There are many complex, ethical issues related to the allocation of human organs. This is one of the scarcest of medical resources. How can organs be fairly and equitably allocated? Who keeps the list, and what are the criteria? Are there non-medical criteria? Should there be?
There is not one waitlist, but many. The United Network for Organ Sharing now unifies the lists and suggests allocation criteria, but each transplantation center keeps its own list and makes its own criteria, generally based on the UNOS criteria. There is some justification for each transplantation center keeping its own list, as people who live closest to the transplantation center have the best chance of putting a useable organ to use. Cold ischemia time, the time from the start of perfusion to the reconnection in a new person, varies depending on the organ, but is generally quite short. Organs also tend to deteriorate within the body the longer someone is braindead. So, when an organ donor is identified as brain dead, it is important that the appropriate recipient also be identified quickly.
Organ transplantation centers try to have criteria that are solely medical, but this is very difficult in practice. If someone is indigent or homeless, the chances that she or he will be able to survive after a transplant are very low. Transplants require long recovery periods, and once recovered a transplant patient must continue to take large dosages of powerful immunosuppressants for the rest of their lives. In addition, most suffer repeated bouts with organ rejection and must be hospitalized and treated each time. Proper nutrition and a daily schedule that allows for rest, shelter, and regular medical care is needed for an individual to be a good candidate for transplant surgery. Thus, the non-medical becomes medical all too easily.
Worries about allocation take two main forms. Some are worried that the criteria for allocation are unfair, because the rich and famous seem to "jump" the waitlist. Others worry that allocating organs to those who have destroyed their own organs through misuse (e.g. alcoholics who need liver transplants) and/or allowing prisoners to receive donated organs is both an injury to those who need organs but cannot receive them because their places on the waiting list are not high enough, and a disincentive to donate, knowing that your organs may go to someone who is somehow responsible for his/her own organ deterioration.
The 1995 case of Mickey Mantle's liver transplant was worrisome to many on both accounts. Mantle, a famous baseball player, was 63 years old, and had spent 43 years as an alcoholic. Although he had been recovering from his alcoholism for a year and a half, his liver was ruined due to both alcoholism and hepatitis C. The hepatitis C was believed to have been contracted from a blood transfusion he received during surgery for a sports-related injury, but may have been contracted during a life-time of drunken womanizing, as well. In addition, he had a tumor in his liver, called a hepatoma, which compressed his bile duct. Although the average wait time on the list to receive a liver in 1995 was three to four months, Mantle received his in a day. However, though the tumor in his liver had not been cancerous, the underside of his liver did have cancerous cells. The transplant went ahead as planned, but the cancer then spread to his lungs, and Mantle died 3 months after his transplant. Critics charged that Mantle was only given a liver so quickly due to his public prominence. Others charged that he should not have been given a liver because of either his alcoholism or his cancer, both of which are reasons not to place someone on the list at some transplant centers.
First, let us address the issue of whether Mantle did, in fact, receive favortism. He did not. His case was treated the same as anyone in the same condition at the same transplant center would have been treated. In fact, the day after his surgery, another liver donor who would have matched Mantle was identified, but there was no one on the center's waitlist to receive the liver, so it was transferred to another center. This center also took patients who were recovering from alcoholism. They did not routinely take patients who had cancer, but no test had shown that Mantle's liver was cancerous prior to its removal, nor could they have shown this, because the cancerous cells were behind the liver, where the testing instruments do not reach.
There is a further question whether someone like Mantle should receive a special place on the waitlist. In fact, since patients can get themselves on more than one waitlist, rich people who can afford to apply in more than one place do have some advantages. They can get their names placed on more than one waitlist, or they can move to the area where people with the conditions they evince are accepted on the waitlist. One might argue that giving a transplant to a famous person would encourage others to donate. Mantle did television commercials encouraging donation. There is also a Mickey Mantle Foundation set up to encourage organ donation. Just as species preservation organizations, like the San Diego Zoological Society argue that they should preserve attractive and interesting species, even when there is not sufficient diversity among the species members or habitat left into which the species could be reintegrated, because that attractive species brings in donations that can further more useful work, Mantle's doctors could argue that giving an organ to a very famous man who had little chance of making years of use of the organ could still be beneficial in raising awareness of organ donation and encouraging people to donate their organs so that others may be saved.
In Mantle's case it is most likely that his liver was deteriorated mostly by Hepatitis C which he most likely contracted through a blood transfusion during knee surgery. However, should people who are alcoholics receive transplants, even when they are in recovery? Many transplant centers take former alcoholics as patients. In the 1970s and 80s they were less likely to do so, because it was believed that alcoholics would have worse survival rates. Since then, in study after study alcoholics have fared as well as or better than those whose livers had been ruined by other means. Since they do not fare any worse than non-alcoholics, the decision not to give a liver transplant to a recovering alcoholic must be a non-medical decision. However, if we are going to give transplants only to those who had no hand in their problems, then we would have to say that people who need heart transplants must not have been work-a-holics, cigarette smokers, or have had poor dietary habits. When someone needed a liver transplant due to hepatitis C, we would have to explore the way in which the hepatitis C was contracted to see whether any choice was involved.
The first principle of allocation is always making the best use of the organ, saving a life that is in immediate danger, yet has a great deal of possibility for long-term survival. More recently, two cases in which organs were accidentally allocated to people who were not the right blood type for the organ have come to light. As there are no statistics kept on this, no one knows how often this has occured. A single waitlist with a single set of criteria might help in insuring that organs are most efficiently allocated.
To read more about Mickey Mantle's Transplant see Ronald Munson's Raising the Dead, published in 2002 by Oxford University Press.
Copyright © 2002 by Louisa Moon
Copyright © 2002 by Louisa Moon