Mahima Sikdar

003

Chapter 11: The God Committee

1) The God Committee and Artificial Kidneys

a) How did Kolff’s and Scribner's inventions create a new moral issue in bioethics? What was this

issue?

● This breakthrough led to something wonderful: Thousands of dying renal patients would now

live. It also led to a new ethical issue: Given the scarcity of machines, what criteria of distributive

justice would be used to select who would live and who would die?(Pg#267)

b) Describe who constituted the Admissions and Policy Committee (aka the “God Committee”) and

how they made their decisions.

● Instead of leaving this problem of distributive justice to physicians, Swedish Hospital, Scribner,

or King County Medical Society took the unusual step of creating an Admissions and Policy

Committee to decide who would get a dialysis machine. They created this committee to take the

burden of moral decisions away from physicians, assuming that physicians would naturally want

their patients to be accepted. The committee of seven members represented the community: a

minister, a lawyer, a housewife, a labor leader, a state government official, a banker, and a

surgeon. Two physicians familiar with dialysis served as advisers and screened applicants for

medical unsuitability. The committee worked anonymously and never met candidates. (Pg#267)

c) How did the media dramatize the issues above and help start bioethics in 1962?

● In 1962, no philosophers had written about ethical issues of allocating organs; indeed, no one had

written about bioethics at all.4 At least, they had not in the modern sense in which cases are
 analyzed to find a just public policy. The previous major writings were in Catholic medical

ethics.(Pg#268)

2) How does the End-Stage Renal Disease Act guarantee all Americans kidney care? What problems

did it solve and create?

● The End Stage Renal Disease Act (ESRDA) mandated the federal government to pay for a

dialysis machine for any American who needed one. Congress passed ESRDA Act in a session

lasting only 30 minutes. The impetus came from a coalition of kidney patients, lobbyists for some

physicians' concerns over high rates of kidney failure in people of color, and concerns that too

much money was being spent on space and the war in Vietnam but too little on dying people who

might be saved. Pg#269)

3) What is the supply and demand issue with regard to donated organs?

a) What is mandated choice?

● Mandated choice requires adults, in obtaining a driver's license, to indicate whether they want to

be organ donors. Most American states require this choice. Required request mandates that

someone at a hospital ask a relative upon admission of the patient. About 47 percent of

Americans are potential organ donors. (270)

b) What is the difference between an opt-in policy and an opt-out policy?

● At least 14 European countries follow France and Spain and adopt presumed consent: Anyone

who has not declined to be a donor in writing to a national agency is presumed to be a donor. This

is also called an opr-our policy. Most American states follow an opr-in policy, where only those

citizens who consent to donate are potential donors. (271)

4) What is meant by “social worth criteria”? Describe in detail.

● The God Committee took social worth into account (although it did not use this phrase) in

distributing machines. Medical sociologists Renee Fox and Judith Swazey, who spent 40 years

studying artificial kidneys and transplantation, reviewed the minutes of the committee's meetings

and criticized its criteria: Within these very general criteria, the specific, often unarticulated
 indicators that were used reflected the middle-class American value system shared by the

selection panel. A person "worthy" of having his life saved ... was one judged to have qualities

such as decency and responsibility. A history of social deviance. such as a prison record, any

suggestion that a person's married life was not intact and a scandal tree, were strong

contraindications to selection. The preferred candidate was a person who had demonstrated

achievement through hard work and success at this job, who went to church, joined groups, and

was actively involved in community affairs. (271)

5) What is the rule of rescue?

● The rule of rescue, named by bioethicist Albert Jonsen, refers to allocating scarce medical

resources to a specific patient rather than to equally deserving but anonymous people.(pg277)

a) Explain how Ernie Crowfeather is an example of this rule.

● Crowfeather was a half-Sioux charmer and small-time criminal. He was on dialysis for 30 months

but refused to follow a regimen, despised his quality of life, drank, imposed his childish needs on

the staff, and eventually refused further treatment and died. (273)

b) What are the opposing issues of whether alcoholics should get liver transplants for ARESLD?

● The opposing issues of whether alcoholics should get liver transplants for ARESLD include: are

people with ARESLD responsible for their liver loss, will they waste the chance to have a liver

transplant, and can someone with ARESLD be blamed for the loss of his liver? Would a drinker

keep on drinking, thereby destroying the new liver, or would drinkers be transformed by receiving

the gift of life? (Page 273)

c) What contradictory messages does the medical system send out?

● The medical system sends out contradictory messages: first, eat healthy, exercise, and take

responsibility for your health; second, we will rescue you from illness and do everything in our

power to keep you alive, regardless of the cost or time spent by medical staff. (Page 273)
6) How would Kant criticize social worth standards of selection? What does he propose as the just

distribution of a scarce liver?

● Kant would disagree with social worth selection standards because he believes that everyone has

a choice, and alcoholism would not be considered an illness in accordance with his ethics. Kant

argues that in order to distribute a limited liver in a reasonable manner, one should first look at

those who lost kidney function due to hereditary disease before considering the less fortunate

individuals at random. (Page 272)

7) What is UNOS and what is its job?

United Network for Organ Sharing (UNOS) that oversees the country's organ transplant system under a

contract with the federal government.(Pg#274)

a) What are the 2 major concerns with multiple listings?

● The 2 major concerns of multiple listings raise questions about wealth and injustice. Some

patients get appointments with surgeons at more than one transplant center and have themselves

worked up at each, but only people who can take time off from work, afford to travel, and have

generous medical plans can arrange for multiple listings. (274)

b) How did Apple co-founder Steve Jobs take advantage of this loophole to get a liver transplant in

2009?

● In 2009, Apple co-founder Steve Jobs illustrated the advantages of multiple listing when he

traveled from California to Memphis to get a liver transplant. Having the money to get himself

worked up in Tennessee, he became the sickest patient on the hospital's list and got the transplant.

(pg274)
c) How did the cases of Mickey Mantle and Governor Casey call into question how UNOS allocates

organs?

● Mickey Mantle: A baseball store who went on the UNOS 'waiting list for a liver transplant got

classified as Stage 2, and he received a liver two days later. Mantle was an alcoholic, and people

argued that he destroyed his liver on his own. People felt that his celebrity status had helped him

get to the top of the list. Critics were against the fact that a transplant was given to an individual

with (1) liver cancer and (2) lifelong alcoholism. Many people believed that he brought his

condition upon himself. After backlash from these cases, UNOS revised its criteria to say that a

successful candidate must be at the top of one of the lists for single organs in addition to his place

on any list for two transplants. (pg275)

d) What are some of the concerns with retransplanting the same patient?

● Retransplantation of the same patient raises other issues about justice. Since patients often reject

transplanted organs, a second or third transplant can be done. But is it fair to rescue a particular

patient with a second heart or kidney when thousands of others never get a first one. Shouldn't

patients get a second organ only when everyone has had a chance at one. Retransplants raise a

profound conflict about justice. (pg276)

e) Why do utilitarians reject UNOS' rule of "sickest first”?

● One partialist theory is to allocate organs according to "sickest first: " or "give the organs first to

the patient most likely to otherwise die" Utilitarians want maximal years per organ to allocate

organs only to first-timers and allow no retransplants. Giving organs to the sickest patients does

not maximize the most years per life per organ. Because some patients are too near death. When

they die, the organs are wasted. (pg279)

What new ethical problems has that created?

● With the Harvard definition of brain death in 1967, the declaration of death in cadavers switched

to neocortical criteria, allowing retrieval of organs from cadavers who had their breathing and

circulation maintained artificially by ventilators. The transplant team understandably focuses on

the sick recipient of the organ, not the donor. Transplants occur only in people who have medical

coverage, so the transplant team and its hospital get paid for medical services to the recipient.

Because living-donor transplant centres then had no obligation to report deaths or injuries to the

UNOS, nor did UNOS have any legal obligation to monitor such deaths and injuries. (Page 283)

a) What is a savior sibling and what ethical problems do they create?

● Savior sibling: A child is conceived for the benefit (and to be used as a resource) of its sibling.

Ethical problems: Does one happy result justify creating 1,000 more children to serve as

resources for dying siblings? (pg280)

b) Explain how transplant teams have asymmetrical relationships with donors and to recipients.

● The transplant team understandably focuses on the sick recipient of the organ, not the donor. Not

only that, transplants occur only for people who have medical coverage, so the transplant team

and its hospital get paid for medical services to the recipient. In contrast, they receive nothing for

caring for donors and give such care at a financial loss. In sum, transplant teams have

asymmetrical relationships with donors and to recipients. (Pg281)

c) Describe the non-heart-beating-cadaver donor protocol and the ethical problems that it creates.

● In this protocol, a patient on a respirator is moved to the operating room where his or her

respirator is removed, breathing stops, the surgical team waits a few minutes for breathing to

resume, the patient is declared dead, and then his or her organs are removed. The ethical issue

where families consented but did not understand the issues? People could not agree on whether

families should be allowed to consent or organ procurement under the new protocol. (pg283)