Calling all Social Workers…

Okay, so my knowledge of social sciences and family well-being aren't all that great, and I know that there are several MSWs here on CC, so I figured I would ask for some help.

We're running a hypothetical transplant board meeting tomorrow for our Doctoring Class in which we have to decide which of three patients should get a heart transplant. The patient that my group is assigned to is a 30-yr-old mother of two (from two different relationships). She can't hardly do anything on her own because she has fulminant heart failure. She lives with her mother and get a lot of help from her brothers. She also has some history of marijuana use.

So here's where I'm doing some research. I am under the impression that this mother is the best qualified to raise her own children. I know that this isn't the case with all mothers, but even in situations where the mother is somewhat negligent, don't children develop better if they remain in their own family? Is this correct?

I found some good support in Donald Winnicott's assessments of a "good-enough mother."  Also, there seem to be a lot of support for child development in a complete family (mother and father), but our case is a single mother. Are there other sources that you know might help?

Not an expert by any means, but what the heck...

What do you mean by some history of marijuana use? When she was 17? Or, in the past few years? Drug use plays a huge role in a parent's ability to raise children. It seems to me that a drug-free loving home would be better than a loving home in which there is a history (or, continued use) of drugs.

We didn't get a very good history of her drug use. From what she told us, she was using MJ up until she got pregnant with her first child, and some before she got pregnant with her second son.

I agree that drug use does reduce her ability to adequately care for her kids, but it seems to me that she would still be the best option when compared to foster care or a group home.

it's not a child-protection issue, it's a medical issue.  hate to say it, but the kids are irrelevant.

i'd like to think the marijuana use is irrelevant, too.  that's a moral question.

you have to focus on the patient, not on peripheral people/things.  look at potential outcomes and quality of life for your patient.  that includes the capacity to be a mother, of course, but it's her wellness you need to focus on, not that of her children.

Medicine is the prominent issue in this case, but the others in my group are researching the medical issues involved with our patient. My job is to look into the social aspect.

If we conclude that this mother is the best person to raise her kids, it should help us decide if she is the most suited for the heart transplant. 

At this point, we don't know anything about the other patients; however, if we compare our mother to a hypothetical researcher without a family, it would seem to me that the mother would be the best choice for receiving the heart (assuming medical issues are equivalent). Someone else can do the research, but only the mother is best suited to raise her kids. No?

sim, you asked for opinions from social workers, and that's what you're getting.  in this sort of dilemma, the first question social workers ask themselves is, "Who is the client," because our mandate is to act in the best interests of the client.  the client, in this case, is the woman, not the kids. 

is it important that she's a mother?  sure.  but only in that it affects her potential outcomes.  she may well be best suited to raise her kids, but that doesn't mean that raising her kids is in her best interests; it may well be detrimental.

if you're not convinced, ask yourself if another patient who doesn't have kids is less worthy because of it.

edit: just to add that the marijuana use is a factor if it's current, in the same way tobacco use would be; it would affect her potential outcomes.

weird... I thought the medical goal would be to give the transplant to the recipient with the greatest chance for a succesful transplant.

Doesn't the social aspect, doctors weighing the worth of a person as a determinant (even if it's just one of many factors) of recieving a transplant strike you as hubris?

I'm not trying to be inflammatory, but it really reinforces the god-complex image of doctors.

totally, iggy.  anything else is moral judgment.

True, though I'm sure it does happen.

Circumventing normal triage to save a cop over a criminal, things like that.

@ pg - I'm not trying to be challenging. When it comes down to it, I know that you are much more experienced in this field and I am not discarding your opinion in any way.

In the case that we are presented with, either these patients get a transplant, or they will die soon. We are essentially choosing who of these three will benefit the most from receiving a heart. If this woman dies, it will likely effect the ability for her kids to develop. If we chose to give the heart to another patient, then we are adversely affecting the lives of three people, not just the patient.

In that sense, I think that having children should be a part of the decision for transplantation. I don't think that not having kids makes another less worthy for transplantation, but I think it adds points for those who do have kids.

@ iggy - Reality is that there are only so many hearts to give out. Most people on the transplant list will die before they get a chance for tranplantation. Somebody has to make the decision of who is best qualified for receiving a donor organ. Real transplantation boards aren't only composed of doctors, but they do make up a good portion of them. Would you suggest an alternative way to do this?

I think every single argument you can find to substantiate your patient's receiving the heart should be made. Including the need of your patient's children. It's the duty of the other two groups to make their case.

This exercise, it seems, is to train you, as a doctor, to face this challenge as an advocate for your patient in front of a board making the decision. From that perspective, it seems like you have a duty to pull any and all heartstrings you can think of.

Pardon the pun.

Likelihood of success.

Likelihood that the patient will live as long as the expected life of the average transplant organ.

Position on the waiting list.

Look, I recognize the intent is noble, trying to do the best social good with a limited resource, but it's not something with which I (and likely many non medical doctors) would be comfortable.

We all judge one another's societal worth every day, but those judgements have marginal to no impact on the other person's life.

In the scenario you present, a doctor's judgement of another's worth to soceity, determines whether they live or die.

That's a tangible difference.

Sure in never-never land lets pretend the fact that she has kids gives her higher standing.

Yeah let's pretend it isn't a load of bullshyte.

Original Post by ignayshus:

Likelihood that the patient will live as long as the expected life of the average transplant organ.

This would give advantage to younger patients who are in better physical condition. Reality is that the patients who need a transplant the most won't survive as long as someone with less organ failure.

Luckily for me, this is just pretend. Personally, I wouldn't be comfortable giving a death sentence to anyone who didn't meet the transplantation criteria.

@ Kathy I think your absolutely right. The reason why we are put into groups and not given information on the other patients is so that we can build a case for our patient. In a real setting, if I ever have to present a patient for consideration of transplantation, I'm not going to be choosing between my patient and others. My job is specifically to advocate for my patient. 

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Just for more information on our patient: She has heart failure because of a poor outcome of her pregnancy. All of her other organs are functioning well for the time being. If she gets this heart, it is likely she will do very well.

Not a social worker(just have an opinion).  I think you can make a case that she should receive the transplant since she is the only parent in the children's lives.  MJ - possibly relevant but maybe it only happened a few times.  She is 30 and with the heart can be expected to live long enough to raise her children.   Since her pregnacy caused the original heart failure, from a medical standpoint can you request to get the tubes tied if it might result in more heart problems?  I vote because she is a single parent that she get the heart otherwise 2 children are orphans.

how can sociological issues not be factors?  two patients, three patients, equally likely to do well, equally positioned on the list (which is determined according to need, you go up based on the emergent level of your condition)... how can you not take into account 2 orphans vs grown children vs no children?  moral judgement?  yes.  playing god?  yes.  this is what has to be done every day.  there are only so many pieces to go around.  a fallible decision must be made.  no other choice.

now maybe with stem cell research reopened (flying my kite very high on that one) maybe we will learn how to alter an organ's biology to reduce rejection or the body's rejection... increasing the ability to do a "first come first serve." or at least "most urgent first served."  until then... we (society) play god every day.  in fact, if it was up to "god" this person needing a transplant would be dead already...

Original Post by ignayshus:

Likelihood of success.

Likelihood that the patient will live as long as the expected life of the average transplant organ.

Position on the waiting list.

 That's the board's responsibility, not Sim's. Sim's is to advocate for his patient. His postition is easy - he only has to make arguments to defend his patient's need.

For anyone who may have been interested, our patient got the heart that she needed; however, she had several rejection episodes which decreased her vitality. She was treated and did okay, but she had several repeated bouts of rejection over the next year.

She became very independent after her transplant and went back to work. She had some issues with non-compliance, and without taking the steroids that were prescribed to her, she had additional problems with transplant rejection.

Eventually, the rejection of the transplant led to recurrent heart failure and she eventually died.

Crap! 

so what was the rationale for giving your patient the heart over the others?

Original Post by drea99:

how can you not take into account 2 orphans vs grown children vs no children?  moral judgement?  yes.  playing god?  yes.  this is what has to be done every day.  there are only so many pieces to go around.  a fallible decision must be made.  no other choice.

 

This attitude that someone's life is more important if they have kids is ridiculous and infuriating! Procreating does not take any talent and does not give someone a god given right to be put ahead of the rest of society. Would the same argument be made of a man who had kids? No. Why not - a father is just as important as a mother. What if the person without kids was a genious and their research was contributing to the cure for cancer - would they then be on the same level as someone who simply popped out a baby? It's ridiculous. Everyone has family/friends who's lives would be affected from a death. Who are you to judge who would be worse off. 

Transplants should be based on science - who is the most likely to survive. And yes, that means that younger people may get a higher chance of wining an organ because they are younger and healthier - and that's how it should be. All other (health) things being equal, the most likely to get the most life out of the organ should get it.