Individual vs. Public Benefit in Liver Donation

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Hannah Giunta

Earlier this month, the United Network for Organ Sharing (UNOS) announced it would hold a public hearing regarding concerns about disparities in donated liver access across U.S. geographic regions. (Q13 Fox News 2014) While donated livers are supposed to go to the sickest patients first, geography is still taken into consideration. So, the person closest to death is not always the first to get a donated liver. Rates of liver donation are highest in the Midwest and South where centers often serve predominantly rural areas and see less overall demand. Patients on the coasts commonly have to wait longer before qualifying for a transplant. This disparity has resulted in patients with means flying across the country to get an organ while lower income patients have to simply wait at home. UNOS considers the number of waiting list deaths resulting from this disparity serious and is entertaining various solutions. One proposal under consideration would involve redrawing regional boundaries to decrease the total number of regions. Those larger regions would then each serve a more equitable number of patients. To date, this proposal has drawn intense criticism, with lawmakers in the U.S. House of Representatives signing an opposition letter in an attempt to stop any map redrawing. (WIBW 2014)

UNOS Region Map
UNOS Region Map

Yet, both critics and proponents of the changes seem to be arguing from self-interest instead of from a well-grounded public health-focused perspective. On the one hand, critics worry that organ-rich areas will become organ “farms” for those areas of the country where grassroots efforts to increase donations have been less successful. Dr. Sean Kumer, a transplant surgeon at the University of Kansas, expressed this sentiment, noting, “What they are attempting to do is say, ‘Hey, those guys have all the organs. Let’s go over and poach those’ instead of having their own grass-roots campaign to identify new donors.” (Q13 Fox News 2014) The University of Kansas publicly announced its opposition to the proposed changes (Bruce 2014), and at first glance, it does seem intuitive that regions where more effort is expended for organ donor recruitment and procurement have a right to increased access. Yet, this view is actually problematic. First, this claim might stand up if transplant centers did not receive support and benefits from belonging to a national network, but I believe they likely benefit from information sharing, training, and system-wide resources. Secondly, it is difficult to tease out just what a needy individual’s responsibility is for circumstances in the larger population. If an individual lives on one of the coasts and personally advocates organ donation but others choose not to donate, then is that individual less deserving of an organ? What about areas where certain religious or cultural groups oppose organ donation? Should needy patients who might support donation themselves bear the burden of others’ different choices? Conversely, what if a patient lives in a region where organ donation is high but they personally are not donors? Should they enjoy the benefit of increased access?

Proponents of map changes also argue from a predominantly self-interested position. Surgeons at the University of Pittsburgh signed on in favor of the proposal—but not really because they see it as a more equitable way to allocate scarce medical resources. (Smydgo 2014) Rather, Pittsburgh surgeons work in an area that stands to gain the most from redrawing the map. It’s unclear whether they would support a proposal that might not be advantageous to their own region. Neither side seems concerned about the broader public implications of liver transplant inequities.

Obviously, any question about the allocation of scarce medical resources is certain to reignite age-old controversies pitting the welfare of individual patients against equitable access for all those in need. I believe this line of thought creates a false dichotomy—one where physicians operate independently of the larger health care system and patients are completely autonomous agents who are not impacted by complex social issues and practices. While seeing one’s duties as specific to an individual patient is helpful in the everyday practice of medicine, it is too narrow a conception when navigating one’s role in a complex public system. Indeed, I would argue that because pervasive inequality has been shown to negatively impact all involved, including one’s current and future patients, physicians have a duty to promote larger public health goals (see Wilkinson 2011 for more on how social inequality impacts us all). By taking a narrow stance on what constitutes one’s ethical obligations, physicians like Dr. Kumer assume their actions impact only their patients, and equally, they then assume they are selflessly fighting to insure access for the needy. However, transplanting an organ into one patient inevitably means it is not available for some other person. In a case where a less seriously ill patient receives an organ ahead of a more critical patient, the sicker individual could be left to die when both lives might have been saved if the healthier patient had waited a bit longer for a transplant. I am dubious that physicians are as willing to acknowledge their indirect role in a disadvantaged patient’s death as they are to take credit for a life saved.

In the narrowest sense, a physician has an obligation to an individual patient. Dr. Kumer articulates this sense of obligation. Especially when making time-sensitive medical decisions, physicians commonly do not have the luxury of considering broader social implications. But, when a physician is operating within the context of a specific allocation system and that entire system is under review, he can and ought to fairly analyze policy implications. Such analysis does not ethically conflict with his duties to individual patients. Yet, it would be unfair not to acknowledge that Dr. Kumer’s position is held by a large and increasing number of physicians. Despite the Institute of Medicine’s recommendation that more physicians earn public health degrees, the proportion of physicians in public health programs continues to decline (cited in Donohoe and Martin 2014). Biomedicine has become increasingly separated from the social and cultural dimensions of patients’ lives and from a broader ethical commitment to the public’s overall health. It therefore is understandable that individual physicians are reticent to engage in these types of discussions, but their complacency cannot be ethically justified. Part of a physician’s professional duties should involve taking an interest in system-wide inequalities, including those perpetuated by the medical system itself. In this case, neither the critics nor the proponents are discharging their ethical obligations.

Those who disagree with my position will undoubtedly contend that asking physicians to serve two masters is unfair; am I advocating that physicians should focus on their role as public health advocate instead of their daily responsibilities to patients? My answer is a resounding “No.” When a patient is on the operating table, the responsible surgeon is and should be focused solely on what actions can be taken to insure that individual’s survival. But, in broader discussions of public policy, there is no reason that carrying out one’s professional obligations as a physician obviates one from considering societal implications and the public’s health. It is just as much of an ethical lapse not to fulfill this obligation as it would be not to promote a patient’s interests in the operating room. Until we can conceive of a world where patients and physicians can operate without being impacted by broader social structures, individual patient welfare and system wide justice are not antithetical to one another. At the very least, individual welfare and social justice are not separate considerations. In my opinion, they are intimately intertwined.

References:

hannah-giunta-100Hannah Giunta is a sixth year DO-PhD student pursuing a PhD in Philosophy and Bioethics.

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2 thoughts on “Individual vs. Public Benefit in Liver Donation”

  1. Probably just my ignorance, but I wonder whether the variation in availability of organ transplantation is not just due to variability of organ donation, but regional variability in the number and size of transplant centers with the volume necessary for achieving excellent results. My guess is that there’s a disproportionate number of those centers on the coasts. Redrawing the UNOS map isn’t going to move those centers. What it might do is decrease the numbers of organs available for transplant at centers elsewhere in the country, which would have to share more with higher-volume centers that lie at some greater distance from the transplant candidate in the South or Midwest. Since getting on the list requires the cooperation of a transplant center that will accept the patient as a candidate, and that’s harder to do by email than in person, mightn’t this work to the disadvantage of these patients? Patient on the coast are doing better– great! Patient’s elsewhere are doing worse–not so great.

    Coming up with a new system that balances these forces will probably not be easy.

    Just one side-note. Time on the waiting list is a pretty poor measure if you want to quantify the harms that results from variation in the availability of organs. It is common practice to wait-list candidates who aren’t at imminent risk of death. Even using death on the waiting list as the measures proves to be much trickier than might be thought. See http://www.ncbi.nlm.nih.gov/pubmed/23279706

    1. Hi Tom!

      Thanks for your comment. Here’s a list I’ve found of transplant centers.You can view it at http://www.srtr.org/csr/current/Centers/TransplantCenters.aspx?organcode=LI. I was actually surprised by the geographic diversity represented. Although I would agree that there may be greater volume on the coasts, I think that could be easily remedied by providing subsidies to people to travel to these centers (think of the way pediatric oncology treatment takes a national perspective by having specialized centers for certain cancers to which kids around the country can travel). It seems that a national system should operate with a national perspective. This perspective could lead to a decrease in the number of patients in the heartland receiving transplants but would make the rates more proportional. First and foremost, we should always be increasing donation outreach efforts, but I think it is still most fair for every patient to have an equal chance at a transplant, no matter where he or she resides.

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