Steady Hands, Heavy Hearts and the Path Forward to Moral Resilience in Organ Transplantation

Rationing of healthcare resources is a strategy for crisis-aversion or crisis-prevention with its ethical roots in the theory of distributive justice. It exemplifies, the simplistic notion of conservation, typically employed as a temporary measure to relieve stress and restore balance to the system, “the normal” state. Within medicine, organ transplantation is unique in that crisis is its “normal” state, rationing is constant, and distributive justice is permanently invoked. The moral stress in transplantation arises from the persistent and ever-widening gap between the demand for organs and their availability. Therein, “normal” transplantation practice is characterized by a constant state of systemic stress, as transplant services constantly strive to balance the needs of the most vulnerable with the imperative to maximize utility. In fact, the perpetual strain on the organ transplant system makes "balance" an ill-fitting term; perhaps "balancing act" more accurately captures the ongoing struggle. This act, driven by the system’s underlying moral stress, translates directly into moral distress for transplant physicians. They are keenly aware that the patient-physician bond they deeply value is constantly influenced by the delicate and precarious nature of this balancing act. Each decision they make is underscored by the awareness that the system itself is built on a fragile and enduring imbalance, making their role even more ethically complex and emotionally challenging. It is in this vein that we disagree with Buchbinder et al. (Citation2024); the moral stress in the transplant system does indeed translate to moral distress.