Chapter  16: The Allocation of Resources: Scarcity and Triage

When there are not enough resources to meet demand for a life saving resource, whether organs, materials or health care worker attention there is a condition fo scarcity and the decisions need to be made as to whom care will be given.  When the resource needed is life saving then you have a scarcity of life saving medical resources: SLMR.

In wartime and in military training of military personnel who render care the word used in prioritizing care is TRIAGE which has become common place now in health care settings.   What it the origin of the term and its use?  What are the devices used to indicate decision made on the prioritizing of care?  Please READ:  On Triage  And there is an article on the evolution of triage systems

Here is a presentation on the issue of shortage of needed resource as applied to organs needed for transplantation.   Summary by James Rowe, QCC, 2005 

Transplant Organs 

            Organ transplantation was one of the chief medical breakthroughs of the 20^th century and one of the most miraculous, offering those previously doomed to death a shot at life, and with survival rates each year climbing. However, undermining the effectiveness of organ transplantation is a systemic lack of organs and various other issues. A cursory examination of some of the main problems and issues of organ donation shall be organized under various subcategories: 

Costs:  

Organ donation is often prohibitively expensive, ranging from 40,000-300,000 dollars a year depending on the organ and other factors, as well as a yearly fee of 10,000-20,000 dollars for the immunosuppressive drugs that are needed in order to prevent the body from rejecting the organs, and which must be taken for the rest of the patient’s life. Due to this, questions arise as to what society ought to pay for.  

Availability: 

As mentioned in the first paragraph briefly, organ transplantation suffers from massive shortages of organs. In the last day of 1996, 50,407 people were on the waiting list for organs, with 30,000 new registrations during that year. For each organ transplanted, two more people are placed on the waiting list. Moreover, only those who need pancreases or kidneys can employ insulin or dialysis to “hold off” until a transplant, with those in need of other organs being incapable of lasting too long without receiving them. Ways whereby the supply may be increased are sorely needed, and considering the current state of affairs where 37-57 percent of the estimated 6,900-10,700 of potential donors do not become actual ones, a means whereby that percentage can be raise could help many.

Request and Consent Laws: 

In 1984 the federal Uniform Anatomical Gift Act has become a standard model for state laws regarding organ donation, with some states adopting a “required response” law which requires people to declare, when renewing their driver’s license, whether or not they want to be placed on the list of organ donors, with many further allowing such printing of that information on the back of driver’s licenses for ease. Moreover, state laws which correspond to the aforementioned acts also allow for an individual to donate any part of their body and even choose who it shall go to, be it a person or institution, and in 1997 a federal law mandated that organ donor cards be included with tax refunds. However, these reforms have not addressed the willingness (or lack thereof) of doctors asking family members whether or not they want to allow their newly dead relative to be cut up and harvested for organs, and owing to the fact that their permission is needed, even when an organ donation card is present, in almost all cases. This fact was illustrated when a 1991 federal appeals court ruled that an Ohio woman had had her property rights violated based on the 14^th Amendment’s due process clause, when a coroner had donated her dead husband’s corneas to the Cincinnati Eye Bank. In an attempt to overcome the physician’s resistance, a law in 1986 passed by the federal government requires all hospitals receiving Medicare or Medicaid payments (97 percent of all) to identify all patients who at death could become organ donors, with a further mandate forcing communication with the families about organ donation, although this has proved to only increase the supply of transplanted organs by 10 percent.

Non-Heart Beating Donors: 

The University of Pittsburgh has involved an approach whereby the patients or their representatives may ask to have their organs donated at the point of the heart stopping and not brain death. In practice this mostly impacts those who are brain dead and permission has been obtained by the families to go on with harvesting their organs. Critics charge that this practice does not take into consideration that the heart-stopping may not be the best way to determine death, as many times the patient may still be capable of resuscitation, as well as the fact that many mentally competent, but terminally or severely ill patients may be “pressured” into giving up their lives, as well as allowing too easy of a rationalization to allow coma patients to have the “plug pulled” by family members.

Organ Protection Before Consent: 

A new process involves sustaining organs of patients who died en route to the hospital or in emergency rooms via the introduction of various drugs and some surgical steps (but no removal of the organ) in order to assure the organs remain as healthy as possible until consent can be granted. Critics charge that it is possible that hospitals do not always make sure the patients are dead before attempting this technique and thus perhaps harm live patients, as well as others claiming this is against the dignity of the person as it is going beyond their consent in an invasive manner, even though they are dead, as well as there existing no moral principles universally held to account for what is proper or not to do to a dead body. Defenders counter that it allows families to recover a bit from the shock of a newly dead family member and thereby is more humane by not having to inflict upon them the cruelty of asking such a question when they are so freshly upset, that and taking these steps can obviously help us save other lives. To put the matter into further perspective as regards brain-dead people, each year 10,000-12,000 are declared brain-dead, with 60,000 each year requiring transplants. Needless to say, 10,000-12,000 more organs would provide a monumental boost to those who could be treated.

Organ Selling: 

Allowing compensation for organs may also boost organ supplies by making recourse to the profit motive through various avenues, including money to the families, tax credits, or legal guarantees that family members of donors would get priority should they require organs. The public, however, has responded negatively to any free market for organs, although it is possible that a government-regulated market may be less revolting to public sensibilities. However, in 1984 the National Organ Transplantation Act made sale of organs for transplant illegal, with 20 other countries having similar laws. However, one could conceive of a possibility for those still alive being able to sell their non-vital organs, such as one kidney or lung, although that would currently be illegal. Supporters of this notion all ready note that we are allowed to sell many other non-vital parts/products of our body, including sperm, blood, and bone marrow, so why not allow the sale of organs? The only problem may reside within the poor suffering the most from this. Moreover, since the National Organ Transplantation Act was instituted directly to stop similar practices, this is unlikely to be allowed. Wrapped up in this issue is also the fact that only the donor, and not anyone else involved in the process, is not allowed to be monetarily helped in anyway whatsoever, not even to help cover burial costs. Critics further note that it is simply better to appeal only to the “best” in people and to keep towards a practice of altruistic donation alone.

Presumed Consent:

In several European countries, a practice currently exists which forces the family to specifically ask that their dead relative’s organs not be donated or for evidence to exist that the person did not want the procedure to happen. Critics of this point to the fact that it has not proved to be that effective, specifically due to doctors being unwilling to participate in such a practice, as well as the fact that since families must be notified anyway under this (in order to allow consent to be given) system and owing to the time-consuming nature of this task and its difficulty, it is further unlikely that this really could work at all.  

Living Donors:  

Aside from full kidney and lung transplantation, some have suggested that using more liver and lung segments may be an extremely effective means of improving the organ supply. Owing to the fact that both the liver and lungs are capable of regenerating relatively rapidly from only parts, this would not even impose any real degree of risk on the part of the donors, and since kidneys have been shown to be better if taken from a live person as opposed to a cadaver, it is possible that this could be better, also. The chief objection to this is centred on the potentiality for “abuse” due to familiar pressures imposing upon individuals to go under the knife for their family members, with counterpoints to this argument noting that one can potentially solve this via devising a system capable of assuring proper consent.

Organ Allocation: 

The issue as to how organs ought to be allocated is, naturally, of vital importance. The typical manner to decide this employs a screening committee composed of surgeons, social workers, psychologists, doctors and nurses, which determine whether or not a candidate ought to be placed on a waiting list for an organ, with medical need being the only the first of many things to be considered, including general medical condition, age, the ability to pay, and other factors. Some larger centres of transplant have even devised a scoring system where values are assigned to what is considered relevant factors, with those with higher rankings getting priority on the waiting list, and if their conditions worsen, they may even be promoted on the list to reflect their need. Other centres do not formally participate in such systems.  

Once a patient is on a waiting list, the federally funded United Network for Organ Sharing’s (UNOS) rules for organ allocation apply. A recent change to these rules mandated transport to the person in the greatest need of the organ so long as it can be received in good condition no matter what region (of which there are nine) they are in, a practice which will likely lead to what amounts to a national waiting list. Critics of this policy note that this will likely close down many organ transplant centres due to all the organs going to the larger transplant centres, with supporters countering that the greater needs shall be met, as well as the fact that the smaller centres may be best to be closed, as they will not have as much experience with organ transplantation as the larger ones.  

The Massachusetts Task Force of Organ Transplantation unanimously issued a report with the following recommendations, which serve us as a prime sampling of a well formulated bunch of acceptable guidelines for allocation: 

1. Those that could benefit the most from organ transplantation, as regards probability of both rehabilitating and living for a long time, ought to be provided with organ transplantation. 

2. “Social worth” ought to not be a criterion. 

3. Age may not be the only factor considered, but may be included in considerations of life expectancy and possibilities for rehabilitation. 

4. If there aren’t enough organs for those in need and who could benefit the most, a random selection process should be instituted. 

5. The capacity to pay should be not considered an issue so long as it does not impact adversely the health-care services with a higher priority in New England. Non New Englanders ought to be accepted, however, only after demonstrating the capacity to pay without assistance. 

However, obviously not all transplant centres adhere to anything similar to these five points, as well as there being much debate as to what should be considered morally relevant in the considerations for organ donation. Many view “social worth” and money as being irrelevant, but others consider very relevant such things as drug abuse and poor health habits and support a general ban on anyone receiving organ transplants that would fall into such criteria.  

As a matter of ongoing concern, there is currently no successful conclusion to any of these issues on a whole.  

SOCIAL CONTEXT- Summary by James Rowe, QCC, 2005 

Implantation of Fetal Cells: 

            It is estimated that over 1.5 million people, most of them over 60, suffer from the degenerative brain disorder known as Parkinson’s disease. Affecting the substantia nigra, Parkinson’s disease affects the cells located in this region of the brain which produce the neurotransmitter dopamine which is used to convey the impulses to the brain cells that control muscle movements. In 1990, a radical new treatment for the disease employed the usage of fetal brain cells to replace the dopamine producing cells and thereby lead towards massive improvements in conditions. These fetal brain cells have an extremely low rate of rejection and are, in fact, more likely to be biologically compatible than cells from one’s own adrenal gland which is used in another form of treatment for the disease. A slew o f other conditions, including Alzheimer’s and Type-I diabetes, may also be cured through advances in this field, not to mention heart and spinal recovery possibilities. Yet since the procedure must harvest these cells from either dead embryos or kill the embryo in the process, ethical concerns immediately jumped to the forefront.

            Opponents of abortion levy the charge that allowing for harvesting of cells from aborted children only allows another rationalization for killing the babies, with others on both side of the debate being concerned over whether some women might deliberately conceive a child just to obtain the fetal tissue and perhaps even sell it to the highest bidder. Although this would be illegal under a 1988 amendment of the National Organ Transplant Act, success of these treatments might lead to a repeal, with some in support of this noting that fetal tissue should be considered analogous to bone marrow or sperm and thus perfectly fine to treat as a commodity. Even if never legalized, some also are alarmed by the potential for a black market in fetal cells to develop, much like a black market currently exists that supplies the world with drugs. Further criticisms centre on the potential for women to be exploited through the procedure, with familiar or monetary pressures “forcing” her into aborting her child for the cells. The Catholic Church condemns abortion, yet does allow for miscarried children to be harvested for their cells so long as they are treated with the same dignity of other organ donors and it is certain that the child is dead before the procedure begins, which is difficult as fetal brain dead standards are currently rather murky. Also, since the prime age for harvesting cells from a developing child is not yet known, women might be pressured to be kept pregnant longer than what would be prime for their health.

            Several solutions may be found to the above mentioned ethical dilemmas, including using only one embryo to extract a large amount of cells via growing the cells in cultures and replenishing those used for medicinal purposes through further growing. This would allow for many treatments to come from only one dead fetus instead of depending on many abortions. Moreover, the usage of miscarried fetuses may produce a good deal of fetal cells for use medicinally, but the matter is complicated as up to sixty percent of these babies show signs abnormalities which may lead to problems in anyone who was to receive tissue from them. A further possibility includes simply cloning cells from an individual patient to replenish what is missing in the body.

            In 1987, the Department of Health and Human Services suspended support of research projects employing fetal cells taken from abortions, but after two reviews of the matter, the National Institute of Health decided in 1988 that fetal tissue may be morally legitimate to use, with a suggestion made by the review panel that women be not permitted to donate fetal tissue to friends or family. However, although in April of 1989 the National Institute of Health following most of the recommendations by its panel, issued guidelines for experimental therapy and research of fetal tissue, the Bush (Sr.) administration continued the Reagan administration’s ban on the use of fetal tissue and federal funding was refused for human fetal-tissue implants, with seven states passing laws that forbade tissue research from aborted fetuses. Researchers objected to these bans, but their voices were unheard until President Clinton overturned the bans as one of his first official acts, and in January of 1994, the National Institute of Neurological granted 4.5 million dollar grants to three institutions to study fetal-cell implantation in Parkinson’s. Amongst the recipients were researchers at the University of Colorado, who having procured private funding during the time the federal ban was in effect,  injected fetal cells into sixteen Parkinson’s patients, with a third showing no improvement, another third showing some improvement, and the last third improving significantly.

            Owing to the extremely passionate debate over abortion in the United States, it is unlikely that the ethical concerns over this type of research will be resolved soon.

VIDEOS:

Organ Donation:

1. Organ Donation - Waiting for a Second Chance

http://www.youtube.com/watch?v=ahEUATK1_O0

2. Organ Donation - Laura's Story - My Dad

http://www.youtube.com/watch?v=4ePVse4bK8E&feature=channel

3. Parents of child organ donor make appeal

http://www.youtube.com/watch?v=nPhfNnchfUg

4. "Big Donor" Organ Donation Game-show Debate

http://www.youtube.com/watch?v=R9WC3S0_YH8

5. Organ Donation - NJN News Healthwatch Report

http://www.youtube.com/watch?v=bJIVGRkF2qY

6. Catherine Herridge talks about Organ Donation

http://www.youtube.com/watch?v=thAUzb8CPKs

7. Organ Donation Speaker

http://www.youtube.com/watch?v=HywxBtzznPA&feature=related

8. American Morning: Make everyone an organ donor?

http://www.youtube.com/watch?v=68lvZE8PU1k

9. ABC World News with Diane: Hero's Heart Beats On

http://www.youtube.com/watch?v=bDtMOl5licM

10. Organ Donation - NJN News Healthwatch Report

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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