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Substandard Organs Routine in Transplant Pool

Jun 26, 2008 | Parker Waichman LLP University of Pennsylvania scientists and ethicists are looking to revamp the organ transplant system over concerns it’s too fragmented, allowing some patients to receive substandard organs while others can pick and choose organs based on “certain risk factors at the time of transplant.”  The group feels patients awaiting transplants should decide in advance if they’re willing to accept substandard organs and organs at risk for serious infectious diseases.

The group pointed to a Chicago case last year where a man whose transplanted organs infected four people with HIV and hepatitis C.  While the man did not test positive for HIV at the time of his death, local officials knew of the man’s risky behaviors. The transplant recipients were not informed of the risks at the time of transplant; at least one patient is taking steps to sue the transplant agency and the hospital.  And, earlier this year we reported on the case of a 15-year-old boy who was originally thought to have died from bacterial meningitis.  His parents donated his organs, which were deemed healthy for transplantation.  A month later, the parents were told their son had actually died of a rare lymphoma, a diagnosis in which his organs would not have been transplanted given the disease’s transmission strength.  Two patients who received the organs died last year of the same rare lymphoma and two other’s were undergoing chemotherapy.

Currently, warning patients about potential transplant problems is an "unknown and unregulated" practice that varies widely by region, hospital and even surgeon, the authors said.  "Disclosure is basically driven by a particular organ transplant team in a particular place," said Art Caplan, director of the Center for Bioethics at the university’s school of medicine and co-author of an article in the latest issue of the New England Journal of Medicine.  The United Network for Organ Sharing (UNOS), a national nonprofit organization, has a policy requiring kidney patients to decide in advance if they'll accept organs from "expanded criteria" donors, such as older or diabetic donors.  After the Chicago debacle, UNOS added a requirement that recipients be informed if organs come from certain high-risk donors, including those considered at risk for HIV.

Caplan and colleagues, led by bioethicist Dr. Scott Halpern, are asking UNOS to create a new, standard system where patients would be informed of risks in advance and could decide to accept “suboptimal” organs when placed on the waiting list.  Advance warning would cover organs from donors identified as high-risk by the federal Centers for Disease Control and Prevention (CDC):  “Homosexual men, injection drug users, prostitutes, people who’ve received certain blood products, those exposed to HIV,” and those who’ve served jail time.  The new plan would bar patients from knowing risks posed by particular donors since such details may result in choices based on bias and fear, not medical need.

Rejecting suboptimal organs could reduce the available pool, delaying surgery and possibly resulting in death before a standard organ becomes available.  At least one patient offered a solution, suggesting that transplant recipients be given the chance to reject or accept substandard organs in advance and again when the organ becomes available.

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