4.5.1 Question Five—Are There Problems of Allocation of Scarce Health Resources That Might Affect Clinical Decisions?
Scarce resources are distributed by various social mechanisms. The number of physicians, the location of their practices, the ability of persons to pay, and the different perceptions of medical need—these factors and many others result in medical resources being allocated in certain ways. In market allocation, supply and demand are primary factors in distributing resources; some regulations may modify market demand. In recent years, the question has been raised whether medical resources should be allocated by explicit criteria. For example, the state of Oregon established priorities according to which particular treatments for particular disease conditions were prioritized on rough estimates of clinical outcomes. Only treatments that met these criteria would be reimbursed by Medicaid. This matter belongs to the ethics of health policy and is not discussed in this book. However, any such policy will have effects at the clinical level. Whether physicians should make allocation decisions by balancing societal efficiency against the interests of individual patients will then become a topic for consideration. This is sometimes called “bedside rationing.”
CASE. Mr. D.P., a 75-year-old man with a long history of heart disease and diabetes, is admitted to an ICU with fever, hypotension, and shortness of breath. The chest film is consistent with acute respiratory distress syndrome, and the Po2 is 50 mm Hg. During morning rounds, the intern asks whether this aggressive, costly treatment is appropriate for an elderly man who has underlying heart disease and diabetes and whose chances of recovering unimpaired from this episode may be no greater than 35%. At the noon conference, the attending physician initiates a discussion among the house officers whether they should provide indicated treatment or should they begin rationing health care by making tough choices, starting immediately with this elderly man.
COMMENT. The most obvious form of resource allocation for individual physicians—and the least problematic ethically—involves forgoing medical activities that are useless or unnecessary. Costly, scarce resources should not be expended wastefully on patients who will not benefit. Many medical interventions are of this sort (see Section 1.2.2). Of course, determining when a particular form of intervention is likely to be useless, unnecessary, or only marginally beneficial requires acute clinical judgment and may not be possible for even the most experienced physicians. Also, given the wide variety of interventions and of styles of care for any condition, failure of one may not rule out the success of others. The recent trend toward outcome studies and clinical epidemiology can be helpful. As illustrated in the case of Mr. D.P., physicians could not be certain when he was admitted whether they were dealing with someone who was “terminally ill” or with a patient who was critically ill but had prospects of full recovery. He subsequently did recover without any impairment. The question raised by the attending physician about bedside rationing is challenging and provocative. In our view, bedside rationing is not appropriate or ethical. Clinical decisions should be made on the basis of medical indications, patient preferences, and quality of life rather than on societal use of resources unless clear policy guidelines are present, as they are for transplantation.
Jr. The findings of the Dartmouth Atlas Project: a challenge to clinical and ethical excellence in end-of-life care. J Clin Ethics
4.5.2 Admission to Services With Limited Resources
The entire health care system strains under ever-increasing needs and demands for service. Certain resources, such as funds for unreimbursed care, physician availability, hospital beds, availability of specialty centers, and the like, are relatively scarce; that is, the scarcity depends on social or institutional budgets and policy decisions and is capable of being changed. How should health care resources be allocated? This is a policy question beyond the scope of this book. Still, the allocation of scarce resources often directly affects patient care. All commentators on the ethics of this problem agree that resources should be allocated in a fair manner. What constitutes fairness?
It seems fair to establish certain basic objective criteria such as medical condition, potential for benefit, and age, then to select randomly within a pool of those who meet these criteria. Three examples of this problem are medical triage, competing claims for service, and allocation of solid organs.
Triage (which is French for “selection”) is the practice of classifying the sick, injured, or wounded in order to most efficiently employ medical resources in a crisis. Triage on the battlefield is common and generally accepted as ethical. There are rules of triage to establish priorities among wounded soldiers. Triage rules have been applied to other disasters, such as earthquakes and severe storms. The rules of triage and its rationale are stated in a classic handbook of military surgery:
Priority is to be given to (1) the slightly injured who can be quickly returned to service, (2) the more seriously injured who demand immediate resuscitation or surgery, (3) the “hopelessly wounded” may be assigned lower priority for attention. The military surgeon must expend his energies in the treatment of only those whose survival seems likely, in line with the objective of military medicine, which has been defined as “doing the greatest good for the greatest number in the proper time and place.”
Emergency War Surgery, NATO Handbook. Washington, DC: United States Government Printing Office; 1958.
COMMENT. The ethical basis for military triage is to return to service those who are needed to fight or to command. Similarly, disaster triage provides priority to persons such as firefighters, public safety officers, and medical personnel in order for them to be returned to rescue work. Also, in epidemic situations, vaccines should be triaged to the most vulnerable and to the necessary providers of care. Present disaster and serious danger to society justify triage rules. Lacking this element of present disaster, urgent utility, and the destruction of the fabric of social order, rules that subordinate the needs of individuals to the needs of society are not justified in ordinary clinical situations.
A serious ethical question is posed by justifiable triage: is it ever morally right to hasten the death of those persons who have been legitimately triaged out of rescue or treatment?
EXAMPLE. After Hurricane Katrina, Memorial Hospital of New Orleans was inundated by water and essentially cut off from communication. Many patients were stranded. After five days of extreme distress (and heroic dedication of providers), certain very ill patients died in unclear circumstances. Several physicians, suspected of hastening the death of several terminally ill patients, were indicted for manslaughter (and eventually exonerated).
COMMENT. This is a case in which the usual logic of ethical discourse is disrupted by two conflicting moral duties: refrain from direct killing and relieve suffering. Both duties cannot be honored because of extreme and uncontrollable circumstances. This is sometimes called a moral dilemma. Some ethicists insist that direct taking of human life is always morally wrong. However, many ethicists will admit that in such dilemmas, either course may be taken if done conscientiously and after exhausting all possible alternatives.
JT. Imagining the unthinkable, illuminating the present. J Clin Ethics
M. Bedside resource stewardship in disasters: a provider’s dilemma practicing in an ethical gap. J Clin Ethics
S. Five Days at Memorial: Life and Death in a Storm Ravaged Hospital. New York, NY: Crown Publishers; 2013.
S. Emergency and disaster scenarios. In: Singer
AM, eds. The Cambridge Textbook of Bioethics. 1st ed. New York, NY: Cambridge University Press; 2008: chap 37.
4.5.4 Competing Claims to Care
There may be clinical situations in which personnel, time, equipment, beds, and other factors may be inadequate to accommodate a certain number of patients. Busy hospital emergency departments have a triage nurse who prioritizes patients in view of seriousness of need. However, despite the use of the term triage, the fundamental ethical justification for warfare and disaster triage, namely, contribution to social good, is not present. Rather this is a competition between rival claimants to medical attention.
CASE I. Mrs. C.Z. is a 71-year-old woman who has a diagnosed lung tumor for which she refused surgery. She developed obstructive pneumonia and was admitted to the ICU of the community hospital in her rural county. She has shown no signs of improvement for 7 days. She is now obtunded. The victim of an automobile accident is brought to the hospital with a crushed chest, apparent pneumothorax, and broken bones in the extremities. This trauma patient requires a respirator immediately. Of the six patients on the six respirators in the ICU, Mrs. C.Z. has the poorest prognosis. She seems unable to be weaned and would probably die if ventilatory support were discontinued. Is it ethically justified to recommend to her surrogate that Mrs. C.Z. be removed from the respirator in favor of the accident victim?
COMMENT. The medical prognosis of Mrs. C.Z. is poor. She has cancer of the lung with bronchial obstruction for which she has refused surgery and pneumonia that has failed to respond to treatment. She is comatose and likely to die within days. She is now incapable of expressing preferences. Nothing is known about her preferences, except her refusal of surgery. Given these considerations, the immediate and serious need of an identifiable other person becomes a challenging ethical consideration. When that person also is in imminent danger of death, the contextual factor of scarcity of resources becomes significant in the decision regarding Mrs. C.Z. In practice, these situations usually are managed on the scene, by such practices as calling in additional ICU nurses or by making exceptions to the rule about use of ventilators outside the ICU. Such practical stratagems often resolve ethical problems. Should no such solution be possible, we believe that it is ethical permissible to discontinue Mrs. C.Z.’s respiratory support.
CASE II. Patient R.A., a known, active drug abuser, needs a second prosthetic heart valve. Several physicians are strongly opposed to providing a second prosthesis. These physicians offer three reasons: (1) Surgery is futile, because the patient will become reinfected; (2) the patient does not care enough about himself to follow a regimen or to abstain from drugs; and (3) it is a poor use of societal resources.
COMMENT. The first consideration, futility, and the second, failure to cooperate, are discussed in Sections 1.2.2 and 2.5. The third consideration, use of resources, raises the following new ethical issues:
What are the criteria that distinguish good from poor uses of societal resources? Although such criteria might be formulated at the theoretical or the policy level, it is impossible to do so at the clinical level because clinicians do not have an overall view of social need or an understanding of how any particular clinical decision might contribute to that need. Also, attempts to formulate such criteria risk introducing serious bias and discrimination into clinical decisions. As we said above, “bedside rationing” is ethically perilous.
There is no guarantee that whatever is “saved” by refusing this patient will be used in any better manner. The societal resources are, of course, not being “absorbed” only by the patient. Instead, they are flowing to the hospital, to the physicians and surgeons, to nurses, and so on.
RECOMMENDATION. The most acceptable ethical justification for refusing to provide a second prosthesis is the medical indication that the risk of surgery with its attendant mortality rate exceeds the risk of managing the patient with medical therapy. Therefore, if medically indicated, the surgery should be offered. Medical indications should not be manipulated as a subterfuge to deny a medically appropriate procedure. A commitment by the patient to enter drug rehabilitation can be a condition of the surgery. The ethical obligation to provide surgical assistance is, however, diminished to the extent that the rights of other patients are directly compromised, as explained in the comment to Case I.
4.5.5 Institutional Staffing Policy
The size and complexity of health care institutions require staffing arrangements that maximize efficiency and economy. At the same time, these arrangements may have unintended negative impacts on patient care. One well-known impact derives from the shortage of nurses: patients may be forced to wait long and sometimes painful periods for attendance. Also, new models for physician efficiency and quality patient care are being constantly implemented. In one of these new models, hospitals contract with physicians called hospitalists, who specialize in caring for hospitalized patients. It is becoming rare for primary care physicians to follow their patients who have been hospitalized. Hospitalists can bring up-to-date methods of care and can be readily available when needed in the hospital. Their work may improve institutional efficiency and efficacy but, at the same time, have unintended side effects.
Hospitalists revolve frequently, leaving patients unsure who their doctor is; gaps in care occur when one shift hands over patients to another. This discontinuity often results in confusing plans of care. Even though one hospitalist may provide full clinical information to her successor, the rationale for decisions, particularly those with ethical import, such as decisions not to resuscitate may be lost in the transition. The resolution of such problems depends on the formulation of hospital policy and organizational changes that emphasize effective communication. In the absence of effective formulation and organization, hospitalists, nurses, and others involved in care of patients must be particularly sensitive to their patient’s history and to full and transparent flow of information. “Handoffs” of patients between rotating physicians must be particularly careful.
HJ. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care
. February 2008;17(1):11–14.CrossRef
4.5.6 Allocation of Solid Organs for Transplantation
Some sorts of scarcity are “relative,” that is, the resource is scarce because some policy decisions or social structures have made them so; these decisions and structures can be changed to improve availability. Other sorts of scarcity are “absolute,” when there is not enough of the resource to go around, regardless of policy. In organ transplantation many patients are candidates for absolutely scarce resources, namely viable organs. Organ transplantation is a great achievement of modern medicine. For the first time in history, individuals with failure of vital organs such as heart, kidney, and liver can often be saved from certain death by the timely transplantation of a donated organ. In this situation, the organ itself takes on a moral value: its use for one patient makes it unavailable for another. Its use in a less appropriate recipient, and subsequent loss by rejection or the patient’s death, deprives a more appropriate recipient of a chance of survival. This represents an unusual “scarce resource”: the valuable organ must be given its highest and best use. How does this feature of organ transplant fit into a fair distribution of resources?
The basic ethical principle of organ transplant requires that the organ be a true “donation,” that is, a gift voluntarily given by the donor to the recipient. A living donor may make this gift, as is often done between relatives in kidney and liver transplantation, or a person may designate that their organs be used after their death, a practice approved by American law. The Uniform Anatomical Gift Act, adopted by all states, provides a system for identification of donors (usually noted on driver’s licenses). Ordinarily, organs cannot be retrieved from the dead without prior authorization of the deceased or, after death, by next of kin. Most transplanted organs are obtained from persons declared dead by brain criteria, although there is a movement to promote donation after circulatory death. Further, in recent years, because the number of deceased donors has remained relatively constant and inadequate, an increasing number of organs are obtained from related or unrelated living donors or from an expanded deceased donor pool that includes older donors than those previously accepted. Many state laws require physicians to report impending deaths to the local organ procurement agency which then sends a trained person to request organ donation from the family.
Despite these efforts to increase organ donation, the demand for solid organs far exceeds supply. In the United States in 2013, 28,954 transplants of all organs were performed. At the end of 2013, over 123,000 persons were on the waiting lists for all organs. Of these, 6259 people died in 2013 while on the waiting list. Ethical criteria for obtaining and distributing organs must be understood, and a fair and equitable system based on these criteria must be maintained. The key elements of such a system are: (1) it avoids social worth criteria; (2) it recognizes the patient’s potential for benefit; (3) it has a place for urgency of need; (4) it avoids discrimination based on sex, race, or social status; and (5) it employs a transparent process perceived by the public as fair.
In the United States, a government-supported private organization, the United Network for Organ Sharing (UNOS), manages the national list, and local organ procurement organizations (OPOs) supervise the distribution of organs. The UNOS policy allocates organs on the basis of medical status, blood type, urgency, time on the waiting list, and geographic distance between donor and recipient. A computerized system manages these data. UNOS policies about organ retrieval and distribution can be obtained on line (http://www.unos.org).
One important feature of fairness is objectivity, based on clinical indicators. In the early days of liver transplantation, allocation relied heavily on the physician’s subjective evaluation (degree of ascites, grade of encephalopathy, and need for ICU admission). This subjective system was susceptible to being “gamed,” thus unfairly advancing certain patients to the top of the waiting list. The allocation system has evolved into one in which disease severity is based on objective laboratory criteria (total bilirubin, serum creatinine, and clotting studies). Under the objective criteria, called the MELD (model end-stage liver disease) score and blood group, a score ranging from 6 to 40 is assigned to each adult patient based on their expected survival over a 3-month period without transplant. A special weighting of the score applies to patients with hepatopulmonary syndrome, familial amyloidosis, and hepatocellular cancer. These patients are given additional MELD points because of the rapidly progressive nature of these conditions.
In 2014, UNOS introduced a new deceased donor kidney allocation system based primarily on the utility concept of net life-years gained from receiving a transplant compared to remaining on dialysis. The stated goal of UNOS is to develop a new allocation algorithm designed to “achieve the greatest total number of life-years from transplant among all the recipients, given the available organ pool. Allocation of each kidney to the candidate with the greatest LYFT (life-years from transplantation) for the organ is a way to maximize the total number of life-years gained.”
Jr. Potential inefficiency of a proposed efficiency model for kidney allocation. Am J Kidney Dis
Transplantation medicine has a complex body of ethical and legal formula for procurement and allocation of organs. There are clinical ethicists who have specialized in mastering this material and who may frequently interact with transplant services. Other clinical ethicists may be less familiar with transplantation ethics. If they are asked to consult, they should acquaint themselves with the discussion above and with the literature cited below. The various agencies that manage transplantation often have personnel competent in the ethical and legal questions.
B. Ethical issues in organ transplantation. Resolving Ethical Dilemmas: A Guide for Clinicians. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013: chap 41.
R. Organ transplantation. In: Steinbock
B, ed. The Oxford Handbook of Bioethics. New York, NY: Oxford University Press; 2007: chap 9.
AS. Organ transplantation. In: Singer
AM, eds. The Cambridge Textbook of Bioethics. 1st ed. New York, NY: Cambridge University Press; 2008: chap 20.
CASE I. Mr. J.J. is a 50-year-old man with end-stage liver disease caused by primary biliary cirrhosis. He has experienced several complications in recent years, including portal hypertension, bleeding gastric varices, ascites, and one episode of encephalopathy. He has a MELD score of 26. Because the geographic region in which he lives has a long waiting list and because he has blood type O, he is unlikely to receive a liver until his MELD score increases to 35. Consequently, at the suggestion of his physician, Mr. J.J. has listed himself at multiple programs in several regions to improve his chance of getting an organ at an earlier stage of his disease.
COMMENT. Taking advantage of multiple listing is not prohibited. UNOS regulations require that patients be informed of the option to multiple list. The question still remains whether multiple listing is fair. Wealthier, better-informed, and more mobile patients have distinct advantages in systems that allow multiple listing. This widely used, tolerated, and even recommended way of “gaming the system” introduces inequities against many patients on the waiting list into a system meant to overcome inequities. In our view, multiple listing does not resolve conflicts of interest within the organ allocation system, but rather exacerbates them.
CASE II. After 2 years, Mr. J.J., the patient in Case I, continues to wait for a liver (despite multiple listing). He visits his surgeon’s office with a person whom he introduces as “my best friend” and says he has read about some transplant programs that use living donors for segmental liver transplants. Mr. J.J.’s friend says that he would like to volunteer as a living donor. The surgeon has several concerns: (1) Should a healthy person be subjected to the substantial risks of morbidity and mortality associated with donor transplant surgery? (2) Because the surgeon has not performed a living donor procedure, should Mr. J.J. be referred to one of the US programs that has experience in performing such procedures? (3) Can the surgeon verify that this person is really a “best friend” rather than a hired “volunteer” who has agreed to donate for a fee? (4) Should the surgeon do the detective work to determine the truth of the matter?
COMMENT. Although living persons have been kidney donors since the earliest days of transplantation, questions remain about the ethics of doing surgery on a healthy person to benefit another. This practice has been deemed ethical if the donor is an informed, free, and uncoerced volunteer, aware of the risks involved in this operation. Segmental adult liver transplant involves a much higher donor risk than kidney transplantation. Also, obtaining organs by purchase is illegal in the United States and most other countries. It must be very clear that Mr. J.J.’s friend is an informed, free, and uncoerced donor. The surgeon should converse privately with the volunteer, informing him of the risks of the surgery. Federal law requires transplant programs to have a “donor advocate.” These advocates explore more deeply the possibility of coercion and medical suitability of donors. Any suspicion of coercion or of financial incentive disqualifies the volunteer. Also, the surgeon should refer the case to a program with ample experience in living donor operations.
4.5.7 Living Unrelated Donors
Case II raises the question about using living, unrelated donors for transplantation. In that case, the problems of possible coercion and illegal donor payment present the primary ethical issues. Because of the shortage of donors, some transplant programs now accept donors neither genetically nor emotionally related to the recipient. This is known as living, unrelated donation, nondirected donation, anonymous donation, stranger, Good Samaritan, or altruistic donation. Because the ethical basis of transplantation is altruistic donation, there would seem to be no problem with such donors, given their medical suitability. Some transplant services, however, worry that an altruistic act that carries the significant risks entailed by surgery might hide a psychiatric condition, and thus not be truly free and uncoerced. (In one major US transplant service, 31% of potential unrelated donors were rejected due to psychological unsuitability.) Careful psychosocial evaluation is ethically imperative.
Another concern is the danger that eagerness to attract nonrelated donors might lead to paying individuals for donating an organ. Transplant organizations have created safeguards in their procurement protocols to avoid this danger. Still the buying, selling, and commercial exchange of organs appears to be growing throughout the world. National legislation should aim to curtail these practices, and international transplant organizations should formulate policies to discourage them. Because this commerce deals in a life and death situation, the most powerful incentives encourage it. Nevertheless, the ethical importance of justice, fairness, and prevention of exploitation must be emphasized.
et al.. The nondirected live-kidney donor: ethical considerations and practice guidelines: a National Conference Report. Transplantation
RM. Saving lives is more important than abstract moral concerns: financial incentives should be used to increase organ donations. Ann Thorac Surg
et al.. Nondirected donation of kidneys from living donors. N Engl J Med
F. Debate on financial incentives is off the mark of national and international realities. Transplantation
4.5.8 Donation After Cardiac Death
The usual procedure for obtaining life-sustaining organs requires that death be declared by brain criteria (see Section 1.5) prior to removal of the organs. In recent years, a new procedure originally called non-heart-beating donation and now called donation after cardiac death or donation after circulatory death (DCDD) has been introduced. Although at first controversial, it is now generally considered ethical.
CASE. A 43-year-old woman is brought to the emergency department somnolent and disoriented, jaundiced, with asterixis, bruises, and swollen abdomen. She has had 4 days of nausea and diarrhea. Diagnosis is fulminant liver failure due to ingestion of poisonous mushrooms. In the hospital is a 24-year-old man who has been in a vegetative state for 4 months after vehicular trauma. He is ventilator dependent. He has failed three attempts to wean him from the ventilator; he shows no spontaneous respiratory effort. His parents have informed the ICU attending that they are ready to have respiratory support withdrawn. They also have expressed a desire that his organs be donated after death. A physician from the Liver Transplant Service suggests that the patient be taken to surgery where ventilatory support will be terminated and his liver removed for transplant. The ICU attending asks whether this is compatible with the usual rule that organs be removed only after declaration of death by brain criteria.
COMMENT. The practice of donation after determination of cardiac death does expand the dead donor rule. The patient is taken to surgery, life support is removed, pain medication is administered and, when the heart stops, death is declared and organ retrieval surgery begins. Ethical criteria for this practice require that the patient be beyond hope of recovery, that permission from designated surrogates be obtained, and that no medications that hasten death be administered. Institutions that utilize this form of organ retrieval should have clear policy, assuring that the practice does not compromise the appropriate care of the donor, that appropriate permissions are obtained, and that all is done in a transparent manner.
AS. Non-heart beating donation: ten evidence-based ethical recommendations. Transplant Proc
Institute of Medicine Committee on Non-beating-heart Transplantation. Non-Heart Beating Organ Transplantation: Practice and Protocols
. Washington, DC: National Academy Press; 2000.
There is brisk international commerce in organs. Available organs and rapid transplantation, often with such amenities as recovery in vacation settings, are advertised on Web sites and through other networks of communication. Clandestine brokers buy organs cheap in poor nations and sell them at exorbitant prices to patients who travel from developed countries to obtain a transplant more quickly than is possible in their home country. The practice of traveling overseas for the express purpose of obtaining an organ transplant is commonly known as transplant tourism. While many overseas transplant centers have technical competence, many others are suspect. It is widely known that some organs transplanted at overseas hospitals originate from people who were not able to give informed consent to donation. Some examples are coerced living donation from spouses (India), living donation from those who are uneducated and unable to understand the risks and consequences (India, Pakistan, Philippines), and living donation from the poor who see such as a way of generating income to meet their daily needs (India). Forced donation from executed prisoners, once common in China, is said to be in the decline.
In the United States, all transplant centers have a living donor advocate or living donor advocate team to ensure the donor’s safety, welfare, and informed consent. It is not clear that countries outside the United States have such safeguards for their live donors. In India, for example, many donors suffer significant medical complications after giving an organ and often regret having done so. Further, the income they generate by selling their organ rarely lifts them from their state of poverty.
Also overseas transplant programs may have looser criteria for accepting patients onto their transplant waiting lists. In the United States, a patient is declined for placement on the organ waiting list when it has been determined that the patient will not benefit from transplant. Patients looking overseas for transplant opportunities should be very cautious about centers promising good outcomes for patients who, actually, may not have good prospects of benefiting from transplant. These unrealistic expectations can also be financially costly to patients and their families.
US transplant teams sometimes encounter patients who have participated in transplant tourism and then seek post-transplant care in the United States. This can cause ethical discomfort for these doctors and nurses. Sometimes patients return to the United States with inappropriate immunosuppressant drugs from the foreign hospital. Sometimes these patients return with complications, such as serious infections (including HIV and hepatitis) and they lack copies of their medical records (or they are written in a foreign language). Typically, documentation of the source of organs is absent.
In the United States, all major transplantation organizations and transplant centers discourage transplant tourism and the associated selling of organs. Often, however, patients desperate for organs will travel for transplant and return home in need of continued or acute care. This poses an ethical problem for domestic transplant centers. They may become complicit in illicit trade, and, most seriously, a patient who needs a retransplant after a failed foreign transplant may use an organ that might otherwise have gone to a patient on the domestic waiting list.
CASE. After 7 years on dialysis, Mr. C. notes a Web site that provides access to kidney transplants in Pakistan. The fee required is within Mr. C.’s means. He travels to Pakistan, is lodged in a pleasant hotel, is transplanted with a kidney from a donor unknown to him, and returns home after three weeks. He is now experiencing painful urination and lower back pain. He phones Dr. M., his nephrologist, to schedule a clinic visit. The nephrologist was surprised to learn that Mr. C. had received a kidney transplant overseas and distressed to learn the patient had purchased the organ. The nephrologist’s transplant center strongly discourages transplant tourism. Should he accept this patient?
COMMENT. Most advisory policies from transplant organizations discourage accepting such patients, except in emergency situations. However, it seems unfair to reject them if they have previously been a patient. It is advisable to warn current patients against going abroad and inform them that they will not be accepted back if they return with medical problems. It is also advisable to have a list of countries whose laws and regulations about transplant are weak and do not protect their own people against exploitation. Finally, US transplant programs may choose to develop referral relationships with foreign programs where medical competence is high and in countries with organ retrieval policies similar to, if not identical with, American law.
RECOMMENDATION. In the absence of an informed warning about local policy, Dr. M. should accept this patient. He should, however, insist that the local transplant center with which he works develop a policy for future cases with the characteristics mentioned in the comment.
FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant
ME. Transplant tourism: outcomes of United States residents who undergo kidney transplantation overseas. Transplantation