Thursday, January 17, 2013

Transplant Morality

In our aging society, older Americans are increasingly receiving organ transplants.
 The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.
The allocation of certain organs in this country is determined by need and severity of underlying illness.  It's not like at the deli where you draw a number and simply wait your turn.  Length of time spent on the wait list has nothing to do with your likelihood of getting the next available liver or lung.  Each potential recipient is assigned a score (MELD, Lung Allocation Score) based on clinical factors, bloodwork, functional capacity, etc etc.  (Kidney allocation still relies heavily on wait times, length of time on dialysis, etc). 

So what can happen is that someone who suddenly develops acute liver failure can find himself at the top of the transplant list, leapfrogging patients with more indolent deterioration who have been on the list for months or years.  While it makes sense that sicker patients ought to have some sort of priority, there is also an element of unfairness in being able to vault to the top of a list when there are other deserving patients who have been waiting for much longer. 

Furthermore, often times these severely ill recipients are so compromised, physiologically, that they have a very difficult time tolerating the transplant and mounting any sustainable recovery.  Worst case scenario is that you transplant a perfectly fine donor liver into a 68 year old with numerous co-morbidities who then dies in the ICU on POD #3.  Meanwhile your 27 year old with advancing autoimmune hepatic insufficiency is told once again that she "just missed out on another organ." 

These are moral dilemmas that are very difficult to hash out on the public stage.  How do we fairly allocate a crucial, life saving resource of limited availability?  Ought priority be given to the sickest patinets or those who have waited the longest.  Should mere age be a precluding factor in eligibility?  

As far as I'm concerned, debating this would be a fruitless exercise.  I see no possibility of universal consensus.  One's point of view is highly contingent on whether you're the one on the waiting list or you're the one with four kids or you're the one who will die tomorrow if you don't get a liver now.  Clinicians are similarly biased by their interaction/relationships with patients, regardless of wait list time or need.  How do we implement over-arching ethical guidelines when the ultimate moral linchpin, that each and every life is valuable, immeasureably, none moreso that any other, would seem to trump whatever consensus is achieved. 

The only solution is to increase the supply of available organs.  Two main possibilities present themselves: 
  • Advances in stem cell biotechnology and the ability to "grow your own" organs
  • Changing the organ donor default option when you die such that, unless one specifically chooses to opt out, all Americans are donor candidates upon death.  Automatically. 


Unknown said...

My name is Alex, I am from Ukraine, I am 32 years old man. I don't smoke cigarettes and don't drink alcohol. My blood is O+ and I have a good health. If you need liver transplant I am ready to give part of my liver, but I want to receive a big compensation for that.

P.S. This is not a joke and I am not a scammer or cheater.

Paracelsus said...

I fear that the second main possibility would only simply mean new and immense mountains of paperwork, along with a new jungle of bureaucracy, all for the purpose of tending to the masses opting out. That is IF the required legislation would ever get passed.

"There is no greater love than to lay down one's life for one's friends." Laying down one's life isn't even required, as in this situations it has already been taken away. But a large part of society sees organ donation as corpse mutilation (whatever that may mean) and desecration, or sometimes as a risk for missing out in the afterlife (whatever that may mean). And that large part of society is, I've noticed, the part that has the above quoted text among its sacred ones. Talk about hypocrisy.