Liver Transplant Ethics

We had a lecture on the allocation of donated organs for transplant. It's a tricky subject. The supply of organs is extremely scarce compared to the demand. How do you decide who gets an organ first? For livers, once a patient is on the list, only the severity of his disease determines his likelihood of getting an organ. Indeed, a computer calculates a MELD score based on bilirubin, INR, and creatinine, values that reflect the prognosis of the disease. This makes some sense; those who need a liver the most get it (as long as they can survive the surgery, have no other comorbidities, etc.).

But imagine this scenario of two people. One is a 40-year-old mother of four who works at a bank and suffers from autoimmune hepatitis. This condition, probably genetically linked, has progressed to such severity that she is considered for the transplant list. She has great social and financial support. The second person is a 40-year-old man currently in prison serving a life sentence. His alcoholic cirrhosis has led him to end stage liver disease which requires a transplant. He has been sober for several years and went through rehab. While he does not have great social support, the prison system will cover a liver transplant and the subsequent medications.

Once someone is put on the list, only his or her MELD score will dictate how soon he or she gets an organ. If both go on the transplant list, the man will get a liver first because he suffers from a more severe disease. What kinds of things should go into the consideration for putting someone on the transplant list?

Clearly, it is unethical to bias medical attention to those with "perceived social worth," though this occurred in the past with kidney dialysis. We should not deny organs to prisoners by virtue of them being in jail. Instead, physicians look at likelihood of transplant success, focusing on other medical conditions, psychiatric concerns, likely compliance with anti-rejection medication, etc. It's really a tough ethical question what kinds of things matter in this decision when each organ is extraordinarily valuable.