Organ Procurement: Are Changes Needed to Ensure Fairness?

In this short post I’ll be asking two important and related questions regarding organ procurement as it is currently practiced: (1) Are the currently policies surrounding organ transplantation fair? And, (2) Is it practical to make changes to the current policies?

Here I’ll deal mostly with question (1) and offer only some brief remarks with regards to question (2). So, are the current policies surrounding organ procurement fair? Well, let me summarize the policy for those of you who might not understand the process then I’ll offer my critique (disclaimer: there are different rules governing the transplantation of each organ, however, they are all very similar).

THE POLICY (truncated version)

The United Network for Organ Sharing (UNOS) maintains the Organ Procurement and Transplantation Network (OPTN). Through the UNOS Computer System, organ donors are matched to waiting recipients 24 hours a day, 365 days a year. All those in need of an organ are put on a waiting list which can only be seen by those who are on the list. Once on the list, a score is given to each person which is generated by an algorithm. The score relates to the patients mortality risk. Meaning; if you’re likely to die from other illnesses or because your very old, etc., then these factors will affect your score. Below is a summary taken from here.

1. If you need an organ transplant, your doctor will help you get on the national waiting list.
2. To get on the list, you need to visit a transplant hospital. Every transplant hospital in the United States is a member of OPTN. You can use the Organ Procurement and Transplantation Network  directory to find a transplant hospital.
3. Transplant doctors will examine you and decide if you meet the criteria to be put on the list. You can get on the waiting list at more than one transplant hospital. Each hospital has its own criteria for listing patients. If you meet their criteria, they will add you to the list.
4. Your name will become part of a pool of names. When a donor organ becomes available, all the patients in the pool are compared to the donor. Factors considered to decide who gets the organ include:
   • Blood and tissue type
   • Size of the organ
   • Medical urgency of the patient’s illness
   • Time already spent on the waiting list
   • Distance between donor and recipient

The organ is offered first to the candidate who is the best match. The organ is distributed locally first. If no match is found, the organ is offered regionally and then nationally until a recipient is found. The hardest part of this process is waiting. There is no way to know how long you will wait to receive a donor organ.

CONCERNING FAIRNESS

That’s the policy, now, is it fair? I don’t think that it is, let me explain. Let’s consider the case of Bobby (a fictional character). Bobby is a 35 yr old man who needs a liver because he drank excessively for 20 years. Bobby has had his license revoked several times due to driving under the influence of alcohol. Bobby was even locked up on occasion for fighting while drunk at the local bar. Bobby is considered by many to be a lost cause. He has had difficulty holding a job (in large part because of his drinking) and has had a tough time making and keeping friends (also because of his drinking habit). Now, let’s say that Bobby has been on the donor list for 2 years. Should he get a new liver when others are also in need?

Well, let’s consider a 2nd case, the case of Nicole.

Nicole is a 50 yr old woman in need of a liver because she found out that she has a rare genetic liver disease (fictional case as well). The bile ducts in her liver have been decreasing in size over the course of her lifetime (let’s assume that  she has never shown any symptoms of such a disease until now). Nicole is the mother of 3 girls, one in college and 2 in high school. She’s been married for 22 years and has never had a drink. She has never been arrested, she has held her job at the local hospital as a Pediatrician for the last 15 years. She also goes to Africa every summer to offer her health care services to people without care. Nicole is considered by many to be a stand-up citizen, a role-model of sorts. She has been on the donor list for 1 year and 4 months. Should she get a new liver when others are also in need? Well, assuming the current policies regarding organ procurement and assuming Nicole and Bobby are the same on all the criteria set forth in (4) (except for time on the waiting list) then it seems Bobby would get the organ because he’s been on the waiting list for 8 months longer than Nicole. I have a problem with this. Bobby’s behavior caused his condition. Nicole’s behavior did not. In fact, Nicole’s lifestyle of not drinking has caused her disease to progress slowly, forcing her to require a transplant later in life. Taking into consideration the character or the type of person someone is does not play a role in the decision process of organ transplantation, it should!

This comes down to accountability. Should we hold Bobby accountable for his actions which directly led to him needing a liver? How could we? One way to hold him accountable would be to give the liver to Nicole instead. She is not in need of a liver because of any act or any series of acts that she is at fault for. She is not responsible for her current state, Bobby is. I’m not saying that we should let Bobby die in every circumstance. For instance, if Bobby and Eddie both needed a transplant and Eddie was in need of a liver for similar reasons to Bobby (the only difference being that Bobby has been on the waiting list for 8 months longer than Eddie) than I think Bobby should get the liver. However, if there is another Nicole type patient waiting for a liver I think she should get it over both of them (all other things being equal with regards to the safety of the transplant).

Fairness requires that we give the organ to Nicole. Considerations of the causes for why one needs an organ transplant should play a part in deciding who should get the organ. Life is precious, even Bobby’s life. But those who live recklessly should not get precedent over someone who flourishes and lives their life in moderation (all other things being equal). Both deserve a chance to prolong their life, Bobby to try to flourish and Nicole to continue flourishing. But who deserves it more? Admittedly, this is a very tough question but it’s a question worth considering. Since we make decisions every single day on who should get an organ I think we should include fairness and desert as criteria in the organ procurement process. Not doing so forces us to look at both Bobby and Nicole in the same manner, that seems odd.

PRACTICAL PROBLEMS

Here are some questions that arise when trying to include considerations of character or fairness in the process of distinguishing who should receive an organ.

(1) – What if the person with good character is not the cause of their need for a new organ (Nicole) but is very old (85)? What if Bobby is only 20 instead of 35 and was the cause of needing a new liver (and had the bad character traits I spoke of)? Would we still think that Nicole should get the liver?

(2) – Why focus on the past? It seems that Bobby could still change, why are we condemning him?

(3) – What about if Bobby was a scientist working on a cure for cancer but is in need of a liver because he drinks all the time? Do we still think Nicole should get the liver?

All of these questions are difficult. With regards to (1); I think Bobby’s age change from 35-20 might play a part in giving the organ to Bobby, especially if Nicole is 85. It seem that in the latter case (Bobby at 20) Bobby could change and is more likely to change when compared to a 35yr old who has been habituated for 15 more years in his bad ways. That’s not to say that 35yr old Bobby couldn’t change, only that it is less likely.

To question (2); the past is all we have to work with. Future considerations play a part but only on the viability of the organ and the type of life we think both would live (but again, this latter consideration is connected to the past as well).

To question (3); I do think that what one does for others should be taken into consideration, however, being the direct cause of needing the transplant should not be taken lightly. This takes us back to accountability and holding one responsible for their actions. Nicole and others like her are not morally or causally responsible for their conditions, people like Bobby are. I think this should play a role in who we decide gets a transplant. Failing to consider this is a failure of our policy to be fair or just.

There is much more to be said about this but this is all I have time for today.

For more on the current policy details click here.