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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
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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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).
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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).
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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
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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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
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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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