Do you always needs to choose a side?

[Corsci]

Example:

 

Two patients need a liver transplant, but there is only one liver available at the time. Tell the interviewer how you would decide between:

a) a 64-year old retired politician who happens to be an alcoholic, or

a 26-year old mother of three who is on welfare.

 

 

With respect to this question and similar questions, is it crucial to actually make a choice? Or just explain how you would come to the decision. When I approach these questions I consider factors that I would take into account but they don't necessarily lead to a choice, since I would consider other factors that there is no information about in the question like: benefit, immediacy of need etc.

[future_doc]

The fact that someone is on welfare is entirely irrelevant and to think otherwise would show unhealthy prejudgment. The mother is young, carrying the responsibily of three young lives who will be future productive contributers to society provided they are not deprived of a nurturing and loving mother, which I take as a given. The other candidate is significantly older and an alcoholic that likely will lead to a poor outcome. So, I would choose the mother without any difficulty.

 

I do not know whether we are required to make a choice, but I would definitely make a choice and defend it. Doctors make choices, they don't simply give options. I think, to a degree, this is ducking the main issue.

[Lactic Folly]

Well, your question was phrased as "how you would decide," not "what you would decide," so I think it would be reasonable to start out by giving your approach. Afterwards, they may well ask you to choose.

[runningdoc]

Well your reasoning for "how you would choose" would most likely lead you to making a choice.

 

Weigh the pros and cons of each individual (even if there are only cons for an individual in your mind) and then you should probably be able to come out with an answer.

 

My guess is that there is no true "correct" response to a question providing you give reasonable justification for your answer - and that it follows a form of logic in relation to medical ethics.

[A-Stark]

Alcoholics don't go on transplant lists.

[future_doc]

Well, your question was phrased as "how you would decide," not "what you would decide," so I think it would be reasonable to start out by giving your approach. Afterwards, they may well ask you to choose.

 

Point taken! Thank you.

[shannn]

Alcoholics don't go on transplant lists.

 

This ......

[aKGDH]

^ You should also know the reason why.

 

 

@OP: But generally, I think that you should always take a side (since the question is likely asking you to choose a side and you MUST answer the question), but present both viewpoints in an ethical argument. You need to show that you have considered the entire situation from all angles before making an ultimate decision.

 

For example: Should it be mandatory for all physicians to practice for at least 1 year in a rural setting? Pros and cons of situation and then your answer (which should be no, since you don't want to be telling a panel of doctors/doctor-in-trainings that they must be 'forced' to go here and there).

[Wingblast]

For this case, you do not need to choose a side because a liver can be divided for two transplants for both patients. This is the unique power that liver has as it can self-regenerate if divided into a certain size.

 

However, if you answer the question this way, there's always the tendency for the interviewer to modify the question a bit by saying 'ok, what if they had kidney problems and there's only one kidney available for transplant and you can't divide the kidney!' Then you will have to choose a side..

[bloh]

You should never answer a question by ducking under a technicality.

[runningdoc]

For this case, you do not need to choose a side because a liver can be divided for two transplants for both patients. This is the unique power that liver has as it can self-regenerate if divided into a certain size.

 

It can, however it is very rarely done for two adults. It's more of an Adult + Paediatric procedure. And given the alcoholism + dependents factors, it would be more than an unlikely procedure.

[Guest viscous]

One's alcoholism and other's dependance on welfare should not matter when we have to decide who should get the transplant. of course alcholism can have impact on the health conditions and that is the max I would go "against" the alcoholic. That he is "more likely" to damage his new liver if he continues with his habits. I would approach as:

 

1- One man should not be given a charge to decide whom to give the transplant, rather a committee should be involved. Absolute power corrupts absolutely. I never heard of a case where a single practicing doctor had to decide who should get an organ! I have not seen things working that way in Canadian hospitals ....

2- The person who donated the liver, did he/she have any wishes as to who should get the gift? or was it taken from some homeless and family-less person with no history.

3- An alcoholic should not be discriminated from getting a liver jsut because he is an alcoholic and he purposely destroyed his liver, could be that he was in severe depression and his alcoholism resulted from his incompetence, can we still blame him for being an alcoholic?

4- depending on the severity of conditions of both patients, it would have to be decided on medical and scientific grounds which patient would benefit the most from the transplant? Which patient's body is more likely to reject the organ etc.

 

I am not sure if I would tell them my choice but I will outline the process. If I had to make a choice, it depends on who will get the most benefit as deduced from contemporary scientific knowledge. And I cannot make that judgment without any data. Could be that young women's body is more likely to reject the liver, if we know that, would we really put the alcoholic in jeopardy just because we have a stereotype against alcoholics?

 

If forced to make a choice when not all the data is available, Id say that the woman should be given the liver because she needs to take care of three kids who are dependent on her and without her, their lives would be put at risk as well or at least they will become parent-less if she dies which is not a desirable outcome.

[aKGDH]

^ The question is really not that complicated. The alcoholic does NOT get the liver. It is not because he 'deserved' liver problems because of his alcoholism, but rather studies have shown that someone who is currently an alcoholic or was in the past 3 months (I think it's 3 -- correct me if I'm wrong), may damage the new liver with his lifestyle/habits. Thus it is required that alcoholics by abstinent for a certain period of time before they may be considered suitable candidates for a transplant. During this time, the liver may even recover enough such that a transplant is no longer needed.

 

By not giving the alcoholic a new liver, physicians are not discriminating against him. Rather, they are choosing to preserve life that has a higher chance of being preserved.

 

 

Also, when asked these kinds of questions, you MUST give an answer. What's worse than giving the wrong answer is being ambivalent and not answering the question at all. Pick a side, stick with it. Hope it's the 'right' side.

[rmorelan]

I believe that on any ethics question on the actually interview it will be incredibly unlikely that there is a simple "shortcut" answer (ie divide the liver in two, or one person is automatically unable to have it, ie due to use of alcohol). There will be two sides, there likely isn't a right answer, you will have to present how you are deciding what you do, and thus likely what you would decide.

[Guest viscous]

^ The question is really not that complicated. The alcoholic does NOT get the liver. It is not because he 'deserved' liver problems because of his alcoholism, but rather studies have shown that someone who is currently an alcoholic or was in the past 3 months (I think it's 3 -- correct me if I'm wrong), may damage the new liver with his lifestyle/habits. Thus it is required that alcoholics by abstinent for a certain period of time before they may be considered suitable candidates for a transplant. During this time, the liver may even recover enough such that a transplant is no longer needed.

 

By not giving the alcoholic a new liver, physicians are not discriminating against him. Rather, they are choosing to preserve life that has a higher chance of being preserved.

 

 

Also, when asked these kinds of questions, you MUST give an answer. What's worse than giving the wrong answer is being ambivalent and not answering the question at all. Pick a side, stick with it. Hope it's the 'right' side.

 

That just supports my point. Without scientific knowledge of what are the requirements of a liver transplant, you cannot decide anything. From that perspective, asking this question to a pre-med on an interview and to expect a medically accurate answer is a bit naive. It seems to appear that even if a pre-med is asked such a question, it would be to see the thought process and the ability of the person to critically reason, than to expect a technically and medically sound answer!

 

As trivial as it might seem that an alcoholic must abstain for 3 months before getting a liver transplant, its a type of knowledge that I (and many non-medical students) would not have unless they majored in human physiology with an applied-sciences approach.

[aKGDH]

That just supports my point. Without scientific knowledge of what are the requirements of a liver transplant, you cannot decide anything. From that perspective, asking this question to a pre-med on an interview and to expect a medically accurate answer is a bit naive. It seems to appear that even if a pre-med is asked such a question, it would be to see the thought process and the ability of the person to critically reason, than to expect a technically and medically sound answer!

I'm not saying your answer was wrong or bad. I agree that demonstration of critical thinking is very important, but this question had a clear answer. Organ transplant and how priority is determined is not a trivial issue nor is it something someone would only know if they majored in physiology. It is something worth reading up on and knowing the basics, just like it's worth knowing the basics on Medicare in Canada and the legality of euthanasia. It is a question that is entirely fair game and in this case, there is a clear cut right answer.

[Guest viscous]

I'm not saying your answer was wrong or bad. I agree that demonstration of critical thinking is very important, but this question had a clear answer. Organ transplant and how priority is determined is not a trivial issue nor is it something someone would only know if they majored in physiology. It is something worth reading up on and knowing the basics, just like it's worth knowing the basics on Medicare in Canada and the legality of euthanasia. It is a question that is entirely fair game and in this case, there is a clear cut right answer.

 

Oooh, so you are telling me that we should know the details of, let's say, retinal surgery? Or vasectomy? So I am expected to know the procedures of incising the skin for a bypass? How thoughtful.

[rmorelan]

Oooh, so you are telling me that we should know the details of, let's say, retinal surgery? Or vasectomy? So I am expected to know the procedures of incising the skin for a bypass? How thoughtful.

 

that was my point before - you won't need to know that at all and there won't be a medically absolutely determinable answer. The question here from the OP does (that's true) but the one on an interview won't. Actually if you look for one you probably will also be wasting time on the interview not thinking about what you probably should be thinking about - which is ethics

[aKGDH]

Oooh, so you are telling me that we should know the details of, let's say, retinal surgery? Or vasectomy? So I am expected to know the procedures of incising the skin for a bypass? How thoughtful.

Are you being provocative on purpose? Don't be mad just because you happen not to know a piece of information that apparently others on this board do know.

 

Knowing the ethics behind organ transplant is perfectly fair for the interview. The point for this question is: The patient with the highest chance of survival gets the organ. I know there's nothing really ethical about that situation, but this question (@rmorelean) HAS come up on interviews before, so it's not entirely irrelevant. It's the same as knowing the ethics behind anything else, like abortion, euthanasia or having basic public health care knowledge, like health reform, private vs. public, doctor shortage in rural areas etc.

 

Claiming that the above is 'too specific' is not going to get you very far. You need to do research and prep for your interviews. Trying to get away with relying solely on critical thinking isn't enough.

[Guest viscous]

Are you being provocative on purpose? Don't be mad just because you happen not to know a piece of information that apparently others on this board do know.

 

Knowing the ethics behind organ transplant is perfectly fair for the interview. The point for this question is: The patient with the highest chance of survival gets the organ. I know there's nothing really ethical about that situation, but this question (@rmorelean) HAS come up on interviews before, so it's not entirely irrelevant. It's the same as knowing the ethics behind anything else, like abortion, euthanasia or having basic public health care knowledge, like health reform, private vs. public, doctor shortage in rural areas etc.

 

Claiming that the above is 'too specific' is not going to get you very far. You need to do research and prep for your interviews. Trying to get away with relying solely on critical thinking isn't enough.

 

well I agree with you on that. Critical reasoning alone would not be enough and facts pertaining to the ethical dilemmas have to be memorized.

 

The one with the highest chance of survival will get the liver. But how do you know the chance of survival of that woman is high, compared to that alcoholic, especially when we do not know about her immune system. It could be that her immune system is such that it would destroy the organ within months after the transplant while it would be relatively more stable in that alcoholic's body. Would you still insist on your interview that she get the organ just because from incomplete information regarding her body you deduced that she will have higher chance of survival compared to the alcoholic?

 

I am not being provocative, I am in search of the correct answer.

[rmorelan]

I see what you are saying! I guess I always initially derived my answers then from first principles. In my mind there are not specific knowledge required for any ethical question - you always have the same few things to worry about and the same framework to apply. Before the interviews I thought about all the basic ethical questions you mentioned, and applied those basic concepts etc. In this case if you apply the normal ones, say social justice (particularly here how we define all people as being equal), patient autonomy, beneficence, etc you really can only be left with giving the organ to the person most likely to survive with it - of course that is because the example is highly constructed I suppose that can be considered specialized knowledge - I personally always thought of it as just applying the rules but it can certainly be considered learned the standard responses as well! Maybe if it is thought in terms of a framework it could be more flexible in application to new areas?

 

You may not know which is the most likely to survive - my brother had a liver transplant where I almost was the living donor (so obviously I read up on the risk factors etc) and I can tell you there are a lot of them But what anyone can say based on what you said it is more likely the young women will have the best chance and unless there are some other health related factors you are not aware of that is the end of it. Just make sure for good measure that you can explain exactly why you made that choice based on the common ethical considerations.

[Star1234]

Example:

 

Two patients need a liver transplant, but there is only one liver available at the time. Tell the interviewer how you would decide between:

a) a 64-year old retired politician who happens to be an alcoholic, or

a 26-year old mother of three who is on welfare.

 

 

With respect to this question and similar questions, is it crucial to actually make a choice? Or just explain how you would come to the decision. When I approach these questions I consider factors that I would take into account but they don't necessarily lead to a choice, since I would consider other factors that there is no information about in the question like: benefit, immediacy of need etc.

 

The question asks you HOW you would decide between the two, and not necessarily WHAT you would decide. In the case of organ transplants, patients are placed on a transplant list and basically whoever is higher up on the list gets the transplant first. There are criteria as to who gets above who on the list based on:

 

1) the likelihood of benefit to the patient

2) the expected improvement in the patient's quality of life

3) the expected duration of benefit

4) the urgency of the patient's condition

5) the amount of resources needed for successful treament

6) the availability of alternative treatments

 

I think the point of this question is that you can't discriminate based on the fact that the 64 year old was a politician and may have had a bigger impact on society versus the mom on welfare. It comes down to justice in that everyone is entited to equal care regardless of their background. So if taking all the above criteria into account, if the 64 year old was higher on the transplant list, you have to give it to him even though your emotions might tell you otherwise.

[sv3]

Does having kids matter? When you make a medical judgement, do you consider people other than the patient? I don't know if this is allowed or encouraged so any insight would be appreciated from someone who knows the answer (we all have opinions but i am wondering if there are guidelines).

 

Basically, if you had two 26-year women - one with and one without three kids, are you telling me the one without kids would be penalized in the transplant lottery? So perhaps, we should all have kids as a safegaurd to up our chances of getting an organ should we need it? By now I guess you can see where I'd fall on the issue but I want to see if I am right or wrong.

 

I thought this was an easier question than most. I didn't think the kids or welfare thing matter, but the alcoholism was the most clear factor in terms of impact on health - and especially the liver. Then you can throw in age as the old guy will die sooner so the positive impact of the liver doesn't last as long. Sure the old guy could change his lifestyle and become "clean" but the odds of him relapsing trump the odds of teh women all of a sudden becoming a hardcore JAck's drinker.

 

anyway, again, if someone has info on the kids thing I'd like to hear it. cheers

 

PS (and no, i have no idea how to talk for 8 minutes on this stuff. I like getting to the bloody answer asap so this is going to be painful)