Allocation of scarce resources

Today in conference, a case was presented of a previously healthy young woman (26 years old) who presented to the hopsital with abdominal pain for two weeks. She was found to have Wilson’s disease, a genetic/hereditary condition, and died from fulminant liver failure in a very short time.

Prior to death, arrangements were attempted for a liver transplant; but these efforts, the presenter noted, were unfortunately unsuccessful as she was an illegal immigrant.

The subtle word choice, “unfortunately,” prompted a bit of informal discussion afterward. Of course anyone caring for a sick patient would want a potentially curative transplant. But when livers are few and the transplant list is long, how should “Who gets the liver?” be decided?

There’s the very personal, intuitive answer: This was a young patient. She had done nothing to cause or exacerbate her disease. She had a very steep downhill course and desperately needed a liver. Who wouldn’t want to give this girl a transplant?

On the other hand, there’s a political perspective. The patient was an illegal immigrant. Some people might balk that this even be considered. “We’re in the here and now! Where is your compassion?!?” I can hear them saying. But should a foreigner (and one here against the law, at that) receive a liver courtesy of Uncle Sam before an American who needs the same liver? Remember, these resources are scarce.

And then, there’s the socio-medical perspective. This patient was young and had an inherited disease. There was nothing she could have done to prevent this. Perhaps the American mentioned in the previous paragraph is a 55 year old alcoholic who has destroyed his liver with his frequent bouts of intoxication. Are age or lifestyle or preventability reasonable factors to consider?

In this post, I have only asked questions and provided no answers. Situations like this, which have obvious emotional overtones, spark me to re-think this classic quandary. And add a few questions of my own: Who should be in charge of allocating scarce resources–in this case, a liver? What criteria should be used? What can I learn from extraordinary circumstances like this to apply to my day-to-day practice?


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11 responses to “Allocation of scarce resources

  1. Anonymous

    That’s a very penetrating analysis, Jonathon. Sure, it mainly focuses on a specific area of medical ethics, but hey, keep this up and you may get a Supreme Court nomination!

  2. Phil

    Officially, each transplant center has its own list of unpublished criteria, and it’s not required to make those criteria known to anyone. That means whether or not you get on the list, and how high often depends on the where you’re being put on the list. Different centers may rank you differently since their criteria may all be different (or all the same, for all we know).

    You mention all sorts of interesting factors. Those are all important things to keep in mind, although some are more important than others.

  3. Anonymous

    I had a patient last year who would have likely benefited from a liver transplant. However, she was poor and had very limited social support (she was a legal resident). Her disease was complex in that she likely inherited a particular susceptibility to liver damage associated with alcohol consumption – thus her pathology was partially due to her decisions and partly due to her genes. She was one of my favorite patients from last year. 🙂

  4. Doctor J

    I’ve had several liver transplant patients over the past few months, and regardless of their politico-geo-socio-economic background they have to jump some serious hoops to get a liver. Only highly motivated patients need apply.

    Generally, if you did naughty things and now you need a liver, then the hoops are tougher to jump through.

    I’m a bit more pragmatic about this subject. The list is long and there aren’t enough organs to go around. I think you should have to prove yourself if you behaved badly and now need a transplant. That being said, my absolute favorite patient during my internship has been a elderly Cuban man that got a transplant after extensive alcohol abuse. He got sober and stayed sober for a long time and waited. Every day when I would come see him he would yell out in his thick accent, “Hey, Papito, how you doing?” and when I left he would ask me to leave his door open so he could watch the pretty girls go by. I was happy to see him get his liver…

  5. Anonymous

    How about the Hepatitis C positive patient requiring a 2nd or even 3rd liver??

  6. Phil

    there’s always the classic from recent memory – Mickey Mantle. Enough said.

  7. Jonathan

    I heard very recently that Micky Mantle’s liver transplant was attempted even though it was clarly contraindicated medically. (Tumor invasion into the portal vein–>bad prognosis.) Did his celebrity status have anything to do with this?

    I’m also told Mantle played for the Yankees. Thanks, Clay.

  8. Anonymous

    Didn’t Mantle receive his transplant at B***** Hospital?

  9. Jonathan

    I don’t know about his transplant. Are you thinking Bellvue?

  10. Phil

    I think the thing is differing criteria at different centers. I personally am not sure that someone who is VERY ill, but due to (essentially) self-inflicted injuries, should be higher on the list than a similarly ill (or maybe even less ill) person who did NOT do it to themselves. I guess it’s sorta based on the idea that this is such a limited resource, we really have to pick people who can show/have shown that they’re not just going to squander what they’ve been given.

    But don’t hold me to that forever. I haven’t fully worked out what I think exactly. That’s just more of a gut reaction.

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