Organ Transplantation pp. 385-388 Textbook Daily Dilemma • During a robbery, a 7-11 clerk is shot and wounded. She returns fire and wounds the suspect in the leg before they escape • Hours later, a man known to police to have a history of robbery arrives in an ER with a bullet in his leg. • Police want to compare the bullet to bullets fired from the shopkeeper’s gun since it is the only physical evidence from the robbery • The suspect then refuses treatment. This may lead to chronic pain and possibly infection, but he is unlikely to die from the wound. • Should doctors be required to remove the bullet safely under local anesthesia in order to use it as evidence? Reflection • The 4th Amendment deals with illegal search and seizure • Medical ethics prohibits involuntary infringements of bodily integrity on mentally competent patients • The Supreme Court has actually dealt with this issue, and they ruled that a “reasonableness” standard be applied that considered the seriousness of the operation to retrieve the evidence as well as the potential evidential value – this should be done on a case-by-case basis • In this case, the argument for forcing the extraction is compelling – the surgery is minor and the bullet is decisive evidence • The other issue is whether physicians can be ordered to perform a procedure that they object to – for example, some states require doctors to draw blood to test for alcohol levels in DUIs whether they want to or not Ethical Considerations We Will Tackle Principle of Bioethics Questions Respect for Persons • Are some ways of distributing organs more respectful than others? Harms and Benefits • What kinds of harms and benefits may come to people who need organs as a result of different organ-distribution policies? Fairness • When there are not enough organs for people who need them, how should they be distributed? • What is the fairest way to distribute organs? • Organ transplantation involves harvesting organs from live or cadaver donors and transplanting them into recipients whose organs have failed or are compromised • Unsurprisingly, there are more needy recipients than healthy organs being donated • Today we are going to study fairness in the allocation (distribution) of scarce, lifesaving biomedical resources. • You will read 3 historical cases regarding resource allocation. • Each case describes a historical situation in which a person or group of people had to decide how to distribute a scarce, lifesaving medical resource. • The purpose is to begin to think about fair ways to allocate scarce biomedical resources. • Note that the facts have changed since the time of these historical cases. Penicillin, insulin, and dialysis machines are no longer scarce. Still, analysis of these old cases will help you understand today’s allocation challenges. The overall ethical question they will be considering over the next three days is this: How can scarce resources be most fairly distributed? • Remember the following : • Scarcity is an issue for many different resources—medical procedures, medications, organs for transplant, and vaccines. • Scarcity arises whenever need exceeds supply. • The theme of scarcity and fairness arose in all three historical cases. After scientists determined the benefits of the treatments (insulin, penicillin, and the dialysis machine), demand for them quickly exceeded the supply. Case Studies • Take a few minutes to read the 3 case studies • They aren’t long, but they are important • You will be divided into groups of three • In your groups, first discuss the questions posed on page 1 of each of the case studies, then discuss the additional information on the second page of each case study • Begin with the insulin case: • What do you think would have been the fair way to distribute insulin when it was in such short supply? • Now turn to page 2 and see how Banting distributed the insulin • What are the pros and cons of how his method of distributing the insulin? • Next, consider the penicillin case. • Guidelines of the Committee on Chemotherapeutic and Other Agents (COC) were created to determine distribution. • Is this a fair and equitable way of deciding how to distribute the limited doses of penicillin? • The COC distributed the penicillin primarily on the basis of how sick the patient was and secondarily on the basis of advancing scientific knowledge. • Is there anything else that the COC should have considered? Why or why not? • Now consider the dialysis committee used to decide who had access to dialysis. • Is it fair to consider one’s social worth—or value to society—as a criterion? • Take a 5-minute break • We are done with the case studies • For the rest of this unit, we will consider only issues involving the allocation of organs for organ transplantation • In the United States, the United Network for Organ Sharing (UNOS) determines organallocation policies. • You will review past and current policies later in this unit. • Let’s first consider livers: livers—like all organs that are transplanted—are in short supply • What would a national policy that governs how to allocate them look like? • We will carry out a brief activity that conveys the current situation with liver transplants in the United States. Scenario • Imagine that all of you are in need of a liver and you are all on the organ transplant list • You have all been given a card that will determine your final status in terms of receiving a liver – do NOT look at it yet! Question Predicted % Actual % Over the next 12 months, what percent of you will receive a liver? 35% Over the next 12 months, what percent of you will die waiting for a liver? 10% Over the next 12 months, what percent of you will still be alive but will not have received a liver? 55% Liver Transplants • We will be examining liver transplants for the next few classes • You will need more information about liver transplants to evaluate allocation policies. • Gathering the relevant facts and concepts is always one of the first steps bioethicists take as they contemplate an ethical question. • Read the handout: Liver and Liver-Transplant Fact Sheet • Use this to complete the assignment titled The Liver and Liver Transplants—Checking for Understanding.
