PubMed · 10562048
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U Weyermann. 1999. [The basic question: do we really have to ration?].. https://pubmed.ncbi.nlm.nih.gov/10562048/
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Previous ethical analyses of organ allocation policies have addressed the trade-off between giving organs to urgent versus non-urgent patients, overlooking the process by which patients become urgent in the first place. This article proposes three criteria for assessing the performance of organ allocation rules that take into account the dynamic nature of patient health. An equitable policy is one under which patients' probability of receiving a transplant is equal at listing. Efficiency captures the goal of giving organs to patients when their benefit from transplantation is greatest. Hope implies that patients should believe that they have a reasonable chance of receiving an organ. The sickest first policy, which is currently used to prioritize patients, is hope-preserving, but may be inefficient. As demand grows relative to supply, patients will only receive an organ once they have reached the sickest status category.
Both the number of recipients awaiting liver transplantation and the length of wait are increasing, giving rise to increasing concern by patients, healthcare professionals, and the public. Greater attention has been focused on the criteria for listing patients for transplantation and for allocation of organs. In the U.K., compared with the U.S., the delivery of liver transplant services is more tightly regulated, with fewer transplant centers, lower transplant rates, shorter waiting lists, and shorter waiting times. The reasons for these differences are unclear. In the U.K., patients are listed only if there is a reasonable expectation that the patient will receive a graft. The criteria for listing are based on overall utility rather than individual benefit, so the criterion for listing is that the patient will have at least a greater than 50% probability of being alive 5 years after transplantation with a quality of life that is acceptable to the patient. Although it is reasonable to offer hope to all patients, this hope should have a reasonable probability of being fulfilled. Listing patients with little likelihood of benefiting from transplantation is not helpful either for the patient, their family, or the other potential liver allograft recipients. While different systems for allocation of donor livers may be more appropriate in other settings, the process in the U.K. seems to deliver satisfactorily.