Lecture # 13, Organ Donation and Transplantation

 Case #1 

Iatrogenic Liver Failure, Transplantation, and Prisoners 

Jerrold Wallace is a 21-year-old Black man from New York City, currently serving a jail sentence.  Both of his parents were IV-drug users and died of AIDS.  Jerrold was raised by his grandmother.  He dropped out of school after eighth grade.  Picked up by the police many times as a minor, Jerrold accepted plea bargains in order to avoid jail time.  Thus when he was arrested at age 18 for drug dealing with a small amount of crack cocaine, prosecutors successfully argued for the maximum punishment for his crime.  Furthermore, Jerrold had a gun on him when he was arrested-for protection, he said-which doubled his sentence. 

Jerrold's medical problems began in a medium-security prison 150 miles from home.  During a routine screening, his purified protein derivative (PPD) test for tuberculosis was positive, and prophylactic isoniazid (INH) treatment was begun.  In order to lower the administrative cost, the prison system's protocol was for high doses of INH twice per week instead of the usual lower daily dose (300mg.)  Isoniazid is known to be a potential hepatotoxin (though this side effect is very rare among men Jerrold's age), and many protocols include routine blood tests to monitor liver function.  No blood tests were done in the prison, however, and Jerrold's liver failure was not detected until he became very ill.  His liver failure was severe, and he was expected to die unless he had a liver transplant.  Finding a transplant center that will take Jerrold proved difficult.  One center refused to even evaluate him- they categorically refuse all prisoners. 

Another transplant center was located (400 miles from home), and Jerrold was evaluated there.  He was told that he was not a candidate for a liver transplant.  Two reasons were given.  First, his positive TB status is a contraindication for transplant, since after a transplant, he would have to be maintained on immunosuppressants, and this would enable the TB to flourish.  Second, his social circumstances make it unlikely that he will be compliant with the post-transplant regime that includes frequent follow-up visits and long-term, even lifetime, maintenance on expensive immunosuppressants. 

Jerrold at first said that he would not want a liver transplant, but now says that his liver disease is likely to be fatal, so the transplant- even though it is highly risky-is his only chance.  Even if a transplant were offered, Jerrold would like to be transferred to a New York City hospital to be near his family, who would visit and comfort him. 

An ethics consultation has been requested.  Some members of the team have questioned whether the reasons stated for excluding a liver transplant should be re-examined.  They report that there have been some anecdotal reports of successful transplants of PPD-positive patients.  Additionally, there is strong sentiment that every effort should be made to transfer Jerrold to a hospital where his family can visit.  The transfer is a challenging issue, because the prison system does not have a suitably located hospital in its managed-care organization, and because time is a crucial factor since Jerrold's condition could become seriously worse in a short time. 

Howe, Edmund G. (Ed.).  (Winter, 1997).  Ethics Consultation: Iatrogenic Liver Failure, Transplantation, and Prisoners.  The Journal of Clinical Ethics, Volume 8, Number 4, 398-399. 

QUESTIONS 

How would you decide? Should he be accepted as a candidate for transplant?  Consider the following points: 

Do prisoners have the same medical rights of autonomy and decision-making (etc.) as those of us not incarcerated? 

What consideration, if any, should be given regarding the severity of his crime,

The duration of his sentence,

The necessary compliance once he completed his sentence etc.

What is the likely prognosis for this patient? 

Case #2 

We rarely blame patients for their medical conditions, but some behaviors, quite clearly, lead to pathologies that resources be withheld from those persons who seem at least partially responsible for their illnesses? 

Malcom B. is a 53-year-old chronic alcoholic.  Married with two adult children, he has worked as a laborer since age 17.  He avoided the health care system until last year.  He presented in the hospital with spontaneous peritonitis.  He spent 2 weeks in the hospital receiving IV treatment.  At that time a diagnosis of alcoholic cirrhosis, advanced degree, was made. 

Four months ago, Mr. B. had a recurrence of his peritonitis and again received IV treatment.  Her responded more slowly and was discharged on antibiotics.  Last month he was again admitted, in an obvious state of deterioration with small liver, large varices on CT scan, and other symptoms. 

Mr. B. is an apt candidate for liver transplantation.  He does have a chronic illness: a swiftly degenerating liver as a result of cirrhosis.  Aside from his liver disease, his organic status is quite good.  (He does not suffer portal veinthrombossis, sepsis, or other complicating problems.)  He has a family that will support him; they hope that he will give up drinking if given a second chance.  Mr. B agrees and states, "Believe me, I'll never touch the stuff again."  I know it is a matter of life and death."  He has told the hospital social worker to give him information about Alcoholics Anonymous as well as about other treatment programs.  "If I get through this hospital stay." He says, "I'll be a new man."

The physicians believe Mr. B. to be sincere.  He has never tried a rehabilitation program in the past, through the dangers of his heavy drinking were pointed out to him during both prior hospitalizations.  The medical and nursing staff are divided: Some feel that the scarce organ should go to someone more deserving; others believe that Mr. B should not be singled out and punished for his disease (alcholism).  

QUESTIONS: 

What do you say?  

What general criteria should be used in choosing patients as recipients of scarce organ resources?  What weight should psycho-social and policy factors play in patient selection criteria?  What do we mean in asserting that a patient is responsible for the behaviors that cause or exacerbate a medical condition?  What is fair and just about either including or excluding patients with a history of risk-taking behavior? 

Partial reference:  Perling, Terry M.  Clinical Medical Ethics: Cases in Practice.