Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a death row inmate should be eligible for a heart transplant.
Yes: 34%
No: 66%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
The U.S. Supreme Court ruled in Estelle v. Gamble (1976) that prisoners cannot be discriminated against in the delivery of medical care. Denying healthcare to inmates who are at the mercy of the state amounts to "cruel and unusual punishment."
As a result, convicts facing stiff terms of incarceration have received costly government-financed organ transplants -- including a California robber who underwent a $1 million heart transplant in the fourth year of a 14-year sentence and a Minnesota murderer who benefited from a $900,000 bone marrow transplant. Yet organs are scarce resources, and in the case of an inmate facing execution, some might view transplantation as effectively squandering a lifesaving organ.
The media often focuses on death row inmates who wish to donate organs prior to, or at the time of, their executions. In 2011, Gov. Haley Barbour (R) of Mississippi freed Jamie and Gladys Scott, two sisters facing life in prison for robbery, so that one could donate a life-saving kidney to the other -- a decision criticized by some ethicists as conditioning release on organ donation.
Christian Longo, an Oregon inmate facing lethal injection for killing his wife and three young children, founded an organization called Gifts of Anatomical Value from Everyone, which seeks to allow death row inmates to donate their organs. Indiana killer Gregory Scott Johnson unsuccessfully sought a stay of execution in 2005 in order to donate a liver to his ill sister. Critics of allowing death row inmates to donate organs fear that prisoners will act in the hope of obtaining clemency or that the state will coerce such donations, as is rumored to occur in several foreign nations.
If condemned prisoners rarely offer to donate organs, still rarer is the death row inmate who seeks listing to receive an organ. The most prominent case is probably that of Horacio Alberto Reyes-Camarena, a convicted killer from Oregon who sought a kidney transplant in 2003.
A consensus exists among all stakeholders in the organ allocation system that perceived social worth will generally not be considered in the distribution of organs. Factors like one's economic status, occupation, and contribution to society should play no role in determining who receives a life-saving heart or liver.
Notably, this was not always the case with critical interventions. In 1962, Seattle's King County Medical Society established a so-called "God Committee" that did use social worth as a determinant in allocating scarce dialysis treatments. A profile of the committee's deliberations in Life magazine led to public outrage -- and ultimately, to federal funding for all dialysis care.
In contrast, while social worth is not considered an acceptable factor in allocating organs, some degree of controversy remains regarding whether "moral responsibility" for one's illness should play any role in the recipient selection process. This debate has largely focused on alcohol and drug abusers seeking liver transplants -- with the current approach excluding moral responsibility as a factor in allocation. An alcohol abuser may be denied a liver because of his current drinking habits or his likelihood of relapse, but not because he caused his liver to fail. Suicidal patients who remain at high risk of repeat attempts raise similar concerns.
In the case of death row inmates, one might argue that denying organs to prisoners like Janet has nothing to do with their crimes, only with impending punishments that will reduce the life expectancy of the organs. Yet in many jurisdictions, the average death row inmate spends more time awaiting execution than the average transplanted organ survives -- even with excellent medical care. Reyes-Camarena is himself an example of this irony. The life expectancy of a cadaveric kidney, for instance, is roughly 13 years. Sentenced to death in 1997 and denied an organ transplant in 2003, Reyes-Camarena remains on Oregon's death row more than 15 years later.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Leak Politician's Medical Secrets?