MMHA 6205 Week 9 Organ Allocation Brief Example

Replace the Fixed Six-Month Rule With an Individualized Assessment: A Brief to the Liver Transplant Selection Committee on a Candidate With Alcohol-Associated Hepatitis

Student Name

Walden University

MMHA 6205: Health Law and Ethics

Instructor Name

Month Day, Year

Replace the Fixed Six-Month Rule With an Individualized Assessment: A Brief to the Liver Transplant Selection Committee on a Candidate With Alcohol-Associated Hepatitis

Recommendation

The committee should evaluate this candidate through an individualized psychosocial and medical assessment rather than declining him under the center's fixed six-month abstinence rule, and it should review the rule itself within the year. The candidate is a composite.

The Candidate

A man in his early forties presents with severe alcohol-associated hepatitis, his first diagnosis of liver disease. He has not responded to medical treatment, and his physicians expect him to die within weeks without a transplant. His history, summarized by category: heavy alcohol use for about a decade, no prior treatment for alcohol use disorder, no previous liver-related admissions, stable employment until recently, a spouse and a sibling who have committed to support him, and abstinence since admission. He has signed an agreement to enter treatment and accept monitoring. Under the center's policy, he is ineligible until he has been abstinent for six months, which he will not live to reach.

The Legal Framework

The law locates the decision more than it decides it. The National Organ Transplant Act established the national Organ Procurement and Transplantation Network to manage allocation and made it unlawful to acquire or transfer human organs for valuable consideration (42 U.S.C. § 274e). Organs are allocated nationally by policy, but each transplant center sets its own criteria for placing a patient on the waiting list. The six-month rule is therefore the center's policy, not a legal requirement, and the question before the committee is one of policy and ethics.

The Ethical Questions

Analysts of allocation have argued that no single principle is enough for distributing scarce medical resources, and that a fair system combines principles such as saving the most benefit and treating people equally (Persad et al., 2009). Three considerations bear on this decision. The first is utility: a donated liver is scarce, and the committee has a duty to place it where it will do the most good, which means attention to expected survival and the risk that the graft will be lost to a return to heavy drinking. The second is equity: patients should be treated alike unless there is a relevant difference between them, and a rule that excludes everyone with this diagnosis treats a patient with strong support and early insight the same as one with neither. The third is responsibility for illness. Some argue that people whose behavior contributed to their disease have a weaker claim to scarce organs. Many ethicists are wary of this view, partly because responsibility is difficult to judge fairly and partly because so many conditions involve behavior. Alcohol use disorder is a medical condition, and the committee does not deny transplants to patients whose other illnesses were shaped by diet, smoking or activity.

What Experience Shows

The six-month rule was adopted on the assumption that abstinence before transplant predicts abstinence after. Published experience has challenged that assumption for carefully selected patients. A European study of early transplantation for severe alcoholic hepatitis that did not respond to medical treatment reported improved survival among selected patients and infrequent return to heavy drinking (Mathurin et al., 2011). A multicenter American study of early transplantation reported comparable findings in selected patients and identified factors associated with return to heavy drinking (Lee et al., 2018). Neither study supports transplanting every candidate; both depend on careful selection. But both undercut the claim that a fixed waiting period is the only defensible test.

Proposed Criteria for Individualized Assessment

The committee should assess candidates like this one on criteria such as the following: a first presentation of liver disease, no response to medical treatment, strong social support, insight into alcohol use and commitment to treatment, absence of severe coexisting psychiatric illness, agreement to monitoring after transplant, and a favorable evaluation by an addiction specialist. Candidates who meet these criteria should be considered on the same footing as others; those who do not should be declined with reasons recorded.

Review of the Policy

The committee should review the six-month rule within twelve months, examining its own experience, published outcomes and the practices of comparable centers. The review should report whether patients declined under the rule differed in survival or relapse from those listed, and whether the rule's effect falls disproportionately on any group. A policy applied to life-or-death decisions should be revisited as evidence changes.

References

Lee, B. P., Mehta, N., Platt, L., Gurakar, A., Rice, J. P., Lucey, M. R., Im, G. Y., Therapondos, G., Han, H., Victor, D. W., Fix, O. K., Dinges, L., Dronamraju, D., Hsu, C., Voigt, M. D., Rinella, M. E., Maddur, H., Eswaran, S., Hause, J., . . . Terrault, N. A. (2018). Outcomes of early liver transplantation for patients with severe alcoholic hepatitis. Gastroenterology, 155(2), 422-430. https://doi.org/10.1053/j.gastro.2018.04.009

Mathurin, P., Moreno, C., Samuel, D., Dumortier, J., Salleron, J., Durand, F., Castel, H., Duhamel, A., Pageaux, G.-P., Leroy, V., Dharancy, S., Louvet, A., Boleslawski, E., Lucidi, V., Gustot, T., Francoz, C., Letoublon, C., Castaing, D., Belghiti, J., . . . Duclos-Vallee, J.-C. (2011). Early liver transplantation for severe alcoholic hepatitis. New England Journal of Medicine, 365(19), 1790-1800. https://doi.org/10.1056/NEJMoa1105703

National Organ Transplant Act, 42 U.S.C. § 274e (2018).

Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. The Lancet, 373(9661), 423-431. https://doi.org/10.1016/S0140-6736(09)60137-9