Ethics + organ transplants

[golden]

Hey I wanted to get some opinions on the following:

 

A sixty year old man and a fifteen year old girl are both in need of a kidney transplant. Both are in otherwise good health. You have only one kidney, and both patients are matches. Who do you give the kidney to and why?

 

Also how do organ transplantations generally work? Is it first come first serve (a list), on the basis of need, or a mixture of both?

[NewfieMike]

well if real life is anything like Grey's Anatomy... there's a list.

 

I'd also need to know so more information about them. Like if it was completely up to me to decide, and the old guy is a repeated sex offender, makes the job a bit a easier. but if he's a husband with like 5 kids and the wife works a low paying salary job, its harder to say

[rmorelan]

Hey I wanted to get some opinions on the following:

 

A sixty year old man and a fifteen year old girl are both in need of a kidney transplant. Both are in otherwise good health. You have only one kidney, and both patients are matches. Who do you give the kidney to and why?

 

Also how do organ donations generally work? Is it first come first serve (a list), on the basis of need, or a mixture of both?

 

In my opinion

 

Give it to the girl - without any more information indicating otherwise, she would have the greatest chance of survival. The age difference is not relevant except where is indicates something medically related. Likelihood of the procedure being successful is a medical reason for making a choice.

 

This assumes all other things are equal.

[blaaaax]

Correct me if I'm wrong, but I believe the average lifespan for a donated kidney is ~10yrs, so either candidate should be able to outlast the kidney (again, assuming equal genetic compatibilities).

 

In Canada, kidneys come on a first-come first-serve basis for the simple reason that you can live a long time on dialysis (which would suck by the way). It's with things like livers that time becomes much more of an issue, and organs are distributed based on severity of disease more than any other factor.

[rmorelan]

Correct me if I'm wrong, but I believe the average lifespan for a donated kidney is ~10yrs, so either candidate should be able to outlast the kidney (again, assuming equal genetic compatibilities).

 

In Canada, kidneys come on a first-come first-serve basis for the simple reason that you can live a long time on dialysis (which would suck by the way). It's with things like livers that time becomes much more of an issue, and organs are distributed based on severity of disease more than any other factor.

 

Interesting! From the quick search I did says 50% of kidney last longer than 10 years - not that I think they would expect you to actually know that Rather silly of me - I did know they actually failed at that rate!

 

However even if they both live the 10 years, 15 year olds are generally more likely to survive the transplantation process ( I believe). I think there is still a medical reason to give the transplant still to the young girl on those grounds with all other things being equal.

[blaaaax]

Potentially she might, but you could also make the argument that the 15 yr old would be better able to survive on dialysis for a longer period of time....

[rmorelan]

Potentially she might, but you could also make the argument that the 15 yr old would be better able to survive on dialysis for a longer period of time....

 

Good point I think the key though is to be arguing the medical side of things. Anything outside of that is outside of scope.

[blaaaax]

There is not always such a clear distinction though. For instance, immunological compatibility is clearly medically relevant and definable, but how about social support networks? They are are very important criteria, especially for things like liver transplants when there is very often a looming specter of addiction issues...

[sailor_d198]

There is not always such a clear distinction though. For instance, immunological compatibility is clearly medically relevant and definable, but how about social support networks? They are are very important criteria, especially for things like liver transplants when there is very often a looming specter of addiction issues...

 

...thats when it becomes more complicated!

 

What if the organ in question was a liver and the potential recipients were

(a) a young woman with a relatively healthy lifestyle or

( a 60 yr old man with a history of heavy drinking who has been waiting longer than the woman for a liver, but may or may not change his drinking behaviour following the transplant.

 

??? I think in this case factors other than relative waiting time would be important, but to what extent?

[A-Stark]

Actually alcoholism is (generally) a major contra-indication for a liver Tx. So in this case we'd go with the young woman. Now if the 60 yr old man had a *past* history of alcoholism but was currently sobre, things might be different.

 

(as near as I can tell, though, most Tx candidates are 40+ and more likely to have histories of HCV or some sort of autoimmune condition like PSC or PBC)

[blaaaax]

It is mandatory for a liver transplant candidate to not only have completed rehab and demonstrated an extended time clean from drugs/alcohol, but to have the necessary social support network in place to ensure they take their medications correctly and don't relapse into an abusive lifestyle post-transplant. Once they have made the list, livers are distributed based on severity of disease, since it's not like kidneys where dialysis can suffice in the mean time.

 

At least that's my understanding of the process...

[Wolvenstar]

Obviously more than just age comes into play here. Health complications are vitally important. However if what you are trying to get at is, if there is some sort of age bias. I.E. both candidates are in good health, no negative facts that could potentially make them a poor recipient, I personally would vote to give it to the younger child.

 

Simple matter of comparison, child has more potential left, have a longer potential lifespan. The elder is just that, older. At age 60 most offspring will be relatively close to the age of independence (ie around 18) if not older. Most people who have some sort of common sense would have been putting their affairs in order around age 40-50 just in case something were to happen. The elder also has less year left, and there would be less harm to their development by putting them on dialysis rather than the child.

 

If this were an altruistic world you would expect the elder to concede the organ to a child, it is what I would do. Children are the future, we are merely the present and the past depending on our age.

[blaaaax]

If this were an altruistic world you would expect the elder to concede the organ to a child, it is what I would do. Children are the future, we are merely the present and the past depending on our age.

 

I'd love to think the same, but honestly if I'm 60 years old I would see a lot of life left in me. Retirement, grandchildren, etc. it would be difficult for me to just pass on that....

 

I think that it can get dangerous to try and make all your decisions on life-years, what if the person is not 60 but 40? 30? Has a newborn child? That is why the system is set up as a queue, objective criteria are necessary because these confounds are inevitable.

[A-Stark]

Age IS a relative clinical indicator as regards both the likelihood of success and the ability of a patient to sustain ongoing dialysis. Keep in mind also that immunosuppressive drugs will be necessary indefinitely to prevent rejection - there's always the possibility of some opportunistic infections secondary to that.

 

Anyway, I'm very reluctant to make this call based on age - I'm interested to know how these decisions get made in practice.

[Mei_Mei_girl]

Sounds like you've thought it well through A-stark! I have an interview at NOSM in two weeks, I think if I said something along those lines they'd be quite impressed...*makes mental note*

[rmorelan]

Age IS a relative clinical indicator as regards both the likelihood of success and the ability of a patient to sustain ongoing dialysis. Keep in mind also that immunosuppressive drugs will be necessary indefinitely to prevent rejection - there's always the possibility of some opportunistic infections secondary to that.

 

Anyway, I'm very reluctant to make this call based on age - I'm interested to know how these decisions get made in practice.

 

Yup, I agree - that is why I was only trying to use a medical reason for the separation. It is my understanding you CAN'T use the age as a factor unless it has a medical reason to be pulled in. Number of years left, quality of life issues etc shouldn't be used - I think it is actually illegal to do so.

Admitted that is usually the first impulse

[Wolvenstar]

Yup, I agree - that is why I was only trying to use a medical reason for the separation. It is my understanding you CAN'T use the age as a factor unless it has a medical reason to be pulled in. Number of years left, quality of life issues etc shouldn't be used - I think it is actually illegal to do so.

Admitted that is usually the first impulse

 

I can not see age being a factor in determining the priority of the patient.

[michellematthews27]

In the case of a liver transplant, in that hypothetical scenario, you could actually divide the liver. Apparently, they do regenerate. It would work especially well if one of the candidates were a child and their portion was smaller. It's pretty amazing!

[rmorelan]

In the case of a liver transplant, in that hypothetical scenario, you could actually divide the liver. Apparently, they do regenerate. It would work especially well if one of the candidates were a child and their portion was smaller. It's pretty amazing!

 

It is - that what was going to happen to me as my brother had idiopathic hepatitis and required a transplant. I was potentially going to be his living donor. Fortunately despite our rarer blood type a match was found instead.

 

He is actually over in Britain - we are duel citizens.

[Atreides]

Contraindications to renal transplants include:

- cardiopulmonary insufficiency

- morbid obesity

- peripheral and cerebrovascular disease

- tobacco abuse

- hepatic insufficiency

- other factors that increase the risks associated with major surgical procedures

 

As well, contraindications to immunosuppression also apply such as current infection or recent (previous 2-5 years) malignancy and uncontrolled HIV.

Poor social support, substance abuse, and intractable financial problems can compromise post-operative management and may also be taken into account.

(E-medicine, http://emedicine.medscape.com/article/430128-overview)

 

Thus if a patient was elderly but passes basic pre-transplant studies to allow for transplantation they would be allowed to have a transplant, but age may make them less likely to pass these studies.

[Atreides]

I know that age is considered for lung transplants, but mainly because advanced age increases the liklihood for co-morbidity and reduces survival chances. We learned in class that they evaluate lung and heart function, look at co-morbid conditions, and whether the patient currently smokes before allowing lung transplants.

[Illuminis]

I would consult each patient, learn more about their backgrounds and lifestyle, what they understand about their situation, and how badly they desire the transplant. Perhaps the man will agree to wait a bit longer.

 

However, chances are that naturally, they would both express the highest level of desire to get off dialysis. In which case, I would decide to give it to the girl due to a higher chance of successful operation, and allowing her to live more normally during those precious years as she pursues an education and secures a future. It is not a matter of life and death, but of freedom from dialysis. Helping the girl will maximize the potential usefulness of the kidney.

[rmorelan]

Out of curiosity, does anyone actually know how the really do select the candidate (maybe an advanced med student might know)? I mean there is probably very exacting formal rules, I don't think any doctor (at the very least there is a committee) decides these things. Something tells me that personal ethics actually has less to do with it that one might think and I am sure that committee at the very least must follow formal laws on the matter.

[Potter]

well,

I don't know the definite answer to the question from an upper med student perspective, but I do happen to be doing my MSc in transplantation rejection...and this is what I gathered from one experience.

 

I was lucky enough to be able to witness a heart transplant surgery, and it appears that there is some long winded "ranking" of perspective recipients. The case that I saw the patient was "4D" or something...(I believe there is a status 1, 2,3 4 with various letters as you get worse). Since the patient had become septic,the LVAD had failed they were intubated the patient received a very high "score" ranking them top of the list for their blood type. The first available heart with matching blood type was given to this patient as they were "top" of the list...aka about to die without it.

[rmorelan]

well,

I don't know the definite answer to the question from an upper med student perspective, but I do happen to be doing my MSc in transplantation rejection...and this is what I gathered from one experience.

 

I was lucky enough to be able to witness a heart transplant surgery, and it appears that there is some long winded "ranking" of perspective recipients. The case that I saw the patient was "4D" or something...(I believe there is a status 1, 2,3 4 with various letters as you get worse). Since the patient had become septic,the LVAD had failed they were intubated the patient received a very high "score" ranking them top of the list for their blood type. The first available heart with matching blood type was given to this patient as they were "top" of the list...aka about to die without it.

 

That is one very cool Msc topic! All of what you are mentioning here sounds very clinical and exacting. Doesn't sound like doctors are arguing from a ethically point of view here at all (which would make sense, can you imagine how exhausting it would be to constantly debating things like this).