Ethics in Liver Transplantation

1
Ethics in Liver Transplantation

• Residents Lecture
• 15 June 2010
• Paul H. Hayashi, MD, MPH

2
Patient Summaries
WD CN JU CB KN
57 yo female with HCV after raped and transfused 26 yo male, school teacher, Tylenol OD. 18 yo male, student, ?Tylenol mishap with psych and drug use history 32 yo male, prisoner with genetic liver disorder 73 yo woman with reaction to herbal product functional and working
3
Scarcity of Donated Livers
4
Liver Transplant Allocation 101

• Patients prioritized by MELD score
• Model of End-stage Liver Disease
• Based on 3 lab values
• INR, creatinine, bilirubin
• Entered into formula to give score
• Whole numbers from 6 to 40
• 6 normal person
• 40 3-4 week mortality approaches 100

5
Unique Factors in Transplantation

• Real time triage allocation of scarce resource
• Few other examples in US medicine
• Mass casualty/combat field medicine
• Vaccine shortage
• Unique stakeholders
• Donor (deceased or living)
• Donor family or loved ones
• Potential donors general public

6
Ethical Principles

• Beneficence doing good
• Non-malfeasance avoiding harm
• Autonomy respecting patient decisions
• Justice fairness
• Utilitarianism
• Communitarianism

7
Justice

• Websters definition the quality of being just,
  impartial, or fair (the principle or ideal of
  just dealing or right action)
• Various forms of justice
• To each according to need.
• Who is most in need?
• To each according to fair share.
• What constitutes fair share?

8
Justice

• In western, democratic societies, the rights of
  the individual is emphasized.
• Personal freedom and choice valued.
• The individual most likely to die is most in
  need.
• Each individual should have fair and equal claim.
• Example At same MELD, 28 year old with Wilsons
  disease and 60 year old with chronic hepatitis C
  use have equal listing and chance at transplant.

9
Utilitarianism

• Websters Definition a doctrine that the useful
  is the good and that the determining
  consideration of right conduct should be the
  usefulness of its consequences specifically a
  theory that the aim of action should be the
  largest possible balance of pleasure over pain or
  the greatest happiness of the greatest number.

10
Communitarianism

• A counterbalance to western, individual primacy
  based theory of justice.
• Justice and individual rights and freedoms must
  be couched in the society in which they are
  rendered and reside.
• our interest in community mayconflict with our
  vital interest in leading freely chosen lives,
  and the communitarian view is that the latter
  does not automatically trump the former in cases
  of conflict.
• Stanford Encyclopedia of Philosophy
  (http//plato.stanford.edu/entries/communitarianis
  m) Accessed 10/19/09

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Communitarianism

• An organ is a uniquely precious community
  resource
• Ironic donated in the midst of community loss
• Immediate allocation decisions made in 1-3
  hours.
• Tangible, living tissue
• unlike health care spending bills or prosthetics
• Honored donation viewed as heroic by community
• Should communitarian ethics have more sway?
• Perhaps, the 28 year old with Wilsons, father of
  three, and gainfully employed should go ahead of
  the 60 year old, former IV drug user, loner, on
  disability with hepatitis C, even though their
  MELD scores are equal.

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Patient Summaries
WD CN JU CB KN
57 yo female with HCV after raped and transfused 26 yo male, school teacher, Tylenol OD. 18 yo male, student, ?Tylenol mishap with psych and drug use history 32 yo male, prisoner with genetic liver disorder 73 yo woman with reaction to herbal product functional and working
13
Case CB

• 32 yo man with cirrhosis due to non-HFE iron
  overload
• Encephalopathy, ascites
• MELD 22
• In prison since age 18 murder with 7 years left
  on sentence.
• () drug use at time of incarceration.
• () opiates at clinic visit--? Source
• Father petitioning Gov. Perdue for early releast
  based on medical need.

14
Case CB

• Patient seen in Hepatology Clinic and denied
  transplant evaluation based on drug history.
• X-jade suggested
• Not seen again in UNC clinics
• Admitted to UNC with worsening liver failure and
  dies 1.5 years after initial evaluation by UNC
  Hepatology

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Policies of US transplant programs regarding
liver transplantation in prisonersFix OK et al.
Hepatology 50338A 2009 (abs.)

• Liver failure on the rise amongst prisoners
• HCV rate 10x the general population
• Survey of all 104 programs
• 67 responded
• Over the last 5 years
• 46 (69) evaluated at least one prisoner
• 17 (25) listed at least one prisoner
• 12 (18) transplanted at least one prisoner

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Background

• 1960s shortage of dialysis machines
• God Squads
• 1973 Setion 2991, Social Security Amendment
  Medicare covers dialysis
• 1976 Estella vs. Gamble
• Secured medical are to inmates under the 8th
  amendment.
• By LESLEY OELSNER
• December 1, 1976, Wednesday
• WASHINGTON, Nov. 30 The Supreme Court ruled today
  that "deliberate indifference" by prison
  officials to serious medical needs of an inmate
  violates the Eighth Amendment ban against cruel
  and unusual punishment and gives the inmate
  ground to sue the officials in Federal court

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Inmate Fears Death Because Prison Won't Finance
Transplant By GINA KOLATA Published February 5,
1994
Should the nation provide expensive care and
scarce organs to convicted felons? Can it justify
a system in which an estimated one in four
employed Americans cannot have a transplant
because they are uninsured or underinsured, yet
ask the Bureau of Prisons to provide them for
prisoners?
Dr. Arthur Caplan, director of the Center for
Bioethics at the University of Minnesota, said
"For me, it's open and shut.It's absolutely
wrong to make judgments about past behavior,
criminal conduct, moral worth, indictments,
charges or convictions."
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Inmate Fears Death Because Prison Won't Finance
Transplant By GINA KOLATA Published February 5,
1994
Ethicists and the public eventually found it so
distasteful to rate the worthiness of a human
life that, Dr. Dubler said, "the clear movement
since then has been to establish rigorously
abstract criteria so that the worth of an
individual is not factored in" when deciding who
should get organs or other lifesaving medical
treatments
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SHOULD A CRIMINAL RECEIVE A HEART TRANSPLANT?
MEDICAL JUSTICE VS. SOCIETAL JUSTICE LAWRENCE
J. SCHNEIDERMAN AND NANCY S. JECKER Departments
of Family and Preventive Medicine and Medicine,
University of California, San Diego, School of
Medicine, La Jolla, California 92093-0622,
U.S.A. Department of Medical History and Ethics,
University of Washington, School of Medicine,
Seattle, Washington 98195, U,S.A. Theoretical
Medicine 17 33-44, 1996

• Two fields of justice defined in opposition
• Medical Justice
• Hippocratic oath
• Societal Justice
• decent and rudimentary levels of health care

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Medical justice argues for transplanting prisoners

• I swear to follow the method of treatment
  which, according to my ability and judgment, I
  consider for the benefit of my patients.
• Hippocratic Oath
• Arguments against bedside rationing
• Risk of error, inconsistency, being hidden and
  manipulated.
• Undermines patient trust in physicians
• Society at large has the mandate to decide
• Physicians not equipped to do it right.

Schneiderman et al. Theorectial Medicine 1996
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Societal justice and transplanting prisoners
Schneiderman LJ et al. Theorectial Medicine 1996

• Prisoners should not be punished again by denying
  health care, but
• What level of health care are we talking about
  anyway?
• Is the prisoner a full member of society still?
• Would a decent minimum only be fair.
• e.g. Illegal immigrants are largely not included
  in the current health care debatethey will
  likely stay at a rudimentary minimum.

22
What did the authors conclude?

• Society will have to decide
• Suggested two lines be drawn
• The limits of a decent minimum of care.
• Treatments that may harm others by deprivation
  (e.g. transplant perhaps should be excluded.
• The level of criminal offense
• Heinous crimes may only be entitled to the
  decent minimum of care only.

Schneiderman LJ et al. Theorectial Medicine 1996
23
Moving Forward

• The hottest places in Hell are reserved for
  those who, in a time of moral crisis, maintain
  neutrality.
• The Devine Comedy (The Inferno). Dante Alighieri
• Have we let the courts decide for us?
• Physicians cannot avoid taking responsibility
  for stewardship over organ allocation and must
  play a primary role
• West JC, et al. Seminars in Dialysis, 2003

24
More to the point

• If confronted with a convicted murderer in for
  life needing a transplant, what will I do?
• Legally we are bound to evaluate (w/o societal
  justice or value in mind), list if appropriate
  and transplant when able.
• Is there a fundamental ethical norm or stance to
  NOT transplant?
• If so, is it strong enough to stand in the face
  of individualism?

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The Underpinnings of Western (democratic)
Individualism

• Emanual Kant
• The original position (1781)
• John Rawls
• The unencumbered self
• Equal basic liberties for all
• Only those social and economic inequalities that
  benefit the least advantaged members of society.
• Lines up well with basic tenets of the
  Hippocratic Oath

26
Communitarianism

• A counterbalance to western, individual primacy
  based theory of justice
• Justice and individual rights and freedoms must
  be couched in the society in which they are
  rendered and reside.
• our interest in community mayconflict with our
  vital interest in leading a freely chosen lives,
  and the communitarian view is that the latter
  does not automatically trump the former in cases
  of conflict.
• Stanford Encyclopedia of Philosphy
  (http//plato.stanford.edu/ accessed 10/10/2009).

27
Unusual Features of Transplant

• Triage based on medical and societal justice
• Few other examples in US medicine
• Mass casualty/combat military medicine
• Vaccine storage
• Orphan diseases
• Unique stakeholders
• Donor (deceased or living)
• Donor family or loved ones
• General public (donor pool)
• Transplant team

28
Communitarianism and Transplant

• An organ as a unique community asset
• Irony donated in the midst of community loss
• Honored donation viewed as heroic and highly
  valued
• organs procured within a community should be
  considered assets of the community
• Resolution 8, 1st International Congress on
  Ethics in Organ Transplantation
• Should communitarian ethics have more sway?

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What would the orignial position say about this
conflict?
The question of whether or not Mr. Murphy is
entitled to a heart transplant then becomes
generalized as If I were to enter a society in
which certain life-saving medical treatments were
limited, would I want persons who have already
taken benefits away from those who have attempted
to live justly to be eligible for further
benefits, such as these limited treatments? It
is hard to imagine that persons in an original
position would answer affirmatively.
Schneiderman et al. Theorectial Medicine
1996 (italics and underline added)
30
Equal or Fair?

• We have always had this idea, which is
  simplistic, that justice requires treating
  everyone, everywhere exactly the same way.
  Justice requires no such thing but simply
  requires us to treat people fairly.
• Ezekiel Emmanuel, Chief of the Bioethics Branch,
  NIH, New Yorker, 2003.

31
Hippocratic Oath

• I will apply, for the benefit of the sick, all
  measures that are required. However, this phrase
  should not be misused as a shield behind which we
  shirk societal responsibility because
• I will remember that I am a member of society,
  with special obligations to all my fellow human
  beings, those sound of mind and body as well as
  the infirm.
• Quoted phrases from Hippocratic Oath Modern
  Version by Louis Lasagna, Academinc Dean of the
  School of Medicine, Tufts University, 1964.
• Unquoted phrase and italics by Paul H. Hayashi,
  MD, MPH

32
Looking East

• Confucianism
• Social order and self-discipline are valued
• men are responsible for their actions and
  especially for the treatment of others
• ..we learn the value of social strictures that
  make an orderly society possible.
• Stanford Encyclopedia of Philosphy
  (http//plato.stanford.edu/ accessed 3/7/2010).

33
Newsletter
China admits death row organ use. China
executes more people than any other nation.
China is trying to move away from the use of
executed prisoners as the major source of organs
for transplants.
Newsletter
From the web... BBC Page last updated at 1332
GMT, Wednesday, 26 August 2009 1432 UK
Chinas Grim Harvest By Andrea Gerlin Sunday, Apr
23, 2006 China's President isn't used to being
heckled. But last Thursday, as Hu Jintao
addressed reporters at the White House during his
U.S. visit, a woman from a newspaper run by the
meditation sect Falun Gong loudly interrupted
him, calling him a "murderer" and threatening
that his days were numbered. Among other
allegations, Falun Gong, which is banned in
China, accuses Chinese hospitals of harvesting
organs from executed prisoners including some
of the sect's own members and selling them for
transplants. http//www.time.com/time/magazine/
article/0,9171,1186533,00.htmlixzz0hVS2DLLb
(accessed 3/7/2010)
Chinas Grim Harvest By Andrea Gerlin Sunday, Apr
23, 2006 China's President isn't used to being
heckled. But last Thursday, as Hu Jintao
addressed reporters at the White House during his
U.S. visit, a woman from a newspaper run by the
meditation sect Falun Gong loudly interrupted
him, calling him a "murderer" and threatening
that his days were numbered. Among other
allegations, Falun Gong, which is banned in
China, accuses Chinese hospitals of harvesting
organs from executed prisoners including some
of the sect's own members and selling them for
transplants. http//www.time.com/time/magazine/
article/0,9171,1186533,00.htmlixzz0hVS2DLLb
(accessed 3/7/2010)
May/June 2007 Volume 13 Number 4
Dr. Jeffrey Crippins AST Presidential Address
The use of donor organs from executed prisoners
is deplorable practice. As a society and as a
field, we should do whatever we can to prevent
such atrocities.
http//www.bbc.co.uk/
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What side of the slippery slope are you on,
anyway?
Are you crazy? Executing prisoners for organs?
Stop that!
Are you crazy? Giving precious organs to
convicted murderers? Stop that!
???????? ????????????? ???!
Individualism
Communitarianism (China)
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Patient Summaries
WD CN JU CB KN
57 yo female with HCV after raped and transfused 26 yo male, school teacher, Tylenol OD. 18 yo male, student, ?Tylenol mishap with psych and drug use history 32 yo male, prisoner with genetic liver disorder 73 yo woman with reaction to herbal product functional and working
36
What would Spock and Kirk say?

• the needs of the many outweigh the needs of the
  few.
• Capt. Spock in Wrath of Khan 1982
• Because the needs of the one outweigh the
  needs of the many
• Adm. James T. Kirk in The Search for Spock --
  2004

37
Utilitarianism

• Outcomes of a transplant are emphasized.
• Maximizing quality life years gained.
• Goal transplant those most likely to die and
  have long quality life afterwards.
• Example Transplanting a 28 year old with
  Wilsons disease over the 60 year old with
  chronic hepatitis C, despite equal MELD.

38
Five Cases for Discussion

• All cases are true and were seen by the
  University of North Carolina Liver Transplant
  Center in the last 3 years.

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Case 1 WD

• 57 yo woman. Raped and impregnated by that rape
  at age 29.
• Required several units of blood during
  therapeutic abortion.
• Acquired chronic hepatitis C from transfusion.
• Now cirrhotic with signs of liver failure.
• MELD 12-15 () ascites () encephalopathy
• Married x 36 years two children worked up till
  recently husband very supportive.
• Non-smoker. No alcohol whatsoever.

40
Case 2 CN

• 26 yo man took Tylenol overdose after break up of
  a relationship.
• Able to get a reasonable psychiatric evaluation.
  
• Patient expresses tearful regrets over his action
  prior to going into coma
• Up and coming teacher, cited by his school for
  most improvement in his class of low
  socioeconomic and low achieving grammar school
  students.
• Strong testimonials of support from colleagues,
  friends and family.
• No prior psychiatric history or suicide attempts.

41
Case 3 JU

• 18 yo student with ?therapeutic mishap Tylenol
  overdose for an unrelenting headache, but took
  all 37 tablets over an hour or less. Claims no
  suicidal intent.
• Acute liver failure mental status sleepy but
  awakens and conversant.
• () history of attention deficit disorder,
  depression and ?bipolar affective disorder.
• () for cannabis use denied any other drug use
  history.
• Father is security guard and quite supportive.

42
Case 4 CB

• 32 yo prisoner in since age 18 for murder 8 more
  years on sentence.
• Non-HFE related hemochromatosis cirrhosis
• Ascites, encephalopathy, varical bleed, ascites.
• MELD 22 Childs B/C
• () drug abuse just prior to incarceration.
• Father strongly advocating for early release and
  transplant petitioning the governor.

43
Case 5 KN

• 73 yo Viet Namese woman with longstanding HCV
  cirrhosis.
• Stable until took Chinese herbals that give her
  acute liver failure (ALF)oddly she is HCV RNA
  negative with this ALF flare.
• No comorbidities whatsoever excellent functional
  status working full time at TJ Max.
• No alcohol or drugs
• Widowed but lots of family around in support.

44
Patient Summaries
WD CN JU CB KN
57 yo female with HCV after raped and transfused 26 yo male, school teacher, Tylenol OD. 18 yo male, student, ?Tylenol mishap with psych and drug use history 32 yo male, prisoner with genetic liver disorder 73 yo woman with reaction to herbal product functional and working
45
Policies of US transplant programs regarding
liver transplantation in prisoners. (abstract
presented, AASLD, 2009)

• Liver failure on the rise amongst prisoners
• HCV rate 10x the general population
• Survey of all 104 programs
• 67 responded
• Over the prior 5 years
• 46 (69) evaluated at least one prisoner
• 17 (25) listed at lese one prisoner
• 12 (18) transplanted at least one prisoner.

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Final Discussion

• Now that youve hear about and discussed all 5,
• Who would you not even list?
• Explain to those denied why you are not going to
  list them.
• Of those you list, how would you prioritize
  assuming they all had equal MELD scores?
• Explain to each patient why the certain person(s)
  is/are ahead of them in line.

47
Ethical Principles

• Beneficence doing good
• Non-malfeasance avoiding harm
• Autonomy respecting patient decisions
• Justice fairness
• Utilitarianism
• Communitarianism