During an ethics discussion today, we were talking about prioritizing patients for organ transplants. Someone brought up the question of cost, and the leader, a specialist in lung transplantation, mentioned that because post-transplant therapy can be extremely expensive, patients are screened for ability to pay for that therapy prior to the transplant. The reasoning for this is, clearly, that it makes no sense to give a patient a donor’s lung if it will simply result in the patient’s death, e.g. from graft-vs-host as a result of inability to obtain proper immunosuppressive medication.
Perhaps I am naive, but this seemed pretty unbelievable to me. Sure, poor people get inferior care for a lot of reasons. Sure, you might call them the victims of clandestine or indirect rationing. But up to this point, I had not been aware of a situation as stark and grim as a patient sitting down with a counselor, opening up his financial and insurance records, and then being told that he cannot receive a life-saving treatment as a result.[1]
Nevertheless, it is true. Buried in Table 4 of this medscape article, listed under “Absolute Contraindications for Organ Transplantation In General” is the item “Lack of financial resources to pay for surgery, hospitalizations, medications, and follow-up care.” According to the physician I talked to, the assessment for this contraindication is made by financial specialists who operate under institutionally-defined guidelines.
Yikes.
The fact above is really the point of this post, and I think it should stand on its own–if it wasn’t already obvious to you, of couse. Just tangentially, however, I’d like to mention two other fascinating “absolute contraindications” from the same list: “History of failure to comply with medical regimen” and “Lack of functional psychosocial support system”. Of course, none of these contraindications are illogical, but the addition of these two, which address “social” issues, on top of the previous one does make it pretty hard to avoid the term “socioeconomic status” in summarizing what might disqualify someone for a transplant.
[1] Even after watching Michael Moore’s Sicko, which contains a very extended segment about a man who dies after his insurance company denies him coverage for a kidney transplant, it was not clear to me that he might have actually been denied the treatment in addition to the reimbursement for it. In fact, the distinction between those two is emphasized by insurance company representatives as justification for denials without explicit rebuttal. Which is strange, because Moore isn’t exactly known for editorial restraint. (This ABC news article, which addresses a similar issue, is better towards the end, but still doesn’t really explicitly make the coverage/care distinction.)
