Hospital Ethics Committee—Who Gets the Heart? Transcript

In this scenario, you are the advanced practice nurse on the transplant committee for Hope Medical Center. All members of the committee have to vote to decide which patient will receive a donor heart. Five other people are on the committee with you:

• The administration member is Wes, the Chief Operating Officer.
• The physician member is Dr. Hasweh, Cardiovascular Surgeon and Head of Transplant Services.
• The social services member is Mahalia, who has worked closely with all clients on the transplant list.
• The chaplain member is Pastor Arturo, pastor of a local church and lead chaplain at Hope Medical Center.
• The community member is Dr. Bashist, a retired general surgeon who serves on the Board of Directors.

Early this morning, a 17-year-old died following a motorcycle accident. The parents want their son to be an organ donor. The team at Heart of Mercy Hospital prepared and began harvesting organs and notified Hope Medical Center that they have a heart for their patient Bernadine Smith, a 32-year-old with a congenital heart defect who needs a transplant after recently enduring her third pregnancy and delivering a healthy baby boy. At Hope, Bernadine has been prepped for surgery. As surgery begins, a member of the organ transplant team is on the way by helicopter to pick up Bernadine’s new heart. After the heart is procured and the team member is on the way back with the heart, Bernadine suffers a massive stroke and dies on the table. Hope Medical Center, having already taken possession of the heart, now has just under an hour to decide who gets the heart.

Your first job is to interview the following candidates who are next in line for the heart.

First is Helen Adams. Helen is a 65-year-old, single Caucasian female with no children or family. Her health history includes coronary artery disease, history of two-packs-per-day smoker, BMI of 29. She has modified her diet and gave up smoking 9 months ago. She currently requires 2 LPM oxygen at all times. She is not a candidate for revascularization. As you interview her, she states, “Yeah, I quit smoking months ago. God, I miss it. I know you all keep telling me I need a new heart or I’ll be dead in a year, but I think I’d feel weird with someone else’s heart in me. I’ve heard people start to like things they never did before and stuff like that. What if it makes me more like the person I get a heart from, and I don’t like it? I’m just not totally sold on the idea.”

Second, you interview Quentin West. Quentin is a 38-year-old African American father of four. His wife has been a stay-at-home mom until recently, when Quentin became unable to work as a result of his inability to perform required duties. His health history includes cardiomyopathy, hypertension, and a BMI of 42. He tells you his BMI was much lower in his 20s, when he played professional football as an offensive lineman. He also says he understands that playing football led to his development of cardiomyopathy. He states that he has seen many of his former teammates and friends die of this condition. He does admit to a history of substance abuse but states that he gave that up before his first child was born.

After your interviews, you are headed back to speak to the rest of the committee when you are grabbed by a nurse to help with a cardiac arrest coming in by ambulance. When the patient arrives, you receive the following regarding the patient:

Earl, a 42-year-old male was snow skiing nearby when he suddenly collapsed. His girlfriend called 911. When emergency services arrived, the patient had a pulse, but the pulse was lost on the way to the hospital; CPR was initiated, and the patient was intubated. The paramedics were able to get a heartbeat back; however, the patient continues to have arrhythmias and apparent low cardiac output. Earl is found to have a history of coronary artery disease, hypertension, heart failure, and previous heart attack resulting from cocaine use. He is stabilized and moved to the ICU on a heart pump with a poor prospective outcome.

When you go in to meet with the ethics committee with your update, you discover that the patient from the ER is the son of Earl Hope Eubanks the third, a major donor to the facility and the person for whom the hospital is named. Mr. Eubanks has contacted the facility and pledged to pay for a new pediatric cancer wing to be developed and built … but it is certainly inferred that the money will be donated only if the son receives the donor heart.

As the committee sets down to discuss who should receive the heart, the following discussion occurs:

Wes: Thank you all for gathering on such short notice. As you all know, we have a big decision to make and not a lot of time to make it in. Just so that we are all on the same page, we have three candidates for the heart that is en route to this facility. I would like to open the floor for comment.

Mahalia: I need to recuse myself. I feel like I am too emotionally involved to make an objective judgement in this case.

Wes: Thank you, Mahalia. I understand that this is certainly a difficult situation. I appreciate your honesty. Does anyone else wish to recuse themselves? Okay, so let’s open the floor for conversation.

Dr. Hasweh: As the surgeon, I want to be clear that neither of the two are great candidates.

Wes: Don’t you mean three candidates? We cannot forget about Mr. Eubanks.

Dr. Hasweh: Wes, we all know about his cocaine abuse. You know that disqualifies him. Wes: But what if he quit? Your Mr. West also has a history of substance abuse.

Dr. Hasweh: History of, not current use. Let’s do a drug screen on Mr. Eubanks and see if he is still using and interview that girlfriend that was with him.

Dr. Bashist: I personally believe that we should eliminate Ms. Adams. She isn’t even sure she wants a transplant.

Mahalia: I believe that she is just scared. Maybe she doesn’t want to get her hopes up. If she is chosen, she can always refuse and then we move on to the next recipient.

Dr. Bashist: But that is a waste of time.

Pastor Arturo: If it was you who needed the heart, I would think you wouldn’t feel it was a waste of time. I understand human nature and can see Mahalia’s points. Ms. Adams is certainly still a valid candidate. She has made strides toward a healthier lifestyle already.

Dr. Hasweh: Ms. Adams may be the best candidate since she has already shown that she can make the required changes.

Mahalia: What about Mr. West? He has a family to support, and he is so young!

Dr. Hasweh: But he has a history of substance abuse and a BMI of 42!

Mahalia: Well your Ms. Adams claims that she “quit smoking,” but how can we really prove that?

Wes: I appreciate all of the conversation, but we must not forget about Mr. Eubanks. Even if he comes back positive for substance abuse, imagine all of the good we could do with a children’s cancer wing. That has to play into this decision.

The drug screen comes back inconclusive, and Mr. Eubanks’ girlfriend said she didn’t see him do anything drug related. After much more discussion, a vote is held. Wes and Mr. Bashist vote for Mr. Eubanks, and the chaplain and Dr. Hasweh vote for Mr. West. Ms. Adams is removed as a candidate. Mahalia again recuses herself.

Your vote decides who gets the heart.

Patients

• Helen Adams
• Quentin West
• Earl Hope Eubanks IV

1. Your vote decides who gets the heart. Who would you choose and why?
2. How did health inequality and inequities affect your decision?
3. What ethics would you use to back up your decision?
4. Why did you not choose the other candidates?
5. Was this an easy or a difficult decision for you?
6. Would you want to serve on an ethics committee in the future? Why or why not?

ANSWER

Ethical Dilemma in Organ Allocation: A Decision-Making Process

Introduction

The scenario presented involves a challenging ethical decision regarding the allocation of a donor heart to one of three candidates: Helen Adams, Quentin West, and Earl Hope Eubanks IV. The advanced practice nurse (APN) on the transplant committee at Hope Medical Center is tasked with casting the deciding vote. This essay navigates the complex ethical considerations, health inequalities, and personal beliefs that influence the APN’s decision.

Decision-Making Process

Choice and Justification

After careful consideration, my vote would go to Quentin West. This decision is based on a combination of factors, including Mr. West’s age, his family responsibilities, and his willingness to overcome past challenges. His history of substance abuse and cardiomyopathy demonstrates that he has faced adversity, but his commitment to a healthier lifestyle and his role as a father of four make him a compelling candidate for the heart transplant. Allocating the heart to Mr. West aligns with principles of fairness and potential contribution to society.

Health Inequalities and Inequities

Health inequalities and inequities play a significant role in this decision-making process. Quentin West’s history of cardiomyopathy, which he attributes to his professional football career, highlights the health risks faced by individuals in certain occupations. Additionally, the disparities in healthcare access and outcomes among different population groups underscore the importance of considering each candidate’s background and potential for benefiting from the transplant.

Ethical Frameworks

The decision is supported by several ethical principles. Beneficence, as seen in Mr. West’s commitment to a healthier lifestyle, suggests that providing the heart to someone who is willing to make positive changes aligns with the principle of doing good. Autonomy respects Mr. West’s personal journey of overcoming substance abuse and improving his well-being. Additionally, the principle of justice calls for allocating the heart to a candidate who has the potential to benefit society, as Mr. West’s family responsibilities indicate.

Exclusion of Other Candidates

Helen Adams is excluded from consideration due to her uncertainty about receiving a transplant and concerns about potential changes in her identity post-transplant. These factors suggest that she may not fully embrace the opportunity and could potentially refuse the transplant, wasting a valuable resource. Earl Hope Eubanks IV is excluded due to his history of substance abuse and inconclusive drug screening results. As a major donor to the facility, the perception of bias could compromise the ethical integrity of the decision-making process.

Decision Complexity

This decision is undoubtedly difficult. Each candidate has unique attributes that warrant consideration, making it challenging to weigh their value against one another. Furthermore, the potential impact of the decision on Mr. West’s family and Mr. Eubanks’ donation to the facility adds layers of complexity.

Serving on an Ethics Committee

Serving on an ethics committee is both an honor and a responsibility. While the decisions are challenging, they provide an opportunity to apply ethical principles, consider societal implications, and prioritize patient well-being. Being part of such a committee allows for active participation in shaping the ethical landscape of healthcare and addressing moral dilemmas.

Conclusion

In conclusion, the decision to allocate the donor heart to Quentin West is rooted in a combination of factors, including his age, family responsibilities, commitment to change, and potential societal impact. The ethical principles of beneficence, autonomy, and justice guide this decision-making process. While the choice is complex, it reflects a thoughtful evaluation of each candidate’s circumstances and potential for benefiting from the transplant.