Beyond Utilitarianism: A Method for Analyzing Competing Ethical Principles in a Decision Analysis of Liver Transplantation

Abstract

Background: The utilitarian foundation of decision analysis limits its usefulness for many social policy decisions. In this study, the authors examine a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with acute liver failure (ALF). Methods. A Markov model was constructed to compare the benefit of transplantation for a patient with ALF versus the harm caused to other patients on the waiting list and to determine the lowest acceptable 5-y posttransplant survival for the ALF patient. The weighting of the ALF patient and other patients was then adjusted using a multiattribute variable incorporating utilitarianism, urgency, and other principles such as fair chances. Results. In the base-case analysis, the strategy of transplanting the ALF patient resulted in a 0.8% increase in the risk of death and a utility loss of 7.8 quality-adjusted days of life for each of the other patients on the waiting list. These harms cumulatively outweighed the benefit of transplantation for an ALF patient having a posttransplant survival of less than 48% at 5 y. However, the threshold for an acceptable posttransplant survival for the ALF patient ranged from 25% to 56% at 5 y, depending on the ethical principles involved. Discussion. The results of the decision analysis vary depending on the ethical perspective. This study demonstrates how competing ethical principles can be numerically incorporated in a decision analysis.