FOUR PATIENTS FOR THE NEXT HEART
CASE STUDY 1: FOUR PATIENTS FOR THE NEXT HEART
By David T. Ozar, Ph.D.
Four patients are awaiting donor organs for heart transplant at University Hospital, and the Transplant Committee must determine which of them will receive the next available heart.
The four patients are comparable in terms of organ-size, blood-type, and tissue-match; so none of these criteria will resolve the allocation question. Moreover, since all four are in otherwise excellent health relevant to the surgery, their chances of coming through the surgery itself are equally good. In addition, the life expectancies of the four, if the transplant surgery is successful, are identical, statistically set at 6.5 years. With regard to the patients’ “status,” i.e. the degree of present risk to their life, none of the four is currently statused as “emergency” (life expectancy of one day); but all four are statused as “urgent” (life expectancy of five days). Therefore, the committee must determine on some other basis, presumably some ethical basis, which of the four patients is to receive the next available heart of proper size and tissue type. These are the four patients awaiting organs.
William Markham is a 53 year old male. He is single and has no known relatives, although he claims that he has “lots of cousins with lots of land” in Ireland. He was admitted through the emergency room, brought there by an ambulance after collapsing in a downtown park where he frequently spends the night in good weather. He is well known to the local police, but is considered harmless. He made intermittent efforts at employment when he was younger, but these have been less frequent in recent years. He suffers from alcohol dependency, although he claims that this is a recent phenomenon and that he could “quit if he wanted to.” There is no evidence of liver damage. Mr. Markham has also been suffering increasingly for a number of months from shortness of breath and other signs of cardiac insufficiency, although he did not want to go to a hospital about it for fear that “they would treat him like dirt.” Tests after his admission through the ER reveal advanced cardio-myopathy, a deteriorating condition of the heart muscle which, in Mr. Markham’s case, has progressed to the point that he is statused as “urgent” for heart transplant, the only treatment possible to save his life. In all other respects he is in good health. He is fully competent, interested in returning to his daily life, and eager for the transplant.
Edna Baines Wilkins is a forty-one year old female. She is married and the mother of three children aged 15, 12, and 5. She is a successful interior designer who has also made extensive donation of her services to various community organizations. She suffers from amyloidosis, an unusual and little understood disease of unknown cause characterized by the extracellular accumulation of amyloid–i.e., nonfunctional proteinous fibers–in the organs and tissues of the body. There is presently no known cure or treatment for this disease. It is ordinarily fatal over time, depending on which organs or tissues are affected and at what rate; but no dependable life-expectancy statistics are available to apply to Mrs. Wilkins in regard to this disease. In Mrs. Wilkins case, it is her heart which has been the recipient of amyloid fibers, impairing its normal function. Consequently, over recent months, she has increasingly suffered the symptoms of heart insufficiency, so that she is now statused as “urgent” in terms of need for a transplant heart, the only possible treatment to save her life. None of her other organs has shown signs of malfunction or insufficiency, although amyloidosis is not ordinarily limited in its effects to just one organ. There is no way to predict whether the new heart would be affected by the amyloidosis or not. In addition, though amyloidosis is ultimately fatal, there is no way to predict that it would end her life before the end of 6.5 years life-expectancy associated with the heart transplant. Mrs. Wilkins has often pleaded with those caring for her that she wants to live and to receive a heart. Her husband and children are very much involved in her care.
Theresa Benedict is an 29 year old female. She is in excellent health except for advanced cardio-myopathy which statuses her as “urgent” for a heart transplant, the only treatment that can possibly save her life. At age 3 she suffered cerebral hemorrhage after a blow to the head from a fall and has been severely developmentally disabled since then. Her mental age is approximately three-and-a-half years. She resides in a state home for the developmentally disabled, where she is visited every few months by her 62 year old mother, who is widowed and has no other children, and whose only income is her husband’s social security survivor pension. Since Theresa has come to the hospital, her mother has visited her on several occasions and has spoken to the staff about caring for her properly even though she is retarded.
Peter Portello is a 41 year old male. He is single, a successful self-employed accountant who was about to expand his business and hire several assistants when he was diagnosed with cardio-myopathy. Since then he has carefully moderated his activity and cooperated with his physicians; but the disease has now progressed to the point that he is statused as “urgent” for a heart transplant, the only treatment that can possibly save his life. He is otherwise in excellent health. An avid sports-fan, Mr. Portello has coached Little League teams from his church for a number of years. Both of his parents are living, in their 70s, in Florida. They are retired and quite wealthy. He has one sister, married, who has been the primary contact between the hospital staff and his family. She has made it clear that, if Mr. Portello’s life is saved through the hospital’s efforts, the family will make a major contribution to the hospital’s capital development fund.
the question is:
1. How does this ethical dilemma challenge each of the biomedical ethics?
a. Autonomy: capacity to think, decide, act on one’s own free will and initiative
b. Justice: ethics should be based on consistency and fairness
c. Beneficence: doing the “most good”, doing what is best for patients
d. Non-maleficence: “do no harm” i will act in the best interest of my paints.
*I KNOW IT IS A LOT BUT PLEASE PROPERLY EXPLAIN EACH ONE AND I WILL GIVE VERY GOOD REVIEW*
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