The award-winning film “Titanic” released in 1997 once again brought to our attention the problems associated with the lifeboat ethic. Stunned audiences everywhere witnessed the chaos on board as, by design, one-third fewer lifeboats were available than for the passenger list. Violence erupted in the competition for a disputed spot; heroism and altruism also abounded. Additionally, viewers of the movie witnessed efforts to cheat and the power of money in having a secret lifeboat for the rich. (A first-class cabin on that cruise cost the equivalent of $75,000 per person in today's money.)

In March 1997, 60 Minutes, a nationally syndicated news magazine program, featured a story in which it was claimed that The Cleveland Clinic Foundation (CCF) had in place a non-heart-beating donor (NHBD) protocol that involved killing patients for their organs. These charges were brought by a philosopher from a local university. A student who worked at LifeBanc, the northeastern Ohio organ procurement agency where the organ donation protocol originated, was given the protocol by LifeBanc with the understanding that it was to be used in class; the student and professor charged that the protocol involved killing patients for their organs. These claims were advanced without noting that the protocol was a draft that was being reviewed and revised and had not been implemented.

Living related organ transplantation is morally problematic for two reasons. First, it requires surgeons to perform nontherapeutic, even dangerous procedures on healthy donors—and in the case of children, without their consent. Second, the transplant donor and recipient are often intimately related to each other, as parent and child, or as siblings. These relationships challenge our conventional models of medical decisionmaking. Is there anything morally problematic about a parent allowing the interests of one child to be risked for the sake of another? What exactly are the interests of the prospective child donor whose sibling will die without an organ? Is the choice of a parent to take risks for the sake of her child truly free, or is the specter of coercion necessarily raised?

Reverence for the autonomy of patients dominates healthcare ethics in the United States. Such reverence emblematizes personal freedom, a cherished American ideal.

The coauthors of this dialogue, a surgeon and an internist, work together on an institutional patient selection committee for transplantation of solid organs. They have observed a spectrum of outcomes of organ transplantation, mostly favorable, at several institutions.

The United Network for Organ Sharing (UNOS) recently changed the policy by which donor livers are allocated to liver failure patients in the United States. Formerly, all liver failure patients were characterized as status 1 and placed at the top of the transplant list. Under the new policy, only patients with liver failure due to acute illness (“ALF patients”) are eligible for status 1; patients with liver failure due to chronic liver disease (“CLF patients”) are characterized as status 2. Since donor organs are allocated first to status 1 patients and then to status 2 patients, the new policy moves all CLF patients down on the waiting list relative to all ALF patients. This means that some livers that would have gone to CLF patients under the old policy will now go to ALF patients. Accordingly, while the new policy will likely increase the number of ALF patients saved, it will also increase the number of deaths among CLF patients waiting for a transplant.

The behavior of people in the presence of scarce resources has long been a source of ethical concern and debate. Many of the responses, ranging from outright brutality and cheating on the one hand to altruism, nobility, and sacrifice on the other, were most recently demonstrated in the movie Titanic. It should come as no surprise, then, that rational efforts to allocate the very scarce life-saving resource of organs are sometimes circumvented by these natural human impulses and sheer human creativity. This is especially true when the organs in question are required for continued life and cannot be temporarily or permanently replaced by technology. Thus the focus of this paper will be on the competition for livers.

Debates continue to surround the system in the United States for allocating transplantable cadaveric organs, due in large part to the scarcity of such organs in relation to the number of individuals waiting to undergo transplantation. Candidates awaiting transplantation gain access to cadaveric organs by being placed by individual transplant programs on the national list of the Organ Procurement and Transplantation Network (OPTN), overseen by the United Network for Organ Sharing (UNOS). In recent years, the UNOS board has visited (and revisited) the issue of multiple listing, that is, allowing one candidate to be registered on the waiting lists of two or more transplant programs, and has continued to permit multiple listing.

Approximately 62,000 people in this country await organ transplants. Ten years ago the waiting list numbered 16,000. The line gets longer every day. Up to 30% of those waiting in line will die waiting. We face a chronic shortage of organs. While demand for organs steadily increases, the number of cadaveric organ donors remains relatively constant: approximately 4,000 in 1988, and approximately 5,500 in 1997. In response to this environment of scarcity, policymakers have considered initiatives in a number of domains.

These CQ Sources were compiled by Bette Anton.

Fox, McGee, and Caplan's “Paradigms for Clinical Ethics Consultation Practice”, in the Summer 1998 issue of CQ, evoked memories and an image.

In an interesting response to an article I published in CQ that questions the ability of advance directives to reflect autonomy, Christopher Tollefsen raises a number of issues that deserve greater attention. Tollefsen offers several examples to illustrate how the critique of advance directives I offer would also threaten other choices that most people would consider autonomous. Importantly, I largely agree that the examples Tollefsen offers should be captured as autonomous. Where I disagree, however, is whether these examples reflect the particular type of second order decision strategy that I categorize advance directives as, and so whether the critique of advance directives I offer, if accepted, would commit us to an unreasonably narrow conception of autonomy.

Carson Strong has argued that if human cloning were safe it should be available to some infertile couples as a matter of ethics and law. He holds that cloning by somatic cell nuclear transfer (SCNT) should be available as a reproductive option for infertile couples who could not otherwise have a child genetically related to one member of the couple. In this analysis, Strong overlooks an important category of people to whom his argument might apply, couples he has not failed to consider elsewhere. In this discussion, however, Strong refers exclusively to opposite sex couples facing obstacles such as surgically removed ovaries and the inability to produce sperm. In fact, however, there are many adult couples who, while fertile in and of themselves, are not fertile as couples. This group includes not only opposite sex couples but coupled same sex partners as well. I believe the defenses Strong offers regarding the use of SCNT by opposite sex infertile couples would extend to same sex couples for two reasons. First, some same sex couples might face the inability to have a genetically related child, and second, Strong's arguments ultimately ground a general defense of SCNT independent of the question of a couple's fertility.

Technical, ethical, and social questions of germ-line gene interventions have been widely discussed in the literature. The majority of these discussions focus on planned interventions executed on the nuclear DNA (nDNA). However, human cells also contain another set of genes that is the mitochondrial DNA (mtDNA). As the characteristics of the mtDNA grossly differ from those of nDNA, so do the social, ethical, psychological, and safety considerations of possible interventions on this part of the genetic substance.

The patient was a 19-year-old female who was transferred to this children's hospital from a community hospital in a neighboring state. She is well known to the hospital staff because she had a kidney transplanted and retransplanted several times there. Her first transplant as at age 8 and she was retransplanted most recently approximately 3 years ago. She immediately rejected her second kidney and received a third. She is currently admitted because she is again rejecting her kidney, probably due to not taking her medication. The ethics consultant was called because the attending physician wanted to know if it was ethical to retransplant a “noncompliant” patient.

Who is this young woman that seems to have chosen to die by default? She is in effect parentless at a labile and vulnerable age. An attempt at a different social environment has failed. She is depressed. Unknowns are her issues, feelings, and concerns and whether antidepressants have been tried, and if so, what their effect has been. Additional data not given is whether dialysis has been tried, and if not, why not? The known track record of adolescents doing poorly on dialysis would be a concern, but then so is the loss of a scarce resource.

Professionals in transplantation medicine have a particularly difficult task that most other healthcare professionals in the United States do not have to face explicitly. That is, the transplanters control the use of scarce solid organs. Because they invariably have more than one patient who might benefit from a new kidney (or liver, heart, etc.), they cannot focus single-mindedly on their duty to each and every patient as if no other patient mattered. In the case at hand, the patient has had more than one “gift” of a life-sustaining organ. At some centers, one, perhaps two, previous organs would count as “enough.” After that, the patient has had her chances and it is time to move on to others. Moreover, some believe the patient in this case has contributed to the current problem by inadequate care of the gifts she has been given.

This case is not about whether retransplant candidates should receive organs over first-time candidates, or whether risks of transplant failure from psychological or social factors are relevant to allocating organs. Rather, it concerns only this patient's qualifications to wait for a kidney transplant. Should the patient's prior transplants, noncompliance, and poor social network exclude her even from the waiting list? Do attending physicians inappropriately favor their patients over all others in need of transplants just by listing them? The answers turn on the difference between identifying a transplant need and allocating an organ.

This tragic case raises two important ethical issues. One is the obvious problem of just allocation of scarce transplant organs. The other is the less obvious problem of the healthcare team's feelings of commitment to their patient. Together they present an unusual conflict for bioethics.

The transplant coordinator scheduled a meeting that included numerous members of the multidisciplinary team, among them the transplant surgeon, a social worker, a psychologist, and an ethics consultant. The ethics consultant outlined the ethical issues and made a recommendation. The consultant argued that the question whether the patient should again be listed as a transplant candidate really came down to the kind of environment that could be provided during aftercare. That is, if a rather structured living environment—one more structured and supportive than the previous independent living facility—could be found for the patient, then retransplantation might be warranted. But without such an environment, the patient would again probably fail to adhere to the medical and psychological treatment regimen necessary for a successful life as a transplant recipient. The psychologist, who had been working closely with the ethics consultant, concurred in this opinion.