Ethics of Organ Allocation

Introduction

Transplantation can be a life saving medical procedure with rather successful returns. However, there is a wide discrepancy between the number of people in need of organs and the available supply of adequate organs from donors. In the United States alone, “120,000 people are waiting to receive a life-giving organ transplant” and every ten minutes another patient is added to a transplant waitlist. (OPTN 2021)

On top of the logistical complexity of allocating organs, their scarcity also engenders several challenging ethical questions and dilemmas caused by age cut-offs, conflicting principles and goals, practical concerns, limitations, and socio-cultural factors, beg the question of “Who’s life is worth saving?” (Reichman 2014 ) While allocation is framed to estimate who the transplant will most benefit, the criteria and normative frameworks that guide the allocation and decision process must be constantly scrutinized and renegotiated.

In the USA, the allocation of organs for transplantation is administered by the Organ Procurement and Transport Network (OPTN), under the United Network for Organ Sharing (UNOS). They are responsible for managing the waiting list, matching donors and recipients,  monitoring guidelines for every organ transplantation, providing support to waiting patients and families, and educating the public on the importance of organ donation etc…

As mentioned above, due to the scarcity of organs available, transplantation is not a universal option and it is therefore essential for medical professionals to recognize this limitation in parallel with their duties to promote health and alleviate suffering.  Accordingly, to achieve maximum benefits the OPTN emphasizes the probability of good outcomes in identifying the best potential recipients. Criteria to match candidates on the waiting list include several medical components to ensure that the  transplanted organ will be a physiological match, moreover, several other non-medical evaluations have also been historically carried out. Evidently, the criteria for these evaluations can sway eligibility of patients in various ways.

The UNOS Ethics Committee current criteria addresses: life expectancy, behavior induced organ failure, patient compliance/adherence, repeat transplant, and the potential option for alternative therapies. Note that this criteria is neither exhaustive nor immutable; standards for organ transplant assessment must constantly be re-evaluated in the light of biomedical advances and social issues to guarantee and preserve the individual and the value of life.

Key Principles

Utility

This principle aims to maximize net benefits via actions that promote the most aggregate net good. Evaluating utility involves a risk-benefit analysis and therefore incorporates both principles of beneficence and non-maleficence. (see Philo Foundations) In the context of organ allocation the potential benefits from a transplant are evaluated according to standardized outcome measures that include factors such as patient survival, graft survival, quality of life, alternative therapies, and patient age.

For ethical purposes, the allocation process is blind to social worth or status related to profession, occupation, socioeconomic background, and group membership.

Justice

As a public program, all members of society are entitled to equitable access to organ allocation. A governing principle that ensures fairness in patterns of distribution is justice. This principle highlights that concerns should not merely be centered around the net good from transplantation according to utility, but also how the distribution is performed amongst its beneficiaries. Therefore, a just allocation system involves equal opportunity for all to receive an organ when in need.

Respect for Persons

Inspired by the Belmont report, the principle of respect from persons emphasizes the dignity of human persons as “end in themselves.” This principle follows from the principle of respect of autonomy that highlights self-sovereignty and self-determination. Respect for a person, includes respecting their ability to make their own decisions, as long as they do not cause harm to others, as well as the right to be free from coercion, and other external interference.

Note that while it is fundamental, this principle is not without limitations in the allocation of organs. For example, while one can autonomously decide to sell their organs, the system prohibits it on the grounds of justice as transplantation is considered a public good requiring equitable access and distribution. The sale of organs puts a price on an invaluable life-saving resource. Moreover, even when it is carried between willing donors and recipient buyers it involves a severe infringement of justice, particularly as it relates to finances and fair access.

Reflection Questions

1. Is the OPTN’s notion of justice coherent? What makes a pattern of distribution fair?
2. Should this idea of desert be factored in the allocation of organs? If so, how?
3. Does the OPTN’s emphasis on social support, in fact contradict with the underlying idea of justice as giving everyone equal access?
4. Is the doctor’s role to advocate for justice or for the wellbeing of their patients? Do these interests conflict one another? If so how can we mitigate this issue?
5. A 75-year-old on the waiting list finally is finally going to receive a liver but an 18-year-old also desperately needs the liver. Should be avoid paternalism and let the 75-year-old decide by asking “Would you consider giving the liver to the younger person?” What are the implications of involving patients in such decisions?

Case Studies

Compliance/Adherence : To Transplant or Not to Transplant?

Mr. S. is a 38-year-old patient who is being seen by Dr. H. for a lipid disorder related to renal failure. He is being considered for a renal transplant in the near future, and Dr. H. has been asked to evaluate and make a recommendation to the transplant program regarding the patient’s suitability for transplantation. In taking the history, Dr. H. happened to comment to Mr. S. that he looked like a Harley rider. The patient told Dr. H. that he was and that, in fact, he had ridden his cycle to the appointment. When asked where his helmet was, he told Dr. H. that he did not use one saying, “When it’s my time, it’s my time.” Dr. H. feels that since personal risk behaviors such as drug or tobacco use disqualify a patient as a transplant candidate, then this type of risk taking behavior certainly should. Indeed, Dr. H. thinks that Mr. S. should not be given a kidney transplant since he has such blatant disregard for his personal health and safety. Dr. H. feels that it would simply not be a wise or prudent use of limited resources.

Should Dr. H. recommend against a kidney transplant for Mr. S.? Why or why not?

Source: https://link.springer.com/content/pdf/10.1007/BF03355203.pdf

Justice and Allocation: The Case of Sarah Murnaghan

In the spring of 2013, the case of a 10-year-old girl awaiting a lung transplant became the center of an unprecedented controversy over fairness in the distribution of lungs from cadaver donors. Sarah Murnaghan was born with cystic fibrosis. At the age of 1 she began receiving her care at the Children’s Hospital of Philadelphia. In December, 2011, her disease had progressed to the point where she was placed on the national transplant waiting list with priority status 1, a status reserved for the patients who most urgently need a transplant. By December 2012, she was on continuous, noninvasive respiratory support at home. In February 2013, she was admitted to Children’s Hospital of Philadelphia because of her worsening respiratory status. Despite maximal therapy, her lungs began to fail. During her year-plus time on the waiting list for a lung transplant, no organ deemed suitable by her transplant team had become available. With no acceptable donor lungs available, her parents told members of the media that they had only recently learned that Sarah was not eligible to receive adult cadaver lungs. Although Sarah had been listed for both whole lung and lobar transplant since 2011, given her age, she was not given a lung allocation score that would make her competitive in gaining access to adult lungs. UNOS is charged by Congress with rationing cadaver organs, including lungs. Adult lungs are distributed based on a lung allocation score that is based on need, regional location, blood type, and size. UNOS updated its pediatric lung policy in 2010, putting 2 tiers in place for children. Lungs recovered from adolescents (age 12–17) were offered first to adolescent recipients, then to children ,<12, then to adults. Lungs from children ,<12 years old were first offered to children ,<12, then to adolescents, then adults. The basis for this policy was that there were data that predicted the efficacy of adult lungs in adult recipients, but few data on the outcomes of partial lobar lung transplants in children, especially in those <12. The known success of adult lung transplantation was given more weight than the unknown efficacy of partial lobe lung transplantation. Sarah’s parents, in an attempt to give their daughter the best chance at life, launched a public relations campaign to get her priority access to lungs obtained from the adult cadaver donor list. The publicity from this case prompted a sympathetic response from many members of Congress, who asked Secretary of Health and Human Services Kathleen Sebelius to override the restrictions on adult lungs for patients ,<12 years old. The Secretary refused to overturn the policy of UNOS.8 In response, Sarah’s family sought the skills of a prominent Philadelphia law firm and filed a lawsuit challenging UNOS policy. With Sarah critically ill, an emergency hearing was held before Federal Judge Michael Baylson. On June 5, 2013, Baylson ordered Secretary Sebelius to allow Sarah to be placed on the adult lung transplant list. This, it was felt, would increase her chances of getting a lung for transplantation.

Did Judge Baylson make the right decision to override the UNOS allocation system in this case?

Source: Ethics Round – Was Sarah Murnaghan Treated Justly?

References and Additional Resources

Reichman T. W. (2014). Bioethics in practice – a quarterly column about medical ethics: ethical issues in organ allocation for transplantation – whose life is worth saving more?. The Ochsner journal, 14(4), 527–528.

Berry, K. N., Daniels, N., & Ladin, K. (2019). Should Lack of Social Support Prevent Access to Organ Transplantation?. The American journal of bioethics : AJOB, 19(11), 13–24. https://doi.org/10.1080/15265161.2019.1665728

Organ Procurement and Transplantation Network (2015) “General Ethical Principles in the Allocation of Human Organs” [White Paper] https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/ethical-principles-in-the-allocation-of-human-organs/

Organ Procurement and Transplantation Network (2021) “General Considerations in Assessment for Transplant Candidacy” [White Paper] https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/general-considerations-in-assessment-for-transplant-candidacy/

Ethics Round: “Was Sarah Murnaghan Treated Justly? ” (source: Pediatrics, 2014)

Book Chapter: “The Ethics of Organ Allocation” Book chapter in Textbook of Organ Transplantation by Allan D. Kirk (2014)