Legal Justice in Organ Allocation. A Legal Perspective on the Failure of the German Organ Allocation System
The German organ allocation system is out of joint. In July 2012, the medical community as well as the broader public got alarmed by several high-profile transplantation scandals, which meanwhile have resulted in a significant decrease in the number of organ donations. Several physicians at different university hospitals have been accused of altering data related to their patients to make them appear sicker than they actually were in order to place them in front of other patients that were on the waiting list for liver donations. The scandal sheds light on the essential normative nature of prioritization decisions and raises the question of ethical and legal justice in public health. The article argues that the regulatory framework of organ allocation in Germany is not in accordance with the constitutional requirements for a state organized allocation order, which directly affects the most fundamental rights of patients. The lack of legitimacy of the current allocation system, which is essentially determined by guidelines of the German Medical Association, makes it impossible to find a satisfactory legal answer to the problem of individual manipulations of the prioritization process by doctors, who arbitrarily try to advantage their own patients.
Die Setzung von Standards in der Transplantation: Aufgabe und Legitimation der Bundesärztekammer
Allokationsentscheidungen in der Transplantationsmedizin haben eine elementar existenzentscheidende Bedeutung. Mit der Frage, welcher Patient eines der knappen zur Transplantation freigegebenen Organe auf den Wartelisten erhalt, entscheiden sich Lebenschancen, kann die Frage von Leben und Tod verbunden sein.1 Da angesichts der mangelnden Spendenbereitschaft in der Bevolkerung ein akuter Organmangel herrscht – 2006 standen den 8473 Patienten auf der Warteliste fur eine Niere lediglich 2776 Nierentransplantationen gegenuber2 – findet sich hier auf der Mikroebene geradezu ein Paradebeispiel fur die grundsatzliche Frage der Verteilung knapper Ressourcen im Gesundheitswesen. Es kann deshalb auch nicht verwundern, dass die in Deutschland 1997 getroffene gesetzliche Regelung im Transplantationsgesetz (TPG) Gegenstand heftiger Kontroversen geblieben ist. Der Gesetzgeber hat die Allokation der Organe, also die Verteilung an die Patienten und zuvor die Aufnahme von Patienten auf die Warteliste nicht en detail vorgegeben, sondern auf den „Stand der Erkenntnisse der medizinischen Wissenschaft“ (§ 12 Abs. 3 S. 1 TPG) verwiesen. Nach diesen Regeln seien die Organe zur Transplantation zu vermitteln, wobei insbesondere „Erfolgsaussicht und Dringlichkeit fur geeignete Patienten“ eine Rolle spielen.
Allocation of transplantable organs: Do people want to punish patients for causing their illness?
Some people believe patients with alcoholic cirrhosis should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) are personally responsible for causing their own illnesses, (2) have poor transplant prognoses, or (3) are unworthy because they have engaged in socially undesirable behavior. We explore the roles that social desirability and personal responsibility have in people's judgments about transplant allocation. We presented prospective jurors with 4 scenarios, asking them to distribute 100 transplantable organs among 2 groups of 100 patients each. In each scenario, 1 group of patients, but not the other, was described as having a history of unhealthy behavior (alcohol or cigarette use) associated with a poorer prognosis. In some scenarios, alcohol or cigarette use was said to cause the organ failure. In others, it only contributed to the patients' transplant prognosis. We also obtained self‐reports of subjects' own smoking status. Subjects allocated significantly fewer than half the organs to those with unhealthy behaviors and worse prognoses (33%; P < .001), but the specific behavior (alcohol versus cigarette use) was not significantly associated with subjects' allocation choices. Significantly fewer organs were allocated to patients with behavior responsible for causing their diseases than to other patients (P < .0001). Subjects who never smoked discriminated the most and current smokers discriminated the least against patients with a history of unhealthy behavior (P < .0001). The public's transplantation allocation preferences are influenced by whether patients' behaviors are said to have caused their organ failure.