On March 3 I told the ICU at Lehigh Valley Hospital to take my brother Danny off life support. Danny was 34 and had been in a coma for sixteen days, since he laid his Harley down on Route 22. His neurologist put his chance of meaningful recovery at about 4% and asked us to wait until day 30 before deciding. I declined. Within 36 hours his liver, both lungs, both kidneys and his pancreas had gone to eight people in four states, and later his corneas went too. In expectation, I traded 0.04 of a brother for eight strangers. It is the best trade I have ever made, and I used to day-trade options.
I hold Danny’s medical power of attorney because nobody else in the family can read a spreadsheet. Our mother wanted to wait for a miracle. Danny’s girlfriend, Tasha, also wanted to wait for a miracle, but she had no legal standing, which simplified things. I understand the impulse. A miracle, though, is just a 4% event with good PR, and while my family prayed, about seventeen Americans a day were dying on the transplant list. Nobody in the waiting room wanted those seventeen on the whiteboard. I put them there, along with a small term for the $9,000 Danny owed me. I’ll get to it, and I set it to zero.
The model
EV(withdraw on day 16) = N·q·s − P(w)·Q − 0·L
N = recipients (8)
q = QALYs gained per recipient (~9)
s = organ viability at day 16 (0.9)
P(w) = probability Danny wakes (0.04)
Q = Danny's remaining QALYs if he wakes (~11)
L = the $9,000 (included for transparency, weighted at zero)
The recipients’ side comes to about 65 QALYs. Danny’s side comes to 0.44. Q is generous. The neurologist’s best case involved a feeding tube and a great deal of Wheel of Fortune, which I scored at 0.28 quality weight across forty years. The waiting room was treating a 147-to-1 trade as a close call.
Why not wait
The day-30 recommendation sounds prudent until you price it. Organs are a perishable asset. Ventilated patients get pneumonia, and lungs go first. By my estimate, viability would have fallen to about 0.7 by day 30, which costs roughly fourteen QALYs. In return we’d have gotten information worth at most 0.44. You would never pay fourteen dollars for forty-four cents at a car dealership. You’d especially not do it in a hospital, where the dollars are other people’s kidneys.
Consent
Danny checked the organ donor box at PennDOT in 2009. It was the clearest statement of values he ever made, his wedding included, which he left early. My mother says checking a box at the DMV is not consent to dying two weeks ahead of schedule. But the box doesn’t specify a date. I chose the date that honored the box most fully.
The $9,000
Danny borrowed $9,000 from me in 2023 to buy the Harley, the same Harley. I’ve been accused of motivated reasoning, so here is the honest version. If money were my motive, I would have waited. In the 4% of worlds where Danny wakes up, he’s alive to repay me, which makes his consciousness worth $360 to me in expectation. I gave up $360 for eight strangers, and I’d ask my critics what they’ve given up for eight strangers lately.
As executor, I have since filed a $9,000 claim against the estate. It was approved quickly, because I approved it. The bike was totaled except for the engine, which I’ve kept, since it was collateral in spirit.
Afterward
I posted “My brother Danny is a hero. He saved eight lives.” on Facebook, and it got 2,400 reactions. Gift of Life asked me to speak at their spring gala. The recipient of Danny’s liver, a nineteen-year-old in Ohio, wrote a letter through the procurement organization. I wrote back thanking him, and gently noted that the true donor had been the decision procedure.
My mother hasn’t spoken to me since the funeral. She keeps asking “what if he would have woken up?” I’ve explained that “what if” is a question about one world, and I made a decision across all of them.
The neurologist says there’s no way to know whether Danny would have woken up. That’s exactly why I didn’t wait to find out.
Donation after circulatory death has a hard rule that the decision to withdraw support is made independently of donation, before anyone from the procurement side is involved. The point is that nobody should be choosing the timing of withdrawal to keep the organs viable. The section titled "Why not wait" is a description of the thing that rule exists to prevent.
The rule protects against undisclosed conflicts of interest. Mine are disclosed, including the $9,000.
The rule is there to protect the patient. Disclosing your conflicts doesn't change what happened to him.
Day 16 is early after a diffuse axonal injury. "Wait until day 30" wasn't a formality. That's when the prognosis stops being a guess. Your 4% was a day-16 number.
Every prognosis is a guess to someone who wants to wait. I priced the uncertainty. I didn't pretend it away.
The day-trading detail explains the model. You priced a 4% event the way people who sell far out-of-the-money options price it, as zero until it happens. Everyone who has done that for a living has a story about the time it happened.
Where does the 0.28 quality weight come from? Nobody measured it. It's your estimate of how much your brother's life would have been worth to him, and it's sitting in the denominator of a 147-to-1 ratio that you're presenting as arithmetic.
The neurologist's best case, combined with my knowledge of Danny's television preferences.
As executor you approved your own $9,000 claim against the estate. In most states that's self-dealing, and if any beneficiary objects the court will look at it closely, along with the engine.
No beneficiary has objected. My mother hasn't spoken to me since the funeral, so nothing is on the record.
Did Danny ever say what he'd want?
He checked the box.
I'll engage on the model since that's what you asked for. You count eight recipients against one patient, but you treat the one as a 0.04 probability and the eight as certainties. Transplant outcomes have their own failure rates. If you discount the recipients' side the way you discounted Danny's, the ratio shrinks a lot. I'd still expect it to stay above one, which is why the procedural rules carry so much of the weight in these cases.