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Day 2: Medical ethics issue focuses on 'doing no harm' to patients

| Monday, March 10, 2008

With a limited supply of organs, liver transplant surgeons must worker harder to maintain the guiding principle of doing no harm, medical ethicists said.

Give a liver to a patient too soon, and the doctor could cut short the person's life or unnecessarily burden them with having to deal with the complications of organ rejection medicines. Wait too long and the patient could become too sick to truly benefit from transplantation -- or the organ might not be available.

"Risk versus benefit has to be weighed together," said Dr. Eugene Boisaubin, clinical ethicist at the University of Texas Medical School in Houston. "If the total risk of the transplant potentially exceeds the chance of a person's continued health or survival otherwise, that's got to be seriously considered."

Unlike other medical fields where parts like knees or hips come off the shelf, transplantation is complicated by the limited supply of organs. Money makes decisions even more complex because the surgeries mean big business for medical centers.

Transplant programs have financial incentives to perform surgeries on patients who are not as critically ill because they cost less and heal faster. Those patients, however, face a greater risk of dying if they undergo a liver transplant than if they keep waiting.

"You want to never be in a position where, in order to get transplants done or bring business to a program, you're putting patients at more risk than they have to face," said Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia.

Federal allocation rules further complicate the question of giving livers to patients at the bottom of the waiting list. Those people only can get organs that have been rejected for every sicker patient in that region of the country. Surgeons who use the rejected livers wonder why others pass on them; those who do not use them question why anyone would.

"When you have an ethical perspective, you would not allocate an organ that is going to come to you after it has been turned down by virtually the whole region," said Dr. Cosme Manzarbeitia, UNOS regional director for Pennsylvania, Delaware, Maryland, New Jersey, West Virginia and Washington, D.C. "If I give that organ to someone who has less mortality waiting than with the transplant, I think that's unethical."

While few people want to talk about money and transplantation, they go together, Caplan said. That's why there are 127 centers doing adult liver transplants, including three in Pittsburgh -- University of Pittsburgh Medical Center, Allegheny General Hospital and the VA Pittsburgh Healthcare System.

"It's an altruistic system: People are doing it to save lives," Caplan said. "All that said, money plays a role. It's a lucrative area of medicine." Success rates drive doctors in their decisions, too. A place that treats more of the sickest patients will appear to have worse results because those patients do not have the best odds. Yet some patients will not be sophisticated enough to realize that, Boisaubin said.

Luis Fábregas can be reached at lfabregas@tribweb.com or 412-320-7998. Andrew Conte can be reached at andrewconte@tribweb.com or 412-320-7835.

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About the data
• Despite a federal rule designed to limit the number of liver transplants in patients who aren't critically ill, four of the nation's 127 programs ...
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