by Craig Klugman, Ph.D.

BioethicsTV is an occasional bioethics.net feature where we examine bioethical issues raised in televised medical dramas.

This past weekend I was binging on House of Cards, season 4. Although this is not a medical drama, a story arch this season is relevant to this column.

If you have not watched yet, please be warned that this post is a big spoiler. Read no further if you care about such things.

One of the storylines this season is about President Underwood being shot and most of his liver removed. The doctors hope that the organ will regenerate but it does not. Doug Stamper, his chief of staff, searches for information on being a live organ donor and when he does volunteer, the doctors tell him that Underwood is too far gone for a partial organ; he needs an entire new liver. What is not discussed because no testing occurs is that Stamper is a recovering alcoholic.

Being the President does not give you much of a leg-up on the organ waiting list, according to Cards and in real life. More simply, the computer algorithm that allocates organs would have no knowledge that a patient is the President. Social worth criteria are absent from the computer system, though such considerations often are taken into account when a transplant center decides whether to put a patient onto the list in the first place.

But in the Cards universe, Underwood is very sick and is number 3 on the list. Stamper makes a visit to the Secretary of Health and Human Services who shows Stamper that the President is now number 2 on the list, because the first person received an organ. Stamper tells the Secretary to make sure that the President is number 1. She explains that the United Network for Organ Sharing (a nonprofit organization) is an autonomous entity and she has no power to change the order of the list. In fact, she tells him it would be illegal for her to tamper with it. Stamper threatens to fire her if she doesn’t make the change, and in a moment of moral cowardice, she makes a call to have Underwood moved to the top.

When a teenager commits suicide, Underwood gets his new liver and recovers. The Secretary emails information to Stamper about the person who had been number 1 on the list and as a result of being bumped, died. Stamper tells her to delete the link and email and reminds her that their conversation “never happened.” In several episodes, Stamper is seen cyber stalking this family, learning about them and presumably feeling some guilt.

This may seem like a farfetched plot point, but former Vice-President Dick Cheney in 2012 received a heart transplant after being on the list for 20 months, a fairly normal time period. Rumors swirled that he got his organ because of his status. However, according to his doctors, Cheney received no special consideration.

While moving someone up on the list based on their celebrity status, or coercion to the Secretary of Health & Human Services, it is legal to be on multiple registries. The president could be listed with multiple transplant centers, which would increase his chances. As long as he could get to the appropriate hospital in time, he could be on many lists.

The other option for the President would have been an appeal to the nation to ask for a directed donation. That is, if a potential donor died and matched Underwood, the family could request that the organ go to the President.

Near the end of this story arc, Underwood is thanking the family of his donor and introduces them to other patients who received their loved one’s organs. Such a scenario is a bit farfetched. First both the donor’s family and all those recipients would have to agree through the transplant center that they want to communicate in writing. Many centers allow communication anonymously and only if all parties agree to direct communication can that be facilitated. To meet in person is another level of connection that would take a great deal of time to happen. Also consider that there were multiple recipients at the press-covered meeting: Unless there happened to be a lot of correspondence from the transplant center, Underwood’s office getting the names of the recipients to set up this meeting would be a HIPAA violation.

Then again, no one watches this television series for its adherence to the rule of law. We watch because it represents the very worst of politics and human nature.