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.
Rechtsfragen der Organverteilung
Organe sind knapp, und die Zahl der Patienten auf den Wartelisten, denen mit einem Transplantat geholfen werden konnte, steigt standig.’ Dabei kann die Frage, wem von diesen Patienten ein Organ zugeteilt werden und wer–vorlaufig oder endgultig–leer ausgehen soll, nicht allein mit medizinischem Wissen beantwortet werden; sie zwingt vielmehr unausweichlich zu normativen Wertungen. Es kann keinen Katalog gleichsam neutraler, rein „medizinischer“ Auswahlkriterien geben, mit deren Hilfe man es vermeiden konnte, bei der Festlegung von Regeln zur Auswahl von Patienten und zur Allokation von Organen ethische und rechtliche Urteile treffen zu mussen.2 Zur Diskussion steht mithin nicht, ob normative Prinzipien die Organverteilung determinieren, sondern welche Prinzipien dies vorrangig sein sollen und wer uber das relative Gewicht dieser Prinzipien zu entscheiden hat.
Evaluation of efficacy of liver transplantation in alcoholic cirrhosis using matched and simulated controls: 5-year survival. Multi-centre group.
BACKGROUND/AIMS
Alcoholic cirrhosis is the most common cause of liver transplantation in US males. The limited number of donor livers calls for "prioritisation", favouring those patients who will benefit most. The aim was to assess the efficacy of liver transplantation in patients with alcoholic cirrhosis.


METHODS
We compared the survival of 169 transplanted patients with two conservatively treated control groups, one of 169 patients matched for prognostic factors (age, cirrhosis severity, bleeding history) and one of 169 simulated patients.


RESULTS
The probability of survival to 5 years in the transplanted group was 66% (95% confidence interval 58-74%) vs. 52% (44-60; p = 0.03) in the matched group and 54% (51-57; p = 0.01) in the simulated controls. Transplantation was associated with survival (relative risk = 1.51; p = 0.02), independently of risk score (risk = 2.07; p<0.001), indication, period of inclusion, centre experience, and alcohol abstinence. Patients with severe disease (Pugh C11-15) benefited most in terms of 5-year survival: 58% (44-72) vs. 31% (17-45; p = 0.008) in the matched and 35% (30-40; p<0.001) in the simulated control groups. For patients at lower risk there was no significant difference.


CONCLUSIONS
Liver transplantation increases the 5-year survival of patients with severe alcoholic cirrhosis. In patients at lower risk, efficacy of transplantation should be confirmed by longer follow-up or by randomised trial.