Problem Statement
Organs are rare and expensive resources. Distributing these resources equitably remains one of the most pressing dilemmas in bioethics. Given that the dying patient did consent to organ donation, the primary ethical dilemmas in this case arise when determining the recipient. The case presents four different options, two of which (Michael and Mario) seem relatively easy to rule out. Mario is an infant who may not be a suitable candidate, and Michael has a history of liver disease due to alcoholism. Emily and Anita, however, both seem equally suitable candidates for the liver.
This case raises several moral questions. If every patient is deemed equally as worthy and valuable, according to ethical principles like equity and justice, then how is it possible to favor one person over the other? The answer to that question would be first to rule out any potential recipient who might reject the organ due to underlying medical conditions or to general incompatibility. In this case, ruling out Michael and Mario is due to their being less likely to successfully adapt to the new organ. It would be tempting to choose an infant based on a raw emotional response, but Mario’s condition might not be resolved with the liver transplant. More research would be needed into the implications of having biliary atresia, to determine whether the infant would have trouble with bile production even with a new liver.
In fact, the only way to really make an informed decision in this case is to eschew any immediate emotional response to the four candidates and consider only the issue of which candidate will maximize the value of the liver. Value in this case is not a financial metric, but is instead related to medical compatibility and the least likely person to develop further complications after the transplant. Above all, this case illustrates the central importance of the ethical principle of justice in medicine. This case also seriously challenges the healthcare team to apply the principle of beneficence equitably. Essentially, the case pits the principle of beneficence against the principle of justice.
Resolution
Technological innovations—including those that have made organ transplants more common and safer–frequently give rise to new ethical dilemmas in medicine (Steinbock, London & Arras, n.d.). This case shows how organ transplants, as beneficial and miraculous as they are, can also become a source of struggle for bioethicists and healthcare workers who contend with difficult choices—many of which are essentially life-and-death matters. The principalist method avoids some of the pitfalls associated with adherence to only one ethical theory like utilitarianism or deontology.
Ethical principles become guiding forces to help people make ethical decisions in cases as troubling as this one, involving who would be the ideal recipient for a precious organ. The primary ethical principles in medicine and healthcare include respect for autonomy, beneficence, and justice. However, confidentiality or nonmaleficence re often included to make four guiding principles that can be applied to difficult situations (“Principlesd of Ethics,†n.d.). These ethical principles are based on values like equity, respect for the individual, and altruism. A principle is “a fundamental standard of conduct from which many other moral standards and judgments draw support,†(“Ethical Theory and Bioethics,†n.d. p. 22). Resolving the organ donor dilemma becomes easier when the foremost ethical principles are applied to the case.
The principle of autonomy is not a central one in this case, except for Mario—an infant who is incapable of making the choice for himself. Mario’s parents are legally and morally responsible for making decisions on Mario’s behalf. If the dying donor were suddenly to withdraw the consent to harvest the organ, then the principle of autonomy would come to the fore. Otherwise, it can be assumed that all four candidates are fully cognizant of the ramifications of the organ transplant. Confidentiality is likewise not the most important factor in this case, and only would be if a member of the medical team had access to personal information about one of the patients and could not disclose that information in order to protect that patient’s privacy.
The two main bioethical principles at stake in this case are justice and beneficence. Resolving the conflict requires a cogent analysis of how to align the principle of beneficence with that of justice. Unless three more livers become available, three of the patients will be denied an opportunity that could result in their premature death. The healthcare team cannot act in an equally beneficent way to all four of the patients waiting for a liver transplant at this time. Doing no harm, the most important feature of the principle of beneficence, means carefully assessing the medical history of all four patients to determine which has the most acute need for the liver. It would not be beneficent to deny the liver to a patient who is at immanent risk of dying. The issue can be resolved first by recognizing that some of the patients may be able to extend their lives and enjoy good health by other means, and can afford to wait for a new liver. Similarly, the principle of beneficence obliges the healthcare team to examine each patient individually and determine which would suffer fewest complications from the transplant. The patient least likely to suffer consequences, and who also needs the liver the most, would be the most suitable candidate and that information cannot be gleaned from the paucity of medical data given in the brief case studies.
Ultimately, the principle of justice becomes the central issue in the case. Distributive justice refers to the “fair, equitable, and appropriate distribution†of resources in a society,†(“Ethical Theory and Bioethics,†n.d., p. 25). Unfortunately, genuine distributive justice is impossible in this case. There is only one liver, and four candidates. To ascribe to the principle of justice, factors such as socioeconomic class status, ethnicity, age, or ability to pay (as in Emily, for example) cannot be taken into consideration when making the choice of recipient. Social justice means each person is equally as valuable.
The decision must be made purely on medical grounds, and if all of the medical grounds are equal, then the only way to make a decision that is aligned with the principle of justice would be to resort to a “first come, first serve†policy. Michael has been on the list the longest—at one year. Whoever was placed on the donor list first may have a legal right to the liver—something that the healthcare team also needs to consider.
Prejudice against older patients has become a real concern in situations like these, in which the team might be biased towards younger recipients (“Principles of Ethics,†n.d.). To resolve the dilemma, it would be critical to make a choice in a way that did not unfairly prejudice any one of the candidates because of age, ability to pay, or even lifestyle. The healthcare team might be tempted to disqualify Michael on the grounds that he has been an alcoholic, and therefore caused his own liver damage. Yet alcoholism has been classified as a disease, like any other, rendering Michael far less responsible for his cirrhosis than his critics might claim. Anita has also recently started drinking and smoking on her own volition, in spite of her medical condition. Her behavior could be construed as being grounds for disqualification. Before the issue is resolved, she would need to commit to lifestyle changes. Emily has no history of self-destructive behavior, and although she has only been on the donor list for a few months, may be a better candidate than Michael.
Recommendations
Before making any decision, the healthcare team needs to conduct a more thorough examination of the biomarkers that affect the recipient’s ability to tolerate the liver, such as immune health or blood type. The healthcare team also needs to consider the legal parameters, such as whether the recipient list must be followed in a particular order or if recipients are randomly chosen. Likewise, the team needs to assess whether one of the patients needs the transplant sooner than the others, under the principle of beneficence.
If all medical parameters prove equal, the team would subsequently be advised to offer the liver first to Michael only because he has been on the list the longest. To deny Michael the liver would be incompatible with the principles of justice and beneficence. As irksome as it might seem to many members of the team, choosing Michael would allow the institution to better align with its most important values. Recommended course of action is as follows:
· Thoroughly assess all patients to determine whether one is in dire, immediate need of the organ transplant
· Thoroughly assess all patients to determine medical suitability and compatibility with the donor organ
· Offer the donor, if he is cognizant and capable, the option for input into the decision. Confidentiality can be preserved if the donor is given only the basic information and is allowed to consult with the medical team about the ethical issues at stake.
· Consult with Michael, and make sure that he understands that in taking the liver he is denying other candidates the opportunity
References
“Ethical Theory and Bioethics,†(n.d.).
“Principles of Ethics,†(n.d.).
Steinbock, B., London, A.J. & Arras, J.D. (n.d.). Ethical issues in modern medicine. 8th edition. McGraw Hill.
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