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Organ allocation should be an equal-opportunity procedure.

WHEN MICKEY MANTLE RECEIVED a liver transplant in June of 1995, there were thousands of people across the country who were also waiting for a lifesaving liver. Most of them had been waiting far longer than Mantle and probably had not directly contributed to their diseased liver through a lifetime of alcohol abuse. How did Mantle get such a scarce resource and get it so quickly? Was it because of his celebrity status, his influence, his ability to pay? Did he really deserve to go to the head of the line? Did he deserve a new liver?

Perhaps even more troubling was the report that a death row inmate in Washington state was on a waiting list for a liver transplant. The inmate was convicted in 1982 of murdering two bank tellers in an armed robbery. There was such a reaction to this report that a bill was introduced in the Washington legislature that would bar state funding of transplants for inmates sentenced to death. Are people who have committed crimes, particularly serious crimes, less worthy of receiving organ transplants? Should criminal status be a criterion for determining who is eligible for transplantation? Is allowing a death row inmate to receive an organ transplant a good use of a limited resource?

Human organs available for transplant are an extremely scarce resource. The supply comes nowhere near the number needed to help the tens of thousands who would benefit from a transplant and the thousands who die every year waiting for one. (As of November 1996, there were 49,000 patients registered on the United Network for Organ Sharing waiting list. This does not take into account the thousands who didn't make the list but who are in need of a transplant.) Depending on the type of transplant, anywhere from 1 in 10 to 1 in 3 potential recipients will die before a liver, a kidney, a lung, or a heart becomes available. Saving one person's life with a transplant means that someone else will likely die. On what basis should one person's life be saved over another's? This is one of the most perplexing justice issues in health care today. How do we choose fairly while exercising responsible stewardship, over a very limited resource?

Some people would begin answering this question by eliminating from the waiting list individuals who do not "deserve" a transplant. They might consider some individuals to be unworthy because their behavior, such as alcohol abuse, has contributed to their diseased organ. Others they might view as not being contributing members of society-the chronically unemployed, the homeless, and those with physical and mental disabilities. Still others they might judge as not being upstanding citizens or good people - the drug abusers, criminals, child molesters, rapists, prostitutes, homosexuals. If we're going to put a scarce resource to the best possible use, doesn't it make sense to offer it to those who in various ways contribute the most or at least don't burden or harm society?

AT FIRST GLANCE, THIS APPROACH DOES SEEM to make sense. But ultimately a social-worth criterion for deciding who gets on the waiting list for a transplant and who among these actually receives an available organ is fundamentally flawed and unethical. Making allocation decisions on the basis of a person's character, value to society, or degree of excellence contradicts our belief in the basic equality of all people. It violates human dignity and robs people of their unconditional worth by reducing them to their usefulness or characteristics, or to negative behavior or their selves. If as Christians we truly believe that all human beings are made in the image and likeness of God and, therefore, have a transcendent and inalienable dignity, we cannot deny someone an equal opportunity for an organ transplant on the basis of merit or social-worth considerations.

The attempt to establish objective and uniform criteria for determining social worth is a hopeless endeavor. How would we even begin to assess someone's value to society or compare the significance of several people's contributions to society? The development of such criteria would require that we clearly identify and agree upon social needs and then be able to rank order to these needs. It is highly doubtful whether we would be able to achieve any degree of social consensus about this. It seems near to impossible to quantify Michael Jordan's contributions to society, for example, and even more impossible to compare these contributions to one of Mother Teresa's sisters working in an urban ghetto. Or how would we compare a neurosurgeon's social worth to a poet's, or a trash collector's, or an automaker's?

In the absence of objectively grounded criteria, the tendency is to employ ad hoc criteria, which often reflects the biases of those creating and employing them. This constitutes another weakness of a social-worth approach to allocation of organs. Recent studies have shown that there is great variability across transplant centers in the criteria they employ to select patients on the waiting list (criteria for deciding who among those on the waiting list receives an available organ are more objective and standardized). Some of these are social-worth criteria and include such considerations as intelligence, productivity, and social involvement. But because there are no criteria for measuring any of these and no standardization across transplant centers, potential organ recipients are left to the judgments, whims, and biases of those making the decisions about who to list. This opens the door to discrimination and injustice. Individuals lacking certain characteristics or belonging to certain groups may have much less of a chance, or no chance at all, to be included on the list because of the preferences of a few individuals.

THESE SITUATIONS ARE DIFFICULT ENOUGH They quickly bring to the fore our own biases and prejudices. Even more difficult, however, is the inclusion of social deviants. It is very difficult to think about giving a rapist, a murderer, or a child molester the same chance at a lifesaving transplant as an upstanding citizen. These cases radically challenge social values and beliefs regarding the fundamental dignity and equality of all. As difficult as it is to believe and admit, even these individuals have been made in the image and likeness of God and have a transcendent worth. Denying them the possibility of an organ transplant not only attacks the core of their humanity but, in most cases, punishes them twice for the crime they have committed or the harm they have done.

When all is said and done, social-worth criteria, although intuitively appealing, are fundamentally unjust. They fly in the face of our belief in human dignity, promote discrimination, and are capricious and arbitrary. The alternative is to try to provide each patient who meets the more objective criteria of medical need, medical feasibility, and ability to pay with an equal opportunity for a lifesaving transplant. The fairest way to do this is through an impartial process that selects patients randomly, thereby avoiding any comparative evaluations of their value or worth. There are two types of impartial selection. lottery and first come, first served. Only the first is truly impartial. The latter favors those who have better access to health care, but it is still more just than social-worth criteria. A lottery is rarely, if ever, employed by transplant centers. First come first served is the usual approach with some attention to psychological and social factors. The former focuses on the potential recipient's attitude toward transplantation and its aftermath and the probability of compliance with the stringent post-trans-plantation regime. The latter focuses on the presence of family stability and support necessary for follow-up to transplant. While both of these criteria are potentially discriminatory by tending to favor certain individuals over others, they at least have some medical justification-maximizing the possibility of a successful outcome and, hence, ensuring the prudent use of a scarce resource.

Who is worthy of an organ transplant? How society answers this question will determine not only who lives and who dies - a matter of profound importance - but also our moral character as a society. Developing criteria for allocating human organs for transplant radically challenges our most basic beliefs about human dignity and justice. So who is more deserving of life than another? The most ethical answer is no one. Allocation decisions will have to be made on grounds other than social worth.

The death row inmate should not have been eligible for a liver transplant, but not because he was worth less than other potential candidates. Like anyone else who was expected to die in a short term, offering him a transplant would seem to be a wasteful and unjust use of a scarce social resource.
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Title Annotation:includes feedback from a reader survey and facts about organ donation; allocation of organs for transplant
Author:Hamel, Ron
Publication:U.S. Catholic
Date:Jan 1, 1997
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