"Social Worth" in the Allocation of Scarce Resources
The following post is taken from my now inactive "Bioethics Discussion Pages". The issue is one of "rationing at the bedside". Does every patient who needs a scarce resource for health should be eligible for the resource? Should factors other than need be considered at the bedside and should thought be given to other patients who might need same or similar resources or should the costs of medical care be considered in treatment decisions of the patient in the hosptial bed or across the desk? Though the responses from my visitors (beginning at the bottom of this post) are from 1996, they are as pertinent in today's period of medical care where resources such as organs for transplant are still scarce and the cost of medical care in general is rising. Feel free to add your views in the Comment section of this post. ..Maurice.
In medicine, allocation of scarce resources has always been a problem but it is more so in these days of organ transplants and expensive technical procedures. Laura MacLachlan raises the ethical issue of to whom the scarce resource should go when there is more than one patient waiting for the resource and wonders if the patient's "social worth" should be a criterion for the decision regarding allocation. Here are her questions:
Date: Mon, Jan 1, 1996 5:30 PM EDT From: email@example.com To: DoktorMo@aol.com
Given that we are currently attempting to manage scarce health care resources, a new area of ethical dilemmas has risen to the forefront. The subject of importance is that of the ethics of subscribing to "social worth" as a criteria for determining which patients receive expensive procedures. Is it ethical for health care providers to allocate organs and dialysis to those who are younger, healthier and more wholesome? For example, a long time alcoholic requires a liver transplant at the same time as a young child who has a congenital liver disorder (given organ availability and that histocompatability is desirable for both). Can we favour one person over another? Is this ethical?
Here is the question:
Is it ethical to favor one patient over another when considering allocation of scarce medical resources based on the "social worth" of the patient?
---- THE DISCUSSIONS ----
Date: Fri, Mar 28, 2003 9:26 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
With today's advanced medical technology, it would seem that somehow the plethora of life-saving procedures available would be able to address the needs of almost all the critically ill or injured, at least in the U.S. The method of allocating these resources, however, has only grown into an increasingly complicated and perplexing issue. Since ancient times, man has struggled with the fundamental question of the nature of human worth, from which these concerns in the distribution of health care stem. Therefore, the ancients of Greece may shed some light in this discussion, despite the stark contrast between their health care resources and America's today. In Plato's "Republic," as Socrates describes the ideal state in his quest for the nature of virtue, he discusses this very issue of allocating health care resources. Condemning those who call for a doctor to cure their illnesses caused by irresponsible, unhealthy lifestyles, Socrates calls this kind of medicine the "nursemaid to the disease." If a man must spend his life consumed by keeping himself alive by constant medical treatment, though he may live a long time, Socrates deems that life worthless. Socrates commends the attitude of an ordinary craftsman, such as a carpenter, who visits the doctor expecting a quick, effective treatment for his disease. The carpenter cannot afford to spend his precious time on prolonged treatment; therefore, if the doctor prescribes such a regimen that will interfere with the man's work, the carpenter will simply return to work and either recover his health naturally or die. In his contempt for the rich and idle who can afford to spend their time being sick, Socrates explains that the doctor should only practice on people with healthy lifestyles who have been attacked by some specific disease. In the event of a terminally ill patient "riddled with disease," Socrates deems treatment useless, since it would only make the person's life "a prolonged misery." Similarly, in the Hippocratic Writing "The Science of Medicine" the author defends doctors for not treating hopelessly sick patients, sayign that "Our practice is limited by the instruments made available by Nature or by Art. When a man is attacked by a disease more powerful than the instruments of medicine, it must not be expected that medicine should prove victorious." Socrates argument against treating the terminally ill more closely relates to the question of social worth of the individual, while the Hippocratic doctor desires to preserve the reputation of those in his trade by not taking on too incurable cases. In Socrates' view of the ideal state, each individual's worth depends on his or her relation to the state. Since the weak, idle, and all those lacking somehow in body or mind cannot contribute as much to the state, doctors should not be as concerned with treating them. The healthiness of a patient's lifestyle and his productivity as a citizen in part determine whether or not a doctor will decide to treat him. The terminally ill cannot contribute tangibly to society and might even produce offspring weak like themselves, rendering them of relatively little worth in the state-minded doctor's eyes. Some of Socrates' judgments may seem harsh to modern readers, but the question he addresses still burns. Should patients receive preferential treatment in the allocation of resources based solely on their contribution to society? Socrates' portrayal of a society operating in this manner might cause doctors to shy away from this method of decision-making. However, if society today judges this criterion too arbitrary, what other measurement can doctors use? The light shining from ancient thought on this issue may serve only to cause modern thinkers to abandon currently-held ideas in their pursuit of more satisfying answers.
Date: Mon, Feb 15, 1999 9:59 AM From: J.Perkins@unsw.edu.au To: DoktorMo@aol.com
Surely "social worth" criteria operate anyway in global terms in that access to even basic medical treatment treatment is denied to most citizens of develping countries. It operates in the allocation of research and other medical expenditures, largely concentrated in developed capitalist economies, towards life-threatening conditions mainly specific to those advanced capitalist economies. The result is a distortion in terms of input (cost) and output (return in terms of lives saved).
Date: Wed, Apr 8, 1998 2:00 PM From: StudentComputer@ACS.WOOSTER.EDU To: DoktorMo@aol.com
My answer to your question is this: No, it is not ethical to use non medical "social worth" factors to favor one patient over another. The use of such a criteria to choose between candidates for scarce medical resources can be critiqued both from Kantian and Utilitarian perspectives. I believe the most basic and powerful objection to "social worth" is that such a criteria reduces patients to their potential for maximizing social benefit. Kantian ethics argue that people should never be treated merely as a means to an end. By selecting between patients based solely on their potential contribution to society, they are being reduced to merely a means of achieving the most possible social good. They are not regarded as people with basic intrinsic value that goes beyond their ability to contribute to society. Any patient that does not have the ability to contribute much to society, because they are elderly, mental, or physically handicapped, automatically is unfairly at a disadvantage.
On the face of it, Utilitarianism would seem to favor the use of such a criteria. Choosing people to save based on their potential future contribution would seem to produce the most net benefit. However, the physican/patient relationship would suffer greatly if patients felt that their physicians were continually looking past their personal welfare to the potential for social benefit. Distrust and suspicion would result if patients perceive that physicians were making treatment decisions based on their potential social value. Thus, over a longer period of time, the eventual erosion of the physician/patient relationship could result in less net benefit for society, a result not favored by Utilitarianism.
Addtionally, there are a host of other practical difficulties with appling a "social worth" criteria. Use of such a criteria would require some type of ranking of respective social worth. How does a professional athlete rank against a priest, or an insurance salesman, or a physician. Hwo much should patients' personal life be involved in selection decisions? Given the pluralism of our society, development of such a list is nearly impossible. And even assuming that such a list could be compiled, whose ideas of social value should we use to make the list? Inevitably, personal bias would influence the ranking of "social worth". Ultimatley, the use of medical factors, such as need, amount of resources required, and potential for success, should be used for patient selection, not non mendical "social worth" criteria.
Date: Sat, Jan 31, 1998 9:23 PM From: email@example.com To: DoktorMo@aol.com
A solution to your social worth dilemma: a formula can be devised to determine who will be most productive in the society. It would go something like this: Last year's earnings as reported to the IRS (or earnings of active parents if under 18) 2(age) x 3(tested IQ), normalized to the same scale. Demerits for past behavioral and health abuses are awarded at the end. Highest score gets the liver. This of course, applies only to those candidates who can afford the procedure, through insurance, wealth, or even community drives. If the person is valuable enough to inspire hundreds of thousands of dollars in donations, s/he deserves consideration. This system helps to insure that the individual whose life is saved is one who is a contributing member of society and one likely to continue to do so after the procedure, and for many years to come.
Date: Sun, Oct 5, 1997 4:08 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
My answer is yes, it is ethical and necessary to make the best use of scarce resources but not before clear criteria of "social worth" are spelled out. Well, OK, but where to start with criteria? My choice (since this is a health-related question) would be to first establish the patient's "general state of health" (aside from needing the scarce resource). From there, I'm going to use this question as an exercise for my students in a "medical law and ethics" class and I will follow this issue throughout the coming months.
Brian Nooney RPh, email@example.com
Date: Sat, Jul 26, 1997 9:05 AM From: DocReading@sprintmail.com To: DoktorMo@aol.com
In allocating scarce resources, social worth (meaning to me utility to society) is almost always considered. For example, in the classical example of a falling plane with 10 parachutes and eleven passengers, how do we decide who will not get the parachute? There are some that suggest that the most able to wrestle the parachutes from another should get them or consider "the first come, first served method". But what about the young child? There are some that suggest that drawing straws is the most fair. But what if the one who gets the short straw is the one who is capable of finding a cure to cancer? Most people tend to settle on the societal worth method. Are we wrong to apply this to medical procedures? The problem arises when social worth does not mean societal worth. Some define social worth as having wealth or insurance. This is where I believe we run into unethical decisions. If it is unethical to allow people to preferrentially buy organs for transplantation, then it is also unethical to allow them to buy the procedure without regard to others. Is it ethical for the government to fund for some what others cannot afford? More specifically is it ethical for the government to fund a life saving transplant for an aging medicare recipient and not to fund the same type of life-saving procedure for a 10 year old underinsured boy or girl?
Date: Sat, Jun 14, 1997 12:03 PM From: firstname.lastname@example.org@henge1.henge.com (Robert Wesley) To: DoktorMo@aol.com
The way this issue is formulated begs the question of what should be "allocated" and obscures the question of "who" should do the allocating. Whenever one talks about how "we" should "allocate scarce resources," it conjures up a picture of these resources (undefined except insofar as they are "scarce") as if they are already "ours" to distribute. At this level of generality, it will necessarily be the case that someone will be "favored" over another; it is trivially true that when any one person receives a treatment, some other person does not. With regard to organ transplants in particular, there is not one answer to the question of how "we" should "allocate" organs because it is not one question. Should "I," as someone who has no connection whatsoever to the transplant program at, say, the USC medical center, have a say in how "you," as a transplant physician decide who should receive an organ? After all, both "I" and "you" are "we," are we not? Again, is "my" liver or kidney a "resource" that "you" ought to allocate? Suppose that I would like to specify that my liver be donated to my alcoholic uncle? Or are we really talking about the expenditure of federal dollars? If so, livers and dollars really are not equivalent "resources" even if both are "scarce," and the answer to the question of whether someone should get a liver paid for by the federal government is not the same as the answer to the question of whether some other individual should get a liver that he pays for out of his own pocket (i.e., unless you have a socialist medical system in which private enterprise is outlawed). There are many ethical decisions in which "we" do not have rightful stake but in which only the relevant individuals have an interest, and not every health care decision is a "resource" to be allocated. To assume otherwise is to beg the question in favor of "collective ownership" of the "means of production."
Date: Mon, Apr 7, 1997 4:24 PM From: S Ryan email@example.com To: DoktorMo@aol.com
I do believe that it is ethical to allocate scarce resources to those who have more social worth. In the case of the alcoholic with cirrhosis, I do not believe they should even be allowed on a transplant list unless they have become sober and are no longer drinking. A child has an entire future ahead, and may be a more productive member of society. Although I do not abdicate letting these people die, Since resources are scarce, it is essential that we do what is good for largest majority of society and a child clearly fits this description in my mind.
Date: Mon, Apr 7, 1997 2:29 PM From: sthievon@REX.RE.uokhsc.edu (S&E Thievon) To: DoktorMo@aol.com
I do believe that health care resources are scarce, and when resources are scarce there must be rationing. To ration, there must be criteria to use in allocating the resources. I feel that the term "social worth" is vague and that the lack of clarity leaves the door open for decisions that may be based on stereotypes and/or prejudices. However, allocating resources based on the best and maximum use of those resources is appropriate. For example, giving a liver transplant to one individual rather than another based on the individual's better ability, capacity, potential, and past history for maintaining health regimens is, to me, the best and maximum use of that resource. The chances that that liver will survive longer are greater. If a patient has been advised about such things as eating a healthy diet, regular exercise, and smoking cessation, but chooses not to adopt and/or maintain these habits then perhaps they should not receive the heart transplant. People must start taking responsibility for their own health. If an individual is not willing to invest any energy into his/her own health, then he/she has not earned the privilege of advanced health care resources. And investing these resources in such individuals is not the best and maximum use. Failing to maximize resources is wasteful.
To address the vagueness of social worth, criteria should be clearly and behaviorally defined. The behavioral criteria should assess the individual's past health behaviors and potential for maintaining the needed/prescribed future health regimen. I realize that this will not address all issues. Issues such as age and financial resources remain. I do not know what would be the maximum or best use of resources when comparing the young with the elderly if behavioral criteria are equal. I do not know whether, behavior criteria being equal, resources should go to a private paying individual or an uninsured individual that has limited financial resources.
Also, some will question what is the best use of resources. Maybe it is not determined by number of years. And if it is determined by an individual's contribution to society, then we may be back to social worth. I always end up in circles with ethical issues. I feel strongly on this issue that resources are scarce and therefore must be allocated. The best and most just way to determine allocation is much more difficult for me. I have included some of my ideas as well as some of my questions. My ideas are always growing and changing with new information and thought.Susan Thievon, Student Nurse in a Bachelor's Program
Date: Thu, Nov 21, 1996 5:52 AM EDT From: firstname.lastname@example.org To: DoktorMo@aol.com
I do not feel that the allocation of organs for transplantation, should be based primarily such a vague criterion as "social worth." How is this accurately assessed? What will be said about a very kind and loved person, who also happens to be poor and on welfare and yet is still struggling to support his or her family, when it is time to place them on an organ waiting list? Under current guidelines, certainly this person would not be considered to have much "social worth."
Date: Sat, Oct 26, 1996 2:03 AM EDT From: email@example.com To: DoktorMo@aol.com
I think that it might add perspective if you looked at social "worth" evaluation in a developing country such as South Africa. The "expensive" transplants need quality of life evaluations as well as survival time evaluation. This gives additional perspective when you foreward only an American. or Eurocentric, based arguement. How many patients with testicular cancer could be cured for the price of one heart transplant? Can you make a value judgement? Do you argue that the individual persons "desire" for treatment [attention] is unrelated to "social worth". Do you exclude the patients right to die from the discussion of allocation of resources? I believe that, when properly informed, many are less enthusiastic about the use of "scarce" resources. For the sake of discussion I sugest that many doctors in the first world "believe" in some of the costly treatments and that this is the major reason for the resources being limited, as unjustifiable disinformation is propagated.
Date: Thu, Oct 3, 1996 1:48 AM EDT From: firstname.lastname@example.org To: DoktorMo@aol.com
Am I right to say that in the American system of health care, to even get on an organ waiting list, you have to have insurance, or be covered by Medicaid? What about all those people (for argument's sake, let's say they're all 'worthy' in the sense that they would comply, don't engage in risky behaviour etc) who cannot afford insurance? By excluding access to these people, is that not a bold statement about social worth criteria in itself?
Shelley Ion, Vancouver BC
Date: Tue, Jul 30, 1996 4:44 PM EDT From: email@example.com To: DoktorMo@aol.com
The question of how to allocate scarce resources on the basis of social worth begs the real question: why have we defined our abilities in terms of scarcity? Are resources really scarce? In the 1970s, debate in the US House and Senate on dialysis, for example, ended with a determination that a nation as rich as the US should assure dialysis for all, irrespective of income. Now, however, we have defined ourselves not in terms of wealth but poverty. It might be better to ask if the cost of health care seems prohibitive, how can the delivery system be changed to assure fair and necessary treatment for all?
The US spends a great percentage of its GNP on health care, and returns less coverage to its citizens, than any other industrialized world. So perhaps, the issue isn't scarcity but a system of health care which puts people after profits, etc.
In cases where scarcity does reign, organ transplant allocation, for example, no system has yet been well defined which allows us to adequately measure "social worth" as a criterion. In pediatrics, for example: Is the dyslexic with low school scores less worthy than the normal child with high grades in reading? Is there any reason to believe the ninth grade basketball center will be a better member of society than, say, the dream and somewhat uncoordin- ated nerd who sits in the back room and fiddles with computers? (for a discussion of organ transplant, see my Normative and Prescriptive Criteria . . . in Theoretical Medicine 1996, 17:1.
No. The question as framed restricts the way we can, indeed, meet the challenges equitably, and with concern for all.Tom Koch
Date: Fri, May 31, 1996 5:57 AM EDT From: Warren@cafenet.co.uk To: DoktorMo@aol.com
While we all have an equal right to life, it does not follow that we have an equal right to healthcare, which is a social good rather than an absolute right. This suggests that, while a basic level of healthcare should be provided by society for all on an equitable basis as an expression of the common good,we cannot be expected to treat every patient in exactly the same way. The dilemma is how to reach an equitable settlement in which each is given their due value and worth, but which at the same time recognises that society must ask the question "ought we to do what can be done?" when allocating health care resources that are increasingly expensive and scarce. Where cost, both personal and clinical, is disproportionate to the good to be achieved it is not unjust, I believe, to decline to treat the patient. In such cases it is not wrong to favour one patient over another, where the good to be achieved - health and extended life expectancy - is greater for one and not the other.
Date: Thu, Apr 25, 1996 11:44 PM EDT From: Findingman@epix.net To: DoktorMo@aol.com
As a physician for 30 years, practicing medicine from a perspective of "hearing the story" of the person, trying to ascertain the depth of their understanding, what motivates them to live, go on, do the unfinished, resolve those difficult relationships, be productive, make a difference, I find that those patients who have had transplants as adults have risen above the flat line of their lives and choose to see life as something to be lived and not something to be chased. "Social worth" has the unfortunate connotation of value, of something to be contributed, something that inherently gives a sense of future. We the elders decide who and again unfortunately are imperfect yet our decisions are irreversible. Committees are covenient because the decisions take on a vote situation based on the facts of the particular case. Sometimes I think that we do too much cerebrating and not enough feeling and deciding from the heart. The heart knows, where the brain has too much debris and stereotype to render fair decisions in who gets what organ. The system is flawed because we try to make sense out of something that exceeds our understanding and we forget what our hearts are telling us.
James C. Barton
Tue, Mar 12, 1996 3:54 PM EDT From: Serratia1@aol.com To: DoktorMo@aol.com
I have been a transplant nurse at a large university-affiliated hospital for nine years. In the course of my employment, I have seen examples of many different transplant scenarios, many involving ex-active alcoholics and/or drug addicts. I feel that "social worth" is not a relevant tool for determining allocation of organs. If there is a choice between giving a donor liver to a patient whose disease was caused by alcohol abuse, and a patient whose disease was "not his fault" e.g. related to Hepatitis C from a blood transfusion, other factors must be considered. If we pay too much attention to assigning "fault" to victims of disease, then we must also reconsider our treatment of patients who develop disease related to cigarette smoking, improper diet, and insufficient exercise. That is a very broad category, which I daresay includes most human beings. In the past nine years, I have seen many past alcohol abusers who have received new livers, are grateful for their second chance at life, follow their medication and treatment regimens religiously, and are enjoying life. Who can tell what the future might hold for such a person? His/her potential could be just as great as that of the newborn baby with biliary atresia who is yet a "blank slate" and could potentially grow up to be either a boon or a nuisance to society. I believe the best criterion to use in transplant decisions is *compliance*. This is not the same as "social worth". This has nothing to do with vocation (or lack thereof), educational level, race, or the cause of the original disease. The key question is this: How likely is this person to value this transplant, and to demonstrate that he or she values it by cooperating with the accompanying medication, diagnostic, and treatment regimens? I am regularly amazed by the number of transplant patients I care for who have a *recent* (right up to the day of transplant) history of flagrant noncompliance with their medical treatment. Not surprisingly, many of these people go home and decide that it is too much trouble to take their medicines or show up for their clinic visits. Then they are angry that they must be hospitalized for aggressive anti-rejection treatment. Even in the hospital, the doctors and nursing staff must waste time threatening or coaxing these people into taking their medications, having their blood drawn, or having their vital signs taken at "inconvenient" times. Not surprisingly, the heroic anti-rejection treatments are unsuccessful, and the person goes back on insulin, back on dialysis, or (in case of a liver) simply dies. When you add up the waste of staff hours "babysitting" these people, the squandering of expensive anti-rejection treatment, and ultimately the waste of the organ, the cost to society is staggering. All of this could be avoided by better screening measures aimed to insure that potential transplant candidates: 1. Are properly educated as to the demanding post-transplant regimen. 2. Have a record of sincere *recent* compliance with medical treatment, regardless of their past behavior. 3. Demonstrate an understanding of the costs and sacrifices involved in the transplantation process from the donor family to the hospital down to the doctors, nurses, and other staff, and an *appreciation* of the gift of the organ. To some, this may sound paternalistic, but the fact of the matter is this: if you receive a gift that you don't appreciate, you're not going to be likely to take good care of it, be it a piece of clothing, a houseplant, or a kidney. Recently, I cared for a patient who lost his kidney graft due to severe, continuous noncompliant behavior. This gentleman had a recent history of medical noncompliance and one of the most uncooperated, unappreciative attitudes I have ever seen. The last time I saw this man, he was being dragged from his hospital room by several security guards. The doctors had discharged him (finally!!) after he had refused all medications, vital signs, and procedures for two days and then, of course, he refused to vacate his hospital bed. As I watched him being wheeled down the hall, a stream of abusive language trailing in his wake, the thought that the organ that had been implanted in him could have been given to someone who would have treasured it, someone whose life would have been truly enriched by it, was almost overwhelming in its sadness.
Date: Wed, Feb 7, 1996 6:36 PM EDT From: firstname.lastname@example.org To: DoktorMo@aol.com
As Gloria J. Banks, Esq., points out in Am. J. of Law & Medicine, V. XXI, (1), s"social worth" allocation criteria have been used to determine a patient's potential to be a "productive citizen" after transplant. "Productivity" criteria have included the person's relationship to authority figures, past irresponsible behavior, intelligence, marital status, number of dependents, income, educational background, and employment record. In order to create a more equitable, random allocation system, some havee suggested a first-come, first-serve or lottery system. However, some argue that this type of system will tend to b enefit only those educated individuals who have greater access to those services. The NY State Task Force on Life and Law concluded that the patient's medical criteria should be the sole basis for organ allocation decisions. The "criteria to select transplant recipients must be uniform, public, and fair...[and] be applied in a process that ensures that like cases be treated alike and precludes the operation of bias based on race, social class, sex, or other invidious criteria."
Signe A. Dayhoff
Date: Tue, Feb 6, 1996 10:43 AM EDT From: email@example.com To: DoktorMo@aol.com
I believe that unless and until the transplant business is based upon the concept of presumed consent (we take your parts unless you tell us otherewise) there will always be a shortage and thus we will be dealing with a system that is "unjust" from the get-go.Joe Beltran firstname.lastname@example.org
Date: Sun, Feb 4, 1996 4:36 PM EDT From: email@example.com To: DoktorMo@aol.com
Re: the question of "social worth" when determining medical treatment and allocation of scarce resources, Dickens' Christmas Carol comes to mind. The scene between Scrooge and Christmas Present is most germaine, and I apologise for not having an exact quote, but the ghost points out that Scrooge would do well to hold his tongue rather than condemn others to die for lack of apparent worth "for in the eyes of God (here substitute any unknowable power if you want to remain PC) mllions may be more worthy than you" or words to that effect. Still a powerful story, and still socially conscious, at times far ahead of his time.John A. Flamini MD
Date: Mon, Jan 29, 1996 8:40 PM EDT From: firstname.lastname@example.org To: DoktorMo@aol.com
Thanks for Majeske transplant criteria studies' info.[BELOW] Neither science nor public policy is value-neutral because the people doing them aren't. Another interesting area touched by "social worth" question is assignment of responsibility for health outcomes. The question generally asked is to what degree should idividuals be "blamed" for consequences of perceived "life style" behaviors/choices? Perhaps,the companion question to it should be to what degree should big business, advertising, the entertain- ment industry, and agricultural subsidies be blamed for obesity; tobacco, alcohol, and drug use; violence; and STDs?
Signe A. Dayhoff, Ph.D. Social Psychologist Bioethics-Genetics-Social Policy Consultant ELSI lecturer at University of New Mexico Health Sciences Center email email@example.com
[Ed.Note:The following review of the criteria for selecting transplant candidates by Rachel Majeske was originally posted on the bioethics list BIOMED-L. I felt it was pertinent to the current discussion of "social worth" in candidate selection and I think the information is rather interesting. It is reposted here with her permission. -M.B.]
Date: Wed, 16 Aug 1995 10:16:44 -0400 From: Rachel Majeske Subject: Criteria for transplant candidate selection
Criteria for transplant candidate selection (who gets put on the waiting list to receive a cadaveric donor organ through UNOS) differ radically from transplant program to program, and across organ types.
One recent study of psychosocial criteria used among transplant programs found, for example, that for heart transplantation, IQ <70 was an absolute contraindication for 25.6% of U.S. programs (and 54.1% of non-U.S.), and an irrelevant consideration for 15.4% U.S. (5.4% non-U.S.) (Olbrisch and Levenson 1991). For IQ < 50, 74.4% of U.S. programs considered it to be an absolute contraindication (91.9% non-U.S.), 19.2% a relative contraindication (2.7% non-U.S.), and 6.4% irrelevant (5.4% non-U.S.). They also found great differences in the type of testing used to evaluate candidates: in the U.S., 80% of programs required that each candidate be evaluated by a "mental health professional" with candidates not beinglisted unless considered acceptable by one or more of these evaluators. 24% of U.S. programs required formal psychological testing for candidates. This study reviews a number of psychiatric and psychosocial criteria, and finds agreement on some criteria (active schizophrenia, currently suicidal, history of multiple suicide attempts, dementia, current substance abuse, e.g.), but major disagreement among programs on other criteria (cigarette smoking, obesity, noncompliance, recent alcohol or drug abuse, criminality, personality disorder, controlled schizophrenia, affective disorder, e.g.).
The other issue in the California case seems to be ability to adhere to the posttransplant regimen. A recent study of kidney transplant programs (Ramos et al. 1994) found signficant heterogeneity regarding the means of evaluating the likelihood of medical compliance posttransplant. A review of the literature on transplantation found that for heart transplant programs, for example, medical compliance was a frequently cited selection criterion (Corley and Sneed 1994), but it would be my guess that the means/criteria for assessing compliance differ radically among these programs as well (since the situation with kidney transplantation is probably more stable, given the maturity of the procedure and some fairly obvious criteria--e.g. attendance at dialysis--for which there are not clear analogues in the case of heart transplant).
The Ramos study also found great differences in the types of health care providers who participate in selection/evaluation committees (e.g. only 16% report having a psychologist and 16% report having a psychiatrist). A study of heart, lung, and liver programs (Finder et al. 1993) found that although only 11% of programs reported having someone with some ethics training on their transplant committee (about half of which were specifically identified as "ethicists"), 69% of programs reported that "explicitly ethical information or judgments" were utilized in decisionmaking.
Corley, M.C. and G. Sneed. Criteria in the selection of organ transplant recipients. Heart Lung 23:446-457, 1994.
Finder, S.G. et al. The ethicist's role on the transplant team: a study of heart, lung, and liver transplantation programs in the United States. Clin Transplantation 7:559-564, 1993.
Olbrisch, M.E. and J.L. Levenson. Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes. J Heart Lung Transplant 10:948-955, 1991.
Ramos, E.L. et al. The evaluation of candidates for renal transplantation: the current practice of U.S. transplant centers. Transplantation 57:490-497, 1994.
Hope this information is helpful!
Rachel Ankeny Majeske, M.A. Center for Medical Ethics, University of Pittsburgh and Ethics Consultant, Cardiopulmonary Transplant Selection Committee University of Pittsburgh Medical Center email: firstname.lastname@example.org
Date: Fri, Jan 26, 1996 11:56 PM EDT From: email@example.com To: DoktorMo@aol.com
Distribution of scarce medical resources should be predicated upon urgency of need, one's place in line for that resource, and the likelihood of medical benefit to be derived from having it. Allocation by "social worth" is subjective, value-laden, and arbitrary. Too often those deemed as less deserving, such as individuals with Down Syndrome, receive less medical care, lower quality care, and fewer expensive pro- cedures. Social justice should obtain in medical/health care resource allocation even when rationing of such resources becomes greater.
Date: Tue, Jan 16, 1996 8:49 PM EDT From: firstname.lastname@example.org To: DoktorMo@aol.com
Regarding the question about considering social worth is deciding how to use a scarce resource eg organ for transplantation: the easy way out is to give it to the person who is deemed sickest and in most urgent need. That, too, is a somewhat subjective evaluation. If one has a list of potential recipients should acuity of illness be the final deciding factor, since all on the list have been screened and felt to be candidates? I have seen a number of transplant candidates whom I felt got on the list by some quirk of fate: blind, diabetic, arteriosclerotic with bilateral leg amps. I think the scarce resource needs to be given to the neediest of those on the list, but that the list itself must have as one of its factors what you might term social worth. The totally recalcitrant IVDA [Intravenous Drug Addict] who needs a liver or kidney or heart should not be on the list.george bower
Date: Thu, Jan 4, 1996 9:36 PM EDT From: email@example.com To: DoktorMo@aol.com
Scarce resources have always been allocated, one way or another. They always will be. The real question is whether or not "social worth" should be used in the mechanism. What is "social worth" anyway? If it is how many tools a person can turn out in a machine shop, or how much profit a person can bring to the bottom line of his/her company, we are in trouble. "Social worth" may be the best mechanism for allocating scarce resources, but perhaps we have to look at it's definition. For instance, few people can see that even a severely handicapped child or adult has "social worth" in that they teach the rest of us how to serve and give unselfishly in their care. That is worth a lot! Unfortunately, sometime you have to have "been there" to understand. I am looking forward to other comments on the issue.