Abstract
BackgroundThe allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined.MethodsThis survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students).ResultsLiver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs.ConclusionsThe strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.
Highlights
The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges
Higher Model of End-Stage Liver Disease (MELD) scores are associated with increased waitlist mortality, post-transplant survival is decreased with MELD scores > 30 [3, 4]
Respondents The survey was conducted on 4 separate groups: 1) Medical staff consisting of physicians and surgeons, nurses and medical assistants working to various degrees in transplantation medicine
Summary
The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. Organ allocation often implies life and death decisions and has to be based on medically reasonable and ethically justified grounds. Liver allocation systems currently rely on algorithms focusing on urgency, a sickest-first approach. In 2006 the Model of End-Stage Liver Disease (MELD) allocation system was adopted in Germany. The MELD score is an urgency-based quantifiable allocation system based only upon serum total bilirubin, serum creatinine and the international normalized ratio (INR) and correlates well with wait-list mortality [1,2,3]. After MELD introduction in Germany, the average MELD score for a regular liver allocation went up from 25 to 34. Higher MELD scores are associated with increased waitlist mortality, post-transplant survival is decreased with MELD scores > 30 [3, 4]
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