Old Age and Frailty in Deceased Organ Transplantation and Allocation-A Plea for Geriatric Assessment and Prehabilitation.

Due to demographic ageing and medical progress, the number and proportion of older organ donors and recipients is increasing. At the same time, the medical and ethical significance of ageing and old age for organ transplantation needs clarification. Advanced age is associated with the frailty syndrome that has a negative impact on the success of organ transplantation. However, there is emerging evidence that frailty can be modified by suitable prehabilitation measures. Against this backdrop, we argue that decision making about access to the transplant waiting list and the allocation of donor organs should integrate geriatric expertise in order to assess and manage frailty and impairments in functional capacity. Prehabilitation should be implemented as a new strategy for pre-operative conditioning of older risk patients' functional capacity. From an ethical point of view, advanced chronological age per se should not preclude the indication for organ transplantation and the allocation of donor organs.

[Attitudes towards organ donation in Germany: Qualitative analyses supplementing quantitative evidence]. / Einstellungen zur Organspende in Deutschland ­ Qualitative Analysen zur Ergänzung quantitativer Evidenz.

BACKGROUND: To this day, the general population's attitude towards post-mortem organ donation has primarily been analyzed using quantitative representative surveys. These studies presuppose the willingness of the interviewees to participate. Since this agreement can be positively correlated with the willingness to donate organs, a systematic bias of the samples in favor of people willing to donate cannot be excluded. Using innovative qualitative databases and methods, rarely observed positions and arguments can be systematically identified. In this way, existing quantitative empirical studies can be beneficially supplemented. METHODS: This qualitative-empirical study analyzes online discussion threads applying the GABEK® method (Software WinRelan®). Differentiated according to positive and negative attitudes towards organ donation, determinants of attitudes are extracted and condensed using network graphs. A similar procedure is used to work out assessments of alternative solutions to the existing scarcity problem in the German organ allocation system. RESULTS: Discussants with a favorable attitude are mainly motivated by altruism and reciprocity. A disapproving attitude is particularly due to problems with the concept of brain death and distrust concerning the health and organ donation system. It can be demonstrated that negative attitudes are more often than not based on missing information and misinformation. With regard to alternative system solutions, monetary compensations are regarded positively, whereas the opt-out solution ("Widerspruchslösung") and concepts based on reciprocity are discussed controversially. CONCLUSION: There is still a great need for information and trust-generating work in the German organ donation and allocation system. Qualitative analyses in addition to quantitative evidence are necessary in order to localize these needs and concretize their content.

The ethical debate over child priority in post-mortem organ allocation: A scoping review and practical-ethical outlook.

BACKGROUND: Organ allocation guidelines in many countries give children relative priority, but the normative justification of child priority is seldom articulated. METHODOLOGY: We conducted a scoping review of the recent international literature (2013-2019) to identify moral positions and normative frameworks to justify or criticize pediatric priority in all kind of organ allocation. We identified 11 relevant papers. RESULTS: Our analysis revealed a complex juxtaposition of pro and contra argumentations along three main normative lines: a) equal treatment of each individual, b) individual benefit, and c) social benefit and the public good. The general type of argument can be found independent of the organ allocated. For each of these three lines we identified and categorized two types of argumentations: those in favor and those critical of the priority rule. Additionally, we discuss a problematic issue that has not yet been mentioned in the literature, namely the effects of age thresholds related to child-priority rules in organ allocation. We illustrate this problem with an analysis of selected German data with allocated postmortal kidneys and livers. These data show non-normal distributions of organ transplantations and waiting times for patients between the ages of 16 and 19. DISCUSSION: Our overview serves as a matrix to reconsider existing guideline policy. The review can assist policy makers or experts on organ allocation committees in increasing the transparency of child priority rules, in explaining their justifications, and in reforming existing guidelines.

Allocating health care resources: a questionnaire experiment on the predictive success of rules.

BACKGROUND: The topic of this paper is related to equity in health within a country. In public health care sectors of many countries decisions on priority setting with respect to treatment of different types of diseases or patient groups are implicitly or explicitly made. Priorities are realized by allocation decisions for medical resources where moral judgments play an important role with respect to goals and measures that should be applied. The aim of this study is to explore the moral intuitions held in the German society related to priorities in medical treatment. METHODS: We use an experimental questionnaire method established in the Empirical Social Choice literature. Participants are asked to make decisions in a sequence of distributive problems where a limited amount of treatment time has to be allocated to hypothetically described patients. The decision problems serve as an intuition pump. Situations are systematically varied with respect to patients' initial health levels, their ability to benefit from treatment time, and the amount of treatment time available. Subjects are also asked to describe their deliberations. We focus on the acceptance of different allocation principles including equity concepts and utilitarian properties. We investigate rule characteristics like order preservation or monotonicity with respect to resources, severity, or effectiveness. We check the consistency of individual choices with stated reasoning. RESULTS: The goals and allocation principles revealed show that the moral intuitions held by our experimental subjects are much more complex than the principles commonly applied in health economic theory. Especially, cost-utility principles are rarely applied, whereas the goal of equality of health gain is observed more often. The principle not to leave any patient untreated is very dominant. We also observe the degrees to which extent certain monotonicity principles, known from welfare economics, are followed. Subjects were able to describe their moral judgments in written statements. We also find evidence that they followed their respective intuitions very consistently in their decisions. CONCLUSIONS: Findings of the kind presented in this paper may serve as an important input for the public and political discussion when decisions on priorities in the public health care sector are formed.

How you ask is what you get: Framing effects in willingness-to-pay for a QALY.

In decisions on financing new and innovative health care technologies a central question is how to determine the value citizens place on the gains in health and life expectancy that result from respective medical treatments. We report results of surveys of four representative samples of the German population. In 2010 and 2012, in total about 5000 respondents were asked for their willingness-to-pay (WTP) for either an extension of their life or an improvement in their health corresponding to a gain of one quality-adjusted life year (QALY). Specific changes of the study design allow for ceteris paribus comparisons of different survey versions. While the initial version exactly copied a questionnaire used in the EuroVaQ (European Value of a QALY) project, which was conducted in nine European countries and Palestine, but not in Germany, in other versions the wording and the survey technique were modified. The findings show that the technique of posing the questions plays an important role when respondents are asked to imagine being in hypothetical situations. This clearly refers to the wording of the questions and the survey setting (personal or online interview). But even simple design elements such as putting a yes/no filter in front greatly affect the answers in terms of both the frequency of zero WTP and the distribution of positive amounts. From the different results, we conclude that it is inevitable to conduct studies comprising a broad variety of versions when trying to elicit WTP for a specific type of QALY in order to achieve an array of values combined by insights into the principles of their sensitivity.

Attitudes of Germans towards distributive issues in the German health system.

Social health care systems are inevitably confronted with the scarcity of resources and the resulting distributional challenges. Since prioritization implies distributional effects, decisions regarding respective rules should take citizens' preferences into account. In this study we concentrate on two distributive issues in the German health system: firstly, we analyze the acceptance of prioritizing decisions concerning the treatment of certain patient groups, in this case patients who all need a heart operation. We focus on the patient criteria smoking behavior, age and whether the patient has or does not have young children. Secondly, we investigate Germans' opinions towards income-dependent health services. The results reveal the strong effects of individuals' attitudes regarding general aspects of the health system on priorities, e.g. that individuals with an unhealthy lifestyle should not be prioritized. In addition, experience of limited access to health services is found to have a strong influence on citizens' attitudes, too. Finally, decisions on different prioritization criteria are found to be not independent.

Problems of priority change in kidney allocation and beyond.

Standardized and transparent priority setting in medicine, desirable as it is, will generally exacerbate inter-temporal equity problems arising from changes in treatment priorities: when can it be fair that the treatment of already waiting patients who would have had priority under an established system should be postponed (withheld) for an extended period of time to advance the treatment of others under a reformed system? The reform of the Eurotransplant system of priority setting in kidney allocation (ETKAS), which is in many respects ideal, is a case in point. To give due weight to new medical knowledge, waiting time after the onset of end state renal failure should change from a priority-enhancing to a priority-reducing factor. Since those who have gained in priority by waiting under the present system would be set back under the new, severe problems of transitional justice must be overcome when responding to advances in medical knowledge. The paper explores conceptually some possible ways of rule change and indicates their general relevance from an ethical and a practical point of view for future problems of medical resource allocation under transparent, standardized priority-setting rules.

Which patients do I treat? An experimental study with economists and physicians.

This experiment investigates decisions made by prospective economists and physicians in an allocation problem which can be framed either medically or neutrally. The potential recipients differ with respect to their minimum needs as well as to how much they benefit from a treatment. We classify the allocators as either 'selfish', 'Rawlsian', or 'maximizing the number of recipients'. Economists tend to maximize their own payoff, whereas the physicians' choices are more in line with maximizing the number of recipients and with Rawlsianism. Regarding the framing, we observe that professional norms surface more clearly in familiar settings. Finally, we scrutinize how the probability of being served and the allocated quantity depend on a recipient's characteristics as well as on the allocator type.JEL Classification: A13, I19, C91, C72.