As students in the medical field, we’re often presented cases where buzzwords and most common signs and symptoms help guide us to recall correct diagnoses or treatments.  Because of this, it’s easy to forget that the decisions we will make as providers in the real world will not be nearly as clean and simple.  In the case outlined here, a relatively young patient who has presented with end stage renal failure (secondary to type 1 diabetes) is relieved to be placed on a transplant list, only to be diagnosed with a malignant melanoma that will delay the transplant and prolong his period of dialysis.  Statistics will play a role in deciding what options are best, but true ethical dilemmas present when the patient is uncertain if they want to postpone the transplant despite potentially disastrous outcomes in the long-term.

    The patient in question, a 51-year-old male, has undergone dialysis treatments for some time that have greatly affected his personal life.  A renal transplant would offer an 85%-89% 5-year survival, while remaining on dialysis alone would offer approximately 70% along with the negative impact on his daily living.  Unfortunately, the situation is complicated by a diagnosis of malignant melanoma of which a transplant would most likely mean recurrence due to immunosuppression combined with a mortality 3x greater than non-transplant patients.  If the patient moves ahead with the transplant without treating the melanoma and waiting somewhere in the range of 3 – 10 years before transplant, then his survival is estimated to be at about 20% (Kirby et al., 2016).

    While it may seem that the obvious decision would be to postpone transplant, treat the melanoma, and wait the appropriate time before considering a transplant, this all depends on how a patient weighs the statistics against their personal values or even emotions.  The patient at time of the melanoma diagnosis had been feeling rather well and was upset at the prospect of postponing the transplant.  The procedure had been fixed in his mind as the return to a somewhat normal life.  Considering the circumstances, it’s difficult to blame him for feeling the desire to remain on the donor list regardless of the melanoma.  By UK law (in this case) as well as in the US, patient autonomy has greater weight in decision making than ever, and here the patient was supposedly made aware of the risk of recurrence and retained the right to remain on the donors list if this risk was of no consequence to him.   

    As stated in the journal, the patient possessed informed consent, was of sound mind, understood the nature of his illness and the objectives of all presented treatment options (AAPA, 2017).  I would argue that the reasonable next step would be to delay the transplant and treat the melanoma.  The collision of two significant diagnosis puts in a position where we must weigh probabilities, although guidelines explicitly stipulate a 3-10 year waiting period before pursuing transplant after a malignant melanoma diagnosis.  In the interest of beneficence, we would initially consider the transplant, on the other hand weighing non-maleficence we can’t justify the risk of a recurring melanoma (Varkey, 2021).  While the patient retains his autonomy to ultimately make this decision, this scenario underscores the importance of applying shared decision-making with our patient to reach an understanding of not only their own feelings and perspective but also in hashing out rather complicated probabilities that may be easily overlooked in their deliberation.   

References:

1. Kirby, L. C., et al. “An Ethical Dilemma: Malignant Melanoma in a 51-Year-Old Patient Awaiting Simultaneous Kidney and Pancreas Transplantation for Type 1 Diabetes.” British Journal of Dermatology (1951), vol. 175, no. 1, Blackwell Publishing Ltd, 2016, pp. 172–74, doi:10.1111/bjd.14554.

2. AAPA Guidelines for Ethical Conduct, 2017. AAPA Website. https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf

3. Varkey B: Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 2021. doi: 10.1159/000509119