Wednesday, May 20, 2009

Thoughts on Justice and Utility

I have been forced to think about 2 concepts recently.
First is justice, the practice of equitably. Second is utility, the quality of being useful.
Justice, as an ethical viewpoint, states that we all have an equal chance to obtain something. Utility, in the same ethical mode, drives allocating that same item to whoever will use it "best."
These concepts arose in a pair of articles in the May issue of ASN Kidney News discussing a proposed kidney allocation system (KAS). Mark Stegall, director of transplant surgery at the Mayo clinic, was a member of the committee that tried to bring utility to the allocation of scarce cadaver organs. John Curtis, a transplant nephrologist at the University of Alabama at Birmingham, expresses concern regarding the potential for this system to undermine equality in the rationing of scarce organs. In addition to the articles, I interviewed both of these doctors about these issues in a podcast that can be found via this link.
The idea that a scarce resource that is also the best treatment for kidney failure should be given to those who will get the best (longest) use out of it is, at first, hard to dismiss. Why should someone only expected to benefit 1 year from a kidney receive it when another will potentially get a 5 year boost from the organ?
The problem is that these "benefits" are derived from database-generated computer models. First, models must rely on historical data that cannot reflect the present day situation for a potential kidney recipient. Even survival data 1 to 2 years old will not tell you the status of present treatments for kidney disease and comorbid conditions. Second, group data apply to similar groups but are difficult to generalize to individual patients. For example, patients with disease X may do worse than others after transplant. The population of transplant recipients with disease X has variability with many doing worse than the general group, but others doing as well or, perhaps, better. No formula, at present, can predict how any given individual with disease X will fare. Do we penalize all patients with disease X because many have bad results?
I would like to use another example to illustrate these concepts, one that hits me a bit closer to home. Many years ago, women were denied opportunities via utility. "Why should we give a medical school slot to a woman who will quit to have babies, when a man could use the training and do more good?" Similar thoughts were expressed in other fields as well. Never mind that not all women had children. Don't consider the possibility that women might work after having children, if given the opportunity. Let's base everything on past results and the average behavior of the group. Eventually justice triumphed in this case. Things are not yet equal for women and men in medicine or any other field, but they are closer. Current data clearly show that the assumptions of the utility mind-set in the mid-20th century is now wrong.
I have some qualms about complete equity in organ allocation. If I were donating a loved one's organs, would I want them going to an octogenarian? Eighty years seems like an adequate lifespan to me, though I might change my mind when I'm 70. In general, though, I prefer to err on the side of equity.
If you want to comment on justice vs. utility in general, feel free to do so below. If you wish to discuss the KAS proposal and organ allocation, please go to the ASN Discuss & Debate Forum.

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