A 53 year-old man has liver failure. His liver is bad mostly because he drank heavily for 20+ years, and now he needs a new liver. His liver function has become poor enough that he now has hepatic encephalopathy, a condition where cognitive function declines because of poor clearance of toxic substances (from the blood stream by the liver). In addition, the man has an underlying dementia as a result of trauma he sustained some 10 years ago. At his current level of functioning, he lives with his family who takes care of him. He is able to carry on conversations, but his short-term memory waxes and wanes, and he usually needs assistance to complete tasks such as preparing meals and paying bills. His cognitive function has declined recently (hence the diagnosis of the hepatic encephalopathy) though even before this decline he was unable to function entirely independently.

The question at hand is whether to place this man on the UNOS organ transplantation list for a non-living donor liver transplant. Absolute contraindications for transplant include metastatic cancer outside the liver, active drug and alcohol use and active infections, all of which almost guarantee the patient will die or destroy the new liver soon after receiving it.

The organ waiting list is maintained by UNOS, the United Network for Organ Sharing????????. This list determines which patient gets what available organs with a complicated matching system. Accoring to the UNOS website:

“The resulting match list of potential recipients is ranked according to objective medical criteria (i.e. blood type, tissue type, size of the organ, medical urgency of the patient as well as time already spent on the waiting list and distance between donor and recipient). Each organ has its own specific criteria. Using the match of potential recipients, the local organ procurement coordinator or an organ placement specialist contacts the transplant center of the highest ranked patient, based on policy criteria, and offers the organ…”

Basically, the worse your liver gets, the more likely you are to die from liver dysfunction, and the higher you go on the list. If things work out in your favor, you will sit atop the list just long enough to procure a healthy liver without dying of liver disease or from some other cause. The score used to determine the waiting list rank for liver disease is called the MELD score (PELD in kids), which is a formula to determine life expectancy with end-stage liver dysfunction. Though not entirely relevant to the discussion, I thought I’d include it for those who might want to know.

Alternatives to transplant from a non-living donor include living-donor transplant or do nothing. The living donor transplant is done by taking a piece of a liver from a living relative. This can be done at any time. For liver transplantation, living-donor transplants have not been shown to have equivalent outcomes with non-living donor, although adequate studies have yet to be completed to say definitively. Doing nothing will result in declining liver function and death. It is impossible to say whether the man would die soon or years from now without intervention.

The only problem is, there are not enough non-living donors to satisfy the waiting list (in which case there would not be a list…). The question at hand is whether this man should be placed upon this UNOS transplant list. The man stopped using alcohol after his accident 10 years ago. He does not use drugs or have any other absolute contraindication for liver transplant. It can be expected that the man’s encephalopathy will resolve at least partially with improved liver function, though it is impossible to predict how much, and his underlying dementia will not improve. In this man’s case, he has many family members who are willing to donate a piece of liver to him, knowing the man’s function and life expectancy may be improved less than they would with a non-living donor transplant.

It is my contention that the man not be placed on the transplant list but held off in favor of healthier potential recipients. The intrinsic value of all lives should be considered equal regardless of family, friends, class, race, income, social status, etc. With that said, there are not enough livers to go around, and we need a way to determine who gets the best treatment.

If recipients cannot be judged on internal features, they must be differentiated on external qualities. I propose that people who have the most earning potential as judged by past income, assuming current cognitive function is comparable, be moved to the top of the transplant list within the existing framework of MELD score stratification. In other words, all the people on the list with score > x should be stratified by earning potential. It sounds harsh, but my philosophy is that those who seem most likely to give the most back to society be given the chance to do so, so that in the future we have (hopefully) enough resources to help everyone. This is in light of the fact that we have almost-as-good treatment available in living-donor transplants.

One argument against this position would be that it might be considered a violation of the American with Disabilities Act. My understanding of this act is that it is intended to preclude businesses from not hiring disabled persons for the sake of their disabilities. In this case, though it seems likely that disabled individuals would be less likely to receive a non-living donor liver, it would not be based on the disability, and therefore there is no discrimination based on the presence of a disability.

To be honest, it is hard for me to propose such a exclusive guideline. However, I also think the overwhelming amount of money spent on end-of-life care in futile resuscitation efforts would be considered an egregious waste if we could see the benefit that could be gained from re-allocation. It goes against American consumer-driven culture to say no, but I think this is one area that the majority would be served by saying no when appropriate, and further that we have a duty to do so as health care is not protected; it is not a right. It is my argument that earning potential is the best way to determine when saying no is appropriate.