Ethical interview question

[rmorelan]

Irrelevant. And buying organs (directly or indirectly) is unethical and certainly illegal (directly).

 

Well you say it is unethical (I agree) but you cannot just throw that out why is it unethical?

[rmorelan]

Should this apply to all cases where the age difference is significant? i.e. Say a 65 year old who's been on dialysis for 15 or 20 years decides he wants to get a kidney transplant. Should a 45 year old who's only been on dialysis for 5 years get it first? Should we begin to withhold any type of medical care from elderly people and always give younger people priority when resources are limited? Or should older people get kicked out of hospital beds only to make room for younger patients?

 

Of note too is the organs don't last for ever - it is likely both of those people would outlive the organ

[future_doc]

Well you say it is unethical (I agree) but you cannot just throw that out why is it unethical?

 

If a donation of 300k gives you access to a transplant organ that would not otherwise be given to you, this is crossing the line. People with money then can buy their right to an organ b/c they have money and know what to do with it. Giving this money to a homeless shelter or a shelter for abused women would not get you that organ.

 

This unethical behaviour already exists in terms of getting moved up the waiting list for an operation. I know someone who needed a certain operation asap and he was schedule 6 weeks away. He then made a donation to a medical foundation to which the surgeon was close. Immediately after the modest donation ($2,000 - tax deductible), his operation was rescheduled to take place in 6 days!

 

I would not consider the $300,000 hospital donation in any way as a factor leading toward a decision as to whom receives the organ for transplant.

[Illuminant]

You seem very focused on just the resource issues - lets through another wrinkle, what if any particular one of them was able to donate 300K to the hospital (well in excess of the cost of treatment). What would you do now?

 

definitely give him/her the priority in receiving the liver. 300 k donation to a hospital can be used to innovate the technological equipments/lead to more hospital staff being hired -> all of these things will help many patients. Thus the benefit of the majority of patients > than the patient who didn't pay 300K.

[future_doc]

Taken to the extreme, a poor family might rob a bank to get 300k to donate to a hospital so their loved one might buy an organ transplant if your considerations apply. The robbery may resultin trauma, injury and death.

 

So, do we seek to do due diligence as how the donor came by 300k to donate? If the donor got the money as a result of unethical conduct or illegal conduct does it matter? Money giving preferred access is just not right.

[PhoenixFlare500]

Taken to the extreme, a poor family might rob a bank to get 300k to donate to a hospital so their loved one might buy an organ transplant if your considerations apply. The robbery may resultin trauma, injury and death.

 

So, do we seek to do due diligence as how the donor came by 300k to donate? If the donor got the money as a result of unethical conduct or illegal conduct does it matter? Money giving preferred access is just not right.

 

So what happens if the donor attained the money in a legitimate manner, even one that helped others along the way, and is then putting that money toward a good cause for just one thing in return? Take it to the other extreme, let's say each dollar that the donor raised saved a life, before it was donated. Will you accept their money?

 

Going on another point, will you even take the first donor's money in the first place? How bout the second? Does that make a difference?

[rmorelan]

If a donation of 300k gives you access to a transplant organ that would not otherwise be given to you, this is crossing the line. People with money then can buy their right to an organ b/c they have money and know what to do with it. Giving this money to a homeless shelter or a shelter for abused women would not get you that organ.

 

This unethical behaviour already exists in terms of getting moved up the waiting list for an operation. I know someone who needed a certain operation asap and he was schedule 6 weeks away. He then made a donation to a medical foundation to which the surgeon was close. Immediately after the modest donation ($2,000 - tax deductible), his operation was rescheduled to take place in 6 days!

 

I would not consider the $300,000 hospital donation in any way as a factor leading toward a decision as to whom receives the organ for transplant.

 

Sure but from an ethical point of view you didn't really answer the question (yes I am being picky but that is the point of the thread I guess - hopefully not in an annoying way). In terms of the standard ethical frameworks we apply, why is it not in your mind an ethical thing to do?

 

So far you have basically just said you don't like it therefore it is wrong. That isn't enough of a structure to fully answer the question I think. What are the negative consequences you foresee?

[rmorelan]

So what happens if the donor attained the money in a legitimate manner, even one that helped others along the way, and is then putting that money toward a good cause for just one thing in return? Take it to the other extreme, let's say each dollar that the donor raised saved a life, before it was donated. Will you accept their money?

 

Going on another point, will you even take the first donor's money in the first place? How bout the second? Does that make a difference?

 

ha I like it - probing questions is one of the best ways of preparing for ethics questions.

 

Phoenix and Illuminant are arguing along utilitarian lines - the optimal arrangement of resources to help the most people/help them the most is the correct ethical choice by that school of thought. You run into utilitarianism all the time in medicine as an argument. Knowing the flaws in such a position is really important to both the understand why you might oppose that way of thinking, or how to reduce the impact any weaknesses might have if you support it and thus make your position stronger.

 

Let's make it real - that 300K can be used to pay for an ophthalmologists OR time for say 4 months (about right if I recall - that is additional costs over not having that run, not the absolute sunk cost). That would restore the sight to say 100 people and by ripple down effect cut for years the wait list for such surgeries and help hundreds more.

 

It could allow be used to run a community support program for quite a while to reduce/prevent drug use that lead to the second liver failure in the process and potentially remove the need for multiple liver transplants down the road for others, freeing those future organs up for other patients. For those programs 300K goes a very long way (to start with the government would match it and so on).

[Robin Hood]

Just curious to what your responses are, but what would you do if two individuals needed a liver transplant, and one individual is an alcoholic and/or drug abuser and the other a hard working middle class citizen that does not abuse drugs and/or alcohol, but has been diagnosed with cancer. Who would you give the transplant to granted you only have one liver? One of the individuals will die if they don't receive the transplant. The individual that has a history of abusing drugs pleads that he is wanting to change his life around and he can only do that if he recieves the transplant.

 

First, let's start by saying that all human beings have the same value, and that as physicians, we should treat them such.

As for the question, before giving a definite answer, some stuff need clarification.

Do both individuals risk death if they don't get the transplant? If only one risks death, then the liver should go to the one who risks death. If not, then my answer will depend on many factors:

Which has more people depending on him?

Which one has the best chance of survival?

I need information about this before giving an answer.

As for drug abuse, it's not relevent since physicians are not there to judge people.

[Porsche]

Should this apply to all cases where the age difference is significant? i.e. Say a 65 year old who's been on dialysis for 15 or 20 years decides he wants to get a kidney transplant. Should a 45 year old who's only been on dialysis for 5 years get it first? Should we begin to withhold any type of medical care from elderly people and always give younger people priority when resources are limited? Or should older people get kicked out of hospital beds only to make room for younger patients?

 

The exception would be if the elderly person has been on the wait list for a long time, I don't think it would be right for the hospital to a younger individual if they just walked through the door. The only time I think that younger people should take priority over the elderly is if they both come in at the same time. With these organs being so scarce, I think it's best to give it to the person who will have the chance to utilize it the most. Is this a sound argument or is it unethical? With only one organ and the only factor that separates two patients is age, wouldn't it make sense to give it to the younger person?

[Porsche]

First, let's start by saying that all human beings have the same value, and that as physicians, we should treat them such.

As for the question, before giving a definite answer, some stuff need clarification.

Do both individuals risk death if they don't get the transplant? If only one risks death, then the liver should go to the one who risks death. If not, then my answer will depend on many factors:

Which has more people depending on him?

Which one has the best chance of survival?

I need information about this before giving an answer.

As for drug abuse, it's not relevent since physicians are not there to judge people.

 

I agree that all people should be treated equally. I also agree that we should factor in who has more people depending on that person. However, I do disagree with your last point. You said that you would factor in the chance of survival of each individual if given the transplant, but then you go on to say that we should not judge the drug/alcohol addict. Don't those two ideas counter on another? Wouldn't the individual that does not abuse drugs or has no history of abusing drugs have a better chance at survival? If you give the liver to the drug addict, and the next day he starts snorting cocaine, then was is worth it?

 

Don't get me wrong, I think that we should look for very good, solid reasons as to why the drug addict should receive the transplant (i.e. we shouldn't judge right away), but when it comes down to it, as good of a person they may be, if I have one organ, shouldn't the organ be given to, as you said, the individual that has the highest chance of survival?

[PhoenixFlare500]

Let's make it real - that 300K can be used to pay for an ophthalmologists OR time for say 4 months (about right if I recall - that is additional costs over not having that run, not the absolute sunk cost). That would restore the sight to say 100 people and by ripple down effect cut for years the wait list for such surgeries and help hundreds more.

 

It could allow be used to run a community support program for quite a while to reduce/prevent drug use that lead to the second liver failure in the process and potentially remove the need for multiple liver transplants down the road for others, freeing those future organs up for other patients. For those programs 300K goes a very long way (to start with the government would match it and so on).

I'll take a stab at this.

 

I'd take the 300k from the rich guy and move him up enough in the waitlist so as to not directly cause someone's death, but also to benefit him. First I'd have to figure out the average time between movements on the waitlist i.e. how often do you come across a viable liver? I'm sure the time is quite variable, so you'd look at the average (median gets rid of any outliers, if the mode is strong enough you might take that instead). Then look at the people on the waitlist, they should generally be prioritized by the order as well as the urgency of their situation (as far as I know anyways, could be wrong).

 

Take the rich guy and move him up to as high of a spot as you can so that you can give him a better chance of survival, while keeping the more urgent cases near the top that need to stay up there to have a chance of living. If the donor's situation is also urgent, make it clear to him that you can't sacrifice someone's life for his just because he's more wealthy, tell him that you'll still move him up and that it's his call to make on whether or not he still wants to give the money or not. On a side note, you can use this time to let him know what kind of benefit his donation will have on others, so even if the worst does happen and he doesn't make it, he'll still make a huge difference to other patients.

 

Now this makes you wonder, how much money do you have to donate in order to get moved up? Should the amount of money you donate to a hospital correlate with the number of spots you move up a waitlist? I'd set some kind of limit, i.e. you have to donate this much to get moved up in the first place. No kind of correlation. You cannot donate your way to the very top, we place you as stated above. I'd set a limit to the number of these types of "donations" per time frame e.g. only one a month, or maybe set different positions on the list e.g. this guy can get moved up to 10th place, after that the next guy can only get moved up to 15th, something like that. That way you don't have loads of rich people pushing poor people down waitlists.

 

You'd also want to look at the rich guy's health, like if he's expected to die in 2 months you're not going to move him all the way just to get a new liver (then again you could move him up as above, knowing there's a huge possibility he won't be taking a liver away anyways, and your hospital would just get free money, but that would basically be lying to him, so unethical). If the donor turns out to be a raging alcoholic/drug user (which he kept secret from you because you didn't look at why he needed a new liver in the first place, or maybe he decided to take it up recently) and three months later needs a new liver, that's not gonna happen.

 

Then you can take the guy's 300k or whatever he's donating, and put it towards some kind of program that would benefit other patients. In order to minimize the amount that you're essentially screwing over the other people on the waitlist, I'd want to put it towards some program that would benefit them, something that improves their treatment or maybe fund some kind of donor program. Overall you'd want some kind of net benefit, you don't want some guy getting a new liver because he's rich, but because it's going to help more people down the line.

 

I'm sure I missed some points which is where you guys come in.

[PhoenixFlare500]

As for drug abuse, it's not relevent since physicians are not there to judge people.

I can pretty much guarantee if you give a liver to a known drug user that's going to run through this new liver like a hot knife through butter, even if he's younger, instead of an older guy that could also greatly benefit from it (probably more since like rmorelan said he could outlive the span of the liver and not destroy it), someone's gonna have a fit if they find out.

 

The older patient that you just reduced to less worth than a drug user (that's how they'll see it) is not going to be very happy with you, also their family.

 

The donor's family, if they find out, will think that the donor died for nothing and you wasted their life, after wasting the family's time by pleading with them to take their dead family member's organs to use for a guy that's just gonna waste their life anyways.

 

If the news finds out then it's just gonna raise a huge debate about this, and they're probably going to paint you and your hospital in a very bad light and your donor program may suffer (people and families may stop signing their organs away).

 

All this aside, I'm pretty sure drug users and known alcoholics aren't eligible for transplants anyways (for these reasons so maybe that's not all these things aside).

 

Edit: Sorry I guess your point is correct in that we shouldn't judge people for their lifestyle choices if we're treating them, but in this case the drug abuse or alcoholism is directly relevant to the liver that is the focus here.

[Porsche]

So what happens if the donor attained the money in a legitimate manner, even one that helped others along the way, and is then putting that money toward a good cause for just one thing in return? Take it to the other extreme, let's say each dollar that the donor raised saved a life, before it was donated. Will you accept their money?

 

Going on another point, will you even take the first donor's money in the first place? How bout the second? Does that make a difference?

 

I think the politicians that govern the United States are a prime example of just why money should no be involved (regardless of the amount). There is a huge ordeal right now in the U.S. where a candidate running for some type office (i.e. governor or president) will have their election highly dependent how much money he/she can raise. Where does the money go to? It goes towards making ads against your opponent. The more opportunity that you have to convince people why you should be elected (and the other person shouldn't) will ultimately lead to your election.

 

Now you can donate to the campaigns of these politicians in an effort to support them. You can donate $5, $10, $100, $1000, etc. What about the people who donate in the hundreds of thousands or even millions? There is no way in hell that anyone that donates hundreds of thousands of dollars or millions of dollars to a politicians campaign is doing it for the "good of the country". There is a huge financial incentive to essentially "buy off" a politican so that you can have legislation passed in your favour. Last time I checked, the return that a corporation receives once they have bought a politician is 200%. That's a huge profit.

 

The same idea holds true here. It doesn't matter where you get the money or where the money goes. It's pretty obvious why someone would all of a sudden find it in the goodness of their heart to donate $300,000 right when they need a transplant. What if the other person doesn't have $300,000 to donate?

 

Even if the money doesn't directly go to any one person, it always finds it way to indirectly influence people. As soon as you bring money into it, everything goes to ****. This is where empathy comes in (what would it be like to be in the other persons shoes?). What if you were the person that couldn't afford to donate $300,000 to receive a transplant? This is not, and should not be, a "I scratch your back you scratch mine" situation. I assume that the longer it takes to receive a transplant, the worse the paitents condition gets. If you have a waiting list of 25 people, and 24 of the 25 people can donate excessive amount of money, why should the guy at the end get screwed?

If this person really cares about a certain organization, they shouldn't need the incentive to move up on a wait list to donate.

[future_doc]

Sure but from an ethical point of view you didn't really answer the question (yes I am being picky but that is the point of the thread I guess - hopefully not in an annoying way). In terms of the standard ethical frameworks we apply, why is it not in your mind an ethical thing to do?

 

So far you have basically just said you don't like it therefore it is wrong. That isn't enough of a structure to fully answer the question I think. What are the negative consequences you foresee?

 

Well, it is a slippery slope if “social values” are considered. We do not all agree on what our social values are, they can be subjective and arbitrary in interpretation and, in my view, they should not be part of the equation, should not be a consideration. A woman on welfare living in a poor area who saves children from drugs and gangs by keeping them engaged in worthwhile activities and ensuring they keep up in their school work is benefiting the community, likely saving lives and preparing these kids to be productive, good parents and role models. The ripple effect of her contribution to society is endless. Who is to say a person making a 300k contribution to a hospital has a more worthy life such that an available liver should be given to this person in priority to the woman on welfare?

 

We can have a philosophical discussion on criteria such as utility (best use) and equity (treat everyone fairly).

[Robin Hood]

I agree that all people should be treated equally. I also agree that we should factor in who has more people depending on that person. However, I do disagree with your last point. You said that you would factor in the chance of survival of each individual if given the transplant, but then you go on to say that we should not judge the drug/alcohol addict. Don't those two ideas counter on another? Wouldn't the individual that does not abuse drugs or has no history of abusing drugs have a better chance at survival? If you give the liver to the drug addict, and the next day he starts snorting cocaine, then was is worth it?

 

Don't get me wrong, I think that we should look for very good, solid reasons as to why the drug addict should receive the transplant (i.e. we shouldn't judge right away), but when it comes down to it, as good of a person they may be, if I have one organ, shouldn't the organ be given to, as you said, the individual that has the highest chance of survival?

 

What I meant by not judging (I should have clarified more) is that we shouldn't discriminate based on whether he was a drug abused and the other was a hard-worker. We shouldn't say: you're a drug/alcohol abuser, then it's your fault, we won't treat you. But I agree about what you said. The abuser said he will change, but most likely, he won't, and since we ant the recepient is the one who will benefit more from the transplant, then we should not give the abuser the liver unless we can make sure s/he will not abuse and waste the liver for nothing.

[Legion]

I'll take a stab at this.

 

I'd take the 300k from the rich guy and move him up enough in the waitlist so as to not directly cause someone's death, but also to benefit him. First I'd have to figure out the average time between movements on the waitlist i.e. how often do you come across a viable liver? I'm sure the time is quite variable, so you'd look at the average (median gets rid of any outliers, if the mode is strong enough you might take that instead). Then look at the people on the waitlist, they should generally be prioritized by the order as well as the urgency of their situation (as far as I know anyways, could be wrong).

 

Take the rich guy and move him up to as high of a spot as you can so that you can give him a better chance of survival, while keeping the more urgent cases near the top that need to stay up there to have a chance of living. If the donor's situation is also urgent, make it clear to him that you can't sacrifice someone's life for his just because he's more wealthy, tell him that you'll still move him up and that it's his call to make on whether or not he still wants to give the money or not. On a side note, you can use this time to let him know what kind of benefit his donation will have on others, so even if the worst does happen and he doesn't make it, he'll still make a huge difference to other patients.

 

Now this makes you wonder, how much money do you have to donate in order to get moved up? Should the amount of money you donate to a hospital correlate with the number of spots you move up a waitlist? I'd set some kind of limit, i.e. you have to donate this much to get moved up in the first place. No kind of correlation. You cannot donate your way to the very top, we place you as stated above. I'd set a limit to the number of these types of "donations" per time frame e.g. only one a month, or maybe set different positions on the list e.g. this guy can get moved up to 10th place, after that the next guy can only get moved up to 15th, something like that. That way you don't have loads of rich people pushing poor people down waitlists.

 

You'd also want to look at the rich guy's health, like if he's expected to die in 2 months you're not going to move him all the way just to get a new liver (then again you could move him up as above, knowing there's a huge possibility he won't be taking a liver away anyways, and your hospital would just get free money, but that would basically be lying to him, so unethical). If the donor turns out to be a raging alcoholic/drug user (which he kept secret from you because you didn't look at why he needed a new liver in the first place, or maybe he decided to take it up recently) and three months later needs a new liver, that's not gonna happen.

 

Then you can take the guy's 300k or whatever he's donating, and put it towards some kind of program that would benefit other patients. In order to minimize the amount that you're essentially screwing over the other people on the waitlist, I'd want to put it towards some program that would benefit them, something that improves their treatment or maybe fund some kind of donor program. Overall you'd want some kind of net benefit, you don't want some guy getting a new liver because he's rich, but because it's going to help more people down the line.

 

I'm sure I missed some points which is where you guys come in.

 

 

1) Will you tell other patients that someone who is donating a large sum of money is moving up the waitlist ahead of them? If so, how will you convince them? Do you think consensus is necessary? If not, wouldn't that be withholding treatment in an unethical manner?

 

2) By setting a pay scale which correlates with the number of spots a donor will move up the waitlist, aren't you indirectly (or directly) giving preference to a rich person over someone who is not? Sure you can make use of that money to provide a program or better treatment option for other patients, but would this justify your unethical withdrawal of treatment from patients by moving the donor up on the waitlist?

[PhoenixFlare500]

1) Will you tell other patients that someone who is donating a large sum of money is moving up the waitlist ahead of them? If so, how will you convince them? Do you think consensus is necessary? If not, wouldn't that be withholding treatment in an unethical manner?

 

One system to get around this is to tell people a general part of the waitlist they're in (kinda like some med schools) e.g. thirds, quarters. This way you can always re-prioritize people as you see fit and then fit in this type of donation stuff. I would not tell people if they were moved down. As far as I can see this, saying that this is withholding treatment in an unethical manner doesn't really apply here because you're treating someone else. That could be like saying if you only had the opportunity to treat one out of two people that came into emergency, you're withholding treatment in an unethical manner from the other, which isn't really how it is. What you're doing is just allocating the limited resources that you have.

 

2) By setting a pay scale which correlates with the number of spots a donor will move up the waitlist, aren't you indirectly (or directly) giving preference to a rich person over someone who is not? Sure you can make use of that money to provide a program or better treatment option for other patients, but would this justify your unethical withdrawal of treatment from patients by moving the donor up on the waitlist?

I guess I didn't emphasize this point enough but you'll notice a small sentence in my answer that says there will be no kind of scale that correlates with the number of spots a donor will move up. Instead you're going to try to benefit as many people as possible as in the first paragraph, but only do this every so often.

[Mourning Cloak]

As for drug abuse, it's not relevent since physicians are not there to judge people.

 

Of course it is. Not that a pre-med would know this in the interview, but for an addict at least 6 months of abstinence from drugs and/or alcohol is a pre-requisite to be considered for transplant.

 

Similarly, in most cases, cancer (except for localized HCC) is also a contraindication to transplant. Steve J. notwithstanding.

 

So both of these guys may be ineligible (depending on the particular circumstances of the story).

[Robin Hood]

I will take a shot,

 

I will give the liver to the hardworking middle class person due to the fact that this individual proved to be hardworking and benefiting society. The other person, who also receive my compassion, will not receive the liver because he could be promising me that he will change his life just so that he would be able to survive. There is 50/50 chance that this person could either stop being alcoholic/drug abuser or not change his life around. While the other person will most likely return to be a hardworking middle class person if he/she survives.

 

Evaluate my answer -> is it good or bad?

 

Physicians are not here to judge whether you were hardworking or not, they don't judge your lifestyle. Their only concern is your health.

The abuser has little chance of stopping his abuse, so giving him to liver could be useless.

But we should also know the chance of survival of the guy with cancer, and whether the transplant can negatively affect his state.

[Robin Hood]

If this person is going to change, then he will be receive the liver as opposed to the other person. The other person have cancer, and so a chemotherapy treatment will cost the hospital's resources. The death of this person is in the interest of maintaining the finite resources of the hospital.

 

 

I never knew any of that, thank you!

 

As physicians, we shouldn't treat human lives on a monetary basis. Also, medical decisions should be based benevolance, by looking at how much we save money, we are not doing this, we are looking as selfish. Also, the patient with cancer didn't ask for chemotherapy, and if he asks and the hospital can't really afford it, they can send him to another hospital.

[Robin Hood]

Should this apply to all cases where the age difference is significant? i.e. Say a 65 year old who's been on dialysis for 15 or 20 years decides he wants to get a kidney transplant. Should a 45 year old who's only been on dialysis for 5 years get it first? Should we begin to withhold any type of medical care from elderly people and always give younger people priority when resources are limited? Or should older people get kicked out of hospital beds only to make room for younger patients?

 

It's somehow tricky. Physicians' concerns should be the chance of survival, not age. If you have to choose for a treatement (barring all other complications) between someone who's 70 and healthy, and someone who's 20 but who has terminal cancer, you would chose the guy who's 70 simply because his chance of survival are higher than the guy who'se 20.

But the issue is when you have a 70-years old and a 45-years old who are both healthy. The younger guy has more chances of surviving more than the old one, but then we would be in a systemic discriminatory system, and physicians shouldn't discriminate on the basis of age. That's a tricky situation.

[Robin Hood]

Well you say it is unethical (I agree) but you cannot just throw that out why is it unethical?

 

Organs should go to who needs them the most and have a better chance of benefitting from them, not to the one who'se richer.

[DR.OK]

You seem very focused on just the resource issues - lets through another wrinkle, what if any particular one of them was able to donate 300K to the hospital (well in excess of the cost of treatment). What would you do now?

 

The buying and selling of organs and tissues, if it became widespread, would undermine the altruism (giving motivated by love) and social bonding now associated with transplants. It could also lead to organs going to the highest bidder. Equity would be violated with ability to pay rather than medical need determining the distribution of organs. However, this could be controlled by regulating sales, and that totally forbidding the buying and selling of human tissues and organs would drive the market underground. Because of the controversy and ethical problems surrounding the buying and selling of human body parts other alternatives should be pursued to increase the supply.

[Robin Hood]

definitely give him/her the priority in receiving the liver. 300 k donation to a hospital can be used to innovate the technological equipments/lead to more hospital staff being hired -> all of these things will help many patients. Thus the benefit of the majority of patients > than the patient who didn't pay 300K.

 

But then, poor people should be kicked out of the hospital and left to die.

Also, physicians should deal with human beings on an utilitarian way, every human being should be given the same concern. Human lives are invaluable.