An Intelligent System for Prioritisation of Organ Transplant Patient Waiting Lists Using Fuzzy Logic Author(s): T.

Perris and A. W. Labib Reviewed work(s): Source: The Journal of the Operational Research Society, Vol. 55, No. 2, Part Special Issue: Intelligent Management Systems in Operations (Feb., 2004), pp. 103-115 Published by: Palgrave Macmillan Journals on behalf of the Operational Research Society Stable URL: http://www.jstor.org/stable/4101862 . Accessed: 07/01/2013 22:28
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Journal of the Operational Research Society (2004) 55, 103-115

? 2004 OperationalResearchSociety Ltd.All rightsreserved. 0160-5682/04 $25.00

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An intelligent system for prioritisation of organ transplant patient waiting lists using fuzzy logic
T Perris and AW Labib*
University of Manchester Institute of Science and Technology (UMIST), Manchester, UK The objective of this paper is to investigate the effectiveness of using fuzzy logic in a complex decision-making capacity, and in particular, for the prioritisation of kidney transplant recipients. Fuzzy logic is an extension to Boolean logic allowing an element to have degrees of true and false as opposed to being either 100% true or 100% false. Thus, it can account for the 'shades of grey' found in many real-worldsituations. In this paper, two fuzzy logic models are developed demonstratingits effectivenessas a model for vastly improving the currentprioritisation system used in the UK and abroad. The first model converts an element of the current kidney transplant prioritisation system used in the UK into fuzzy logic. The result is an improvementto the current system and a demonstration of fuzzy logic as an effective decision-making approach. The second model offers an alternative prioritisationsystem to overcomethe limitations of the currentsystem both in the UK and abroad, as broughtup by research reviewed in this paper. The current UK transplant prioritisation system, adapted in the first model, uses objectivecriteria(age of recipient,waiting time, etc) as inputs into the decision-makingprocess. This alternative model takes advantageof the facility for infinitelyvarying inputs into fuzzy logic and a system is developed that can handle subjective (humanistic) criteria (pain level, quality of life, etc) that are key to arriving at such important decisions. Furthermore,the model is highly flexible allowing any number of criteria to be used and the individual characteristicsof each criterionto be altered. The result is a model that utilises the scope of fuzzy logic's flexibility, usability and effectivenessin the field of decision-makingand a transplantprioritisationmethod vastly superiorto the original system, which is constrainedby its use of only objective criteria.The 'humanistic'model demonstratesthe ability of fuzzy logic to consider subjectiveand complex criteria. However, the criteria used are not intended to be exhaustive.It is simply a templateto which medical professionalscan apply limitless additional criteria.The model is producedas an alternativeto any currentnational system. However, the model can also be used by individualhospitals to decide initiallywhethera patient should be placed on the transplantor surgerywaiting list. The model can be further with the researchand adaptedand used for the transplantof other organs or similardecisionsin medicine.Concurrently work carriedout to develop the two models the investigationfocused on the constraintsof the currentsystemsused in the UK and the US and the seemingly impossible dilemmas experiencedby those having to make the prioritisation decisions. By removing the parameters of objective-only inputs the 'humanistic' model eradicates the previous limitations on decision-making. Journalof the Operational ResearchSociety (2004) 55, 103-115. doi:10.1057/palgrave.jors.2601552 Keywords: fuzzy logic; waiting lists; organ transplants;prioritisation

Introduction Within engineering, fuzzy logic has been used in many industries ranging from complex robotic control' to the more mundanetrafficlight control.2Within manufacturing,
fuzzy logic has been used in developing arc sensors3 and on a systems level is popular in failure mode and effect analysis (FMEA).4 Fuzzy logic has been successfully implemented in many engineering applications including the recent work of Vanegas and Labib5'6 in engineering design, and Sudiarso and Labib7 in maintenance and
AW Labib, Manufacturing Division, Department of *Correspondence.: Mechanical, Aerospace and Manufacturing Engineering, University of ManchesterInstitute of Science and Technology, (UMIST), PO Box 88, ManchesterM60 1QD, UK.

production schedulingas well as in intelligentmaintenance

modelling in Labib et al.8 Fuzzy logic is also becoming increasingly popular in medicine for use in fields such as diagnosis,9 expert systems'0 and monitoring." It is proposed that fuzzy logic's ability to mimic human thinking, in its ability to deal with both qualitative and quantitative measures, lends itself perfectly to decision-making situations, especially decisions as complex and sensitive as transplant prioritisation. Kidney transplant operations have been available in the UK under the NHS for 40 years. In year 2000, about 1820 kidney transplants took place, but at the end of the same year, 6284 patients were still awaiting a transplant. On an average, patients have to wait about 11 months for a transplant. Prioritisation decisions are therefore extremely sensitive. (Data from www.uktransplant.org.uk.)

E-mail: ashraf.labib@umist.ac.uk

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104 Journal oftheOperational Research Vol. 2 55, No. Society

The paper is structured as follows: the following section presents the current UK transplant prioritisation system. Two models are then proposed by the authors in order to address deficiencies and challenges in the current system. Discussion of results are presented followed by a Conclusion section.

CurrentUK transplant prioritisation system

The kidney waiting list prioritisation system is highly complex involving medical, social and political factors. The detailed prioritisation process is run and maintained by the 'United Kingdom Transplant Support Service Authority' (UKTSSA)12 and can be found at the UK Transplant web site (www.uktransplant.org.uk). Essentially, when a kidney becomes available, potential recipients are assessed on their suitability for that kidney using the following criteria (Figure 1). The test results for a patient's compatibility of tissue type results in a 'perfect match', 'favourable match', 'nonfavourable match' or 'no match'. The kidney is allocated to the patient with the best match. Within each match, the kidney always goes to paediatrics before adults and then to the patient in the same district as the donor before going on the national list. In the event of equally matched patients at any level of the decision-making process (as is often the case) the scoring system as shown in Table 1 is used. (Each patient is evaluated on the six criteria and the kidney is allocated to the person obtaining the highest score.)

Information obtained from the UK transplant web site www.uktransplant.org.uk. Transplantationis a modern day success story. The developmentsin this specialityof medicine in the last 50 years have been phenomenal,with thousandsof patients benefiting from a successful transplant. But this success has broughtnew problems.Waiting lists have grown steadily, with an increasing number of patients being considered suitable candidates for transplantation.At the same time the number of organs becoming available each year has fallen as deaths from road trafficaccidentsdecrease and the techniques for managing critically ill patients improve. It is thereforeimperativethat all available donor organs are allocated to recipients ensuring that the best possible outcome for each is achieved from this scarce and preciousresource.12 The UKTSSA was established in 1991 to run and maintain the whole transplant system. We have already seen the system that is successfully implemented for the prioritisation of kidney transplant waiting lists. The following discussion highlights the fact that there are many variables that could be considered. It could be argued that the current system does not take these into account. Complications in the decision If it were up to you to choose who should be treated in the public health servicehow would you decide?Would you treat the sickest first? The poorest? Young people before old? Perhaps you would hold a lottery to select patients - first prize, a heart transplant.13 The above quote is a very cynical view of decisions that are made in the health service; however, it throws up some very important issues. How do you decide who should receive treatment first and, perhaps more significantly, who should not receive treatment? These issues are no different with regard to transplant decisions. Initially, it may seem obvious that the youngest and sickest patient should receive the available kidney. However, 'Sicker people are more likely to die after their transplants, or to need 2nd and even 3rd transplants'.14 The kidney could have gone to somebody else with a much better chance of survival. In effect it has been wasted.

of tissuetype Compatibility

Non-favourable matchNo Perfect match match Favourable match

Paediatric
or

adult

Paediatric

or

adult

Paediatric

or

adult

Local

or

national

Local

or

national

Local

or

national

Figure 1

Current prioritisation system.

Table 1 Current point scoring system Factor Recipient age Donor/recipient age difference Waiting time Matchability Sensitisation Balance of exchange 5 and 48.5 points. Totalbetween Scale Old to young Large to small Short to long Easy to hard High to low Low to high Points available 1-10 1-10 0.5-5 1-10 0.5-3.5 1-10 Who benefits? Favours younger recipients Avoids large age difference Favours longest waiting Favours rarer HLA types Favours low sensitisation and avoids cross matches Favours higher centre balance

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Labib-Prioritisation TPerris and AW oforgan lists 105 waiting transplant patient

The situation is further complicatedwhen we introduce medical science. As we have seen, a kidney from donor to recipientcan be classifiedas a perfect match, a favourable match or a non-favourable match. All situations have the potentialfor successbut with varyingdegrees.Currently, the kidney goes to the most favourable match. Again, this seems a sensible decision. However, what if the closest match is somebody with a non-life-threatening condition and there is somebody else, weeks away from death, whose match may be close but just not as close. The kidneywould currentlybe allocatedto the patient in less need. It would be more realisticto assess all criteria together. The point system(Table 1) suggeststhat waitingtime and sensitisationare less importantthan the other criteriawith a maximumof only 5 or 3.5 points achievable.Some thought has obviouslygone into theseweightingsbutjust how much? Are we to assume that recipient age, age difference, matchability and balance of exchange are exactly as do these six variables importantas each other?Furthermore, constitute an exhaustivelist of considerationsin matters as importantas kidneydonation?The currentsystemcannot be assumedto be the best. Gordon'5 calls for the need to take 'sociocultural' factors into consideration such as the patients' lifestyle and pain level. 'Should those in more pain get higher a considerationthan those who aren't?'If so, should they still get higher prioritisation if the tissue match is less favourable? The situation is complicated further still in America wherea National Health Servicecomparableto the UK does not exist. In this system, insurance companies and their policies are a major factor. Finally, Ham'6 calls for more justification of the decisions that are made in transplant waiting lists.

criteria,and assess them at the same time, or do they have limits? The problems associated with such decisions are highly complex and sensitive. At the end of the day, these issues affect peoples lives, aiming to improve the quality and/or the survival of that life. Dr Robert D Gibbons, from the University of Illinois in Chicago conducted an analysis of approximately 68 000 patients on the liver transplantwaitinglist between1995and 1999.He concluded 'current allocation policies fail to provide organs to the neediest patients'.18 The current prioritisation systems could do better and an alternativeis needed. This paper offers two models using fuzzy logic with the flexibility to include the more sensitive and humanistic criteria discussed above. Fuzzy logic has been chosen due to its capabilityof dealing with qualitativemeasures,the storage and provision of knowledge in the form of rule-base and its decision support and visualisation capabilities. Neither model explores the full range of criteria that should be considered. They simply present the possibility of using fuzzy logic in such a sensitive decision-making situation and offer an example of how other, more humanistic criteria can be used. The result is a flexible template by which medical professionals can apply the relevant criteria based on medical researchand their own knowledgeand experience.

The models Model one, simply applies fuzzy logic to the currentpoint the effectiveness of fuzzy logic scoringsystem,demonstrating in making such decisions while improvingthe sensitivityof the point scoring system. Model two utilises fuzzy logic's full potential by demonstratingthe applicationof humanisticcriteriato the prioritisationproblem. The models are only an example of what is possibleusing fuzzy logic. They have been developed to allow professionalsto adapt readilythe actualcriteriaand weightings of the criteria using knowledge from their experience.

Entry onto the waiting list Johnson et a1'7 looks at the problems associated with deciding whether a patient should be added to the waiting list or not. The paper looks at the UK system, which currently leaves the decision up to the individual doctor and the patient. The doctor asks questions such as would this person like a transplant? Is it possible? Would it seem reasonable to give them a chance? The paper calls for the need to take more explicit and quantitative criteria into consideration as the current approach 'may not make best use of a scarce national resource'such as kidneys. The systemused to prioritisethese waitinglists must be as accurateas possible due to the sensitivityof the decisions. What is the best system and what criteriashould be taken into consideration? Are the systemscurrently used in the UK and abroad capable of taking into consideration more

Model One (fuzzy applied to the current system) By applying fuzzy logic to the current point scoring mechanism (Table 1), great advantages are achieved and fuzzy logic's flexibilityand usabilityare well demonstrated. The rules devised in this model demonstrate an original, highly systematic process. The model is developed in a numberof stages. The model (Stage One) Membershipfunctions: Each of the six attributes in the point scoring system is used as inputs into a fuzzy

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Vol. 2 oftheOperational Research 106 Journal 55, No. Society

system resulting in a single output function. Initially, all six inputs are given two membership functions, each with the same characteristic (shape); this is shown in Figure 2 for the 'Age' input. Notice that the first membershipfunction (MF) in each case representsthe favourablechoice from the mechanism (Table 2). For example, the highest priority will go to the recipientwho is the youngest, with the least age difference between donor and recipient,who has been on the waiting list for the longest, with a difficult matchabilityrating, low sensitisation and from a region which has the highest balanceof exchange.The output has seven MFs. The reason for this relates to the rule-makingprocedure and will be explainedbelow.

Rules: If an AND rule is made for every combination of input MF then there will be 64 (26) rules. This will become clear. The system used for deciding the rules is a systematic seven-step procedure: Step 1: The highest priority (top) is allocated when all inputs have the favourable MF. There is only one combination in this scenario (number 1 represents the favourable MF) (Table 3). So the rule is as follows: IF (Age is Young) AND (Age Difference is Small) AND (Waiting Time is Long) AND (Matchability is Hard) AND (Sensitisation is Low) AND (Balance of Exchange is High) THEN (Output is Top). Step 2: The next highest priority (very high) is allocated when five of the six inputs have the favourable MF. There are six combinations in this scenario (number 0 represents the unfavourable MF; these cells are highlighted to clearly differentiate them) (Table 4). Step 3.: The next highest priority (high) is allocated when four of the six inputs have the favourable MF. There are 15 combinations in this scenario. MFs will be represented by their number only from now on (1 for favourable and or unfavourable). Table 8 in the Appendix shows the highpriority permutations. Step 4: The next highest priority (medium) is allocated when three of the six inputs have the favourable MF. There are 20 combinations in this scenario. Table 9 in the Appendix shows the medium-priority permutations. Step 5: The next highest priority (low) is allocated when two of the six inputs have the favourable MF. There are 15 combinations in this scenario. Table 10 in the Appendix shows the loil'-prioritypermutations. Step 6.: The next highest priority (very low) is allocated when one of the six inputs have the favourable MF. There are six combinations in this scenario. Table 11 in the Appendix shows the very-low'-priority permutations.

Degree of membership

K:~C?

Age Figure 2 MFs for the age input. MF names MF1 MF2

Table 2 Input

Age Age difference Waitingtime Matchability Sensitisation Balanceof exchange

Young Small Long Hard Low High

Old Large Short Easy High Low

Table 3 Rule no. 1 Age Young (1) Age difference Small (1) Waiting time Long (1)

Top-priority permutations Matchability Hard (1) Sensitisation Low (1) Balance of exchange High (1) Output (priority) Top

Table 4 Rule no. 2 3 4 5 6 7 Age Young (1) Young (1) Young (1) Young (1) Young (1) Old (0) Age difference Small (1) Small (1) Small (1) Small (1) Large (0) Small (1)

Very-high-prioritypermutations Sensitatsation Balance of'exchange Low (1) Low (0) High (1) High (0) Low (1) High (1) Low (1) High (1) Low (1) High (1) Low (1) High (1) Output (priority) Very high Very high Very high Very high Very high Very high

te Matchaility Waiting te Matchabiiting Long (1) Long (1) Long (1) Short (0) Long (1) Long (1) Hard (1) Hard (1) Easy (0) Hard (1) Hard (1) Hard (1)

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lists 107 AW oforgan T Perris and Labib-Prioritisation waiting transplant patient

Bottom V.Low of Degree membership

Low

Med

High V.High

Top

0 Figure 3 Output MFs.

10

Output(Priority)

Table 5 Input Age Age difference Waiting time Matchability Sensitisation Balance of exchange

MF weightings Points acailable 10 10 5 10 3.5 10 Weiqhtincj 1 1 0.5 1 0.35 1

Every rule is initially given a weighting of 1 (Table 6). If a rule includes the favourable MF for 'Waiting Time' (ie 'High'), then the rule's weighting is multiplied by 0.5 (the weighting for 'Waiting Time'). Similarly, if the rule includes the favourable MEF for 'Sensitisation' (ie 'Low'), then 0.35 multiplies the rule's weighting. For example: Rule 43.: IF (Age is Old) AND (Age Difference is Large) AND (Waiting Time is Short) AND (Matchability is Easy) AND (Sensitisation is Low) AND (Balance of Exchange is High) THEN (Output is Low) WEIGHTING=0.35 (1 x 0.35). Rule 44. IF (Age is Old) AND (Age Difference is Large) AND (Waiting Time is Short) AND (Matchability is Hard) AND (Sensitisation is High) AND (Balance of THEN is is Low) (Output High) Exchange WEIGHTING = 1. Rule 45.: IF (Age is Old) AND (Age Difference is Large) AND (Waiting Time is Long) AND (Matchability is Easy) AND (Sensitisation is High) AND (Balance of Exchange is High) THEN (Output is Low) WEIGHTING=0.5

Step 7: The next highest priority (bottom) is allocated when none of the six inputs have the favourable ME. There is only one combination in this scenario. Table 12 in the permutations. Appendix shows the bottonm-priority The doctor will allocate points as normal to the six inputs. The fuzzy system will manipulate the inputs to produce a degree of membership for the output functions resulting in a single output number representing the priority number. As described by the rule devising system above, there are seven output MFs as shown in Figure 3. The output (priority) is given on a scale of 0-10 as can be seen. This concludes the first stage of the model. It is extremely simplistic; there are only two MFs for each input, the shapes of every MF are the same and no weightings have been taken into account. Subsequent stages in the model will deal with these issues starting with the weightings. The model (Stage Two) weightings

(1 x 0.5)
If further research discovered that the weightings should be altered, the model can easily be adjusted to cater for these changes by adapting the rule weightings. Figures 4 and 5 show a sample of the surface views developed. The surface views simply show a three dimensional representation of two of the inputs compared with the output. Figure 4 (Age difference versus age) shows a moderately smooth surface model, this is representative of the majority of the surfaces produced in this particular fuzzy model. Figure 5 (Weighting time versus sensitisation) has a slight bulge. This occurs when one or both of the inputs are weighted as both weighting time and sensitisation are.

For the moment we will just look at the weightings that have already been applied to the current prioritisation system. Additional weightings will be discussed in subsequent stages. The weightings shown in Table 5 are currently used (taken from Table 1). Some of the inputs in the mechanism allow points to be allocated as low as 0.5, while others only allow points as low as 1. One of the advantages of fuzzy logic is its acceptance of decimal numbers, that is, 7.5 would be an acceptable score. Therefore, this model allows points to be allocated as low as required (eg 0.1-9.9).

The mnodel (Stmge Three) -

MF shiapes

The model has chosen the shapes of the MFs arbitrarily to prove the effectiveness of fuzzy logic in such situations.

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108 Journal oftheOperational Research Vol. 2 55, No. Society

Table 6 Rule no. 43 44 45 Age 0 0 0 Age difference 0 0 0 Waiting time 0 0 1

Example of rules Sensitisation 1 0 0 Balance of exchange 1 1 1 Output (priority) Low Low Low

Matchability 0 1 0

.. ?

-'-- .___

28
.

26 4524
S2

:Cc(~ . . .~?.:: .T ... . _

..

"..

:...:

: ....

10

.-

....
?~D~'r ,,.
. ..,

~F
...
-.

Age~

R2
Figure 4 surface model. loe1 Age difference versus age

In reality, each of the six inputs to this priority decision will have different characteristics. For example, you may want the age MF to favour any recipient under the age of 18 years equally. This would give the MF as shown in Figure 6. There are many ways that the shape can be changed to represent a particular characteristic. As doctors become familiar with the technique, they will be able to use their judgement to alter the shapes accordingly. Alternatively, a medical professional may have a very good idea of how he or she expects the decisions to affect the outcome. Therefore, they will have a good idea of how the surface model should look. MFs could be altered appropriately in order to achieve the desired effect. This may involve an element of trial and error but with increasing fuzzy experience the process would become more systematic and accurate. Further examples of the effect of shape changes can be seen in the second model. With appropriate medical expertise and experience, the shapes of all the MF can be adapted very easily to produce a more accurate decision-making model.

The model (Stage Four) -

No. of MFs

The greater the number of labels (MFs) assigned to describe an input variable, the higher the resolution of the resultant fuzzy control system, resulting in a smoother control system. However, it is unusual to have more than nine MFs. Currently, each input has only two MFs. This is probably too low and does not allow for any great degree of resolution or smoothness. In reality, one would hope for smoother surface views. However, we already have 64 (26) rules. The value 26 describes the number of combinations of two MFs in six inputs. If we were to slightly increase the number of MFs to three per input, then we would have 36 (7 2 9) rules. Even then, the surface may not be as smooth as we would like. Maybe six MFs would produce a better system; however, this would then require 66 (46 656) rules. This is an NP-hard problem. Implementing the model MFs that model the real-life characteristics of the criteria are set up by medical professionals with knowledge

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lists 109 AW oforgan T Perris and Labib-Prioritisation waiting transplant patient

30

24--

0.5 . 1.5 2 3.5 Figure 5 5 3

Waiting time versus sensitisation surface model.

Young of Degree Membership

Middle Aged

Old

18
Figure 6 Effect of MF shapes.

Age

and experience in the transplant field by adjusting the rules, rule weightings and MF shapes. For each patient, the relevant information is then simply input into the system. Model Two (the 'humanistic' fuzzy model)
Belief or attitude emphasizing common human needs and seeking solely rational ways of solving human problems; system of thought concerned with human matters...Oxford Dictionary definitionof humanistic

researchcarriedout it does not pretend to be an authority on medical decisions. It is argued, however, that decisions of such importance (somebody's life or death in certainsituations)should take into account more humanistic issues. Currently, the criteria are purely objective considering only real things that can be easily measured (age, waiting time, etc). This section offers an alternative system that concentrates on the humanistic elements involved in such decisions. Fuzzy logic 'blurrs' input boundaries allowing smooth transitionbetweenMFs. It also allows evaluationof multiple inputs. The fuzzy logic model has been designedwith the view to aid the decision-makingthat takes place to prioritise the kidney recipientwaiting list. When a kidney is donated, all the patientsfor whom the kidneyis suitableare analysedand put through the program.The program asks the doctor to classify certainfactors, such as patients'pain level, and then provides a prioritypercentageof how criticalthe need for a kidney is. Criteria these are 'life Threeissues (criteria)are looked at specifically; expectancy', 'pain level' and 'quality of life'. These criteria are representative of some of the issues and debates previouslydiscussed.However,it is by no means exhaustive and many more will be added as a result of professional input. The model developedis only aimed at highlightingthe possibility of such a model existing and working.

Does the current system offer an exhaustive list of inputs? In light of the many debates that occur in such decisions(some of which were discussedearlier)it seems that perhaps more considerationscould be taken into account, in particular sociocultural or humanistic elements.15 This is a purely scientific paper and despite the medical

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oftheOperational Research Vol. 110 Journal 55, No.2 Society

Table 7
'Pain level'

'Pain level' criteria

Best description o/fpatient

10 9 8 7 6 5 4 3 2 1 0

Patient is in no pain Patient rarely suffers from pain, but when they do it does not require medication Patient suffers from regular (daily) discomfort that does not require medication Patient is in constant discomfort, but not to the extent that it requires medication Patient occasionally (one to two times a week) experiences discomfort that requires 'over the counter' medication. Patient regularly (daily) requires 'over the counter' medication. Patient constantly taking 'over the counter' medication. Patient occasionally (one to two times a week) experiences pain that requires prescription medication. Patient requiring constant doses of a mixture of prescription and non-prescription medication. Patient regularly (daily) requires prescription strength medication. Patient is in constant pain that requires prescription strength medication to control.

Life Expectancy V.Short Short Degreeof Membership

Medium

Long

NotLifeThreatening

2 Figure 7 'Life expectancy' MFs.

Life Expectancy (months)

Life expectancy is defined as the length of Life expectancy.: time that the patient is expected to live, should a transplant be unavailable. Pain level. A number between 0 and 10 is assigned indicating the amount of pain a patient is suffering. Number 10 is no pain and 0 is excruciating. A doctor will assess this level. Table 7 shows possible criteria that could be used when allocating a value. It should be noted that pain level does not have to be an integer, allowing room for medical discretion. The aim is to make the determination of the amount of pain a patient is in less subjective and therefore a crisp input to the system. Quality of life: This indicates how much the quality of life of the patient would change if they received a kidney. The shape of the MFs controlling each input can be changed to put more or less emphasis on any of these input variables. Much thought has been put into the shape of the MFs, but as this method is subjective, consultancy with experts will be required to ensure that the functions chosen are appropriate. The shapes decided upon are described below. MFs The shape of the MFs controlling the three inputs can be changed to put more or less emphasis on any of the input variables.

The MFs are measured in months (Figure 7). The scope of each MF increases as they move from 'very short' to 'not life threatening'. (The shapes get bigger.) This implies that changes in life expectancy become increasingly insignificant. For example, a difference of 1 month when a patient has 6 weeks to live has a far more drastic effect than if life expectancy is 3 years. After 48 months, it is assumed that the condition of the patient is not life threatening. The trapezoidal shape of the 'very short' MF is important. This initial level platform lasts for 2 months. If the life expectancy is within this time, it will belong to the 'very short' MF to a degree of 1. Therefore there is no distinction between life expectancies of less than 2 months. The time period during which it is level can be altered easily, demonstrating the flexibility of the program. Three membership functions are used, all being symmetrical about the centre. This allows smooth transition between each of the MFs. The inputs were purposely simplified in this way due to the subjective nature of pain (Figure 8). There are no rules stating how critical pain is other than 'humanistic' common sense. By leaving the MFs like this, it is left to the rules to portray a common sense approach and attribute any exceptions to the current smooth nature of the input. Of course, any future research into pain level may enable the MFs to be adapted. The model is flexible so as to allow for such improvements.

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lists 111 TPerris and AW Labib-Prioritisation oforgan waiting transplant patient

Patientsrequirea kidneymore urgentlyif they are in great pain than if they are only in some pain. Pain may be measuredon a scale of 1-10, and great pain assigneda value of 2 and below. Without fuzzy logic. a person with a pain level of 2 would have a much higher prioritythan a person with 3 (all other things remaining the same), although in reality they may actually be experiencingvery similar pain. This discrepancy may be further highlighted if different

doctors are assessing the pain level. Fuzzy logic allows blurringof these boundariesenablinga smoother transition between two pain levels. Fuzzy logic also allows multiple inputs to be evaluatedsimultaneously. The MFs that determine the recipients' 'quality of life' have been specifiedas havingthe same shapeas those used in 'pain level'.The same analysiscan be made of 'qualityof life' as that of 'pain level' (Figure 9). Rules

Pain Level
GreatPain Degree of Membership Some Pain No Pain

Pain Level

Figure 8
Qualityof Life
Vast Improvement Degree of Membership

'Pain level' MFs.

Beneficial Change

No Chanige

Qualits of Life

Figure 9

'Quality of life' MFs.

Every combination of input functions was analysed using only AND commands, and an appropriate priority level (very high, high, mediumand so on) was established.In this case the total numberof possible rules is 45 (5 x 3 x 3). The decisions reached are subjective and open for change by medical professionals. This model does not use the systematicrule method as used in model one, instead each rule is analysed and devised separately. This benefits the system by giving it a human input. An example of the decisions reachedwhen developingthe rules is described for the 'life expectancy' input. Here the rules have been set to give the 'very short' MF overall priority over the other inputs and MFs. A sample of the rules is shown in Figure 10. As can be seen, every rule that has 'life expectancy'set at 'very short' has the top output. Combined with the 'very short' MFs level platform (discussedabove), this means that if patients have less than 2 months to live, they get priorityover everythingelse. This is just one exampleof how humandecisionscan influencethe rules.

33. IF (Life Expectancyis 'Short') and (Pain Level is 'Some Pain') and (Qualityof Life is 'Vast Improvement')then (Priorityis V.High) 34. IF (Life Expectancy is 'Short') and (Pain Level is 'Great Pain') and (Quality of Life is 'No Change') then (Priorityis High) 35. IF (Life Expectancyis 'Short') and (Pain Level is 'GreatPain') and (Qualityof Life is 'Beneficial Change') then (Priorityis V.High) 36. IF (Life Expectancyis 'Short') and (Pain Level is 'GreatPain') and (Quality of Life is 'Vast Improvement')then (Priorityis ExtremelyHigh) 37. IF (Life Expectancy is 'V.Short') and (Pain Level is 'No Pain') and (Quality of Life is 'No Change') then (Priorityis Top) 38. IF (Life Expectancyis 'V.Short') and (Pain Level is 'No Pain') and (Qualityof Life is 'Beneficial Change') then (Priorityis Top) 39. IF (Life Expectancyis 'V.Short') and (Pain Level is 'No Pain') and (Quality of Life is 'Vast Improvement')then (Priorityis Top) 40. IF (Life Expectancy is 'V.Short') and (Pain Level is 'Some Pain') and (Quality of Life is 'No Change') then (Priorityis Top) 41. IF (Life Expectancyis 'V.Short') and (Pain Level is 'Some Pain') and (Quality of Life is 'Beneficial Change') then (Priority is Top) 42. IF (Life Expectancyis 'V.Short') and (Pain Level is 'Some Pain') and (Quality of Life is 'Vast Improvement')then (Priority is Top) 43. IF (Life Expectancy is 'V.Short') and (Pain Level is 'Great Pain') and (Quality of Life is 'No Change') then (Priority is Top) 44. IF (Life Expectancyis 'V.Short') and (Pain Level is 'GreatPain') and (Qualityof Life is 'Beneficial Change') then (Priority is Top) 45. IF (Life Expectancyis 'V.Short') and (Pain Level is 'GreatPain') and (Qualityof Life is 'Vast Improvement')then (Priority is Top) Figure 10 Sample of the rules.

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112 Journal oftheOperational Research Vol. 2 55, No. Society

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'Quality of life' versus 'pain level' surface model.

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Figure 12

'Life expectancy' 'versus quality of life' surface model.

Surface models
A sample of the surface models is shown in Figures 11 and 12. Figure 11 is almost perfectly flat representing the equality of the shapes and rules involving 'quality of life' and 'pain level'. Figure 12, however, includes the life expectancy' input. The bias towards 'life expectancy' can be clearly seen.

given by Ratcliffe et al.19 The current paper would acknowledge that such issues are beyond its scope.

Conclusion
This is a purely scientific paper and despite the medical research carried out, it does not pretend to be an authority on medical decisions. The models are devised as a tool to be applied by medical professionals. The models can also be used to aid the many problematic issues as discussed above. The first model was produced to demonstrate the effectiveness of fuzzy logic in making prioritisation decisions. This was successfully achieved by improving the existing

Discussion of results
The paper does not deal with the question of what makes one decision rule better than another. A completely separate modelling exercise is required to assess the value of a specific decision rule: an example in the case of liver transplants is

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lists 113 oforgan AW Labib-Prioritisation TPerris and waiting patient transplant

kidney prioritisationsystem used in the UK. The improved betweensmallchangesin inputscreating model distinguishes a much more reliableand realisticsystem(the smoothnessof the models can be seen in the surface models). This is essential when dealing with such sensitive decisions where the differencebetweenlife small discrepancies may represent and death. Furthermore, decisions can be more clearly is highly systematic. justified, as the decision-making Owing to the systematicnature of the rules presentedin this first model, it is proposed that as further work, a computer program could be written to devise the rules automatically.This would solve the problems experienced when too many rules are required. The second model continues where the first model finished, extending the model to allow humanistic inputs. This model demonstrates the effectiveness of fuzzy logic when dealing with humanistic criteria by consistently determiningthe priority of patients waiting for transplant and attempting to remove some of the sharp boundaries. This follows the call for such criteriato be considered(found in an increasingnumberof papers researchedand analysed in this paper). Both models developed improve the quality of the prioritisation decisions. The decisions are more realistic and more confidence can be placed in them. This in turn leads to a justificationof the decisionsas called for in many papers such as Ham.16 The models leave the door open for medicalprofessionals to add alternativecriterionand adjust the weightings and characteristicsof the criteria already modelled. A further exampleof an input to the model could be the doctors' own decision-making characteristics.For example, a hospital may use a number of doctors to assess the humanistic elementssuch as pain level. This producesan inconsistency, as different doctors would allocate points differently. However, the doctors'previousdecisionscould be analysed, measuredagainst the outcomes of those decisions and used

as an input into the system and used as an input into the system. The models are highly flexible and can be adapted into many forms. Furtherinputs and modificationscan be easily added should medicalprofessionalssee fit or some analysis of pain or quality of the inputs (for example,measurement are be of life) published.Initially,they producedas potential national to alternatives transplant prioritisation systems. However, they can be just as useful if used by individual hospitalsand even individualdoctorsto help decidewhether a patient should be put on the waiting list in the first place. Each hospital could cater the criteriaand input characteristics to suit their particularsituation. Much of the researchcarriedout in this paper focused on the complications involved with such sensitive decisionmaking, should the sickestpatientsbe treatedfirstor last for example.The models do not directlyanswerthese questions but are designedto be flexibleenough to cope with constant changes in criteria agreed on. Changes, which in the US occur on almost a monthlybasis.The resultsof such changes can be easily seen and thus analysedin the surfacemodels. Both models can be combined to produce an overall system. Other criteria could also be added to this with medicalprofessionalinput. For example,the currentsystem in the UK follows a step-by-step procedure (shown in Figure 1) assessingcriteriaindividuallybefore finally using the points system. The models producedin this paper allow all criteria to be considered at the same time. So blood matches are analysedalongsidepain level and age, etc. The main conclusion of this researchwork is that the optimal decision rule selected from a larger set of possible decision rules is likely to be better than the optimal rule selectedfrom a more restrictedset of possible rules. Appendix Tables 8-12 relate to model one.

Table8 High-priority permutations

Rule no. Age Age difference Waiting time Matchability Sensitisation Balance of exchange Output (priority)

8 9 10 11 12 13 14 15 16 17 18 19 20 21
22

1 1 1 1 0 1 1 1 0 1 1 0 1 0
0

1 1 1 0 1 1 1 0 1 1 0 1 0 1
0

1 1 0 1 1 1 0 1 1 0 1 1 0 0
1

1 0 1 1 1 0 1 1 1 0 0 0 1 1
1

0 1 1 1 1 0 0 0 0 1 1 1 1
1

0 0 0 0 0 1 1 1 1 1 1 1 1 1
1

High High High High High High High High High High High High High High
High

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114 Journal oftheOperational Research Vol. 2 55, No. Society

Table 9 Medium-priority permutations Rule no. 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Age 1 1 1 0 1 1 0 1 0 0 1 1 0 1 0 0 1 0 0 0 Age difference 1 1 0 1 1 0 1 0 1 0 1 0 1 0 1 0 0 1 0 0 Waiting time 1 0 1 1 0 1 1 0 0 1 0 1 1 0 0 1 0 0 1 0 Matchability 0 1 1 1 0 0 0 1 1 1 0 0 0 1 1 1 0 0 0 1 Sensitisation 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 Balance of exchange 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 Output (priority) Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium

Table 10 Low-priority permutations Rule no. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 Age 0 0 0 0 1 0 0 0 1 0 0 1 0 1 1 Age difference 0 0 0 1 0 0 0 1 0 0 1 0 1 0 1 Waiting time 0 0 1 0 0 0 1 0 0 1 0 0 1 1 0 Matchability 0 1 0 0 0 1 0 0 0 1 1 1 0 0 0 Sensitisation 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 Balance of exchange 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 Output (priority) Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low

Table 11 Very-low-prioritypermutations Rule no. 58 59 60 61 62 63 Age 0 0 0 0 0 1 Age difference 0 0 0 0 1 0 Waiting time 0 0 0 1 0 0 Matchability 0 0 1 0 0 0 Sensitisation 0 1 0 0 0 0 Balance of exchange 1 0 0 0 0 0 Output (priority) Very low Very low Very low Very low Very low Very low

Table 12 Bottom-priority permutation Rule no. 64 Age 0 Age difference 0 Waiting time 0 Matchability 0 Sensitisation 0 Balance of exchange 0 Output (priority) Bottom

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lists 115 oforgan T Perris AW Labib-Prioritisation and waiting patient transplant

thank the refereesfor their valuablecomAcknowledgements-We ments.

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