Last week I talked about the fair distribution of resources when discussing whether the meningitis B vaccination should be extended to those over 1 yr. However in considering a finite amount of funding a decision to do so would inflict other harms – resources would be taken away from other areas currently funded, such as expensive cancer drugs. A another commonly encountered scenario based of the 4th pillar of medical ethics – Justice, namely distributive justice is found in the scenario – Who gets the organ.
An ex-alcoholic patient [who is a mother of two children], a seven year girl, a 75 yr old war hero and a homosexual man need a liver transplant. Who should have it?
A doctor should never be judgemental. As in most complex situations a decision would only be made after consulting with senior doctors, the hospital ethical committee and the hospital legal team and/or your medical defence body. All of these are sources of valuable advice and it is important to share responsibility for any decision with them. Remember doctors work in teams not in isolation.
The case for the ex-alcoholic woman to be given the liver transplant
Some people may say that her illness was self inflicted but that is no reason to discriminate against her. Ex-alcoholics may relapse and start drinking again but many diseases affecting the liver such as auto-immune diseases may also affect a new liver and she should not be denied treatment because of this. Being the only parent to a child is a very important role but it is wrong for a doctor to value one life more than another and positive discrimination may lead to a slippery slope where people in certain important roles, e.g. national leaders, have priority in transplant waiting lists.
The case for the seven year old girl and the war hero.
Some people would say that the war hero has served his country, paid his National Insurance tax and deserves to receive his liver transplant on the NHS. Others would say that he has lived a reasonably long life while the young girl who probably has most of her life ahead of her is more deserving. The NHS and NICE does sometimes look at QALYs [quality added life years] when deciding to fund certain expensive treatment. If a treatment costs less than £20,000 for each extra year of good health it extends life by, it will be funded. In this scenario the girl would probably benefit by gaining more QALYs than the war hero. However the use of QALYs has been denounced as ageist and it is considered wrong to discriminate because of age.
The case for the homosexual man
His entitlement is as valid as anyone else – it would be discriminatory and completely unacceptable to think otherwise.
A doctor should never be judgemental and never value any one life above that of another. For this reason transplants and ‘who gets the organ’ problems are decided in this country solely on:
1. clinical urgency [who needs it most],
2. The best match [whose tissue type is most similar and least likely to reject the organ]
3. the length of time they have been on the waiting list.
There is a massive under supply of organs for organ transplant and each year many patients die while waiting for a suitable organ that may have saved their life.
At present there is an ‘opt in’ system in the UK which means that it is important for people to carry donor cards, sign the organ donor register and make their wishes clear to relatives if they wish their organs to be used to help someone if they die.
A few months ago, because of the shortages of organs NHS Blood and Transplant suggested that people who agree to donate their organs when they die could be given priority if they themselves need a transplant. This, however met with a backlash from the Church of England and patients’ groups, who say ‘such a change would mean doctors treating two patients differently – something which would undermine medical ethics.’
Just year the Welsh Government agreed to change the laws regarding organ donation in Wales to presumed consent. This means that it is presumed individuals are happy to become donors in death, unless they opt out or family members strenuously object. Countries, such as Spain, that have a system of presumed consent have less of an organ shortage.
Which do you think is the fairest system?