Covid-19 vaccine refusal and organ transplant eligibility

The latest hot topic in the news is organ donor ethics. Several donor clinics have removed from eligibility potential recipients who refuse to get a covid vaccine. Let’s learn about the ethics of organ donation to understand the policy.

There are about 100 000 people in the US waiting for an organ transplant. Unfortunately, not everyone will get one. Choices need to be made regarding who will receive this scare resource and who will not. There are three major factors that determine eligibility (there are others but they carry less weight):

1) Medical need and

2) Post-transplant chances of long-term survival

3) Candidate biology (do they have the same or compatible blood type as the donor)

Medical need: Someone who can survive another 2 years without a new organ will be lower on the list compared to someone who will die within a few weeks without one.

Post-transplant chances of long term survival: An 80 year old with multiple comorbidities is lower down the list than a 20 year old with no comorbidities.

Example Case: Abe and Bob equally need a new liver. Both love to drink alcohol. However, Abe has given up drinking for the last 6 months and pledges never to drink again. Bob has not given up drinking and refuses to, even after a transplant.

If there’s only one liver available, who gets it? We give the liver to Abe. Importantly, the reason we choose Abe is not because we have a moral objection to drinking (or drugs, for that matter) but because Abe better fits with the second criteria. Abe’s chances of long-term survival are higher. In fact, to get a liver transplant potential recipients are required to give up drinking 6 months prior to transplant.

Precedent: Because of the importance of criteria 2 for organ allocation, organ recipients are already required to get a flu shot and hepatitis shot before transplant. The reason is obvious. Those that do not get the shot reduce their chances of long-term survival and deprive of an organ someone else who would have survived longer than them (Thank you to Stephan Kesting for the link, link, link). In short, giving a scarce resource to someone who isn’t going to use it wisely is an unwise and unjust allocation of resources.

The exact same line of reasoning applies to the Covid shot. Organ transplantees must take medications to suppress their immune system so they don’t reject the organ. Even the most mild infection can cause severe medical complications or death. Someone who does not get the Covid shot is massively reducing their chances of long-term survival—just like the alcoholic who refuses to give up drinking after a liver transplant.

Denying organs to candidates who refuse the covid vaccine is a straightforward application of the existing reasonable framework.

This is no conspiracy against anti-vaxxers. They are not being persecuted.

Nerd note: In 2018 the eligibility framework was modified to create a continuum rather than categories of eligibility. So, technically, vaccine refusers should not be removed from the list but pushed down in the ranking. Give the extreme shortage of organs and the weight that probability of long term survival is given in the algorithm, removing them from the list amounts to the same practical outcome.

What if the donor refuses the vaccine?

There is one last kind of case to clear up. A organ donor clinic has refused to perform an organ transplant because the donor refuses to get the vaccine. They reason that the donor will put the recipient at risk during the operation.

On my view, this is not a good policy. Instead, a PCR test can be performed 72 hours (or whatever is appropriate) then quarantined before the surgery instead. The donor would then be retested as close to the operation as possible. Excluding (already scare) donors from donating gets the cost/benefit trade off wrong.

Nevertheless, in the particular case in the news this is all irrelevant because the recipient also refuses to get vaccinated which should take her off the list for the reasons I mentioned above.