Annas: Rationing and Organ Transplants

The Problem

• The number of potential transplant candidates is greater than the available number of organs

• Therefore, some method must be developed for deciding who gets the available organs

• This debate reflects a traditional debate in medical ethics: two patients, can save only one…

Dialysis (1960s)

• Similar problems to current issues in transplantation

• Annas describes a situation in Seattle, where a screening committee was set up to determine who should receive dialysis

– Quotes one member who voted against a prostitute and a playboy

• There was a general negative reaction when the biases of the selection committee were made public (middle class values, etc.)

Approaches to Rationing

• The market approach

• The selection committee approach

• The lottery approach

• The customary approach…

5. A combination of approaches

The Market Approach

• Those who can pay receive treatment (whether private insurance or out-of-pocket spending)

• High value on individual rights

• Low value on fairness

• Also, “bake sale” approach, where the poor must make public appeals for funding: demean individual and society

• Places a price on human life

The Selection Committee Approach

• Occurs in many hospitals for making rationing decisions

• Tends to be a response to problems that occur when criteria are made public

• But this approach is also problematic: two types of outcomes are possible and neither are acceptable:

• Either a pattern develops OR

• No pattern develops

If a pattern develops, then the pattern can be described and used without the committee’s input

If no pattern develops, then the committee can be accused of dishonesty or arbitrariness

• Also, like the market approach, this approach implies that it’s okay to prefer that some individuals live while others die; undermines society’s views about equality, value of human life

The Lottery Approach

• “The ultimate equalizer”

• BUT makes no distinctions among candidates:

– Strength of desire for a transplant

– Chance of survival

– Quality of life

• The first-come, first-served approach is kind of a natural lottery, but the rich tend to come first

The Customary Approach

• Avoids explicit recognition of the problem of rationing

– E.g. “general understanding” among British G.P.s that individuals over 55 years of age in end-stage renal disease not be referred for transplants or dialysis

• In the U.S., the customary approach tends to involve selection according to clinical criteria, but views of social worth are embedded in these criteria

• Some of the social judgments include whether a patient has sufficient family support for after care, age of patient

– May be difficult to separate from medical considerations

• This approach “gives us the illusion that we do not have to make choices, but the cost is mass deception”

• An approach to rationing must be fair, efficient, reflective of important social values (e.g. fairness, equality, value of life)

• It must also be efficient, in that it reflects the desires of patients and their expected medical outcomes

A first step…

• Initial screening should be based on judgments of medical criteria bearing on the probability of a successful transplant only

• Therefore, we must attempt to develop medical criteria that do not rely on social values

– Transparency will help with this goal

Next…

• There will still be more candidates than organs

• Kidney transplants: complicated matching criteria, so organ should go to the best matched candidate (natural lottery)

• Livers, hearts, etc: less exact matching, so must choose between a lottery approach and the use of explicit selection criteria

• “the most reasonable approach seems to be to allocate organs on a first-come, first-served basis to members of the pool but to permit members to ‘jump’ the queue” (if in danger of immediate death)

Equity

• This proposed approach most closely resembles a lottery

• Still some unfairness (because wealthy, medically savvy will be in line first)

– public awareness of the system will decrease these advantages

Problems arising from limited resources

• Can be minimized by:

– constructing stricter criteria for medical necessity (QOL)

– Increasing resources given to organ procurement and transplantation

– Persuading individuals not to join the pool

What kind of persuasion?

• Education about the actual process will lead people to make an informed decision about how badly they want a transplant

– Need for a lifetime commitment to immunosuppressant therapy (daily)

– Monitoring for symptoms of rejection

– This education should occur before screening

Ethical Issues in Living Donor Transplants

Menkes vs. OHIP general manager

• Case: appeal of a decision made by the General Manager of OHIP not to refund costs for a living donor renal transplant performed outside of Ontario

Background

• Menkes diagnosed with renal failure

• On dialysis 3x/week

• Longtime, live-in housekeeper volunteers to donate a kidney and is a match

– What about her motives?

– Agreement signed: no financial compensation

The Hospitals’ Response

• Toronto General Hospital refuses to do the transplant

– Ethics committee

– Members of Kidney Transplant Program

• Also St. Michael’s, LHSC, a Vancouver hospital

• Mayo Clinic agrees and operation is performed successfully

Should OHIP Reimburse Menkes?

• Reimbursement depends in general on whether the treatment is performed (and covered) in Ontario and

• Whether waiting for therapy would result in death or irreversible tissue damage

The Consequences of Waiting

• Waiting for a cadaveric organ would quite likely have resulted in deterioration of Menkes’s condition

Is the Procedure Done in Ontario?

• The answer to this question depends on the applicant’s “medical circumstances”

• In this case, the medical circumstances include the ethical evaluation of the case: “ethical review and ethical decision-making constitute an essential part of medical decision-making in relation to organ transplant”

The Board’s Job:

• Given this definition of medical circumstances, the Board must decide whether the transplant would be generally accepted in Ontario as appropriate

The Board’s Findings

• Renal transplant, in general, is acceptable

• This specific type of transplant is not: “on the basis of ethical considerations arising from the recipient-donor relationship”

• Note that this is not the Board’s decision, but it is based on the fact that three Ontario transplant centres indicated that the surgery was unacceptable for ethical reasons

• Also considered (sparse) literature on ethics of living-donor transplants