How Do We Allocate Scarce Resources

The Ethical Challenges in Organ
Donation and Transplantation
8th Annual Bioethics and Palliative
Care Conference
Margaret Allee, RN, MS, MSN, JD
November 7, 2014
Margaret Allee, RN, MS, MSN, JD has
no relevant financial relationships to
disclose that would present a conflict of
Disclosure Slide
Participants will be able to:
 Identify the ethical principles associated with
organ donation/transplantation
 Describe acceptable and unacceptable criteria
for the allocation of scarce resources
 Explain why the application of ethical
principles is critical in the allocation of organs
The goal of saving an individual has to be
balanced against concern for the social
good and the wish to preserve such basic
values as:
- justice
- fairness
- human dignity
- bodily integrity
Organ transplantation depends on its very
existence on a unique trust between
society and physicians, and on the
willingness of ordinary people to share
their organs and tissue.
Transplantation is steeped in:
Religions and cultural values of atruism
Sacrifice and generosity
Political notions of: community
shared risk
social solidarity
But there are also deep contradictions
“Organ transplantation is both lifesaving
and death-ridden. The so-called gift of
life most often demands a counter gift, a
‘gift of death’ from the donor or his or
her next of kin.”
Renée Fox
Behind the death-defying scenes of
transplantation is a life and death
struggle for scarce organs.
The Gap between Ideology
and Practice has widened:
Tissues and organs can be bought and sold in
some parts of the world
Proposals have been made to allow financial
compensation for donors or their families
There are inequities in access to transplant
medicine and in regional distribution of
Living donation is at the forefront, but not
without risk and unnecessary deaths
Organ Availability
Patient Access
Prisoners and Transplant
Organ Trafficking
Medical Errors and Truth Telling
Therapeutic Cloning
Allocation of Scarce Resources
There are not enough organs available to
meet the current demand
And there is controversy in how the
limited number of organs should be
Patients die - Ethical issues arise out of desperation to
prevent death occurring
How do we Allocate Scarce
Who shall live?
Who shall decide?
Definition of Scarce Resources
Resources or “the use of resources that,
because of naturally limited supply or
economic constraints, are not readily
available to all who need them.”
Council on Ethical & Judicial Affairs
American Medical Association
Traditional medical practice has its
foundation in the principles of doing no
harm, acting for the good of patients and
caring for all of those who come in need
The ethical practice of allocation of scarce
resources, may require the thoughtful
practitioner to violate these central moral
Acceptable Criteria for
Resource Allocation
1. The likelihood of benefit to the patient
2. The impact of treatment in improving the
quality of the patient’s life
3. The duration of benefit
4. The urgency of the patient’s condition
(i.e.: how close is the patient to death)
5. The amount of resources required for
successful treatment
Each of these five criteria serve to
maximize the following three goals of
medical treatment:
1. Number of lives saved
2. Number of years of life saved
3. Improvement in quality of life
Likelihood of Benefit
Giving priority to patients with a greater likelihood
of benefiting from treatment is necessary for any
efficient use of medical resources
- Maximizes number of lives saved as well as
length and quality of life
- Care that has a low likelihood of benefit
must be distinguished from care that is truly
futile (care that cannot be expected to have
any physiologic benefit)
Change in Quality of Life
Benefit to patient will be maximized if
treatment is provided to those who will
have the greatest improvement in
quality of life
Deciding on a standard definition is
dependent on patient individual values
Focus on functional status allows for
objective measure of QOL
Duration of Benefit
The length of time a patient benefits from
treatment can, in certain situations, be an
appropriate consideration in maximizing overall
- Limited to life expectancy but not an
absolute consideration
- Based on patient’s own medical history
and prognosis, not aggregate statistics or
membership in a group
Urgency of Need
Prioritizing patients according to how long they can
survive without treatment can help achieve the
goal of maximizing the number of lives saved,
depending on type of resource involved
- Important consideration but must be tempered
with other criterion
- Preventing death (by treating urgency first)
should generally be given priority in
allocation decisions
- But not if the life saved would be of extremely
poor quality or extremely short duration
Amount of Resources
On occasion - assigning higher priority to
patients who will need less of a scarce
resource maximizes the number of lives
Inappropriate Criteria for
Resource Allocation
Often used, but considered ethically
1. Ability to pay
2. Contribution of the patient to society
(social worth)
3. Perceived obstacles to treatment
4. Contribution of the patient to his or her
own medical condition
5. Past use of resources
Allocation Mechanisms
Should Be
- Objective
- Flexible
- Consistent
The need for the decision makers not to
be personally involved with patients
competing for a scarce resource
Requires decision makers to weigh
carefully all relevant facts of a case, and
not reflexively apply a blanket rule, such
as an age cap to all cases
Requires decision makers to consider the
same (appropriate) criteria, interpreted in
the same way, to ensure that all decisions
are fair to the patients involved
Three Basic Ethical Concepts
in the Allocation of Scarce Resources
- Utility
- Justice
- Autonomy
Utility holds that an action or practice tends
to be right if it results in as much or more
aggregate good than any alternative action
or practice
- It requires calculating the net benefit of
the use of a resource for each person
affected and summing the benefit over
the number of total persons affected
( Continued )
In rationing scarce medical resources, it is
morally imperative to consider medical
utility, understood as maximization of the
welfare of patients in need of treatment
Issues of allocation are, at their core, issues of
justice and distributive justice
- Being just is consistent with the principles of
 Moral Right
 Equality
 Fairness
( Continued )
Is a primary concept for the allocation of scarce
- A concept of fairness, proportionate to
needs, to ensure that all are treated equally
- It refers to fairness in the distribution of
benefits and burdens of an allocation
- But - What is fair?
( Continued )
“For decisions to be just the process by which
the decision is made must be a just one.”
Tony Hope
Journal of Medical Ethics, 2001, 27:179
Equal Access to Care
Equal access to care is based on the
concepts of equality and justice,
wherein all persons must be able to
compete on an equal footing for the
opportunities that society offers,
however, no rights are absolute
These rights are conditioned by the
presumptions that we, as individuals, have
no control over our genetic inheritance,
over our susceptibility to disease, or to the
way our organs function or the body reacts
to certain chemicals and conditions
Autonomy is seen as both a moral
principle and a psychological state
- Persons want to make their
own decisions and are,
thus, autonomous
( Continued )
If a resource, such as an organ,
becomes available and the person is
best-qualified by the principles of
utility and justice to receive the
resource (organ), and they decide to
turn the opportunity down for
whatever reason, they shall have
exercised the principle of autonomy
Clinical Considerations in
The concepts of Utility, Justice and
Autonomy are not without conflict
Utility Must Consider
 Patient survival
 Survival of the resource
 Psychological state of the patient
 Quality of life
 Age
 Availability of alternative treatments
Fairness and Justice Must Consider
 Medical urgency of the patient
 Likelihood of finding or accessing the
resource in the future
 Waiting times
 First versus repeat resource utilization
 Efficacy of the use of the resource
Autonomy Must Consider
 The issue of the right of the individual
to refuse the resource
 Free exchanges among autonomous
 Allocation of the resource - such as
through directed donation
 The voluntary behaviors of potential
In Summary
Decisions should respect individuality
Ethically appropriate criteria must be used
Decision making must be objective, flexible
and consistent
Patients need to be informed of criteria
Patients need realistic expectations

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