This 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)
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.
Q13 Fox News. 9/3/2014. “Fight brewing over liver donation.” Last accessed at http://q13fox.com/2014/09/03/fight-brewing-over-liver-donation/.
Bruce, Giles. 9/1/2014. “KU Hospital opposes changes to the way transplant livers are distributed.” Lawrence Journal-World. Last accessed at http://www2.ljworld.com/news/2014/sep/01/ku-hospital-opposes-changes-way-transplant-livers-/ on 9/23/2014.
Donohoe, MD Martin and Schiff, MD Gordon. (2014) A Call to Service: Social Justice Is a Public Health Issue. Virtual Mentor 16(9): 699-707.
Smydo, Joe. 9/14/2014. “National changes in liver transplant protocols favored by Pittsburgh doctors.” Pittsburgh Post-Gazette. Last accessed at http://www.post-gazette.com/local/region/2014/09/14/Proposed-changes-to-liver-transplant-protocols/stories/201409140027 on 9/23/2014.
WBIW News. 9/12/2014. “Yoder Joins House Members Opposing Liver Transplant Changes.” Last accessed at http://www.wibw.com/home/headlines/Yoder-Joins-House-Members-Opposing-Liver-Transplant-Changes-274985131.html on 9/23/2014.
Wilkinson, Richard. 11/6/2011. “Why inequality is bad for you- and everyone else.” CNN. Last accessed at http://www.cnn.com/2011/11/06/opinion/wilkinson-inequality-harm/ on 9/23/2014.
Hannah Giunta is a sixth year DO-PhD student pursuing a PhD in Philosophy and Bioethics.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 9, 2014. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.