Second-hand and second-class organs. Should the patient know?

Second-hand and second-class organs. Should the patient know?

In a urology journal this month American surgeons describe transplanting kidneys that would previously have been rejected as unsuitable. In each case the donor kidneys had been found to contain a solitary mass during the transplant work-up that was potentially cancerous. Rather than cancelling the donation the surgeons removed the kidney, cut out the tumour, and then transplanted the tumour-free organ. This follows reports from a couple of weeks ago that surgeons are increasingly using "risky" organs from donors who are elderly or who have other serious illnesses.

The underlying reason for these developments in transplantation is the major shortfall in organs for transplantation. There are 8000 patients on the organ transplant waiting list in the UK but only 3000 transplants per year. Close to 500 patients per year in the UK die on transplant waiting lists. In the US 18 patients every day die while waiting for an organ to become available. So it is unsurprising that transplant surgeons are considering casting the net wider in the search for organs to transplant. Unless the transplanted organs have a very high chance of failing it is better to provide a less-than optimal transplant than to have none at all.

This obviously raises questions discussed previously in this blog about ways to improve the supply of organs.

But setting that aside for the moment. If an organ is used that isn't as pristine as it could be, should the transplant recipient know about this in advance? Should they be given the option of refusing the organ?

The obvious answer to this question is that of course the recipient should be aware of any relevant information that may affect the success of the transplant. As part of a standard consent process for surgery the surgeon should make the patient aware of the risks of the procedure, including, in particular, any information that could potentially affect the patient's decision to proceed. If the transplant organ has a higher than average risk of running into problems, the patient might well choose to defer transplantation until an alternative organ is available.

In the recent American case series all of the transplant recipients had medical reasons for needing a kidney transplant fairly urgently. They didn't have the option of remaining on long-term dialysis if they didn't have a transplant. And in each case they had found a matching family member who was willing to donate their organ. They were aware of the lump in the donor kidney and the potential risk of developing cancer as a result of the transplant. All nevertheless wished to proceed.

In contrast, in a recent UK case described in the media, a heart transplant recipient, John Richardson, died shortly after receiving a heart. Apparently the donor had committed suicide, was a smoker, had several tattoos (raising the possibility of undiagnosed hepatitis), used cocaine, and had recently been resuscitated from a cardiac arrest. Mr Richardson's wife claimed that John had not been given this information prior to surgery, and that he would not have gone ahead with the operation if he had.

What reasons might be given for not providing this information to recipients before the surgery?

One reason relates to the time-pressure associated with some donations. In the kidney donation cases the donors were healthy and living, and there was plenty of time for the recipient to be made aware of, and take account of, the increased risks. But in other cases there can be much less time. For patients receiving heart, lung or liver transplants there is often a relatively short window of time between a donor organ becoming available and surgery needing to take place. There would be little time for patients to take stock of information about the donor and decide whether or not to go ahead. The process of discussing the details of the donor organ with potential recipients and attempting to find someone willing (and matching) to take it might mean that the organ goes to waste. However, if an organ is unable to be transplanted because no recipients will accept it, it doesn't seem that this is necessarily a large problem. It is no different to the problem encountered when an organ is found to be unsuitable to transplant (as many of these organs would have been judged previously to be). It also seems that there would be ways of reducing the time-pressure problem. Potential recipients could consider in advance whether or not they are willing to accept higher-risk organs. Those who are in more urgent need of an organ (and risk dying if one does not become available) would have reason to agree in advance to accept such an organ.

A second reason that might be given for not providing donor-organ information relates to the difficulty in quantifying risk associated with donor organs. Although organs from older donors may have somewhat higher risk of complications than those from younger donors this will not always be the case. (There are some very healthy older individuals, and very unhealthy younger ones). It may be difficult to quantify the risk of transplant failure, and consequently very hard for the potential recipient to decide whether the risk associated with the organ is worth taking. But difficulty in quantifying risk is not usually taken to preclude talking about risks with patients. Even if the transplant surgeon is not able to say how much higher risk a particular donor organ represents, they will presumably be able to give the recipient some idea as to whether it is a higher risk than average, or a much higher risk.

The third reason that might be given is that providing information to the recipient might lead them to make decisions on more dubious criteria. What if the patient, for example, was extremely choosy, and opted only to receive an organ from a young, fit donor with no other health problems, ie an organ with a better-than-average chance of success? Alternatively, what if the recipient wanted to refuse organs from anyone with a criminal record, or for some reason only wished to receive organs from donors of a particular gender or racial or religious background? Should such choices be respected? The first thing to say about such choices is that the main person to suffer from such choices is the patient. The most likely consequence of this sort of fussiness is a prolonged wait for a transplant organ, and the risk of dying or becoming too ill to receive a transplant before one becomes available. In general we think that we should respect autonomous choices that can negatively affect only the individual. We would respect the patient's choice if they decided to refuse any organ even if we knew that a transplant had a reasonably high chance of helping them, and they had a high chance of dying without one. If such choices represented a particularly suspect social norm (for example racism or sexism), there may be reasons not to support such a choice because of a desire not to support or encourage such views. The third point relates to limitations of choice in a public health care system. Patients may not have the freedom to choose higher than average levels of healthcare (they can't choose to go to the best surgeon for example) because of the perceived value of equality of healthcare provision. This might lead to a prohibition of patients picking and choosing the best organs.

However, even if some choices are not made available to patients, it does not follow that no choice should be provided. Given the shortage of organs, the real practical question is not about patients choosing better organs, it is about whether they have the right to refuse organs that are less than the best. There are no good reasons to deny them this.

-- http://www.practicalethicsnews.com/practicalethics/2009/12/secondhand-and-secondclass-organs-should-the-patient-know.html