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.

Links

Cancerous kidneys used in transplants to
combat donor shortage Daily Mail 7/12/9

Living-donor
renal transplantation of grafts with incidental renal masses after ex-vivo
partial nephrectomy BJUI December 2009 

Transplanting kidneys with cancer Wall St
Journal blog 7/12/09

‘Risky donor’ kidney transplants prove
successful BBC 7/12/09 

Organ transplants’ hidden risk 24/11/09

National organ shortage is leading to the
use of more 'high risk' donors, say health chiefs Daily Mail 25/11/09