Okay, I was getting carried away, so here is a very brief idea of the paper. It aims to evaluate the ethical underpinnings and implications of the continuous distribution framework (CDF). I call it a framework because it does, and importantly, it says:
The continuous distribution framework does not presuppose the optimal ethical balance of competing ethical goals. Though relying on a point system instead of a classification system will inherently increase equity by eliminating unnecessary hard boundaries, the framework itself is neither for nor against broader distribution. Instead, continuous distribution provides a framework by which the community can more clearly express their preferences regarding ethical tradeoffs.
According to this paper, the OPTN saw that mixing scientific/operational discussions and ethical ones caused difficulty in discerning scientific fact from "ethical opinion."
The Continuous Distribution system scores candidates based on attributes that work in line with the following goals:
- Reduce waitlist mortality.
- Improve post-transplant survival.
- Lessen biological disadvantages.
- Enhance patient access.
- Improve the efficiency of the organ placement system. And the attributes seem to align with one of two ethical principles, utility or equity:
When selecting which attributes to include in the scores, the committees described the purpose of each attribute, which allowed the OPTN to ensure that the attribute was aligned with its ethical principle. For example, reducing biological disadvantages aligns with equity, while improving the efficiency of the organ placement system aligns with utility. Some attributes, such as prioritizing pediatric candidates, align with both equity and utility.
They value transparency and public participation because
Like most of the world, the US organ transplant system relies upon the altruistic act of donation from both donor families and living donors. Donors are more likely to donate to a system that they believe honors their gift and reflects their values.
But of course,
though it is important to include the public when setting priorities for organ allocation,... Some members of the community may hold personal opinions that are inconsistent with the norms of organ transplantation.
Enter AHP
To develop continuous distribution, the OPTN sought to enhance the public’s ability to inform prioritization of candidates for transplantation. Using Analytical Hierarchy Process (AHP) exercises, the OPTN elicited the public’s input regarding candidate prioritization under the continuous distribution framework.
The AHP methodology was selected for its flexibility, ease of use, and ability to assess the community’s priorities for continuous distribution Saaty. AHP is one of the most widely used multicriteria decision-making (MCDM) methods for both medical and nonmedical applications.
Beautifully, they cite a paper that says AHP could be used for medical applications [Dolan JG. Multi-criteria clinical decision support. The Patient: Patient-Centered Outcomes Research. 2010;3:229–48]. That paper is written by an MD who says:
After the comparisons are complete, they are combined using a matrix algebra calculation called the right principal eigenvector.
and
Because the AHP is also a theory of measurement, the mathematical operations involved in the analysis are theoretically justified and assumption-free.
The Alcorn paper does make it clear that they do evaluations on the outcomes of AHP, so they aren't just taking the results and running with it.
Finally, there are two discussions on:
- How explainability is important for public trust, and this is in tension with better attributes:
OPTN could integrate live traffic and weather information to optimize the transportation of organs. If there is a blizzard in Denver or an outage at O’Hare airport, transporting organs to those locations would be less efficient. The OPTN could redirect the allocation of organs to places more likely to accept the organs and thus increase utility. To achieve this would require a system that is constantly updating and may call into question the source and reliability of the data.
- AI can help solve ethical delimas
Addressing ethical dilemmas with the help of computers is not unique to continuous distribution, and can be helpful when ethical dilemmas are paired with complex, computational problems that exceed practical human capabilities [36]. Using these methodologies allows the OPTN to iterate tens of thousands of policies to identify those that meet the ethical goals and priorities of the community [37]
So even though 1, we have 2... Dont worry though because
The use of visual tradeoff curves also helps committees and the community understand how competing ethical goals interact.
So, you know, we still have great explanibility because of the vizuals.
I mean this paper seems to just commit to all of the problems we thought CDF had. Unfortunaltely for use they have at the end of the paper a huge discliamer:
Conflict of Interest James Alcorn works for the United Network for Organ Transplantation, the OPTN Contractor, and has been involved in the development of the continuous distribution of organs.
Disclaimer The opinions in this article are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the OPTN or the US Government.
What is useful about this paper is they cite all of the OPTN papers that went into the developement of the CDF [1,9,16,17,19,35] they cite 2 AHP papers [28,29]and they point to some actually intresting papers/ post [37,38].