People with liver failure and cirrhosis die every year because there are not enough livers available. Who should receive the treasured life-saving organ? There is an organ allocation system in place, which has evolved over time, which ranks patients who need liver transplants. Without such a system, there would be confusion and chaos. How can we fairly determine who should receive the next available liver? What criteria should move a candidate toward the head of the line? Age? Medical diagnoses? Insurance coverage? Employment status? Worth to society? Criminal record?

Consider the following six hypothetical examples of patients who need a liver transplant to survive. How would you rank them? Would those toward the bottom of your list agree with your determination?

• A 50-year-old unemployed poet is an alcoholic. He has been sober for one year. His physicians believe he will not survive another year without a transplant.
• A 62-year-old prisoner has end-stage liver disease from hepatitis C, contracted from prior intravenous drug use. He has been showing serious medical deterioration and his physician is concerned that his demise approaches unless he undergoes a liver transplant. He will be incarcerated for life. He is taking college classes pursuing an undergraduate degree.
• A 45-year-old piano teacher has a malignant liver lesion. Her physicians have advised a liver transplant. Although the survival rate for a liver cancer transplant is reasonable, it is lower than for sober alcoholics or hepatitis C. There are no other effective treatments available. Her prognosis with standard medical treatment is dismal.
• A 40-year-old has end-stage liver disease of unclear cause. Liver transplant would likely save his life. He is self-employed and has no medical insurance.
• A 60-year-old hedge fund operator needs a new liver to survive. He is concerned that according to medical criteria, he will not be given a liver soon enough. In exchange for a liver, he offers to donate $5 million to the medical institution to fund cutting-edge research in treating liver disease. This research has the potential improve the lives of thousands of individuals.
• A 55-year-old is trying to get a liver transplant for his child. In exchange for preferential treatment, he will stipulate that several family members will agree to donate various organs upon death.

How should the ranking decision made? What factors should be weighed? Ability to pay? Worth to society, assuming this could be calculated? Probability of long-term survival?

Every one of these six individuals has a right to receive a new liver, but some of them will be left aside because others will be judged to have a greater right to a transplant. When any decision is made that creates winners and losers, the system will be challenged and attacked by those who decry what they believe to be an unfair process and outcome. It is for this reason that transplant policy be made primarily by those who are as free as possible from agonizing conflicts of interest.

A conflict of interest understandably taints our views. For example, we may be against paying ransom for kidnapped hostages, until our kid is taken hostage.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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