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Second Place, 2004

Writing Center Awards

 

 

Prioritizing Life

 

Willis Kann

 

As medical technology advances, doctors find new ways to treat patients who were untreatable in the past.  With each of these new treatments comes a new slate full of ethical dilemmas in need of discussion.  For many years, organ transplantation has proven to be the subject of many ethical debates, and is considered “the most controversial issue facing the transplant community” (SangStat, “Organ”).  Doctors and councils struggle to decide how to properly and fairly devise the UNOS, which is the United Network for Organ Sharing, waiting list and allocate organs.   Despite all the debates, there seems to be no proven correct way, as doctors continue to amend the waiting list.

            First, it is important to know who is eligible for a transplant.  Any patient in need of an organ transplant is eligible, but finding an organ that will “fit” is not easy.  Our current system puts patients who are in need on a waiting list until an organ is available.  Priority on this list is determined by such criteria as “waiting time, tissue and blood-type matching, size matching, and severity of illness”(SangStat, “Organ”).  Upon examining these relatively simple criteria, it is discovered that there is a lot more to determining priority than is shown.  These simple criteria do not account for the individual patient’s circumstance.           

Each patient must be looked at as an individual case.  This is necessary because there are no two exact cases in the medical field, just as there are no two exact human beings in our world.  The preceding criteria touch on the basic areas of a patient’s condition, but do not take into account most of the other aspects of the patient’s life.  For instance, age plays a big role in list priority.  Younger patients generally receive priority over an older patient with a similar case and need.  This is important because more than 2,200 of the 80,000 people on the organ transplant waiting list are minors, children under the age of 18 (United Network).  These children have high priority due to their post-transplant lifespan potential.  Along with age, the patient’s lifestyle must be assessed.  The ailment should be considered either unavoidable or avoidable through lifestyle changes.  In many liver transplant cases, for example, alcoholism has destroyed the patient’s liver.  In cases such as these, it is the doctor’s responsibility to address these issues and prioritize patients accordingly.  According to the specific criteria listed, a patient who is an involuntary victim of chronic liver disease would assume the same priority as a patient who has destroyed their liver with alcohol.  One popular case that exemplifies this situation is the life of Mickey Mantle, one of the greatest legends to ever play baseball.  Mantle developed liver disease after a lifetime of alcoholism.  He was put on the UNOS waiting list.  While in the 6th spot on the list, a matching donor was found, and he received a liver, but it proved to be too late, as he died two months later.  This raised and reinforced questions of who should have had the highest priority for transplant (Calif. State).

Before transplantation can occur, doctors must also assess the patient’s quality of life before, and what they expect it will be after, the transplant.  If an older patient will remain static in health status, assuming that their health will not diminish or augment, where should the patient be placed on the list?  Many young people have a need for organs, but will have what could be called poor quality of life after the surgery.  These young people are “in competition” with older patients in need of surgery that may result in better quality of life.  This once again shows the importance that a doctor takes each case as an individual.

Doctors are also expected to look at the patient objectively, without letting emotions play into their decisions regarding permission to perform surgery or not.  A doctor must be honest and motivated only by wanting to help the patient.  They must keep their business to the side when dealing with these situations.  Unfortunately, this decision-making process is not always completely pure.  Instead, it is diluted by the business and money that goes along with it.  “It is not possible to purchase or donate money to receive a higher position on a waitlist, [but] money can be helpful in taking advantage of the present allocation system” (University of Pennsylvania).  In 1997, “acquisition costs for hearts and lungs averaged $16,314; $32,845 for kidneys; and $10,312 for livers. These costs are then factored into the total price for transplant surgery” (Anderson).  “First-year expenses associated with a kidney transplant average $100,000, including follow-up care” (qtd. in SangStat, “Cost”). Keep in mind that a kidney transplant is the least expensive transplant surgery.  With such large amounts of money being involved, it is inevitable that finances would become a large motivating factor in waiting list placement.  This being said, there are four general scenarios that occur in regards to financial influences.  First, the doctor may decide that the patient is not a good candidate for transplantation, and for this reason, he declines performing the surgery.  Second, a doctor may decide that a patient is not a good candidate for surgery, but may accept performance of the surgery in order to receive payment.  In such cases, these dishonest doctors are using organs for low-list candidates, when the organs could be allocated to patients higher on the priority list.  Third, the patient may be considered a good candidate by the doctor, and is granted permission to undergo organ transplantation, in which the doctor gets paid the same amount for performing the surgery.  Doctors may also look strictly at the patient’s ability to pay.  This gives us a fourth situation in which the doctor deems a patient a good candidate for surgery, but declines performance of surgery due to the patients inability to pay.  The exact number of these cases is unknown, and cannot be correlated or generalized to a specific region, race, or social standing, but it is a current problem (Newman).

            Geography also plays a vital role in the procurement of an organ.  When an organ becomes available, it is offered to the local list of possible recipients.  If it is not needed, the organ is passed on to the regional list (Seton).  Recently, our current system has undergone “new regulation to improve the nation’s organ transplantation system, ensuring that allocation of scarce organs will be based on common medical criteria, not accidents of geography” (Health).  This legislation may improve our methods of allocation, but seems as if it is just reinforcing what is already being done.

So how can a list that affects so many people worldwide be prioritized properly?  Many people propose a lottery system, or a random assignment of compatible donors and recipients.  Others suggest that we adopt a simple approach, such as a strictly enforced first come first served system (Lamb 203).  The problem with these systems lies in their lack of individuality.  They are very simple to enforce, but are totally ignorant of the severity and time restraints of each individual’s ailment.  Time frames will not be met for many patients, while others will undergo transplantation well within their possible waiting periods.  Currently, “about a third of those waiting for a transplant will die before receiving an organ” (University of Michigan).  This portion will only grow if the first come first served system is adopted.  Many groups suggest organ allocation by “social utility” and “egalitarian framework” (Lamb 203).  This system would take the individual patient’s circumstance into account, but defining “social utility,” or social worth, is practically impossible.  The fact that every human being holds different beliefs, involving socioeconomic, religious, and circumstantial beliefs, makes defining social worth impossible.  One person may judge a priest as the most socially worthy, while others may judge a Wall Street broker as having the most social worth.  In the Mickey Mantle case, many people argue that he received an organ over others who were higher in priority on the waiting list simply due to his celebrity status, although as it stands now, “no consideration in allocation can be given to social factors such as wealth, citizenship or celebrity status” (TransWeb).  If it were definable, who would be empowered with the job of defining and enforcing this judgment of social worth? 

Another way to ensure fair and proper prioritizing is to eliminate priority completely.  While this sounds extremely radical, it may be a possibility in the future, though very distant.  Experimenters are currently researching the idea of xeno-transplantation, or transplantations from animals (The Transplant Pharmacy).  This could open up the possibility of “mass-producing” organs at a rate fast enough to allocate all the necessary organs.  Theoretically, organs would be as readily available as a t-bone steak at a market.  This method has not yet been mastered, and research continues.

            I suggest that we continue use of our current system, and amend it if, when and where necessary.  Our current system uses a subjective points-based survey in which it determines priority to the best of any survey’s ability.  Using the criteria currently laid out, with the addition of more specific circumstantial (though non-social), lifestyle, and potential-based criteria, the waiting list would be more accurately and honestly composed.  Using a cut-and-dry first come first served system, or basing it on social worth is too harsh, and will cause major negative repercussions.  Continuing use of our current system will fairly assess patients’ ailments, and place them accordingly on the UNOS waiting list.  A more rigorous system of checks and balances between doctors, physicians, UNOS, and any person involved in a transplant team should be developed to ensure honesty and prevent emotional or ulterior motives within the group.

            Prioritizing organ transplant will never be easy.  There are too many variations in beliefs and lifestyles among the people of Earth to find a single, clear-cut solution to organ allocation that will satisfy everyone.  We can only take the systems we are familiar with and improve them through research, compromise, and most importantly, honesty among specialists in the field.

 

 

Works Cited

  

Anderson, William L., Andy Barnett. “Waiting for transplants.” The Free Market 17.4 (1999): 11 February 2004 <http://www.mises.org/freemarket_detail.asp?control=

29&sortorder=articledate>

 

California State University, Chico. The Mickey Mantle Controversy. 11 February 2004<http://www.csuchico.edu/engl/faculty/engl1Tom/Mickey%20Mantle.html>

 

Health Resources and Services Administration.  HHS Rule Calls for Organ Allocation Based on Medical Criteria, Not Geography. 27 April 1998. U.S. Department of Health and Human Services.  5 February 2004 <http://newsroom.hrsa.gov/ features/OPTNRule.htm>

 

Lamb, David.  “Organ transplants, death, and policies for procurement.” Monist 76 (1993): 203-214.

 

Newman, Joel. “Denial of txp – Inability to Pay.” TransWeb. 11 February 2004 < http://www.transweb.org/qa/asktw/answers/answers9701/ Denialoftxpinabilitytopay.html>

 

SangStat Medical Corporation. Solid Organ Allocation: Organ Allocation. 11 February 2004 <http://www.sangstat.com/resource/solid_allocation.asp>

 

SangStat Medical Corporation. Solid Organ Allocation: The Cost of Organ Transplantation. 11 February 2004 <http://www.sangstat.com/resource/ solid_allocation.asp>

 

Seton. Transplant and Organ Allocation. 31 January 2002. Seton.net. 11 February 2004 <http://www.seton.net/AboutUs/CommunityService8/SetonCareCoalition/ TransplantandOrganA0CD1/index.asp>

 

The Transplant Pharmacy. The Future of Transplantation.  Chronimed.  7 February 2004 <http://www.transplantrx.com/resources/geninfo/future.htm>

 

TransWeb. UNOS Statement on Mickey Mantle Transplant. 11 May 2000. 7 February 2004 <http://www.transweb.org/news/news/archive/unos_mantle.html>

 

United Network for Organ Sharing. Fact Sheets. 11 February 2004 <http://www.unos.org/inTheNews/factSheets.asp>

 

University of Michigan Health System. The Health Science Center and the Mickey Mantle Foundation. Health Science Center at Brooklyn. 7 February 2004 <http://www.med.umich.edu/trans/transweb/mantle/suny_mantle/

suny_article.html>

 

University of Pennsylvania School of Medicine. Financial Status of Transplant CandidatesThe Bioethics Student Paper Fair at http://bioethics.net2 December 2002 <http://www.med.upenn.edu/bioethic/Museum/ Degeus/Txp%20Web%20Page/HTML%20Pages/txpmoney3.html>