A close friend of mine recently took a new job
as a heart transplant coordinator. One of her patients was on the
transplant list due to ischemic cardiomyopathy. A previous acute myocardial
infarction (heart attack) that the patient experienced caused oxygen loss to
vital heart tissue. Normally elastic, muscular, and contractile, the heart was
rendered weak, stretched out, and floppy. Put simply, this man’s heart could no
longer effectively pump his blood to his tissues, and he would die without a
new heart. One night, my friend received a call that this patient had presented
to the emergency room severely intoxicated—so severely that he needed to be
intubated. When he awoke, startled, my friend had to visit him and explain the
unfortunate policy that would require him to prove sobriety for six months
before qualifying for a heart. This meant that his status on the transplant
wait list would be on hold. Both my friend and the patient knew, however, that
he may not have six months to spare.
Accustomed to a system where ethics require that
patients’ potentially poor decisions be left out of treatment plans, I was
shocked to hear that this patient’s choices were the sole basis for a decision
of such weighty consequence. Should he really die for having too many drinks?
After further discussion and researching
the reigning ethical principals in regards to transplants, it is evident that
the scarcity of organs for transplant transforms transplantation from any other
treatment to a sought-after privilege. The U.S. Department of Health and Human
Services cites utility, a sort-of hybrid between beneficence and justice, as
the reigning ethical principal in allocating organs. This idea of utility means
an organ is not allocated based solely on medical need, but on the absence any
evident habits, such as smoking or substance abuse, that would hinder the
patient’s chances of surviving after the transplant. However, such policies
call into counter ethical concerns such as patient autonomy and justice in
regards to ability to comply with all regulations. For example, a patient can
be put on hold for failure to attend appointments. Physicians and medical
personnel argue that if the patient is unable to quit smoking or consistently
attend appointments before transplant, he or she is less likely to do so afterwards,
increasing the risk of failure and potentially “wasting” a scarce resource.
However, we know that it is more difficult for patients of a lower SES to
attend appointments and comply with health regulations. Is it just to take
lifestyle into account when deciding whether a patient gets a second chance at
life?
We are fortunate to live in a society where true
scarcity is minimized. However, more attention ought to be paid to how we
handle difficult moral and ethical decisions that are made in allocating scarce
resources.
Caplan, Arthur. “Bioethics of Organ
Transplantation.” Cold Spring Harbor Perspectives in Medicine 4, no. 3
(March 2014). https://doi.org/10.1101/cshperspect.a015685.
“Ethics - Ethical Principles in the Allocation
of Human Organs - OPTN.” Accessed October 15, 2018. https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/.
Wow, I had no idea that these policies existed. So, what does this mean for patients who have a clinically diagnosed substance abuse disorder? Or for patients with schizophrenia, whose illness often affects their self care (with smoking, alcohol abuse, and illicit drug abuse all falling under the umbrella of self care)? How can these patients be denied a transplant because of other medical conditions that may be associated with their smoking or drinking habits? I wonder if there are protocols set in place for these types of populations.
ReplyDeleteThe ethics of organ transplant can be an interesting but tricky topic, especially because so many factors come into play. It can be hard to agree with policies that were created for a black and white world, when we know that life often operates in the gray. Unfortunately, I think that an individuals SES plays a larger role than it should in having accessibility to organ transplants, at times even excluding their age or illness, all because they have necessary money. I read an interesting article a year or so ago researching the relationship between donors and recipients of differing SES. They were looking to see if there was a difference in an individuals willingness to donate based on their SES and found that donors and recipients for kidney transplants fell within the same SES.
ReplyDeleteI personally can understand why these policies are in place. To put it simply, we do not want healthy organs to go to unhealthy people. From what I understand, the patient knew that they needed a heart transplant and still they decided to put their life at risk even though they knew that their body was in such a fragile state, because hearts are not something to mess around with. Any organ takes time to grow and they are not for free, each organ that we use had to have come from someONE. Most organ donors are people who are dying but still have functional parts to them that others can use. How would you feel if you knew that your liver when to an alcoholic or that your lungs went to a chronic smoker? These policies are in place to ensure that the person who gave you a literal piece of them did not do so in vain. They signed up to be organ donors because they wanted to help other people even after they are gone. On paper, you might seem like a model citizen, but in actuality you could be an addict which is why they have to assume that an intoxication visit to the hospital is not a one-time event. And plus, in addition to receiving new organs, most patients have to take organ rejection drugs which if combined with alcohol or smoking could have detrimental side effects and add to overall strain on the body. On regards to the appointments, they want to see dedication; if you can’t make the appointments, you do not want the organ. I for one would walk to the appointment if I had no other means of transportation because getting a new heart and continuing my life is far more important than a house or any other material possessions. If you are to continue living, you have to prove it that you have the fight in you to not throw away that chance that someone else died for.
ReplyDeleteFor a personal perspective on this ethical question, I recommend you read Siddhartha Mukherjee's (he's the author of The Emperor of All Maladies, which you've probably read) op-ed on the difficult decisions doctors have to make when it comes to transplants and the scarcity of organs: https://www.nytimes.com/2017/10/24/magazine/the-rules-of-the-doctors-heart.html.
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