Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on prioritizing Roy, a famous athlete, for a liver transplant even though he is an alcoholic. The reasons for doing so include the fact that he may turn himself around and draw publicity to organ donation.
Is it ethical to put Roy on the transplant waiting list for these reasons?
Yes: 16%
No: 84%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
A long-standing perception exists -- whether accurate or not -- that celebrities receive favoritism in the allocation of scarce organs. For example, during his second term in office, Gov. Robert Casey of Pennsylvania received a heart-and-liver transplant after waiting for a donor less than 24 hours in 1993. Television actor Jim Nabors and singer David Crosby both obtained livers in under a month, while the median waiting time is 208 days.
Yet few organ recipients have generated as much controversy as baseball slugger Mickey Mantle, who received a liver 1 day after announcing he needed a transplant in 1995, and died 2 months later of liver cancer. Whether or not Mantle benefited from favoritism -- and there is no compelling evidence at this point that he did -- the possibility that he had "jumped the line" generated much public criticism, as well as soul-searching among transplant providers and ethicists. Mantle's own transplant team was concerned that the appearance of favoritism would do damage to the organ allocation system.
Concern for the perception of favoritism is an ongoing issue in the allocation of organs that extends beyond celebrities. For example, an organization called Renewal, founded in 2006, has worked to further altruistic kidney donation within the Jewish community. The donors are generally ultra-Orthodox Jews seeking to do a good deed, or mitzvah. Only half of the recipients are religious, yet all but one have been Jewish -- reflecting an unspoken principle underlying Renewal's recruitment system.
Writing in the Forward, Paul Berger estimated that while Hasidic and Haredi Jews account for 0.2% of the U.S. population, they made up 17% of all altruistic kidney donations in 2014.
Advocates for allowing such religiously targeted donations note that they not only save lives in one particular group, but also free up organs that can be used by others on the waiting list. If Renewal arranges for a Jewish patient to receive a kidney, that is one fewer person ahead of a non-Jew waiting for a kidney. Alternatively, without Renewal, these donors would likely not donate any organs at all.
Critics object that should people come to perceive the organ donation system as favoring certain ethnic groups, people of other backgrounds may prove reluctant to donate organs in the future -- and the overall pool of donor kidneys might actually decline.
In the case of baseball star Roy, the hospital's transplant team leader wants to alter the criteria for eligibility. The United Network for Organ Sharing uses criteria known as the Model for End-Stage Liver Disease score in determining who receives cadaveric livers -- generally allocating them to the sickest patients. Yet transplant teams also evaluate patients for eligibility based on social and psychological criteria.
The goal of these screenings is to weed out potential recipients who will be unable to take care of transplanted organs -- either because they lack social support or are unlikely to comply with the complex regimen of follow-up care that successful transplantation requires.
Although active alcohol use has historically been an exclusionary criterion, because it may predict long-term transplant failure, a few medical centers have recently pioneered transplants in patients with acute-onset alcoholic hepatitis. Giving transplants to otherwise-qualified alcoholics who pledge to stop drinking is highly controversial; long-term data does not yet exist on the outcomes of these cases.
Advocates argue that alcoholism must be treated as a disease like any other -- and such patients should be afforded the benefit of the doubt. Critics note that, in the context of a widespread organ shortage, each organ given to an alcohol abuser means a nonabuser waiting for an organ will die, while there is a strong chance the organ recipient will prove noncompliant and die too.
A utilitarian argument -- favoring the greatest good for the greatest number of people -- does not necessarily favor transplantation for Roy. It is possible that a successful transplant for a celebrity athlete would generate more donor organs, but another, more troublesome, possibility also exists: the public would perceive favoritism in an allocation process that advantages the wealthy and famous, which would lead to fewer donations.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Should Doctors Perform Genital Cutting on Girl?