6.15.10 Hayashi Ethical Issues in Liver Transplantation

8/12/2019 6.15.10 Hayashi Ethical Issues in Liver Transplantation

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Ethics in Liver

Transplantation

Residents Lecture

15 June 2010

Paul H. Hayashi, MD, MPH


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Patient Summaries

WD CN JU CB KN

57 yo female

with HCV

after raped andtransfused

26 yo male,

school

teacher,Tylenol OD.

18 yo male,

student,

?Tylenolmishap with

psych and drug

use history

32 yo male,

prisoner with

genetic liverdisorder

73 yo woman

with reaction

to herbalproduct;

functional and

working


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0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

patients

91 94 97 2000 2003

year

Figure 1 U.S. liver transplant list

listed

deaths

OLT

Scarcity of Donated Livers


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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%


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Ethical Principles

Beneficence: doing good

Non-malfeasance: avoiding harm

Autonomy: respecting patient decisions

Justice: fairness

Utilitarianism

Communitarianism


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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?


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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 chronichepatitis C use have equal listing and chance at

transplant.


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Utilitarianism

Websters Definition: a doctrine that theuseful is the good and that thedetermining consideration of rightconduct should be the usefulness of itsconsequences;specifically:a theory thatthe aim of action should be the largestpossible balance of pleasure over pain orthe greatest happiness of the greatestnumber.


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Communitarianism

A counterbalance to western, individual primacybased theory of justice.

Justice and individual rights and freedoms must be

couched in the society in which they are renderedand reside.

our interest in community mayconflict withour vital interest in leading freely chosen lives, and

the communitarian view is that the latter does notautomatically trump the former in cases of conflict. Stanford Encyclopedia of Philosophy

(http://plato.stanford.edu/entries/communitarianism) Accessed10/19/09
http://plato.stanford.edu/entries/communitarianismhttp://plato.stanford.edu/entries/communitarianism


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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 employedshould go ahead of the 60 yearold,former IV drug user, loner, on disabilitywithhepatitis C, even though their MELD scores are equal.


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Patient Summaries

WD CN JU CB KN

57 yo female

with HCV


26 yo male,

school

teacher,Tylenol OD.

18 yo male,

student,

?Tylenolmishap with

psych and drug

use history

32 yo male,

prisoner with


73 yo woman

with reaction

to herbalproduct;

functional and

working


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Case: CB

32 yo man with cirrhosis due to non-HFEiron 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.


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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 liverfailure 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 50:338A 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 8thamendment.

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 inmateviolates the Eighth Amendment ban against cruel and unusual punishmentand 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 makejudgments about past behavior, criminal conduct, moral worth, indictments, charges or

convictions."


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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

Inmate Fears Death Because PrisonWon't Finance Transplant

By GINA KOLATA

Published: February 5, 1994


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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 oftreatment 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 hiddenand 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

Prisoners should not be punished again by

denying health care, but

What level of health care are we talkingabout 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.

Schneiderman LJ et al. Theorectial Medicine 1996


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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


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Moving Forward

The hottest places in Hell are reserved forthose who, in a time of moral crisis, maintainneutrality.

The Devine Comedy (The Inferno). DanteAlighieri

Have we let the courts decide for us?

Physicians cannot avoid taking

responsibility for stewardship over organallocation and must play a primary role West JC, et al. Seminars in Dialysis, 2003


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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 ifappropriate 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


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Communitarianism

A counterbalance to western, individual primacybased theory of justice Justice and individual rights and freedoms must

be couched in the society in which they arerendered and reside.

our interest in community mayconflictwith our vital interest in leading a freely chosenlives, and the communitarian view is that the

latter does not automatically trump the former incases of conflict. Stanford Encyclopedia of Philosphy

(http://plato.stanford.edu/ accessed 10/10/2009).
http://plato.stanford.edu/http://plato.stanford.edu/


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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


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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, 1stInternational Congress on

Ethics in Organ Transplantation

Should communitarian ethics have moresway?


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What would the orignialposition

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 whohave 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)


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Equal or Fair?

We have always had this idea, which is

simplistic, that justice requires treating

everyone, everywhere exactly the sameway. Justice requires no such thing [but]

simply requires us to treat people fairly. Ezekiel Emmanuel, Chief of the Bioethics

Branch, NIH,New Yorker, 2003.


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Hippocratic Oath

I will apply, for the benefit of the sick, allmeasures that are required. However, this phraseshould not be misused as a shield behind which weshirk societal responsibility because

I will remember that I am a member of society,withspecial obligations to allmy fellow human

beings, those sound of mind and body as well as theinfirm.

Quoted phrases from Hippocratic OathModern Version by

Louis Lasagna, Academinc Dean of the School of Medicine,Tufts University, 1964.

Unquoted phrase and italics by Paul H. Hayashi, MD, MPH


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Looking East

Confucianism

Social order and self-discipline are valued

men are responsible for their actions andespecially 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).
http://plato.stanford.edu/http://plato.stanford.edu/


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Chinas Grim HarvestBy 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 prisonersincluding some of the sect's own members

and selling them for transplants.

http://www.time.com/time/magazine/article/0,9171,1186533,00.html#ixzz0hVS2DLLb (accessed 3/7/2010)

Chinas Grim HarvestBy 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 prisonersincluding some of the sect's own members

and selling them for transplants.

http://www.time.com/time/magazine/article/0,9171,1186533,00.html#ixzz0hVS2DLLb (accessed 3/7/2010)

Newsletter

Newsletter

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.

May/June 2007 * Volume 13 * Number 4

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.

From the web...

BBC Page last updated at 13:32 GMT,

Wednesday, 26 August 2009 14:32 UK

http://www.bbc.co.uk/
http://www.time.com/time/magazine/article/0,9171,1186533,00.htmlhttp://www.time.com/time/magazine/article/0,9171,1186533,00.htmlhttp://www.time.com/time/magazine/article/0,9171,1186533,00.htmlhttp://www.time.com/time/magazine/article/0,9171,1186533,00.htmlhttp://www.time.com/time/magazine/article/0,9171,1186533,00.html


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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!
http://oregonstate.edu/dept/EOARC/kids/fire.gifhttp://oregonstate.edu/dept/EOARC/kids/fire.gif


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Patient Summaries

WD CN JU CB KN

57 yo female

with HCV


26 yo male,

school

teacher,Tylenol OD.

18 yo male,

student,

?Tylenolmishap with

psych and drug

use history

32 yo male,

prisoner with


73 yo woman

with reaction

to herbalproduct;

functional and

working


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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 themany

Adm. James T. Kirk in The Search for Spock -- 2004


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Utilitarianism

Outcomes of a transplant are emphasized.

Maximizing quality life years gained.

Goal: transplant those most likely to dieandhave long quality life afterwards.

Example: Transplanting a 28 year old

with Wilsons disease overthe 60 yearold with chronic hepatitis C, despiteequal

MELD.


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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 thatrape 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 tillrecently; husband very supportive.

Non-smoker. No alcohol whatsoever.


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Case 2: CN

26 yo man took Tylenol overdose after break up of arelationship.

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 mostimprovement in his class of low socioeconomic and lowachieving grammar school students.

Strong testimonials of support from colleagues, friends and

family. No prior psychiatric history or suicide attempts.


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Case 3: JU

18 yo student with ?therapeutic mishap: Tylenoloverdose for an unrelenting headache, but tookall 37 tablets over an hour or less. Claims nosuicidal intent.

Acute liver failure; mental status: sleepy butawakens and conversant.

(+) history of attention deficit disorder,depression and ?bipolar affective disorder.

(+) for cannabis use; denied any other drug usehistory.

Father is security guard and quite supportive.


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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 andtransplant; petitioning the governor.


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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 HCVRNA 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.


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Patient Summaries

WD CN JU CB KN

57 yo female

with HCV


26 yo male,

school

teacher,Tylenol OD.

18 yo male,

student,

?Tylenolmishap with

psych and drug

use history

32 yo male,

prisoner with


73 yo woman

with reaction

to herbalproduct;

functional and

working


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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 discussedall 5,

Who would you not even list?

Explain to those denied why you are not goingto list them.

Of those you list, how would youprioritize assuming they all had equal

MELD scores? Explain to each patient why the certainperson(s) is/are ahead of them in line.


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Ethical Principles

Beneficence: doing good

Non-malfeasance: avoiding harm

Autonomy: respecting patient decisions Justice: fairness

Utilitarianism

Communitarianism

Documents

6.15.10 Hayashi Ethical Issues in Liver Transplantation