Bioethics principles and applications

Bioethics: Transplant Case Study thorough examination of any "real life" ethical question involves the examination of all of the issues at hand. It is no different for issues of problematic bioethics. Thus, in consideration of the famous "botched heart transplant story," one must ask the salient questions, "what went wrong," "what should have been done," and "what can one do to insure that this issue will be less likely to occur in the future."

In the unfortunate case of the deceased 16-year-old female, the operating physicians failed to ensure that the patient's blood type matched that of the organ donor. Although it is possible for some organ transplants to utilize non-matching organs as a time-buying device until a match becomes available, this event was neither intentional, nor viable in the case of heart/lung transplant requirements. Although there was clearly an error, as well as a lapse in communication between the state donor services and the operating physicians, it cannot be denied that the physician and physician's team are the ultimate "final authority" and responsible party for ensuring that the organ is appropriate for the patient. However, placing fault is not the main ethical issue under consideration before the ethics committee. Instead, the two main issues that present significant ethical dilemmas are:

Should a significantly health compromised patient be granted a second set of organs if there is a significant (and statistically abnormal) chance of death during or following surgery?

Should the fact that a gross medical error during transplantation is responsible for the patient's compromised condition be an influencing factor in regard to the aggressiveness with which an assignment of future organs is pursued?

Analysis

The first issue at hand, namely if a health compromised patients, at significantly greater risk for an unsuccessful outcome be granted transplant organs is an old one. Of course, it is based on the fact that there are simply not enough organs to go around. In fact, according to current estimates, it is estimated that among the 80,000 patients awaiting transplants, an average of seventeen die every day in the United States alone simply because an organ never becomes available (IHI). Given this reality, many have proposed that the method by which transplant candidates are ranked on the national transplant lists depends not only on the severity of the need, but also on other factors relating to overall health, lifestyle, as well as age.

Although there are several factors which determine ones placement on any transplant list, one of the most important criteria is that a patient have an extremely limited time before the current organ/s are expected to fail. In some cases (the liver), this translates into seven days (Keen). Further, according to the United Network for Organ Sharing (UNOS), the agency responsible for producing and maintaining the transplant lists, "when an organ donor becomes available, all patients waiting...are compared to the donor to determine which potential recipient is best suited for the donor (Keen, 2001)." Just what constitutes "best suited" has been open for debate over the years, however.

Again, according to the UNOS, "Factors such as medical urgency, time spent on the waiting list, organ size, blood type and genetic makeup are considered...the organ is offered to the candidate that is the best match.(Keen). Further, UNOS asserts that "all patients have a fair chance at receiving the organ they need -- regardless of age, sex, race, lifestyle, religion, financial, or social status (Keen). Yet, despite UNOS's assertion that "medical urgency" is one of the top factors that determine list placement, there exists a line between medical urgency indicating transplant readiness, and medical urgency indicating the window of opportunity has closed.

It is true that "when an organ becomes available for transplant, patients who are sicker are given top priority (UMHS)." However, just what "sicker" means is often up for debate. Indeed, the collective ethical imagination of the world has focused on this issue quite extensively. For many, "sicker" means sick as a result of the failing organ, not due to other factors that may affect the health of the donor organ once implanted. This means, for instance, should a patient be infected with life (and organ threatening) diseases such as AIDS, certain cancers, Hepatitis B and C, alcohol related cirrhosis, or even some forms of mental illness that would prevent or interfere with the successful complex aftercare regimen he or she may be considered out of the running for a transplant. Further, even if the patient is, in theory allowed to rank on the list regardless of factors like the above, he or she may still fail to find a hospital willing to take on the procedure. For example, the nation's VA hospitals refuse to even consider AIDS patients for organ transplants (Lambda). Still others refuse to even consider adult patients for transplant "until he passes "the green screen" by demonstrating his ability to pay for the operation, which in practice means that he must have first-class health insurance coverage (DeLong, 1998)."

Regardless of any individual hospital policy, however, the United States Government, under the authority of the Department of Health and Human Services, has leaned toward a universal criterion for transplant elegibility -- one in which hospitals receiving medicare eligibility are required to accept. Specifically, this entails allocating organs on the basis of "neediness" based on the "most danger of imminant death (DeLong). In short, "the department argues that patients everywhere should have an equal chance at an organ under uniform medical criteria. HHS draws not distinctions by age or cause of disease (DeLong)."

It is worth noting, however, that regardless of government oponion under HHS, there are some who raise significant ethical issues regarding transplant allocation based on this rule. They argue that it is simply unfair to decide that "a small chance of a couple extra years for a cirrhotic senator is more important than a good shot at 40 years for a young person who contracted liver disease while in the Peace Corps (DeLong)."

Regardless of the opinion of HHS opponents, there remains the philosophical enviornment in which "sickest first" of course, tempered by ability to pay (in adult patients), seems to hold promenance. Further, since the hospital in question in this case does receive Medicare, one should assume that this cases of transplantation decisions should be based on the HHS criteria.

Be that as it may, however, the second ethical question still remains after considering whether "needyist first" should apply with regard to the second transplant after medical (type matching) error in which the patient's health is compromised. This is because it is possible to draw the line between a failed transplant due to medical error (similar to a failed transplant due to medical complications, in that possible medical error may be a statistical complication similar to any other that might be found in the operating room). Consider, for example, the statement made by Barbara Russel in "Clinical Error, Scarce Ogans":

It will not be possible to prevent all harmful errors because illness and healthcare inescapably involve uncertainty, fallibility, and danger. With this said, however, facing and responding to practitioners' errors can be turned into ethical opportunities to demonstrate integrity, trustworthiness, and compassion. (Russel, 2004)

However, it is also possible to consider another angle on the problem.

If one were to consider the medical error in the present case to be similar in type to any of the myriad possibilities of complications that can occur in serious medical procedures, then it is possible to consider the remedy to be similar in kind -- that is, a continuation of the procedure using all available supplies to its legal end (that is, the legal definition of death -- i.e. In this case, as demonstrated by hospital policy on life support termination, brain or physiological death).

In other words, the young patient in this case was still in dire need of an appropriately matched organ immediately following the first attempt. Further, because one would imagine that the patient is logically still classified as being in the same degree of need as before (specifically, the same level of need that moved her to the top of the list in the first place), she would still be considered to be first in line for another organ. Even more if it were possible to be higher on the list than the top, an even greater amount of immediate need would be present. Therefore, in this case the patient was need of, as well as entitled to, a speedy and exhaustive search for a matching set of organs, regardless of the present nature of her health. After all, if one were to operate on a patient in any other circumstances, and, upon encountering life threatening complications, discontinue treatment based on the patients likelihood of dying, such an action would be, under present norms of ethics, abhorrent. Given then, that the donated organ is for all intents and purposes, a supply of the transplant surgery that has been granted under the qualification criteria as defined by the HHS laws on transplantation, it only makes sense that the operation would continue immediately to its conclusion, with the urgent and immediate search for an appropriate organ paramount in that endeavor.

Again, as quoted in the article "Clinical Error, Scarce Organs," In conclusion, clinical error is an extremely complex subject which, in turn, necessitates avoidance of a "rush to judgment" as well as avoidance of "knee-jerk reactions." Not only did the hospital staff and administration jump to judgment based on a knee-jerk reaction, but it used criteria to make decisions on which the HHS disapproves.

What, then, after one realizes what should have been done, can be implemented in order for similar tragedies to be avoided? Of course, before the ethical question is raised, the actual physical prompt of the error must be remedied. In this case, this means implementing a strict policy of redundancy in type-matching, so that one failure in the process (as was the case here) does not spell catastrophe (Duke). However, given that there was a significant breakdown in matters of ethical understanding, it is important for the ethics committee to recommend a protocol of action to be used in similar circumstances.

While it is undoubtedly true that the numbers of transplant organs are currently insufficient to meet demand worldwide, there are ethical concerns that must be decided within each medical institution. Further, although, in some respects each medical center is independent, there remain standards for ethical policy that are determined based on a mutual consensus with governmental and legal authority. Moreover, the hospital enters into an implied agreement with said authority by virtue of its acceptance of other symbols of that authority -- namely, in this case, participation in the donor program, under the governing body, HHS, as well as its demonstrated acceptance of other ethical standards (including the working definition of death).

Further, because the current criterion for transplants does not limit based on future health of the patient, as demonstrated by increasing acceptance and performance of transplants on patients with adverse health and behavior indicators, alcoholism paramount among them. Take for example, the following statement, found in BMJ Journal, Even in an era of donor shortage, the question should therefore not be whether patients with alcoholic liver disease should receive transplants but whether enough is being done to support such patients through a successful operation." Given, then, that transplants are performed on confirmed alcoholics, and that alcoholics are estimated to have a 60-80% relapse rate at two years (Webb, Newberger, 2004), it seems to be given that need is the standard above all else, including possible outcome.

The best way to describe this concept ethically (especially to the hospital board), is to demonstrate the problem with associating "fitness" for transplantation based on perceived or probable outcomes. That is, if a person is denied transplantation based solely on the likelihood of death following, then, how long until one gives preference to a 40-year-old over a 60-year-old based on the greater years of life expectancy? Further, what of the woman who has been treated for breast cancer in her past, yet now requires a kidney transplant. Should she be passed over due to her higher chance of someday dying of cancer?

The only simple fact about the ethics of transplantation is that it is not simple. After all, it is easy to see the perceived injustice in allowing a Hepatitis or Aids patient receive a healthy organ while a child with no other disease awaits his or hers. However, given the "real world" milieu in which the hospital is forced to operate, one in which governmental determination regarding Medicare funding and procedural guidelines are the base on which the hospital runs (thereby avoiding chaos), it is important to accept the legal and ethical majority -- especially when the alternatives are no less troubling.

Given this conclusion, it is therefore the recommendation of the committee is the following:

First, it is imperative, given the identification of a known flaw in the organ type confirmation process, that the hospital introduces redundant and independently confirmed tests regarding the compatibility of the organ to be transplanted into the patient. As stated before, although medical error is a natural (albeit, tragic and unfortunate) occurrence, protocols should be taken to avoid similar situations in the future.

Second, it must be communicated that the criteria for transplantation is not life expectancy post-transplantation, but patient placement on the transplant list based on current high need. Although it is tempting to place a value on the organ, given the extreme shortage under which transplant centers worldwide suffer, as well as the perceived value that organ might have on another patient, hospital physicians and staff must place the life of their patient as paramount over the organ, as well as over other patients, real or imagined, once the patient has qualified for immediate transplantation.