A story broke Monday that Anthony Stokes – a teenager in Georgia, given six months to live on account of his dire heart condition — was denied a place on a heart transplant list due to his history of “non-compliance,” that is, not following medical orders. (Anthony’s family said the real reason they believe their child was denied a spot was due to “low grades and trouble with the law” according to anABC news report.)

Either way, though it was announced today by Stokes’ family that their son will now be placed on the transplant list, this controversy raises important questions: should bad behavior block a patient’s acces to the list?

While it may seem harsh to deny a child a spot on the heart transplant list because of past transgressions, George Annas, Chair of the Department of Health Law and Bioethics at Boston University, says a patient’s ability to follow post-transplant medical advice is an important screening criterion.

“There are not enough hearts for everyone,” he says.  “When someone gets a heart transplant that means there is someone who does not get one.  The last thing you want to do is give an organ to someone who doesn’t want one or who’s not likely to use it well.  If you’re certain that a person (receiving a transplant) will not comply, then you’re essentially wasting an organ.”

But how can anyone – including expert transplant surgeons — be certain of someone’s future behavior?  This, says Annas, is what makes the issue so controversial: it’s hard to be sure.

“Requiring a transplant to survive is a life changing experience,” says Annas.  “(A patient’s) past behavior may not be as predictive as one thinks as post-transplant behavior.  There is no blood-test to determine this.”

Indeed, when it comes to assessing the probability of someone’s future behavior, there is no scientific test that can be used to asses this.  In the absence of objective medical criteria, the decision to deny someone a spot on a transplant list on grounds for “non-compliance” can seem arbitrary.

“It’s actually unusual for transplant surgeons to use this criteria,” he says, “because it appears to invite all sorts of social worth determinations which wind up looking like discrimination against poor people or racial minorities.”

According to Annas, most people in need of a heart transplant are denied this opportunity because the list of people in need is much, much longer than the supply of organs available.  Because of this chronic mismatch, the issue of who gets on organ transplant lists is consistently controversial.

“This is the major place in medicine where we have to do rationing because of the limits in the numbers of organs available.   It forces us to confront the issue on how to do this fairly.”

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