determining the social worth of individuals is entirely subjective and runs the risk of being biased and extremely vulnerable to abuse by those powerful enough to impose their personal values on others.

In Mr. Mantle's case, I might add, there is no indication that he was given special treatment despite his status as a baseball icon.

Another criterion that might seem compelling, and the one that opened this article, is whether the extent to which a person is responsible for his diseases due to risky lifestyles choices should play a role in his receiving an organ. Specifically, should a person whose liver disease was predominantly caused by years of drinking alcohol compete equally with other candidates for liver transplantation?

The answer to this question is important, as alcoholics represent more than 50 percent of the patients with end-stage liver disease. Hence, if more alcoholics were to go on the waiting list and receive a transplant, the scarcity problem would be exacerbated and patients whose livers failed through no fault of their own would get a decreasing portion of the available livers.

But does alcoholism represent a moral failing and a voluntary lifestyle choice for which illnesses resulting from this behavior are deserved?

At present, alcoholism is considered a disease with multiple causes, such as genetic, environmental, social and cultural factors. To determine personal responsibility would be a complex and perhaps impossible task, and therefore a policy of excluding "risk-takers" would be unjust. The degree with which society attributes a diseased state to be a "voluntary" lifestyle choice may be more strongly rooted in bias and prejudice than a coherent theory of personal responsibility.

Some commentators admit that alcoholism is a disease, but maintain that alcoholics should assume responsibility for seeking treatment and modifying their lifestyles. Even Alcoholics Anonymous puts the burden on the individual to develop a new lifestyle. Furthermore, the high success rates of some alcoholism treatment programs indicate that many patients can accept responsibility for their treatment. But social support is invaluable in aiding alcoholics to change their behavior, and unfortunately many alcoholics do not have the support they need. Additionally, many alcoholics may not have ready access to treatment centers or access to the medical personnel who can help guide them through their illness. Hence, once again health and a healthy lifestyle may be interdependent with social circumstance.

Excluding alcoholics from the liver transplant waiting list also would be inconsistent with other transplant policies for placing candidates on a waiting list. For example, people with kidney failure are not excluded from the kidney transplant list because they were not compliant with their therapy for hypertension and/or diabetes.

Finally, no medically compelling reason exists to deny liver transplants to alcoholics, as a study conducted at the University of Pittsburgh showed that survival rates for individuals with alcoholic-related diseases were similar to persons whose liver failure was not due to the effects of alcohol. Consequently, the current system for the prioritization of scarce livers primarily based on extreme need seems fair and equitable.

Henry Silverman, M.D., is a medical professor and ethicist at the University of Maryland School of Medicine.

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