High-risk liver transplant candidates: An ethical proposal on where to draw the line

In making liver transplantation (LT) listing decisions, transplant programs accept that very large differences in expected 5-year posttransplant survival should matter and that small differences in expected survival should not matter. To date, the transplant community has not explicitly addressed the difficult question of how to make decisions when the differences are less dramatic. Existing well-accepted transplant policies neither articulate a criterion for where to draw the line nor provide an ethical justification for distinguishing those who should not be eligible for transplantation from those who should be. Herein we analyze a case from our LT program that raises the issue of how much of a difference should separate the eligible from the ineligible. We explain how our ethical analysis is consistent with the Scientific Registry of Transplant Recipients cumulative sum metric for transplant center performance, the United Network for Organ Sharing standard of capping Model for End-Stage Liver Disease scores at 40 for listing purposes, and the longstanding tradition of allocating scarce medical resources in accordance with the principle of triage. We also discuss how subjectivity can influence judgments about likely outcomes. We conclude by calling for research to gather data that could make survival predictions objective and by proposing a policy that would make the treatment of all patients fair.