Transplant ethicist guards organ donors' rights"

Transplant ethicist guards organ donors' rights"

Sam Whiting, Chronicle Staff Writer

Monday, March 23, 2009

As a transplant ethicist, Katrina Bramstedt deals in hearts, kidneys, livers, lungs, pancreases and lengths of intestine. But mostly what she deals in is motivation.

For recipients, it is obvious: They get the organ or they die. For deceased donors, it comes down to the consent of survivors or a sticker on a driver's license. Stickier than that is the third category: living donors willing to endure surgery and risk complications of their own in order to help a sick relative or even a stranger.

"They are alive and well. They're healthy; they don't need a surgery, so that's a little odd," she says. "Why does somebody want to come and give away part of their body?"

Finding out is Bramstedt's job at California Pacific Medical Center. For living donors, CPMC only deals in kidneys, which is also the body part most in demand. (As of late January, there were 78,220 patients nationwide and 8,465 in Northern California awaiting a kidney, according to Bonnie Jacobson-Lee, clinical manager of the program at CPMC.)

Maybe that is why we are born with a spare. If someone gets in touch - (415) 600-1000 or www.cpmc.org - and offers to donate, a nurse does a telephone interview. This process weeds out the grandstanders who will probably lose interest once they see the scalpel. Those who are legitimate are invited in for medical screening to make sure the part is up to par. Then both a psychiatrist and a social worker give the candidate a going-over. If either interview raises a doubt, Bramstedt is the next in line.

"I do a bioethics assessment for candidates who might have some red flags," she explains from her office on the top floor of the historic medical library at CPMC. "Maybe some odd or offhand comment about the relationship with the recipient or complete lack of a relationship."

One red flag is if a donor candidate is being leaned on. Informed consent for voluntary surgery is an ethical and regulatory requirement, and you don't get that with a relative standing by. All of Bramstedt's interviews are done one-on-one in an exam room at the CPMC Department of Transplantation.

What she's probing for is, "do I feel like they are being coerced, like they really don't want to do this but they're going through with it anyway," she says. "Do I detect a lot of hesitation in their voice or their body language?" If she does, she'll notify the living-donor team. Decisions are made by committee, but her "no" vote goes a long way.

Cost of the surgery is not a "red flag" because the recipient's insurance pays, including a week's stay in the hospital. But lost wages and day care aren't covered by insurance, and it takes donors up to two months to return to full strength. (CPMC social workers will assist in applying for a grant with the National Living Donor Assistance Center.)

April is Donate Life Month, and there is hope it will be a busy time for Bramstedt, 43, who practices an obscure subspecialty of medicine. "I'm one of the few in the world who is formally trained as a transplant ethicist," she says. To get that training, she had to go all the way to Monash University in Melbourne, Australia, for three years, bringing back her doctorate in community medicine and general practice, with a bioethics emphasis.

Her first job was at the Cleveland Clinic, which was just starting to work on full-face transplants, she says. That is a recipient-only interview. There are no live donors of faces.

The transplant-recipient interview at CPMC is not as rigorous as that for donors. It is done by committee, and when there is reason to doubt a candidate, Bramstedt is sent up to the hospital for a bedside assessment.

"If you can't follow orders now and take medications, those are huge predictors of noncompliance after transplant," she says.

The list is constantly in flux, but the notion that prominent people can leapfrog upward is "a myth that keeps being propelled by TV, etc.," she says. "What moves you up on the list is how sick you are." This can also be what moves you down on the list. The perfect candidate is somewhere between sick and "too sick to benefit," she says. "You might die on the operating table. That won't be good."

It is also a myth that marauding gangs go around looking for kidneys to steal from drunken stockbrokers. What isn't a myth is what she calls "organ tourism. Residents of the United States check into an overseas hospital and purchase an organ, often from a prisoner. Some of these people, it has been reported, have been executed without a trial."

Coincidentally, this is said to happen just before the organ is supplied to the paying customer.

E-mail Sam Whiting at swhiting@sfchronicle.com.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/03/23/DDU216BV82.DTL