Winners and Losers: Allocating Scare Resources for Patients with Hepatocellular Carcinoma

Excerpt

The allocation of a scare resource requires considerable thought and application of ethical principles. This is a constant struggle as we try and balance the principles of population utility versus individual justice in the field of organ transplantation. Scarce donor organs, in this case, livers, are distributed according the illness of the patient. In many countries, this is according to the MELD score, which reflects the 90-day mortality for patients with end-stage liver disease. In most situations patients with hepatocellular cancer (HCC) do not manifest a high enough native MELD score to be competitive for a transplant and must be given exception points to increase their chances of transplant. Too much priority and non-HCC patients have a more challenging time receiving a transplant. Too little and HCC patients start dropping off the waitlist due to disease progression beyond reasonable criteria. For many years in the United States, these HCC patients have received too much priority despite numerous policy changes. This has been shown multiple times when one looks at the dropout rate from the liver transplant waiting list.1,2 Recent policy changes in the United States have changed the waiting time and exception points that HCC patients will receive in attempts to place these patients more equitably with non-HCC patients awaiting a liver transplant (LT). Only patients meeting strict criteria are eligible for excess priority for transplant. The criteria (Milan) have been challenged as being too restrictive, and thus many series have been reported showing good results with patients with HCC beyond Milan.3 …