A systematic review of physicians’ and patients’ preferences regarding the allocation of deceased donor organs: To what extent are physicians acting as advocates for their patients?
Tim Bartling1,2, Carina Oedingen1,2, Thomas Kohlmann3, Harald Schrem4,5, Christian Krauth1,2.
1Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany; 2Center for Health Economics Research Hannover, Hannover, Germany; 3Department for Methods of Community Medicine, Institute for Community Medicine, University of Greifswald, Greifswald, Germany; 4Department of General, Visceral and Transplant Surgery, Medical University Graz, Graz, Austria; 5Transplant Center Graz, Medical University Graz, Graz, Austria
Introduction: Overcoming the mismatch of donor and recipient numbers is a challenge lawmakers are facing worldwide. In order to improve this mismatch, a possible solution is adaption of the existing legal framework for donor organ allocation. Furthermore, this situation calls for a fair and just distribution of the limited resources available. Following the World Medical Association’s “Medical Ethics Manual”, physicians act as advocates for their patients and owe them complete loyalty, which is especially hard to do when loyalty to one patient interferes with loyalty to another, for example in the topic of center allocations. This systematic review seeks to identify how physicians and patients perceive the question of organ allocation with regards to the concept of distributive justice, and what attributes and preferences are finally making the difference when it comes to allocating a donor organ.
Materials and Methods: This systematic review is searching all entries in the databases PubMed, EBSCO, Web of Science and PsycINFO from Jan 2000 to Dec 2018. The search string was conducted to include relevant MeSH terms. A total of 9,643 initial records were identified. 13 studies in 14 publications were finally included in the synthesis, whereas 6 focused on physicians, 7 on patients and 1 on both groups. The relevant attributes were extracted from their studies and grouped together in similar topics.
Results and Discussion: The criteria and attributes elicited from the relevant studies were grouped in six different categories, indicating where the respondents deviated from the principle of equality: “Effectiveness/Benefit”, “Medical urgency”, “Own fault”, “Social value”, “Medical background” and “Socio-demographic status”. Patients demanded equal access, maximization of outcomes and the punishment for behaviors damaging the organ or negatively influencing the success of the transplantation. However, patients also found it hard to make clear cut-offs, sometimes allocating organs to hypothetical candidates with survival chances <10%. Physicians sometimes prioritize clinical evidence over equal chances and access, e.g. in the case of sex and ethnicity. Furthermore they show a higher level of medical knowledge, which was expected. This leads to them giving less priority to medical factors that have fewer implications in practice such as tissue or blood group match, whereas patients prefer a best possible match unknowingly of the respective importance.
Conclusion: Patients prefer equal access and maximization of outcomes, while at the same time considering every candidate transplantable, regardless of the expected survival. Physicians perceive organ allocation as a complex system, seeing all patients rather than individuals and are ready to make cuts when necessary.
This work was supported by the German Federal Ministry of Education and Research [Grant Number 01EH1603B], financing TB and CO. The funding source had no role in the study and no influence on data collection and analyses, interpretation of results or writing of publications..
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