Organ transplants: who decides?
Imagine if two women of the same age were eligible to receive a kidney:
Person A has served time in jail for robbery and has connection with gang members.
Person B is a single mother of 2 children and regularly helps out at her local soup kitchen for the homeless.
If Person A is estimated to be able to live longer than Person B following the transplant, then under current kidney allocation criteria, Person A would be assigned priority for the kidney. Do you disagree with this allocation? Would you have preferred Person B over Person A?
The discrepancy between public opinion and medical experts
When deciding who to prioritise for an organ transplant, medical professionals tend to place high emphasis on the prognosis, or outcome, of patients following a transplant. Current allocation criteria use medical prognosis as their basis, attempting to maximise the lifespan of the organ by allocating it to the person who is estimated to live the most number of years in good health. However, people who were not medical professionals felt that patients with slightly better prognosis did not necessarily deserve to be prioritised over patients who have been waiting longer for a kidney (Ubel et al., 1996). They also tended to prefer a patient who had been waiting longer, even if they had a worse prognosis (Geddes et al., 2005). There might be value in such prioritisation as medical prognosis is not a hard and fast rule, but merely an estimate. It is possible for a patient with a poor prognosis to survive much longer than expected, with the help of medical developments (Su et al., 2004).
Using non-medical criteria to select patients for the waiting list
In the United States, for example, the criteria for organ allocation is strictly reviewed, but such stringent regulations do not apply to the criteria for being entered into the transplant waiting list as this decision is left to the individual transplant centres (OPTN, 2016; Zalewska, 2016b). At these centres, staff look at both the patients’ health and their social characteristics, such as whether they live in a “stable environment capable of supporting compliance with the transplant regimen”, before determining whether to include them on the waiting list (UC Davis Health, 2017). Such criteria are not necessarily backed by research and allow for subjective interpretation and human biases. If the staff of transplant centres could use arbitrary social criteria to determine who gets the chance to receive a kidney, one could argue that members of the public should also have a say as well.
My research findings
In a study I conducted during my undergraduate degree, I asked survey participants to rank, in order of priority, 16 hypothetical patients who differed in terms of their involvement in community service, attractiveness, intelligence and emotional intelligence. The findings revealed that highly intelligent patients were prioritised over patients of average intelligence, patients who volunteered were prioritised over those who did not, good-looking patients were prioritised over those who were average-looking and patients with high emotional intelligence were prioritised over those with average emotional intelligence.
Policy implications
My research findings indicate that people do have a significant preference for one profile of hypothetical patient over others. Does this mean that public opinions should always inform policies relating to healthcare resource allocation? Dicker and Armstrong (1995) argue that since priority-setting in organ allocation implies attaching a value to a person’s life, the public should have a say in how these values are assigned. Additionally, we might think that taxpayers who contribute to the funding of the healthcare system have the right to decide how their money is spent.
However, being heavily reliant on public opinion to guide healthcare policy may be unwise.
It could lead to discrimination against minority groups, since people tend to prioritise people of the same race when allocating a resource (Furnham et al., 2010). Moreover, eliciting public opinion regarding scarce resource allocation without providing clear information may be ill-advised. The public may not fully understand the ethics behind their choice, or its implications. Furthermore, if allocation criteria were to also look at traits such as intelligence and emotional intelligence, the public being surveyed need to be educated about these concepts and the debates surrounding them, such as whether intelligence can be accurately measured at all. Then there are practical issues over how public opinion could be surveyed – such as how to identify a truly representative sample of the population to elicit opinions from
So what should we do?
There might be value in understanding the public opinion and using it as a guidance rather than as a rigid rule. Some preferences are generally clear: studies have shown that people tend to adopt utilitarian views by prioritising people who have the most dependents (Wiseman (2006) and Furnham et al. (2010)). In Israel, to address public disapproval regarding people who wanted to be organ recipients but did not register to be donors themselves, policy was modified such that the principle of reciprocity was reflected: registered organ donors were prioritised over non-donors (Lavee, Ashkenazi, Gurman & Steinberg, 2010).
This particular example of organ donation raises wider issues about when it is necessary to seek public opinion to inform public policy. If it is deemed important to understand the society’s preferences in terms of who is valued more to receive a scarce resource like a kidney, does this logic apply to all other resources in society? It would be a time-consuming and difficult process to survey people’s preferences for each resource that needs to be allocated in society. Thus, one might argue that the decision is best left to the experts or policymakers.
References
Dicker, A., & Armstrong, D. (1995). Patients’ views of priority setting in health care: an interview survey in one practice. British Medical Journal, 311, 1137–1139.
Geddes, C. C., Rodger, R. S. C., Smith, C., & Ganai, A. (2005). Allocation of deceased donor kidneys for transplantation: Opinions of patients with CKD. American Journal of Kidney Diseases, 46, 949–956.
Furnham, A., McClelland, A., & Drummond-Baxter, E. (2010). The allocation of a scarce correctional resource: Deciding who is eligible for an electronic monitoring program. Journal of Applied Social Psychology, 40, 1605–1617.
Lavee, J., Ashkenazi, T., Gurman, G., & Steinberg, D. (2010). A new law for allocation of donor organs in Israel. The Lancet, 375, 1131–1133.
Maxwell, J., Rosell, S., & Forest, P.-G. (2003). Giving citizens a voice in healthcare policy in Canada. British Medical Journal, 326, 1031–1033.
OPTN. (2016). Policies.
Su, X., Zenios, S. A., Chakkera, H., Milford, E. L., & Chertow, G. M. (2004). Diminishing significance of HLA matching in kidney transplantation. American Journal of Transplantation, 4, 1501–1508.
https://doi.org/10.1111/j.1600-6143.2004.00535.x
Ubel, P. A., DeKay, M., Baron, J., & Asch, D. A. (1996). Public preferences for efficiency and racial equity in kidney transplant allocation decisions. Transplantation Proceedings, 28, 2997–3002.
UC Davis Health. (5 February, 2017). The Evaluation Process - UC Davis Health System Transplant Center. Retrieved from ucdmc.ucdavis.edu: http://www.ucdmc.ucdavis.edu/transplant/learnabout/learn_eval_process.html
Wiseman, D. (2006). Medical resource allocation as a function of selected patient characteristics. Journal of Applied Social Psychology, 36, 683–689.
Zalewska, K. (2016b). Patient Selection for Deceased Donor Kidney Only Transplantation (POLICY POL184/2.2). NHSBT.
About the Author
Deepa Selvaraj is currently studying for the Oxford MSc in Comparative Social Policy. During her undergraduate degree in Psychology at UCL she undertook research in the allocation of scarce resources, with a focus on the policy around kidney transplants. Her supervisor, Prof. Adrian Furnham, had already done a number of studies on what traits make someone a ‘deserving’ organ recipient in the eyes of the public. Her research explored this further, using traits which have not been studied before.