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Organ donation and the use of psychosocial criteria
UNC philosopher has "justice concerns"
While Rebecca Walker, PhD, assistant professor, Department of Social Medicine Adjunct Assistant Professor, Department of Philosophy at the University of North Carolina at Chapel Hill, says she does not "mean any one thing" by the use of the term "justice," she does have justice concerns regarding the use of psychosocial criteria in determining individuals who are selected to receive organs from donation for transplantation.
Walker gave a presentation on this topic at the American Society of Bioethics and Humanities annual conference in Washington, DC, in October, and spoke to Medical Ethics Advisor later in the year regarding that presentation.
"I'm talking about theoretical perspectives on justice, and in particular, I think I look at utilitarian considerations and equity-based considerations . . . I don't have an assumption about what constitutes justice," Walker tells MEA.
"And then I also think about substantive concerns, and by that I mean how you would actually allocate things, in comparison with procedural concerns, so, how you would go about setting up the right process for allocation," she explains.
One of her concerns about the use of psychosocial criteria is that the criteria in use don't appear to be uniform from institution to institution, and what is meant by that term within the transplant community.
Although she says that within the transplant community anything described as psychosocial means anything non-medical, "it's not really what you might think of as psychosocial."
"So, you might think that term would just indicate psychological issues or social issues, like support networks," Walker explains. "It means those things, but it also means behavioral issues. So, things like addiction would be encompassed by that term."
As for other conditions that might be considered as part of psychosocial criteria, she explains, "Well, this is, again, an area where it's kind of tricky, because there are different kinds of criteria that get considered in different places, so it's not entirely clear what the full, comprehensive list would be. But the kinds of things that can be considered, as I mentioned, [one is] social support, which would be 'Is your family going to be able to support you through this process? Are there other people who are going to be able to help you [following transplantation]?'"
The behavioral issues that come into play relate to addiction, including alcohol, cigarette, and illegal drug use. However, it might also mean "cognitive capacity," Walker says.
Walker's specific concerns
Walker says there are "a number of areas" that create concern. For example, she notes, the assessments of potential recipients "take place as a determination of whether or not a person is eligible for receiving an organ at all. So, it's not a question of determining how high somebody is on a priority list, but rather determining if someone is eligible or completely not eligible for the resource."
The essential problem, as she sees it, is that "it's not entirely clear what the relationship is between some psychosocial evaluations and outcomes after transplant. So, you would think that if a psychosocial evaluation was going to cut somebody off from the possibility of receiving an organ at all, that you'd want to have very, very strong reasons for thinking that the organ actually would not do [the recipient] any good, or would be very badly allocated if you allocated it to [a particular recipient]," she explains.
There is a Catch-22 to this situation, as she explains it, which is that because individuals with addiction issues, for example, are typically screened out of receiving organs for transplant, there's very little "good" research to determine how they fare on health outcomes.
"So, for some kinds of psychiatric disorders, for example, there just really isn't very good research," Walker says. "For some kinds of criteria, there [are] some kinds of research, but it's not really clear what the implications are. The only kind of meta-analysis that I could find on psychosocial evaluations across the board, it really seemed like there wasn't very good overall evidence, so that was something that, I think, was a little bit concerning."
As to how psychosocial criteria became part of the screening criteria for organ recipients, she says that she believes people "just think that there's good reason to think that these criteria are linked to outcomes . . . "
In theory, she notes, it may "seem like that's correct."
Standardizing the criteria
While she hasn't found evidence-based medical research that would indicate psychosocial criteria are necessarily linked to outcomes, she does think that psychosocial evaluations can play a valuable role in identifying "needs that potential recipients have and hooking them up with services that can fill those needs."
Transparency is also very important, she notes. If institutions are going to use these criteria, she suggests that they make the evaluation process transparent to both potential recipients and their families, as well as to the general public.
Another area of concern relates to standardizing the criteria, so that the same criteria are used by all institutions.
"It is pretty clear that not everybody is using the same criteria," Walker says. "There's no obvious reason why people should use different criteria, other than sort of specific institutional features. If those are important, then those could be recognized in a transparent way," she says.
On a positive note, she does think this is a topic that is just now coming to the forefront of people's thinking when it comes to organ allocation.
"I think as it comes out more as something to think about — not just in terms of where the organs should go, but in terms of justice concerns, I think they're more likely to take some action," Walker says.