Chapter 16: The Allocation of Resources: Scarcity and Triage
|Section 5. Decision Scenarios
Summary of Methodology for Analyzing and resolving Cases involving moral dilemmas in Health Care:
Paradigm for the Method: http://depts.washington.edu/bioethx/tools/4boxes.html
Sample Case Analysis: http://depts.washington.edu/bioethx/tools/cecase.html
Introduction to Clinical Ethics, 4th edition using the case of Dax Cowart.:
For each of the scenarios you should consider how a person would reach a decision if that person were using the basic principles from EACH of the following traditions:
1.Rejection of a liver transplant by 5 yo. Should she receive another/
2. Presumed Consent for the removal of organs from a cadaver
3. Transplant for unknown or school board/socialite
4. Organs for Sale from Living Donors
5. TRIAGE of an ICU bed reserved for emergencies
6. TRIAGE of surgical resources, room, equipment and staff : Hand reattachment
7. Selling organs!!
8. Refusing to cooperate with a bone marrow transplant from half brothers
9. Liver Transplant of an Alcoholic
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page794, Decision Scenario #1
“Karen’s rejecting the liver,” Dr. Sola Beni said. “A severe rejection like this happens sometimes, then the next time the new liver presents no problem that we can’t handle.”
“Can Karen stand up to another operation?”
Mrs. Singer asked. “She’s only five, and she seems so fragile.”
“I’m not so worried about her response to the surgery as I am getting her another liver,” Dr. Beni said.
“At least she’ll be at the top of the waiting list, won’t she?” Mrs. Singer asked. “I mean, she’s in the hospital, and she’s dying. Don’t you have a duty to stick with her?”
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page 794, Decision Scenario #2
“We haven’t been able to get in touch with his wife or any family member,” nurse Becky Small told Dr. Sam Long. “Dr. Soon has declared him dead, but we’ve left him on the respirator.”
“Call the organ procurement people,” Dr. Long said. “Tell them we’ve got a twenty-four-year-old head-trauma victim with usable heart, kidneys, lungs, and liver, and they should arrange for surgical teams to remove them.”
“Don’t we have to get the consent of at least somebody in the family?” Becky asked.
“Not any more,” Dr. Long said. “We’re operating under a new doctrine of presumed consent.”
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 Page 794, Decision Scenario #3
“What do you mean, you don’t know who he is?” asked Dr. Bridewell, the head of the Oakbrook Hospital Renal Unit.
“He was unconscious when the police brought him to the ER. We started the IV, stopped his bleeding and patched him up. But he still hasn’t recovered consciousness. The police think it was a hit and run driver.” Dr. Kathy Mc Dowel spoke in a precise, matter of fact voice. Dr. Bridewell always frightened her, but she was determined not to show it.
“He didn’t have any identification?”
“No. They think somebody came along and robbed him. He was wearing jeans and a sweatshirt, nothing that gives any clue as to his background. Both of his kidneys were hopelessly damaged. But his general physical condition is good, and we think he’s a good candidate for a transplant.”
“You know we’ve got someone declared brain dead.”
“Yes, and we’ve done an HLA match.”
“We’re going to have only one kidney to transplant because the other one is shot. But I’ve got a candidate, too, so we have to decide which patient get the kidney.”
“Who’s the other candidate?”
A Mrs. Benson. She’s a woman in her early sixties who’s on the school board. Her husband’s a rich lawyer, and both of them move in high social circles. She does a lot of work now with a foundation that helps minority children in school. She also happens to be a good candidate physically for a transplant.”
‘So you’ll choose her over my patient?” Dr. McDowell felt herself getting angry.
“I didn’t say that. How old is this guy?”
“Early or middle thirties. He’s in good physical condition.”
“But we don’t know anything about him,” said Dr. Bridewell. “He might just be a drifter passing through town. He’s probably not a member of the community this hospital is supposed to serve, the one that pays bills and makes donations.”
“Not that we know of,” Dr. Mc Dowell admitted.
“But we don’t know for sure, do we?” said Dr. Bridewell.
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page 795, Decision Scenario #4
Colin Benton, a British citizen, died in the summer of the 1988 of renal disease after a kidney transplant failed. Benton’s widow later revealed that the donor kidney has been obtained from a Turkish citizen who traveled to London for the surgery. The kidney donor was paid the equivalent of around $4400. When asked why he had sold the organ, the man explained that he needed the money to pay for medical treatment for his daughter. It was this case that led the British Parliament to outlaw organ sales.
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., page 795, Decision Scenario #5
Valdez Regional Hospital is the primary medical facility for the residents of Valdez County, Arizona. Its intensive care unit is the only one available in the entire county, and the closest comparable unit is eighty-five miles in Sonora County. The Valdez ICU is a twelve-bed facility, and—from the statistical point of view—it is generally adequate to serve the needs of its patient population. That is, the cost of adding extra equipment and staff to increase the size of the facility is much greater than its actual use would justify.
Valdez’s ICU policy, which is similar to policies of hospitals everywhere, requires that the staff make the effort to keep at least one of the twelve beds free for use in a genuine emergency.
On a bright, clear afternoon one day after Christmas, sixty-eight-year-old Harry Aveni was brought to the emergency room after he had collapsed on the patio of his house. Mr. Aveni had been brought to the ER twice before. Both were episodes of congestive heart failure, and this third occasion was no different. Mr. Aveni had broken his diet during the holidays and consumed an unaccustomed amount of salt.
He responded well to emergency treatment. The fluid surrounding his heart was withdrawn, a glycoside medication was administered, and his condition seemed to stabilize. Then, that evening, there was a sudden onset of fibrillation—his heart started beating erratically. Again, Mr. Aveni responded well to treatment, and after emergency defribrillation his condition again stabilized.
“He needs to be put into the ICU,” Dr. Ellen Gracian said. “We can’t car for him sufficiently on the ward because he’s got to have constant monitoring.”
“I don’t think Dr. Franklin is going to want to admit him,” the nurse said. “There’s only one bed left.”
Dr. Gracian immediately left the floor and went to the ICU director’s office. She explained what she wanted and waited while he seemed to be thinking it over.
“I don’t think I can admit him,” Dr. Franklin said. “Here we have an elderly gentleman who has now gone through three episodes of congestive heart failure and also seems to have something wrong to cause the fibrillation. He didn’t stick to his diet, and in general his days are likely to be in the rather small numbers.”
“But if he doesn’t have intensive care, the numbers may be even smaller,” Dr. Gracian said.
“That’s no doubt true. But as things are, we’ve got eleven people who need to stay right where they are for God knows how long, and we’ve got just one bed at our disposal.”
“But that’s all I need, just one bed.”
“I understand that,” said Dr. Franklin. “But let’s suppose we install your patient in the ICU and fifteen minutes after we put him there an eighteen-year-old accident victim is brought in. She’s going to have to have emergency treatment, then close a constant monitoring , or she’s likely to die.”
“But you don’t know that somebody like that is going to come in,” Dr. Gracian said. “And Mr. Aveni is here right now and is in need right now.”
“I’m sorry,” said Dr. Franklin. “But the chances are very good that somebody is going to need that bed, somebody who’s got a better chance to live a long and more normal life.”
I see,” Dr. Gracian said. “But I thought we were in the business of saving lives.”
“We are. But we can’t save them all, and that’s where the problems come in.”
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000. page 797, Decision Scenario #6
The microsurgical team at Bentaon Public Hospital consisted of twenty-three people. Five were surgeons, three were anesthesiologists, three were internists, two were radiologists, and the remaining members were various sorts of nurses and technicians.
Early Tuesday afternoon on a date late in March, the members of the team that had to be sterile were scrubbing while the others were preparing to start operating on Mr. Hammond Cox. Mr. Cox was a fifty-nine-year-old unmarried African American who worked as a janitor in a large apartment building. While performing his duties Mr. Cox had caught his hand in the mechanism of a commercial trash compactor. The bones in his wrist had been crushed and blood vessels severed.
The head of the team, Dr. Herbert Lagoio, believed it was possible to restore at least partial functioning to Mr. Cox’s hand. Otherwise, the hand would have to be amputated.
Mr. Cox had been drunk when it happened. When the police ambulance brought him to the emergency room, he was still so drunk that a decision was made to delay surgery for almost an hour to give him a chance to burn up some of the alcohol he had consumed. As it was, administering anesthesia to Mr. Cox would incur a greater-than-average risk. Furthermore, blood tests had shown that Mr. Cox already suffered from some degree of liver damage. In both short-and long-range terms, Mr. Cox was not a terribly good surgical risk.
Dr. Lagorio was ready scrubbed when Dr. Carol Levine, a resident in emergency medicine, had him paged.
“This had better be important,” he told her. “I’ve got a patient prepped and waiting.”
“I know,” Dr. Levine said. “But they just brought in a thirty-five-year-old white female with a totally severed right hand. She’s a biology professor at Columbia and was working late in her lab when some maniac looking for drugs came in and attacked her with a cleaver.”
“What shape is the hand in?”
“Excellent. The campus cops were there within minutes, and there was ice in the lab. One of the cops had the good sense to put the hand in a plastic bag and bring it with her.”
“Is she in good general health?”
“It seems excellent,” Dr Levine said.
“This is a real problem.”
“You can’t do two cases at once?”
“No way. We need everybody we’ve got to do one.”
“How about sending her someplace else?”
“No place else is set up to do what has to be done.”
“So what are you doing to do?”
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page 798, Decision Scenario #7
“Your baby’s liver is not fully developed,” Dr. Robert Amatin said, “The bile duct is missing, and blood can’t flow through the liver the way it’s supposed to.”
Clarissa Austin nodded to show she understood something wrong with her child. She had already made up her mind to do what ever she had to do to see to it that her baby was all right.
“That means the live can’t do it’s job and that the blood is backing up,” Dr. Amatin went on. “Surgery really can’t correct a problem like this.
“Can you give him a new liver?”
Dr. Amatin avoided answering the question directly. “A transplant is his best hope,” he said. “If we can surgically remove the malformed liver and attach a new one, the baby has a very good chance of living.”
“I’ll be happy to give my permission, if that’s what you’re waiting for,” Clarrisa said.
“It’s not that simple,” Dr. Amatin said. He looked uncomfortable. “It really comes down to a matter of money.”
“I don’t have much money,” Clarissa said. “You know I’m on Medicaid, and I don’t have any insurance.”
“I Medicaid will pay for the surgery, but not for any organ, and that’s the only way we can get one.”
“How much does a liver cost?”
“I’ve got a family right now that says it wants $15,000 for the liver of their baby. She died this morning.”
“I can’t get money like that,” Clarissa said.
“I can ask them to come up and talk to you. Maybe they would take less, or maybe you cold work out some kind of deferred payment with them.”
“What if I can’t?”
Dr. Amatin shook his head. “I can’t arrange for a transplant without an organ that size, and I suspect they will try to find somebody else to sell it to.”
“That don’t seem fair,” Clarissa said. “Just because I haven’t got the money, my baby is going to die.”
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page 798, Decision Scenario #8
Jean-Pierre Bosze, twelve years old, had leukemia. The disease was under control for a while, but then Jean-Pierre has a relapse. His father was told that his son’s only hope was to have a bone marrow transplant, but neither the boy’s father nor his mother was a suitable match. Bosze’s twenty-two-year-old son from a previous marriage also failed. To be a match and his thirteen-month-old daughter by another woman was too young to be a donor.
In desperation, Tamas Bosze turned to his other children, Jimmy and Allison Curran, Three-year-old twins by yet another woman. The chance of a tissue match between them and their half-brother would be much greater than the 1-in 20,000 chance offered by an unrelated individual.
However, the mother of the twins, Nancy Curran, from whom Tamas Bosze was estranged, refused to permit the children to be tested. Curran explained that she did not want the twins to suffer the pain of having the marrow extracted or to be subjected to the risk involved. General anesthesia carries a risk of death in 1 in 10,000 cases and of complications in about 1 in 300 cases.
Bosze’s paternity had been established in a suit by Curran seeking child support. The blood tests showed that the twins matched Jean-Pierre in two of the six factors considered basic for compatibility.
“Strangers are calling up to offer bone marrow and blood, and she won’t help,” Bosze said. He decided to file suit to force Curran to allow the twins to be tested.
“I don’t feel like I’m killing this boy,” Curran said. “I could be killing my own children if I let this happen.”
On September 28, 1990, the Illinois Supreme Court ruled that the mother of the twins could not be compelled to permit them to be tested as potential bone marrow donors for Jean-Pierre. Jean-Pierre Bosze died early in 1991.
From: Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000 ., Page 799, Decision Scenario #9
Dr. Sarah Brandywine hurried into Dr. Kline’s inner office. Dr. Kline was transplant coordinator at Mid-western General Hospital, and he was expecting her. She had called him for an appointment as soon as she had realized the dimension of the problem with Mr. Wardell.
“So tell me about Mr. Wardell,” Dr.Kine said, nodding toward the chair beside his desk.
“He’s fifty-one-year-old man who came to the hospital two days ago because he was frightened by the jaundice and ascites he developed over the course of the last week,” Dr. Brandywine said. “He have been experiencing fatigue and loss of appetite several weeks prior to the jaundice. His liver is swollen and lumpy.”
“Sounds like cirrhosis,” Dr. Kline said. “I’m sure you did liver function tests, but what about a biopsy?”
“We did both yesterday. And I called you right after the final results. There’s so much scarring that Mr. Wardell has little liver function left.” She shook her head. “I want to put him on the transplant list.”
“What’s the cause of his disease?”
“It’s alcohol induced.”
“No way.” Dr. Kline shook his head. “No livers for alcoholics. No ifs, ands, or buts about it.”
“This is a man with two kids.” Dr. Brandywine tried to keep her voice level. “One’s twelve, and the other is eight. Their mother died two years ago, and their dad is all they’ve got left.”
“Oh, God, the kids make it particularly sad.” Dr. Kline’s voice took on a pained expression. “But look, thirty thousand people a year from alcoholic cirrhosis, and we can’t treat them at all.”
“I know we can’t, but can’t we treat some?” Dr. Brandy wine leaned forward. “Is being an alcoholic enough for an automatic turndown?”
“I’m afraid so.” Dr. Kline nodded. “These are people who created their own problem. There are far being enough livers to go around, so it’s only fair for us to put folks with problems not of their own making on the list and to leave others off.”
“But, look, this guy’s got two kids depending on him.” Sarah squeezed her hands into fists. “If I can get him into a rehab program, can we promise him the chance at a liver then?” She quickly added. “Not a guaranteed liver, but a chance at one.”
“The answer’s still no.” Dr. Kline paused. “I’m not saying alcoholics can’t be reformed, but I am saying they’re bad risks. If we give a transplant to somebody whose liver was destroyed by biliary cirrhosis, we’re likely to get a good, long-term survival. But if we transplant somebody who’s been drinking for the last ten or twenty years, we’re not likely to get food, long term results. The guy may promise to stop drinking and maybe he’ll do it for a while. But chances are good that, within a few years, he’s going to be back in the hospital with liver failure again, and alcohol is going to be the cause.”
“I admit the numbers are against me.” Dr. Brandywine inhaled deeply, then let her breath out in a long whoosh. “There’s nothing I can say to convince you?”
“We can’t afford to risk wasting a liver,” Dr. Kline said. “That’s what I’ve got to convince you of.” He shook his head. “It breaks my heart to think about Mr. Wardell’s children, but I’ve got to think about the parents with cirrhosis who aren’t alcoholics.”
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