Explain the financial social worth and medical factors that influence how organ
Explain the financial social worth and medical factors that influence how organ transplants are awarded.
2. Contrast the American and British ways of rationing health care.
a. What are the benefits and weaknesses of each?
b. In which system is it ethically easier for a physician to say no to a request for expensive treatment? Why?
c. Which system do you think is the most ethical and why?
There was a time not long ago when doctors could offer only limited help but they
dispensed that help generously to their patients. Today doctors have amazing medical resources
but they are limited in supplying them by scarcity and economics. How for instance do they
decide whether a patient gets a liver transplant? First they have to determine if the patient is a
good candidate for organ transfer. Then they have to locate a liver donor or apply to an organ
registry. They also have to consider how the surgery will be paid for since they will need
approximately $100000 to cover the expense.
What should doctors do? Should they follow the market approach and allot treatment to
those who will pay the most for it? Should they decide on the basis of medical need? Should
they depend on a committee to make the decision? Should they depend on a lottery system or an
HMO to make decisions regarding allocating treatment? Or should they follow the customary
approach which is a bunch of practices that mask the fact that treatment is being rationed? Each
of these approaches has its advantages and disadvantages.
The market approach is consonant with the free market economy. It simplifies the choice
because the transplant goes to those who can pay for it either with their own money or with
insurance. Many libertarians feel comfortable with this idea because people would get the care
that they have earned and deserve. Many of us would be troubled if society followed this option
exclusively. It is however a component of the customary approach discussed below.
The medical-need approach would allot organs by giving priority to patients who most
need them to stay alive. It would be supported by a prognosis on the patients likelihood of
recuperating to live a healthy life. According to medical need a 93-year old man who would
almost certainly die with a transplant would have priority over a 30-year old woman who could
live for six months without a transplant. According to medical prognosis the woman would
receive the transplant.
The lottery approach is another simple approach to rationing transplants that guarantees a
kind of fairness because it treats all seekers of expensive and scarce treatment equally. This
approach may be too simple because it does not take into account the seriousness of need the
likelihood of success the length of time on a waiting list or the persons age or importance to
their families and society. On the other hand everyone would have an equal chance of receiving
treatment.
The committee approach merely moves the decision making from a doctor to a
committee without dealing with underlying ethical concerns. The committee is likely to reflect
the arbitrary biases of its members. It does however distribute feelings of guilt and gives its
members a feeling of justification because ones judgment is supported by ones peers. The
customary approach on the other hand offers some comfort to the medical establishment. It
conceals the reality that people are denied treatment because of rationing and conceals reasons of
economics and bias that shape the rationing. In short it does not rock the medical status quo.
For these reasons the customary approach will remain in place with only minor
modifications until situations interest groups and individuals mount campaigns for more
transparency. This is the ordinary course of democracy: Elites make decisions for their own
benefit until people make them decide for the benefit of ordinary people.
One practical decision-making strategy for allotting organ transplants or other scarce
and/or expensive procedures is an explicit or implicit checklist. Using such checklists doctors
committees and HMOs automatically disqualify certain groups of people from receiving them.
Such people might be excluded on the basis of: age criminality drug or alcohol abuse mental
illness likelihood of medical failure quality of life low social standing or lack of insurance.
Carl Cohen (as cited in Card 2004) argues that there are no special reasons that should
automatically deprive alcoholics of liver transplants a position with which many Americans
disagree as evidenced by the furor that erupted when Mickey Mantle an alcoholic got a liver
while those who had not been alcoholics went without. Daniel Callahan (as cited in Card 2004)
argues that scarce treatments should not be allocated to people who have completed their
productive life spans because society owes people a good life not a long life and because giving
old people those treatments will deprive younger people of opportunities for a full life. He
believes that old age is meant to be a time of reflection and making peace with inevitable death.
George Annas (as cited in Card 2004) considers ideas for deciding between prostitutes
playboys poets and other reprobates. He says the process should be fair efficient and
reflective of important social values (p. 458). He believes that the initial screening should be
based exclusively on strict medical criteria. The secondary criteria should minimize social worth
criteria and move toward a randomized method of selection for which he prefers a modified
first come first served procedure. For example every prospective kidney recipient would first
be typed with prospective donated kidneys on the basis of compatibility and likelihood of
successful outcomes. After the first selection had been completed the prospective recipient who
had been on the list the longest would be awarded the transplant.
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