Interview Question: Organ Transplant Dilemma

Suppose you’re a surgical consultant in charge of assigning organs on a transplant list, and a liver becomes available. Your hospital currently has two patients that urgently need the transplant; a 14 year old girl, and a 33 year old man with two infant children who is a regular drinker.

This is a pretty dire situation, because whatever your choice, someone is going to die and you might feel you like you have indirectly condemned them. However, without treatment, it is likely that both patients will die anyway, and therefore it is important that the chance to treat someone be seized.

The very first thing to do is work out which of the patients are a biological match for the transplanted organ. If either of them isn’t, that ends the dispute immediately. Mechanical factors could also be considered - meaning whether the size and shape of the donor liver would suit each patient and whether the procedure would be substantially more difficult in either of them, for example if one of them had hemophilia.

In the UK, only around 1% of organ donors die in circumstances where their organs can be safely donated to another person.

In the UK, only around 1% of organ donors die in circumstances where their organs can be safely donated to another person.

There are then an enormous number of circumstantial factors that could then be assessed. For example, the father patient has a history of drinking, although the question does not say to excess. Might the teenage girl be more responsible with the liver and avoid heavy drinking? Demonstrate to the interviewer that you are aware that many of these social elements can be important in making the choice.

Perhaps the most important concept is that of Quality of Life (QoL). Which of the patients stands to gain the most with regards to long-term prognosis as a result of the transplant procedure? This is difficult to measure, but the Quality-adjusted Life Year is the most commonly used method. Essentially you’d wish to know which patient would live the largest number of years with the highest level of health - the girl has longer to potentially live, but would this necessarily be in the same health state as the father if something went awry during the operation?

Is it right that a heavy drinker should get a liver transplant over a non-drinker? These questions are very important for systems with constrained resources such as the NHS.

Is it right that a heavy drinker should get a liver transplant over a non-drinker? These questions are very important for systems with constrained resources such as the NHS.

You may also consider the social impacts of your choice. The parents of the teenager are likely to suffer very badly emotionally if she were to die, due to her not having lived a full life, which would seem a great injustice. Conversely, the QoL for the two infant children would also likely be negatively affected by the lack of their father if he were to die.

Your interviewers will not expect you to choose ‘the right answer’ in these scenarios, as very often (if not always) the questions are designed such that one does not exist. Avoid jumping to a conclusion very quickly, as it’s all about how carefully you can assess the situation and consider as many factors as possible. Do choose an answer and provide solid reasoning to back it up, but always communicate that there are valid arguments on both sides.

Interview Preparation: Four Pillars of Medical Ethics

Medical ethics refers to a series of principles that when considered together aim to ensure that everyone receives the same standard of healthcare and serve to guide doctors in approaching the care of their patients. While healthcare professionals must use them each and every day in carrying out their roles, they can also be examined more closely when conflicts arise to work out exactly how they should be resolved. Such cases are known as ethical dilemmas.

These ideas are loosely defined in four key values, known as the four pillars of medical ethics. In no particular order, they are Autonomy, Beneficence, Non-maleficence and Justice. This article will address each of these ideas in turn and elaborate on their meaning and consequences for the practice of medicine, which you’ll want to be aware of before your medical school interview. We’ll explore them more individually in future articles but for now here’s a primer.

The Hippocratic Oath, dating back to the 5th century BCE, outlines many principles of medical ethics which are still used today

The first, autonomy, is recognition that the patient has ultimate control over whether they receive the treatment or not - medical practitioners may not force treatment upon them under normal circumstances. The exception to this is when patients cannot be deemed able to reasonably make decisions for themselves, for example when detained under the Mental Capacity Act.

At this point you’re concerned with establishing whether you have explained all the treatment options the patient has available to them, the patient understands their choices and that they are capable of making that decision. Lastly, whatever actions need to be taken in order to deliver that treatment can only be taken if the patient has provided their informed consent - moving ahead without this consent is treated as battery, or unlawful personal violence.

Beneficence refers to the idea of having the best outcome for the patient in mind at all times, particularly when all the options available (of which there may be many) have been considered. It is the duty of medical practitioners to identify which treatment would give the best outcome and to communicate that to the patient.

Do bear in mind that this could be more complicated than it sounds, as the patient will have their own views about the treatments beyond medical statistics. There might be elements to their lives that make some methods incompatible with their situation, for example. It’s all about identifying that best outcome and discussing it with the patient.

Non-maleficence is taken together with beneficence, and is essentially a concise version of the Hippocratic Oath: Do No Harm. I highly recommend that anyone interested reads the memoir of neurosurgeon Mr Henry Marsh, who applies this principle very frequently throughout the book. The risks of an intervention should always be weighed up against the outcome of doing nothing at all.

Of course harm can come by neglect, which is where the latter case comes in. A holistic assessment of the situation is therefore necessary, to identify all possible sources of risk, be it the competence and experience of the medical practitioner, the circumstances of the patient beyond the hospital and of course any basal risks that are inherent of the treatment itself.

The last of the four pillars and perhaps the most complex is Justice, which concerns identifying whether or not an action is fair in society and within the realms of the law. As one might imagine, this is no easy feat because of the nuances and subjectivity associated with the idea of fairness.

Say you were faced with two patients who desperately needed liver transplants and would surely die without them. You have access to one liver, compatible with both patients but you may only choose one. The first patient is a middle-aged male with two young children and a morphine addiction, while the second is a sixteen year old female. In this case, do you choose the option which gives one patient more years of life, or that might result in fewer for the other but provide the two children with a more stable environment?

This is an extreme example but reflect on the point made - responsibility lies in very large part with the doctor and you must be able to live with the consequences of your choices. The four pillars serve as a way to inform these choices and ensure the best outcomes for your patients.