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Charlie Four Star: A Case Study

By Jon Fiorella

Type of Entry:

  • Lesson/class activity

Type of Activity:

  • Group/cooperative learning

Target Audience:

  • Life Science
  • Biology
  • Advanced/AP Biology
  • Science-Technology-Society
  • Bioethics

Notes to Teacher:

This case study was portrayed on the short-lived NBC television show "The Crusaders" on 9/25/93. The actual television segment is very powerful and moving. Future lessons of this type can be taped from television for personal use, so be on the look-out for them in the television programming guides.

Required of students:

Very little is required of your students in advance. A high level interest factor is built into the case study. Students tend to get very involved so your normal classroom protocol will be called into play. The usual common courtesies of students raising their hands, not calling out, and respecting their neighbors are called for. On a higher intellectual level have the students justify all their answers and not simply shoot from the hip. See if you can get them to tie their viewpoint into some ethical value. A discussion of ethical values might be called for in advance. Be aware that dilemmas may have several right answers based on the values of the individual. Be sure to explore this area fully.

Preparation time needed:

This is basically a self-contained lesson. Background research can be performed by the teacher or students, or both, regarding the current state of organ transplantation.

Class time needed:

This lesson can be done in a standard class period (40-50 min.).

Assessment for this activity may run from simply evaluating class discussion of the questions included to written answers to homework assignments. This can be turned into a group activity by assigning groups the job of researching the different questions provided or of new questions that may arise during class discussion. Depending how you approach this topic, the time needed will vary from a single period to a full week.


This case study is a real-life situation that was reported on the NBC television show "The Crusaders" on 9/25/93. It deals with a young Native American girl in need of a five organ transplant to survive. Medicaid refuses to pay for the procedure because they consider it experimental. The family is frustrated until the staff of "The Crusaders" steps in to help them. Various questions arise concerning the fairest way of allocating scarce medical resources, including organs for transplant.


What question does this activity help students to answer?

This case study allows students to engage in a debate dealing with the allocation of scarce resources. They will be forced to think critically and effectively as they attempt to determine what is fair for the individual requiring an organ transplant while at the same time establishing policy for society in general.


Charlie Four Star, a young Native American female from Poplar, Montana, was born with a rare liver disease that left her unable to eat or digest food. Her condition was considered terminal unless she had an intestinal-bowel transplant that would cost approximately one million dollars. The problem the family encountered was that Medicaid considered the operation experimental and therefore not reimbursable. Intestinal-bowel transplants were not eligible for coverage under Medicaid. Charlie's grandmother summed up the family's attitude by saying: "Money is nothing compared to human life."

The family fought with the government for over two years with no success. It wasn't until a then-new television investigative reporting program called "The Crusaders" intervened that some progress was made. Reporter Doug McConnell did a segment on this story. The program hired a lawyer to sue Medicaid, saying that the operation was essential and not experimental. A pioneer transplant surgeon, who promised to waive his fee, was brought in to review the case. He diagnosed Charlie's condition as portal hypertension and said that the window of opportunity for helping her was closing rapidly.

This doctor approached Children's Hospital of Pittsburgh and asked them to waive the normal $500,000 down payment for this type of surgery. The hospital declined saying that they could not afford to become a free care center and that this could risk the future of the program. A lot of children could die with the death of this program.

In a sudden turn of events Medicaid finally agree that the operation was not experimental and agree to pay for it. At first the team could not find a hospital to perform the operation for the limited Medicaid fee. Finally, the University of Pittsburgh Medical Center agree to accept the limited fee.

Charlie's case was publicized on television around the country, but it still took six weeks before a suitable donor was found. The sixteen hour surgery was performed and Charlie received a new liver, small and large intestine, pancreas and spleen. It turned out to be the first five organ transplant performed.

Although Charlie faced a number of set-backs after the surgery, she returned home to eat solid food for the first time. She turned out to be the first child to survive a multiple organ transplant beyond six months.

Questions For Discussion

  1. The grandmother was quoted as saying: "Money is nothing compared to human life." If life is priceless, can we afford the cost?

  2. Is it right to give five organs to one person when five others could possibly benefit?

  3. Do you think the television show "The Crusaders" had any underlying motive for doing this story?

  4. Is it right for the media to intervene in situations like this?

  5. If Charlie only needed a liver and it came down to her or your grandmother, how should it be decided who gets it?

  6. If this were a celebrity, like Mickey Mantle, would the same rules apply?

  7. Do you think they would have done this story if it were your grandmother in this situation?

  8. Do you consider this operation experimental? Was it ordinary care or extraordinary care?

  9. What was your reaction to the statement from Children's Hospital of Pittsburgh that: "We cannot become a free care center or we would be forced to close our doors and then a lot of children might die."

  10. Who were the stockholders involved in this dilemma? Using an ethical scale of 1 to 10, with 10 being the best, how would you rate each party involved in this case study?

Other Questions To Consider

  1. What organs of the body can be transplanted?

  2. Is it right for Medicaid not to cover medical procedures that are experimental?

  3. Is it right for the media to take on a cause of this type? What about others that do not have access to the media?

  4. Should a patient ever be allowed a second transplanted organ?

  5. What ethical values come into play in this case study?

  6. Establish a plan for fairly determining who should get a needed organ. What criteria did you include in your plan?

  7. People have described this dilemma as a case of microallocation versus macroallocation of limited resources. How do we go about doing what is right for the individual and yet establishing a policy that is good for society?

  8. We have a shortage of donated organs. Suggest ways that we could increase the number of organs available for transplant.


Adapted from New Choices, New Responsibilities: Ethical Issues In The Life Sciences Case Study Supplement: A Program On Bioethics For High School Biology Courses Made possible by a grant from Hoffman-La Roche Inc. 1995

  • Organ transplants have reached successful levels. In the past ten years the number of transplants has tripled.

  • The number of medical centers performing transplant surgery has increased from170 to 547 in the past ten years.

  • Heart, liver and kidney transplants have had the greatest chance of success.

  • Costs range from $39,00 for a kidney to $145,000 for a liver.

  • The need for organs exceeds the supply.

  • About 23,00 Americans await transplant operations.

  • 80% of kidney recipients survive more than ten years. 41% of heart recipients survive more than ten years.

  • More than 80% of the transplant patients indicate that they are physically more active and happy with their lives.

  • This year more than 500,00 people will require bone or bone products or soft tissue surgery.

  • About 35,000 people per year have vision restored through cornea transplants.

  • In 1992 more than 8900 kidneys, 1500 hearts, and 1180 livers were transplanted.

  • 17,000 people are on waiting lists for donor organs, 35% of these ill die due to lack of donor organs.

  • Organs cannot be transplanted unless there is a reasonable tissue match between the donor and the recipient.

  • The best tissue matches are found within family groups: ideally with an identical twin, sibling, parent, or other relative.

  • Organ donation does not alter the appearance of the donor body.

  • A national network of organ needs and donors has been formed.

  • At least 5,000 people die each year because organs are not available. Elderly and sick people do not have organs suitable for transplant. Priority is given to residents for all organs donated in the state. Waiting time varies from state to state.

Method of Assessment/Evaluation

Assessment for this activity may run from simply evaluating class discussion of the questions included to written answers to homework assignments. This can be turned into a group activity by assigning groups the job of researching the different questions provided or of new questions that may arise during class discussion. Depending how you approach this topic, the time needed will vary from a single period to a full week.

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