Organ allocation ethics in substance abuse cases

Ethics

Organ Transplants for All?

The Bioethical Question of Organ Transplantation:

Transplants significantly increase the chances that a person will survive. Transplants do not guarantee survival or extension of life, but they certainly improve the chances, especially with respect to organ transplants. Organ transplantation is a medical procedure that is prone to ethical dilemmas. One of the biggest dilemmas regarding organ transplantation is whether or not people who abuse their bodies, whether it is with substance abuse, physical abuse (reckless or dangerous living) or other kinds of behaviors that are fully avoidable or controllable that bring on unnecessary damage.

Organ transplantation is a part of medicine, in an area called regenerative medicine, in which organs, tissues, and even cells are considered part of regenerative science. A number of organs can be transplanted, including: the liver, the kidneys, the heart, lungs, pancreas, bone marrow, intestines, eyes, and skin. Organ donors do not always have to be alive or awake in order to donate organs. Organ donors may be living, brain dead, or physically (cardiac) dead at the time of organ extraction. Once a person experiences cardiac death, everything within his/her body begins to die and deteriorate. This is yet another reason why physical abuse to the recipient body really must be avoided.

People are often on waiting lists for organ transplants for weeks, months, and even years. Even the people who may have the most dire physical circumstances or have the money to pay for the procedure still have to wait for their organs to be transplanted from donors into their bodies. There are instances when there are patients in need of organ transplants because of prior physical abuse to their bodies, such as a person who requires a liver transplant due to long-term alcohol abuse. Yet there are also instances where patients are in need of organ transplants because of an accident or something otherwise out of there control, and as a result of the trauma, may develop a substance abuse problem that threatens the integrity/success of the procedure, such as an addition to pain killers.

Physical abuse before or after an organ transplant is not an intelligent choice. Certain forms of physical abuse lead directly to a need for an organ transplant, as with the case of alcoholism, or respiratory problems due to smoking, or a heart transplant due to a malnutrition, poor diet, and lack of regular cardiovascular exercise. Physical abuse should be additionally avoided after an organ transplant because the body is weakened during illness. The body is additionally in a weakened state when the illness or medical condition has advanced to the point where an organ transplant is necessary.

Furthermore, after the procedure, the body is still vulnerable to infections and there is always a chance that the body will reject the organ, resulting a poor or violent physical reaction to the transplant. All of these things are likely and possible even when the patient is healthy outside the need for the transplant -- let alone what may happen and what damage may be done when the patient willingly and unnecessarily engages in physical abuse.

Substance and physical abuse in organ transplant recipients is actually a topic that has not received a lot of attention in terms of official research. There is some recent research that argues that "there is no reason to exclude prior substance abusers from transplantation because their outcomes were similar to those who did not have any strong history of substance abuse," said co-investigator Nicole Sifontis, PharmD, Clinical Associate Professor at the Temple University School of Pharmacy in Philadelphia. (Schieszer, 2010) at the same time though,

Some programs may require patients to enter rehab before they get transplanted. It is theorized that addictive behavior may affect compliance or adherence after transplantation, which is paramount in renal transplantation. However, there are no data to support this concept and few studies have looked at this issue. (Schieszer, 2010)

The lack of research and the contradictory practices in the medical industry must contribute to the ethical controversy of this issue. On the hand, those who abuse their bodies have the right to organ transplants just as much as people who live cleaner, healthier lifestyles. On the other hand, there are many transplant programs that require people who show signs of self inflicted physical abuse, such as addictions, to enter into rehabilitation programs before becoming fully eligible to receive their organ transplants. There is also lack of information regarding any kind of abusive behaviors that develop in organ transplant recipients, whether the organs come from live human donors, dead human donors, animals donors, or are artificial prosthetics. Healthy living increases the changes that the host would accept the new organ and that the organ will more easily integrate itself into the host's body, working as intended.

Viewpoints on Bioethical Viewpoints:

Dr. Punch, MD of the University of Michigan and the Stanford University (2013) has a unique perspective upon physical abuse and organ transplantation that in a way, removes the question of ethics from the issue, and at the same time, makes the issue even more complicated as he inquires:

Who is going to define just how much abuse was permissible? What about the person that "abused" his heart by choosing to have a job with a high amount of stress? Many occupations are known to be associated with higher rates of heart failure. Do people in those occupations deserve a heart transplant when someone who chose to be a librarian needs the heart as well? What about the person who was abused by their spouse and dealt with it by drinking alcohol to excess? Are they not accountable for their disease? It is known that abused people tend to drink too much. Do we want a medical system that defines exactly how we have to live in order to be judged worthy of care? Organ transplant is the standard of care for chronic liver, kidney, heart and lung failure. (if someone abuses their body, will they still be given a transplant?)

This perspective states that there is some clear responsibility on the part of the organ transplant recipient to practice some kind of health. This statement additionally argues for or at least opens up the possibility that physical abuse done to the body is not just a result of individual behavior, but is also a result of fundamental aspects of society, such as a capitalist society that promotes labor and capital over health. People often sacrifice their health because of their jobs or because of their jobs. This is an argument that the need for organ transplantation and the physical abuse is generated by the individual and also by the various lifestyles possible and permissible within a specific culture and society. This is one perspective upon the bioethics of people who abuse their bodies before and after organ transplants.

As with other major or serious medical procedures such as transplants, surgeries, or even sex changes, patients/recipients are often required to undergo psychological evaluation as part of the process to receive an organ transplant.

Psychosocial assessment of transplant candidates also serves other purposes such as promoting fairness and equal access to care providing a description of the patient's neuropsychiatric and cognitive functioning, serving as a guide for the clinical management of the patient and addressing the psychological needs of the transplant team with regard to patient care. Although psychosocial evaluations may be used as a means to select or prioritize candidates this is not usual practice. There is considerable debate about whether psychosocial factors, other than extreme noncompliance, should ever be considered as absolute exclusion criteria…Although it has been argued that transplant evaluations require assessment of psychiatric, psychological, and social factors a great deal of variation exists among transplant programs in the methods and criteria for psychological assessment of candidates; few use formal, written psychosocial criteria for selection…With substance-abusing patients, collateral information about history, current usage, and corroborated reports of abstinence serve to clarify the nature and extent of the addiction and allow the team to intervene with strategies for treatment or relapse prevention. (Olbrisch, et al., 2002, 773)

This is a different perspective on bioethics of physical abuse in organ transplant recipients. This statement reveals yet other reasons why this issue is controversial due to lack of research, lack of data, and lack of consistency in evaluation/measurement. Programs that psychologically evaluate organ donor recipients do not have uniformity across programs regarding the actual means of assessment and evaluation, as well as the uniformity in the ways in which the data from the assessment is applied with respect to the approval or denial of organ transplantation for that specific patient/recipient. Psychological assessment is not a tool that is even uniformly used in organ transplantation. Thus, in this way, we can ask, what is the point of psychological evaluation of organ transplant recipients anyway? There is no consistency in assessment measures. There is no consistency in how the results are applied. There is very little data that shows connections between psychological evaluation and prevalence of abusive behaviors, so why have the evaluations at all? Unless these aspects change, then there does not seem to be any use for evaluations.

In theory, such evaluations could be useful, but as is, they are fairly useless. Plus, the validity and necessity of evaluations are up for debate themselves, besides the actual results from the evaluations being up for debate. Thus, the bioethical dilemma in those who abuse their bodies before and after receiving organ transplants lies not necessarily just with the recipients, but also with society, and with the medical field with respect to the issue as well.

Taking an Ethical Stand:

This is not a simple issue and ethics are very much a part of the stance on takes in this matter. It is, to a degree, unfair for people who abuse their bodies to receive organ transplants. As aforementioned, there are a number of instances that lead to the necessity of an organ transplant in the first place -- some of which are entirely avoidable and under an individual's control, if they retain any kind of self-discipline and support.

It is not fair to those who need organ transplants and lead healthy lifestyles, taking the time to consciously take care of their health, yet still needing a transplant because of an accident or dormant medical condition or other circumstance that is not under their control. Moreover, there is no denying that there are certain prominent facets of society that contribute to physical stress and that support physical abuse. Society is responsible and the individual is responsible. As the last quotation stated, there is also responsibility for ethical confusion in this matter because of the practices of relevant medical professionals.