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?