Organ Transplantation Denying Mrs. Burgone the organ transplant could be ethically justified under certain conditions and circumstances. However, denying her organ transplantation surgery under these circumstances is not one of those instances and cannot be ethically justified. The decision is arbitrary and serves no purpose for any stakeholders in the outcome of the issue. Moreover, the ethical justification purported to be at the heart of the decision is logically flawed and ethically untenable.

Consistency with the Notion of Equal Access to Medical Care

The notion of equal access to healthcare justifies many types of decisions that may, unfortunately, lead to undesirable outcomes in individual cases (Tong, 2007). Typical examples of that notion in relation to organ transplantation cases would include decisions to conserve public financial resources by cutting off eligibility as a function of objective criteria, such as the statistical likelihood of surgical success and post-surgical survival. Likewise, it would be justified to make the decision to deny certain patients based on the extreme under-supply of suitable transplant organs so that every available organ goes to the patients with the lowest risk of rendering the procedure a waste of a precious organ that could be used to save the life of another patient with a much higher likelihood of success based on empirical data.

Therefore, if the policy for cutting off Mrs. Burgone at the age of 70 were the result of the need to conserve financial resources based on the cost-benefit analysis in relation to elderly patients' surgical success, survival rates, and longevity after surgery as compared to those same criteria applied to younger patients, the policy and the denial of surgery to Mrs. Burgone would represent an ethically justified decision. That analysis would have to reflect the relative difference between her surgical success, survival rate, and projected longevity in comparison to those of younger patients requiring similar surgical procedures. However, the ethical justification of that analysis would be predicated, very specifically, on two issues: (1) payment, and (2) organ availability.

In this particular case, there is no legitimate issue of financial concerns since the patient can afford to pay for the surgery. For the sake of argument, assume that also includes the costs of lifelong follow-up care which usually exceeds the substantial costs of the initial transplant surgery itself (Victory, 2006). Therefore, if the surgery were any type that did not involve the consumption of other very limited resources that could otherwise benefit other patients (i.e. non-transplant surgery), the policy denying the procedure to Mrs. Burgone would directly violate both the specific notion of equality of access to healthcare and also general ethical principles.

The fact that organs for transplant surgery are in extremely short supply is a legitimate justification for establishing strict criteria intended to ensure that the available organs are directed to those patients who are most likely to survive, even at the expense of the lives of patients who are much less likely to survive or to survive as long after surgery. In that case, even patients like Mrs. Burgone could be rightfully denied transplant surgery under the doctrine of the "greatest good" for all members of society, which, in this context, would mean the highest chances of achieving optimum welfare of the greatest number of organ transplant recipients. That is simply a function of the fact that if Mrs. Burgone is permitted to purchase an organ despite her much lower chance of survival and her shorter expected life afterwards, it would necessarily be directly at the expense of another potential organ recipient who might have otherwise received that particular transplant organ (Beauchamp & Childress, 2009; Munson, 2012).

Single-Payer Issues

Naturally, under any framework where the cost of medical care is borne by public funds, it is ethically justifiable to establish eligibility criteria that simply conserve public funds by directing them to where they...

Under a single-payer framework, the ethical justification would be even stronger, since, in principle, that justification only holds up to the extent surgical expense are borne by public funds (Beauchamp & Childress, 2009; Munson, 2012). Conversely, where individual patients pay directly for their own care, there is absolutely no ethical justification for withholding care from a patient who is capable of paying for it fully and without requiring any public resources. Since Mrs. Burgone can pay for the entire cost of her surgery (and we assume for the sake of argument, for all of her necessary follow-up care), the single-payer issue does not apply to this scenario in any respect because the reasons given for denying her surgery are supposedly matters of fairness in principle and not cost.
The fact that the supposed justification for denying Mrs. Burgone the transplant surgery is "fairness" in principle rather than fairness in any practical sense is precisely the reason that the decision cannot be justified ethically. In principle, there must be some cost or negative consequence to others to justify denying surgery to Mrs. Burgone that she wishes to pay for without relying on public funds. Assuming for the sake of argument that the surgical procedure at issue did not involve any precious commodity in short supply such as transplantable organs, there would be absolutely no benefit to others of denying a patient any form of care just because other people might not be able to afford it. For example, there is no ethical justification for denying brain surgery or any other expensive medical procedure to Mrs. Burgone on the basis of arbitrary criteria (such as age) if that surgery is available without limitation from private medical practitioners who are paid directly by the patient. In principle, the age-based eligibility criterion serves absolutely no articulable public interest and shadenfreude is not a recognized ethical concept; in fact, it is the exact opposite of ethical morality.

Curiously, the scenario makes no mention of the strongest ethical justification for denying Mrs. Burgone the transplant surgery that she is willing and able to pay for without burdening public resources. Namely, it is presumed that any donor organ that Mrs. Burgone would receive will necessarily be at the expense of another patient on a waiting list for the same organ. If the ethical basis for the age-based eligibility criterion is the relative likelihood of surgical success and the likely projected longevity after surgery, it is perfectly ethically justifiable to prefer to direct the transplant organ to those patients who have the lowest statistical likelihood of rejecting the organ, or dying during or shortly after surgery, or of living much shorter lives afterwards. All other factors being equal, it is more ethical to provide the organ to a patient projected to live four more decades after surgery than a patient projected to live approximately one decade afterwards. Again assuming for the sake of argument that there is an available donor liver that is perfectly suitable to Mrs. Burgone but much less well suited to a younger patient (or that is suitable to no other patient), then there is no ethically justifiable basis for denying the surgery to Mrs. Burgone if she is willing and able to pay for the entire cost of the surgery and follow-up care.

Organ Transplants in Relation to the Concept of "Decent Minimum" Health Care

The concept of "decent minimum" health care does not necessarily require that public funds be spent to provide a donor organ for every person who needs one. In principle, the concept of equal access to healthcare requires that the governmental authorities charged with decisions about allocating public funds for healthcare make the most cost-effective decisions possible. With respect to providing the greatest benefit to the largest number of people in society, that requires establishing a hierarchy of the relative value of all medical expenses with those that are cheapest and most effective at the top of that hierarchy…