Public perceptions of the importance of prognosis in allocating transplantable livers to children

Background. The system to allocate scarce transplantable livers has been criticized for not giving enough weight to the prognoses of the patients receiving the transplants, but little research has been done looking at how the public weights the relative importances of efficacy and equity in distributing the organs. Methods. This study was an experimental survey of prospective jurors asked to distribute transplantable livers among transplant candidates grouped according to their prognoses. The relative prognoses of the transplant candidates were varied across survey versions. Results. As the prognostic difference between transplant groups increased, the subjects became less likely to distribute the organs equally between them (p < 0.005). However, the subjects' willingness to base allocation on prognosis was moderated by a number of factors, including their understanding of how to use prognostic information and their attitudes toward using prognostic information for individuals versus groups. Thus, even when the relative prognoses of transplant groups differed by 60%, less than a fourth of the subjects were willing to give all the organs to the better-prognosis group. Conclusion. Many subjects feel that prognosis is an important consideration in allocating scarce livers. However, few are willing to base allocation purely on maximizing survival. Policies that base allocations purely on outcomes will violate the values of a significant portion of the public.