Transforming objectivity to promote equity in transplant candidate selection

Theoretical Medicine

Volumn 17, Issue 1, 1996, Pages 45-59

  Majeske, Rachel Ankeny ^a  

^a UNIVERSITY OF PITTSBURGH   (United States)

Author keywords

candidate selection; equity; ethics; fact value distinction; objectivity; philosophy of science; transplantation

Indexed keywords

HUMAN; MEDICAL ETHICS; PATIENT SELECTION; REVIEW; TRANSPLANTATION;

ACCOUNTABILITY; ANALYTICAL APPROACH; COMMITTEE MEMBERSHIP; EMPIRICAL RESEARCH; EVALUATION; HEALTH CARE AND PUBLIC HEALTH; INSTITUTIONAL POLICIES; INTERDISCIPLINARY COMMUNICATION; JUSTICE; PUBLIC PARTICIPATION; RESOURCE ALLOCATION; REVIEW COMMITTEES; SCARCITY; SELECTION FOR TREATMENT; SELF INDUCED ILLNESS; SOCIAL WORTH; STANDARDS; TRANSPLANT RECIPIENTS; UNITED NETWORK FOR ORGAN SHARING; UNITED STATES; VALUES;

ADULT; ADVISORY COMMITTEES; COMMITTEE MEMBERSHIP; EMPIRICAL RESEARCH; ETHICS, MEDICAL; HIV INFECTIONS; HUMANS; INTERDISCIPLINARY COMMUNICATION; MALE; ORGAN TRANSPLANTATION; PATIENT SELECTION; PHILOSOPHY, MEDICAL; REFUSAL TO TREAT; RESOURCE ALLOCATION; SOCIAL RESPONSIBILITY; SOCIAL VALUES; TREATMENT OUTCOME;

EID: 0029963820     PISSN: 01679902     EISSN: None     Source Type: Journal    
DOI: 10.1007/BF00489740     Document Type: Review

References (32)

1. Fox RC, Swazey JP. Spare parts: Organ Replacement in American Society. Oxford: Oxford University Press, 1992:83.
2. UNOS (United Network for Organ Sharing). Patients waiting for transplants: number of patient registrations on the national waiting list - 07/31/95. UNOS Update 1995;11:40-41. Some candidates are multiply listed (at more than one transplant center); therefore, the number of registrations may be slightly greater than the actual number of individual candidates.
3. For example, see Massachusetts Task Force on Organ Transplantation. The Report of the Massachusetts Task Force on Organ Transplantation. Boston: Department of Public Health, Commonwealth of Massachusetts, 1984; and
4. Mudge GH et al. Task Force 3: recipient guidelines/prioritization (in Report of the 24th Bethesda Conference on Cardiac Transplantation). JACC 1993;22:21-31;
5. American Medical Association Council on Ethical and Judicial afairs. Ethical Considerations in The allocation of Organ and other scarce medical resource among patients. Arch Int Med 1995;155:29-40.
6. It may be that allocation and procurement are targeted as the appropriate levels of governmental intervention simply because of the difficulties (and resistance) that would be faced if attempts were made to monitor the processes that precede and follow it. However, the establishment of the national system regulated by UNOS also seems to be based on the premise that equity can be achieved merely via standardized, objective national allocation policies and increased organ donation and procurement. UNOS has recently established subcommittees to examine selection criteria for various transplant types.
7. The few notable discussions of candidate selection include: Caplan AL. Obtaining and allocating organs for transplantation. In: Cowan DH et al., eds. Human Organ Transplantation: Societal, Medical-Legal, Regulatory, and Reimbursement Issues. Ann Arbor: Health Administration, 1987:5-17;
8. Evans RW, Yagi J. 1987. Social and medical considerations affecting selection of transplant recipients: The case of heart transplantation. In: Cowan DH et al., eds. Human Organ Transplantation: Societal, Medical-Legal, Regulatory, and Reimbursement Issues. Ann Arbor: Health Administration, 1987:27-41;
9. Robertson JA. Supply and distribution of hearts for transplantation: legal, ethical, and policy issues. Circulation 1987;75:77-87;
10. Brock DW. Ethical issues in recipient selection for organ transplantation. In: Mathieu D, ed. Organ Substitutional Technology. Boulder, CO: Westview, 1988:86-99;
11. Mathieu D. Organ substitutional technology: identifying and framing the key issues. In: Mathieu D, ed. Organ Substitutional Technology. Boulder, CO: Westview, 1988:3-21;
12. Caplan AL. Problems in the policies and criteria used to allocate organs for transplantation in the United States. Transplant Proc 1989;21:3381-3387;
13. Robertson JA. Patient selection for organ transplantation: age, incarceration, family support, and other social factors. Transplant Proc 1989;21:3397-3402;
14. Kilner JF. Who Lives? Who Dies?: Ethical Criteria in Patient Selection. New Haven: Yale University Press, 1990;
15. Surman OS, Purtilo R. Reevaluation of organ transplantation criteria: allocation of scarce resources to borderline candidates. Psychosomatics 1992;33:202-212.
16. I am limiting my discussion to solid organs from cadaveric sources because other transplantable materials and living donation present some qualitatively different issues.
17. Longino H. Science as Social Knowledge: Values and Objectivity in Scientific Inquiry. Princeton: Princeton University Press, 1990:62.
18. In addition to the studies discussed in detail below, see Kilner JF. Selecting patients when resources are limited: a study of U.S. medical directors of kidney dialysis and transplantation facilities. Am J Pub Health 1988;78:144-147;
19. Keefe EB, Esquivel CO. Controversies in patient selection for liver transplantation. West J Med 1993;159:586-593;
20. Stevenson LW, Warner SL, Steimle AE, et al. The impending crisis awaiting cardiac transplantation: modeling a solution based on selection. Circulation 1994;89:450-457; and
21. Corley MC, Sneed G. Criteria in the selection of organ transplant recipients. Heart and Lung 1994;23:446-457.
22. Olbrisch ME, Levenson JL. Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes. J Heart Lung Transplant 1991;10:948-955.
23. Levenson JL, Olbrisch ME. Psychosocial evaluation of organ transplant candidates: a comparative survey of process, criteria, and outcomes in heart, liver, and kidney. Psychosomatics 1993;34:314-323.
24. Randall T. Criteria for evaluating potential transplant recipients vary among centers, physicians. JAMA 1993;269:3091,3094.
25. Ramos EL, Kasiske BL, Alexander SR, et al. The evaluation of candidates for renal transplantation: the current practice of U.S. transplant centers. Transplantation 1994;57:490-497.
26. Interestingly, among those who advocated use of compliance criteria, many admitted that the practice discriminated against the poor and uneducated (45%) and against minorities (37% of respondents); Randall: 3094.
27. Dummer JS, Erb S, Breinig MK, et al. Infection with human immunodeficiency virus in the Pittsburgh transplant population. Transplantation 1989;47:134-140.
28. Tzakis AG, Cooper MH, Dummer JS, Ragni M, Ward JW, Starzl TE. Transplantation in HIV+ patients. Transplantation 1990;49:354-358.
29. The following discussion is drawn from Longino's arguments: 62ff. Although I do not agree with all of her conclusions, I think her approach takes an important step towards deflating various myths about science, and in particular, the supposed fundamental differences between pure and applied sciences.
30. Indeed, there has been at least one court case that dealt specifically with discrimination in transplant candidacy. In 1986 (Allen v. Mansour A., U.S. District Court for the Eastern District of Michigan, Southern Division, 86-73429), a federal district court invalidated a Medicaid rule requiring that alcoholics demonstrate two years of abstinence to receive coverage for liver transplant. The court held that the abstinence criterion had not been shown to be correlated closely enough with expected outcome (which was its stated purpose), and thus reflected arbitrary bias against alcoholics. The candidate who brought the suit unfortunately died before he received a transplant. See also Merriken K, Overcast TD. Patient selection for heart transplantation: when is a discriminating choice discrimination? J Health Polit Policy Law 1985;10:7-32.
31. U.S. Task Force on Organ Transplantation. Organ Transplantation: Issues and Recommendations. Washington, DC: HEW Committee of Public Welfare, 1986.
32. Kamm FH. The Report of the U.S. Task Force on Organ Transplantation: criticisms and alternatives. Mt Sinai J Med 1989;56:207-220.