Error message

The page you requested does not exist. For your convenience, a search was performed using the query news events news 2016 02 25.

Page not found

You are here

Should this patient get a liver transplant? (Nov-08)

There aren't enough donor organs to go around for patients who need aliver transplant. This sometimes forces doctors to make tough choices.If you were the doctor, how would you decide in the following scenario?  There aren't enough donor organs to go around for patients who need a liver transplant. This sometimes forces doctors to make tough choices. If you were the doctor, how would you decide in the following scenario?Suppose there is a person who develops acute liver failure (ALF). While waiting for a liver transplant, this person gets sicker and sicker. When an organ is finally available, the chance that this person will survive WITH a transplant is only 42% at five years after the transplant. Since the average survival for most patients who receive a liver transplant is 75% at five years, the doctor wonders if it would be better to save the liver for someone else. Two possible ethical principles may guide the doctor in making this decision. 

Using the principle of URGENCY, the doctor would give the first available organ to the sickest patient on the transplant waiting list, the ALF patient, because she/he is otherwise likely to die within a few days.

Using the principle of UTILITARIANISM, the doctor would try to maximize the quality and quantity of life of all the people on the transplant list. Let's say there are 25 other patients currently on the waiting list, and transplanting the ALF patient increases their risk of death by 2% each, for a cumulative harm of 50%. Since this harm of 50% is more than the benefit to the ALF patient (42%), the liver should be saved for someone else on the list.

A third possibility is for the doctor to weigh both URGENCY and UTILITARIANISM in making a decision about a transplant.

If you were the ALF patient's doctor, what would you base your decision about a transplant on?
 
  • URGENCY (sickest patient on the list gets preference)
  • UTILITARIANISM (maximize benefit for the entire waiting list)
  • A combination of URGENCY and UTILITARIANISM

How do your answers compare?

There's no absolutely right or wrong answer in this case—the choice depends on which of several competing ethical principles or which combination of principles you follow. In choosing a combination of URGENCY and UTILITARIANISM, you've decided to try to balance the needs of the sickest patient with the needs of all the people on the transplant waiting list.

CBDSM researcher Michael Volk, MD, is the lead author on a recent article that tackles difficult decisions like this one. Volk and his colleagues examined a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with ALF. Currently, liver transplantation in the United States is determined by the principle of “sickest first," with patients at highest risk for death on the waiting list receiving first priority. In other words, the principle of URGENCY is paramount. However, most experts agree that, given the limited supply of organs, there should be a cutoff for posttransplant survival below which transplantation is no longer justified.

Where does society draw this line? And what framework can we use for ethical guidance?

Decision analysis of resource allocation would utilize the principle of UTILITARIANISM, to maximize the broad social benefit. But surveys of the general public have shown that most people prefer to temper utilitarianism with other considerations, such as equal opportunity, racial equity, and personal responsibility. Another factor that might be considered is the principle of fair chances. This is the idea that patients who have not had a chance at a liver transplant should receive priority over those who have already had once chance at a transplant.

Volk constructed a mathematical model (Markov model) to test the use of competing ethical principles. First he compared the benefit of transplantation for a patient with ALF to the harm caused to other patients on the waiting list, to determine the lowest acceptable five-year survival rate for the transplanted ALF patient. He found that giving a liver to the ALF patient resulted in harms to the others on the waiting list that cumulatively outweighed the benefit of transplantation for the ALF patient. That is, using UTILITARIANISM as the sole guiding ethical principle gave a clear threshold for the transplant decision: if the ALF patient did not have a five-year survival rate of at least 48%, she/he should not receive a transplant under this principle.

But UTILITARIANISM is not always the sole guiding ethical principle. When Volk adjusted the model to incorporate UTILITARIANISM, URGENCY, and other ethical principles such as fair chances, he got different thresholds. Depending on the combination of ethical principles used, Volk and his colleagues have shown that the threshold for an acceptable posttransplant survival at five years for the ALF patient would range from 25% to 56%.

The authors of this study conclude:

"Our model is an improvement over clinical judgment for several reasons. First, the complexity of the various competing risks makes clinical decision making challenging without some form of quantitative synthesis such as decision analysis. Second, a systematic approach helps ensure that all patients are treated equally. Most important, this study provides moral guidance for physicians who must simultaneously act as patient advocates and as stewards of scarce societal resources."

Volk ML, Lok ASF, Ubel PA, Vijan S, Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation, Med Decis Making 2008;28, 763-772.

Online: http://mdm.sagepub.com/cgi/content/abstract/28/5/763

More information:

Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation.
Volk M, Lok AS, Ubel PA, Vijan S. Medical Decision Making 2008;28(5):763-772.

 

Bioethics Grand Rounds: Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Wed, January 27, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

"Implementation of the Program in Clinical Ethics"

Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Abstract: The Program in Clinical Ethics within the Center for Bioethics and Social Sciences in Medicine represents an expansion of existing services designed to promote a culture of patient-centered excellence by developing a comprehensive set of ethics-related activities at UMHS. We will introduce and outline the projects and services available to all members of the UMHS Community.

PIHCD: Jessica Mellinger

Thu, February 11, 2016, 4:00pm
Location: 
B004E NCRC Building 16

Alcoholic liver disease represents a large and growing portion of the liver disease in the US and worldwide, and the most powerful treatment shown to improve outcomes for patients with ALD is complete abstinence from alcohol.  Unfortunately, many patients with ALD continue to drink or relapse to alcohol use, even after their diagnosis, worsening liver-related outcomes and  mortality. Jessica Mellinger will be speaking about her K award project to improve outcomes for patients with ALD by developing and testing a pilot intervention designed to increase engagement in alcohol use disorder treatment.

CBSSM Seminar: Jason Rose, PhD (Toledo)

Wed, March 09, 2016, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jason Rose, PhD
Associate Professor
University of Toledo

Title: “Decisions, Decisions: The Impact of Treatment Choice on Health-Related Outcomes”

Abstract: From selecting a health care provider to choosing among an array of over-the-counter treatment options, choice has become a ubiquitous element of health care. Using an experimental, lab-based approach, the current research examines how, why, and when treatment choice impacts health-related outcomes (e.g., pain, discomfort).

 

Thu, March 03, 2016

In an interview with MedicalResearch.com, Dr. Sarah Hawley discusses her new study regarding breast cancer patients' understanding of risk. She states, "Research has shown that breast cancer patients do not have a good understanding of their risk of distant recurrence, and and that the fear of cancer spreading is one of the biggest concerns that patients have. The research that has been done shows that most patients over-esimate this risk, and think they have a bigger chance of the cancer coming back than they actually have."

CBSSM Seminar: Michael D. Fetters, MD, MPH, MA

Thu, April 14, 2016, 3:00pm to 4:00pm
Location: 
NCRC Building 16, Conference Rm 266C

Michael D. Fetters, M.D., M.P.H., M.A.
Professor, University of Michigan
Co-Director, Michigan Mixed Methods Research and Scholarship Program
Director, Japanese Family Health Program
Co-Editor, Journal of Mixed Methods Research

"Mixed methods research approaches for empirical medical ethics”

Abstract: Mixed methods research involves the integration of qualitative and quantitative methodology. The purpose of this presentation is to illustrate potential applications of mixed methods methodology for conducting empirical medical ethics research.

Emily Chen, MA

Research Associate

Emily Chen joined CBSSM in February 2016 and works with Drs. Julie Wright and Darin Zahuranec on several grant funded research projects on developing decision aids and family perspectives in decision making. Prior to moving to Michigan, Emily worked on several studies regarding mindfulness and cognitive styles at Harvard University. Emily received her BS in Atmospheric Science and a certificate in Neurobiology and Cognitive Science from National Taiwan University. She went on to receive her MA in Psychology from Boston University.

Last Name: 
Chen

CBSSM Seminar: Reshma Jagsi, MD, PhD

Wed, May 18, 2016, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Reshma Jagsi, MD, PhD
Associate Professor, Radiation Oncology

"Stewardship and Value:  Are we choosing wisely in managing breast cancer?"

Abstract: This lecture will begin with a brief discussion of the moral foundations of physicians' obligations to serve society, in addition to the patients they directly serve.  It will then consider analogies between financial stewardship and antibiotic stewardship, and it will conclude by focusing on several examples of opportunities for better physician stewardship in breast cancer, including slow uptake of short courses of breast radiation and rapid increases in the use of bilateral mastectomy for unilateral disease.

Bioethics Grand Rounds

Wed, June 22, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

Timothy Johnson, MD

"Ethical global health engagement: the Michigan Women's Health Model"

Millennial learners are experiencing and want to engage in global issues.  As institutions develop opportunities for their students, ethical issues need to be considered.  Transnational, transcultural, and translational issues as well as issues of equity, bilateral gain, economic transparency, academic values and sustainability must be factored into academic institutional partnerships between Western and low income countries.  The Ghana experience will be used to develop the concept of a “Michigan Model”.

CBSSM Seminar: Stephen Molldrem, PhD Candidate

Thu, July 07, 2016, 3:00pm
Location: 
NCRC Building 16, Conference Rm 266C

Stephen Molldrem, PhD Candidate, American Culture

Title: Collecting and Managing Sexual Orientation and Gender Identity Data in Health Contexts: Bioethical Dilemmas from a Queer Historical Perspective

Abstract: This talk, drawn from dissertation research, historicizes a number of regulatory changes governing the collection and management of sexual orientation and gender identity data in health contexts in the United States that have taken place since 2009. It focuses on a range of less-considered bioethical dilemmas that stem from the introduction of questions about sexual orientation and gender identity into the battery of demographic information collected in certified Electronic Health Record technologies.

Pages