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Pushing the envelope in transplantation: Three lives at stake

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Anyone involved in transplantation has witnessed the Lazarean awakening of many of our patients. On the verge of dying, these patients receive a transplant then go home to their loved ones, to their communities, and to the rest of their life.

Transplantation has always straddled the border between life and death; it has always pushed the biological envelope.

But it has also always pushed the ethical envelope.

How? In forcing all of us, not just transplant surgeons, to reconsider some of our most fundamental ethical dilemmas:

  • What is death?
  • Can we extend life?
  • Whose life do we extend?
  • At what price the extension of life?
  • Just because we can extend life, should we?

And every one of these dilemmas is further complicated by another issue unique to transplantation. At stake in every transplant is not just the patient’s life, but three lives—the patient, the donor, and the person on the waiting list who likely died because the organ went to your patient, not her or him.

While we are not focusing today on organ donation or allocation, let us not forget that transplantation is unique in this regard. There are always three patients to consider.

What we will focus on today are transplant and post-transplant innovations. To help introduce the discussion, I would like to share a narrative that I believe illuminates ethical dilemmas that go hand-in-hand with transplantation’s innovations.

THE STORY OF MAX

Max was the tiny embodiment of a biological keystone cop. In utero he had developed a gaping defect of his abdominal wall. His intestines twisted around themselves, and the obstetricians had to deliver Max emergently. The pediatric surgeons immediately removed the gangrenous remnants of nearly his entire bowel.

At 10 months, Max received a liver and small bowel transplant. The transplanted organs worked initially; with a small feeding tube inserted directly into his gut, Max digested for the first time in his life tablespoons of food, albeit a chalky liquid supplement.

But Max, within 2 months of his transplant, had again become a permanent resident in the pediatric intensive care unit. Achieving the right balance of immunosuppression so Max could keep the transplanted organs and yet maintain sufficient immunity to fight off infection had become an impossible task.

I was in my fellowship at the time of Max’s transplant; and Eric, an attending surgeon with a square jaw and dark Dick Tracy looks, led the surgical team’s management of Max’s case.

As Max became sicker, Eric spent more hours with his tiny patient. I found him by Max’s bedside at 3:00 in the morning and then at 7:00 the next night, his hair, clothes, and personal aura in a state that reflected obliviousness to his own care. Just by being with Max so much, Eric knew all the particularities of that baby, all his idiosyncratic reactions, every significant lab result of Max’s entire life.

At first I found Eric’s dedication inspiring, almost thrilling in a martyred saint kind of way. And Max seemed to call out to any of us who hoped to be divinely touched. During rounds, Max giggled at me, as if he understood that playing with him was infinitely more interesting than arguing over doses of medication with other doctors. Spurred on by Max’s cause, I raced to uncover test results before Eric, as if my quicker response would translate into an equal or greater enthusiasm for Max’s plight. I nagged the radiology technicians to give me Max’s x-rays hot off the presses. I set the alarms on my beeper to see Max in the middle of the night and on mornings long before any member of the surgical team, particularly Eric, arrived.

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