Thread by @EMIMDoc

As an ethicist who teaches #medstudents about the ethics of organ allocation I'm thrilled that organ transplantation is in the news. But many are troubled by the latest case. Is it right to refuse a heart to the unvaxxed? Who decides? Read on for, I hope, some clarity... A🧵...

First, some background.
One perspective:
cbsnews.com/news/brigham-a… ⬇

And another:
nypost.com/2022/01/25/pat… ⬇

So, who are you mad at? Mr. Ferguson, who has the audacity to refuse medical care and still demand a heart? Or the evil docs who would rather let this guy die than give him a fighting chance of being there for his kids and family? This is a horrible situation. ⬇

Despite the press' desire to open up another front on the cultures wars, two facts can ground us
1) In the US we generally respect self determination and autonomy with regards to medical decision making
2) There MANY more people waiting than there are organs available to them
⬇

Some examples:
Region 2 (including Mr. Ferguson's MA) has 320 other people waiting for a heart. In Region 5 (CA, NV, UT, AZ, NM) 360 people wait for a 💖. 170 folks are in line for a heart in Region 8 (CO, WY, IA, NE, MO, KS).
Need a kidney? Almost 100k other Americans do too⬇

We should be able to provide an organ for every heart, lung, kidney, liver, pancreas, cornea (and other odds and ends) that fail. Every person should be able to get the organs they need. But the eternal question is:

How?

Demand far outstrips supply. ⬇

Maybe one day we'll create organs from stem cells that are genetically identical to the recipient. Or perhaps, as envisioned in Heinlin's Time Enough for Love, we'll reach immortality by harvesting organs from purpose made clones:
goodreads.com/book/show/5830… ⬇

A more realistic way to bolster supply is by creating more organ donors. To all the death squad types, no, we're not pulling the plug on grandma. But legislating an opt-out system would make organ donation the default. In the meantime, sign up here: organdonor.gov/sign-up ⬇

And yet, even if everyone donated we *still* would not have enough to save everyone in need.

So we need to RATION.

There, I said it, the current US organ allocation system is a form of rationing an extremely limited resource.

Learn more here: unos.org/data/transplan… ⬇

In the US, when a determination is made that a person's organ, heart for example, is failing severely enough, they are added to the waiting list.

Next the question becomes:

How do we run the line? ⬇

Line management for beginners:
➡Take a number, a-la your local deli counter?
➡Fastest to the transplant center?
➡Closest to the donor?
➡Sickest first?
➡Richest first?
➡Drop childless?
➡Oldest get dropped?
➡Felons get dropped? (see below)

bbc.com/news/world-us-… ⬇

Believe it or not, all of these and more have been discussed over the years. Where we are now is this:

💖Trying to ensure that the organ itself is given the best chance to succeed for the longest amount of time possible.🩺

Has nothing to do with virtues (or shortcomings)⬇

So how are people ranked on the lists themselves? Somewhat different for every organ, but in general:

🎯Very sick, with good chance of recovery from surgery (scoring systems)
🎯Ability to adhere with medical guidance to maximize survival (trickier)

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The second bullet is why people who are unable to stop drinking despite liver failure are generally ineligible for liver transplantation. That new liver will just die. Might it not have been put to better use by the next person on line who has stopped drinking?
⬇

And that's also why so many vaccinations (not just COVID-19) are required. Transplant recipients usually need to take lifelong medications that essentially SHUT DOWN their immune system, making them much more likely to die from otherwise "minor" infections. ⬇

How tragic would it be for a heart recipient to die from a preventable disease? For the heart to go to waste, while that next 30 year old with two small kids at home dies waiting for their heart? Instead of 1 dead patient you have 2, not 2 orphaned kids, but 4. ⬇

Medical professionals of all roles, all political, religious, social, and cultural backgrounds are responsible for the wellbeing of our patients and, when resources are limited, to the fair use of those resources themselves.
⬇

This means we are regularly called upon to make difficult decisions. In the case of organ allocation these decisions are made by specialized groups of medical professionals and members of the public who are informed by local, regional, and national policies. ⬇

The decision to delist Mr. Ferguson is not a political statement, not a judgment on his character, and not a condemnation by the medical profession. Presumably it was done in respect to his autonomy, his right to make his own decisions. ⬇

And his decision not to adhere to standard regimen, including numerous other required vaccinations and medications meant to ensure that he will be there for his kids and survive as long as possible with the valuable gift that would be placed in his chest, resulted in delisting⬇

Whatever the COVID vaccination risks he is worried about, they are absolutely and quantitatively trivial, null, compared to the very real, absolute, risk of death from heart failure that he is facing, otherwise he would not have been listed. ⬇

What makes this so sad is that pseudoscience, lies, and misrepresentation have led this gentleman who I am sure loves his family as much as I love mine, to make a decision that is likely to result in his abandoning his children. All in the name of political smoke and mirrors😓⬇

I'm hoping no one harbors anger towards Mr. Ferguson or towards the hospital, only sympathy and compassion

We can be certain that the next available heart in his region will go to another person no less deserving, but perhaps more likely to give the heart a fighting chance. ⬇

Hopefully this has been helpful. If you've noticed errors, please let me know.

As usual, these are my views only and do not reflect my employers', colleagues, etc.

If you've made it to the end, don't forget to share the thread with anyone who might find it useful, and please visit: organdonor.gov 🛑