PHILADELPHIA — Emergency court decisions regarding the allocation of life-saving donor lungs have recently sparked widespread debate over current wait list and allocation policies. In the June 25 issue of the Annals of Internal Medicine, Scott Halpern, MD, PhD, MBE, medical ethicist and assistant professor of Medicine, Division of Pulmonary, Allergy and Critical Care, at the Perelman School of Medicine at the University of Pennsylvania, discusses the implications of such judicial activism and suggests several ways to improve the availability and allocation of transplantable organs.
In his commentary, Dr. Halpern suggests that judicial intervention for specific cases risks providing preferential treatment for some patients, or placing a higher value on some lives over others. Such intervention, Dr. Halpern said, can set a troubling precedent.
“I don’t think we should allow policies to be bent in favor of those who have the resources and connections to create the biggest media splash, or who have the quickest access to lawyers and judges,” Dr. Halpern said. “Even if policies are imperfect, the integrity of the system is completely undermined when judges make medical decisions, particularly when they do so without considering the medical facts as happened in the Philadelphia cases.”
Under the current policy, enacted in 2010 by the Department of Health and Human Services (DHHS) Organ Procurement and Transplantation Network (OPTN), priority for donated organs is given according to age group. For example, children younger than 12 years are the primary recipients for lungs from donors younger than 12 years; adolescents aged 12-17 years are the highest priority for lungs from donors aged 12-17 years. Pediatric patients are given second priority for organs from donors aged 12 to 17, and lowest priority for organs from donors 18 years or older.
These current guidelines are structured such that lungs from a donor aged 18 or over would rarely be received by a pediatric patient under 12 years. Recently high-profile cases surrounding pediatric patients have left many questioning the fairness of this rule given the scarcity of pediatric donor lungs.
First, Dr. Halpern writes, the OPTN will need to conduct research comparing access and outcomes under present and alternative age-stratification policies, using more sophisticated tools, such as Scientific Registry for Transplant Recipients’ simulated allocation models. “If such models suggest that the population of patients awaiting lung transplantation would fare better by altering age-based prioritizations, then the policy should change accordingly,” Dr. Halpern writes.
In addition to upholding their duties to their patients, transplant physicians will also need to become thoughtful stewards of resources. For example, some patients with pulmonary diseases who are on the list for a double-lung transplant may fare just as well from a single lung. New policies that set explicit, evidence-based criteria for listing patients for double-lung transplantation would enable more patients to receive a transplant with the same supply of lungs.
The transplant community also should work to expand the lung supply by making better use of donors after circulatory determination of death, a practice that could increase lung supply by as much as 50 percent.
Finally, Dr. Halpern suggests that transplant centers reconsider eligibility criteria that prevent accepting donor lungs with blemishes, such as those from moderate smokers.
"Not only would these steps provide more patients with access to life-extending interventions, but by being more proactive the transplant community can protect the system it has worked so hard to build from future judicial intervention," Dr. Halpern writes.
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