Decisions not to transplant: futility or rationing

Since the 1980s, heart transplantation has become an acceptable treatment therapy for patients with end-stage congestive heart failure. In recent years, the demand for heart transplantation has exceeded the supply of available organs. Potential transplant candidates undergo rigorous screening to determine which patients will be offered transplantation as a treatment option. Heart transplant recipients are selected based on a determination of which patients will experience an improvement in symptomatology, functional class ability, and life expectancy after transplantation. Refusal of transplantation for an individual patient is usually framed in a futility argument: Either transplantation will not benefit the patient or the risks involved in undergoing the transplant are considered to outweigh the benefits. However, futility is an elusive and ambiguous concept. Furthermore, although authors, clinicians, and ethicists argue for the separation of futility and rationing issues, clearly it is not always possible to do so. The purpose of this article is to argue that many decisions to refuse heart transplantation are actually based on the rationing of organs and not on futility.