Another view: Transplants and ‘bad’ recipients

Troubling questions have been raised about whether doctors should consider the moral character or criminal history of patients before saving their lives with an organ transplant. Concerns also have been raised about whether a hospital should accept financial donations from grateful organ recipients, regardless of their backgrounds, and whether foreigners should be able to receive transplants in the U.S.

The controversy has focused on UCLA Medical Center, which runs one of the world's top liver transplantation programs. The Los Angeles Times' reports alleged that the medical center provided a transplant to a Japanese man suspected of crimes in his own country, and that the man later donated $100,000 to the medical center. Because of patient privacy issues, the center cannot address the allegations directly.

The outcry has revealed profound moral and ethical issues, but those who argue that criminals should not get transplants are on shaky ethical ground. Do we want to force caregivers to make a life-or-death decision based on whether a patient is a "good" or "bad" person?

Much of the criticism can be attributed to a lack of understanding of the federally mandated donor organ allocation process, governed by the United Network for Organ Sharing, or UNOS. These guidelines are needed because there aren't enough donor organs. In 2007, for example, of the 16,311 people waiting for liver transplants, about 40 percent received them, and 10 percent died waiting.

Under the guidelines, the liver transplant system is based primarily on disease severity. Patients are placed on a list, and UNOS prioritizes them according to need. As livers become available, organ procurement agencies match them to those at the top of the list, based on such factors as travel time, blood type of organ and patient and the quality of the organ.

But the decision as to whether a particular organ is best for a given patient must be made by the patient's physician. If the physician decides it can't be used for the patient designated by UNOS, the organ goes to the next person on the UNOS list, who might be waiting for the procedure at another hospital. UNOS does not allow a transplant program to use that organ for another of its patients who has not been given priority by UNOS.

In addition to medical considerations, UNOS guidelines require some "nonmedical" judgments, such as whether patient behaviors are likely to result in failure of the new organ or how well doctors think a transplant candidate would adhere to post-surgery protocols. Teams of physicians, nurses, clinical social workers and other experts make these judgments.

The need to apply these "nonmedical" criteria relates solely to the future viability of the transplanted organ, not to the intrinsic worthiness of the recipient as a human being. No physician should be making that judgment; to do so would be to impose a death sentence on some patients, and, besides, matters of punishment are best left to the justice system.

The UNOS Ethics Committee states: "Punitive attitudes that completely exclude those convicted of crimes from receiving medical treatment, including an organ transplant, are not ethically legitimate." Moreover, doctors are ethically bound by the Hippocratic Oath: "Most especially must I tread with care in matters of life and death. ... Above all, I must not play at God."

As for the role financial donations, or the promise of them, might play in a patient receiving an organ, the rules governing transplant lists as well as periodic audits all but eliminate any possibility of manipulating the process. That said, there is nothing unusual or improper about patients or their families donating money after transplant surgery.

Regarding recipients from other countries, UNOS allows noncitizens to receive U.S. transplants not only for humanitarian reasons but because they are part of the donor pool -- in Southern California, about 20 percent of donors are foreign-born -- and excluding them might reduce the number of donors. The guidelines call for roughly 95 percent of all organs to go to Americans, and UCLA Medical Center has abided by this rule.

Because of the variables involved in matching donor organs to patients, a recipient might have been waiting a short time, while those who have waited longer are passed over. This reality has been a source of confusion and anger for patients who don't understand the process and has led some to speculate erroneously that factors such as financial donations play a role.

Such criticism is completely misguided when directed toward UCLA Medical Center's liver transplant program. Dr. Ronald Busuttil's program has led to transplants for nearly 5,000 individuals, rich and poor alike. Without his and his team's expertise, they would have died.

UNOS and transplant programs such as UCLA's are certainly not above criticism. They need to be accountable to the public. So by all means, the public should question UNOS' policy and transplant centers that fail to live up to their obligations to their patients.

But what a tragedy if, because of rumor, suspicion and a lack of understanding about the organ allocation process, people choose not to donate a liver -- a consequence that would be detrimental for everyone waiting for these lifesaving organs.

Levey is vice chancellor of medical sciences and dean of the David Geffen School of Medicine at UCLA.

(June 8, 2008)