ADVERTISEMENT

Transplant innovation and ethical challenges: What have we learned?

A collection of perspectives and panel discussion
November 2, 2008|Cleveland Clinic Journal of Medicine
Denton A. Cooley, MD;John J. Fung, MD, PhD;James B. Young, MD;Thomas E. Starzl, MD, PhD;Mark Siegler, MD;Pauline W. Chen, MD
Author and Disclosure Information

Denton A. Cooley, MD
Founder, President, and Surgeon-in-Chief, Texas Heart Institute, St. Luke’s Episcopal Hospital, Houston, TX

John J. Fung, MD, PhD
Chairman, Departments of General Surgery and Hepato-pancreatic-biliary Surgery; and Director, Transplantation Center, Cleveland Clinic

James B. Young, MD
Chairman, Endocrinology and Metabolism Institute; Director, Kaufman Center for Heart Failure; and Chairman, Academic Department of Medicine, Cleveland Clinic

Thomas E. Starzl, MD, PhD
Distinguished Service Professor of Surgery, University of Pittsburgh School of Medicine, and Director Emeritus, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA

Mark Siegler, MD
Lindy Bergman Distinguished Service Professor of Medicine and Surgery; Director, MacLean Center for Clinical Medical Ethics, University of Chicago, IL

Pauline W. Chen, MD
Bestselling author of Final Exam: A Surgeon’s Refections on Mortality (Vintage 2008) and a transplant surgeon most recently on faculty in the Division of Liver and Pancreas Transplantation, University of California, Los Angeles.

All authors reported that they have no financial interests or relationships that pose a potential conflict of interest with this article.

This article was developed from an audio transcript of the panelists’ presentations and a panel discussion. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed and revised/approved by each of the panelists and the moderator.

We have come far, but selecting organ recipients remains an ethical minefield

By Denton A. Cooley, MD

Only 40 years ago, on December 3, 1967, the world was electrified by news of the first cardiac transplantation, performed in Cape Town, South Africa, by the renowned Dr. Christiaan Barnard.

We have progressed considerably since that time, but not all issues have been settled. After several attempts by Dr. Norman Shumway and by Dr. Adrian Kantrowitz in this country, we in Houston performed the first successful cardiac transplantation in the United States in April 1968. Initially we were impressed with the results, and we embarked upon a very active cardiac transplant program, performing as many as had been done in total around the world. But after we had done some 15 or 20 cardiac transplants, the discouraging news began to emerge that the patients were not surviving long: our longest survived for only 2 years.

As a result, our group in Houston, like others, declared a moratorium on cardiac transplantation. The only group that continued throughout this era was at Stanford University under Shumway, who had some success with immunosuppressive drugs. In the early 1980s, a new immunosuppressant, cyclosporine, appeared that was used for kidney transplantation, which reinvigorated us and others to use this drug for cardiac transplantation. Since then, under the direction of my colleague, Dr. Bud Frazier, we have performed more than 1,000 cardiac transplantations at the Texas Heart Institute.

From the beginning, we were called upon to identify appropriate donors and suitable recipients. Although we rely on certain objective factors, such as age, weight, body size, gender, and blood type, many other issues must also be considered. Fortunately, the modern concept of brain death has now been accepted not only by the public and ethicists, but also by the legal community; in contrast, at one time it was considered homicidal to remove a beating heart. I credit Christiaan Barnard with having the courage to remove a beating heart from a 26-year-old donor who had suffered irreversible brain damage. Many of us had wanted to get into the transplant program but we could not identify a donor.

The following case illustrates some of the other ethical complexities that we continue to struggle with today.

CASE STUDY: A 17-YEAR-OLD WITH HEART FAILURE AND A DESTRUCTIVE LIFESTYLE

Several years ago, a 17-year-old Latin American boy came to our clinic in heart failure. He was very disarming, but when we looked into his background we found that he had dropped out of high school after 1 year and was living with a girlfriend who was 2 months pregnant by him and already had a 2-year-old child. The patient’s cardiomyopathy was related to cocaine and alcohol abuse. Nevertheless, his stepfather was eligible for Texas Medicaid, and he was accepted for cardiac transplantation.

After the transplantation, he abided by the immunosuppressive drug regimen while he was under our care. Then he moved to Fort Wayne, Indiana, where Indiana Medicaid would not honor his Texas Medicaid coverage. So our hospital had to send him his immunosuppressive drugs, which he used rather sporadically.

While in Indiana, he was incarcerated for assault and battery on his girlfriend. He began to have heart failure but did not qualify to have the biopsies required for proper study of rejection of his heart. He returned to our clinic and was scheduled for catheterization the next day when he went into acute cardiac failure. He had emergency late-night implantation of a percutaneous ventricular assist device, which required catheterizing the left atrium by perforating the interatrial septum, taking the oxygenated blood out of the left atrium, and pumping it back into the aorta with a centrifugal pump. His heart began to recover, and the device was removed after 72 hours.

At this point he needed another transplantation. Our medical review board considered his eligibility and turned him down, citing that others on our waiting list were more deserving of a transplant and that retransplantation has a poorer success rate than initial transplantation.

EACH CASE POSES PROBLEMS, BUT A RECORD OF SUCCESS EMERGES

Although this patient could be viewed as a sort of sociopath, he nevertheless is a young man who is incapacitated and in need of heroic measures. His case illustrates the kind of nonmedical problems that face those of us who are actively involved in cardiac transplantation. It can be very difficult to find solutions to the myriad social, economic, legal, and ethical issues.

We perform about 50 transplants a year in our institution, and every one of them has some issue. Nevertheless, we just honored 25 patients who have survived more than 20 years with cardiac transplantation.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT