By Andrew Rock

In this interview with The Daily Circuit, Ezekiel Emanuel, Professor of Medical Ethics and Health Policy at the University of Pennsylvania, discusses questions and considerations that arise when one asks one of the most important bioethical questions: With a scarcity of organs, how does one decide who receives priority?

The current structures in place for dealing with such dilemmas “vary depending upon the organ that’s being transplanted,” explains Dr. Emanuel. The system used to allocate livers differs from the system that allocates kidneys which differs from the system that allocates hearts, for example. However, the current system in place for livers focuses on who is the most ill.

For livers, a scoring system, called the MELD (Model for End-Stage Liver Disease) Score, is used in the decision-making process. It considers the liver’s ability to perform tasks like clearing toxins and producing proteins as well as how well the kidneys are functioning, as all of these factors taken together determine the severity of one’s liver failure. In addition to the MELD Score, factors such as the patient’s proximity to the nearest hospital are accounted for when determining priority.

Some believe that the “sickest first” principle should not dominate the realm of organ allocation. Though a consensus does not exist, different positions argue for the importance of criteria such as years of potential life, earthly obligations, age, or social standing. Factors like age and social standing are considered most important in places like China where the elderly are held in high esteem.

Though it is not currently considered, occupation has been a factor taken into account in American transplant history.

Criticisms against the “sickest first” principle often invoke an argument from efficiency. In the segment, Dr. Emanuel explains, “if you want to save the most people…saving the sickest first would not be your main criterion.” Under the current system, for example, if a patient’s kidneys and liver are both failing, they would receive higher priority than a patient who had a failing liver but functioning kidneys. However, it is likely that allocating organs to those who are less sick could save more lives.

Occasionally, however, determining factors of allocation choose themselves. For example, in the 60s, when renal dialysis machines were limited, those physically capable of using the machines were given priority over those who lacked that capacity. Problems like this occur often, as not everyone can handle certain treatment, or even organs. Occasionally, people reject donor organs, which causes many health complications. The 5-year survival rate among “young kids” who receive organ donations is about 80%, while the rate for people over 65 is around 63%, according to Dr. Emanuel. For many, this provides evidence in favor of giving preference to children over older patients, as they are more likely to reap long-term benefits.

In order to escape the difficult dilemmas of organ allocation, many economists propose new systems of organ procurement, such as providing money in exchange for organs. This practice is currently illegal in the United States, but it has the potential for success. Dr. Emanuel, however, warns that similar methods of obtaining blood have attracted people with various health risks. Others make the objection that some potential donors will be lost with the removal of an altruistic element.

Listen to the full interview here.