Ethical issues in liver transplantation
- Lisa Anderson-Shaw, DrPH, MA, MSN, ANP-BC
Lisa Anderson-Shaw, DrPH, MA, MSN, ANP-BC
- Assistant Clinical Professor
- University of Illinois at Chicago
- Scott J Cotler, MD
Scott J Cotler, MD
- Professor of Medicine
- Director, Division of Hepatology
- Loyola University Medical Center
- Section Editor
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
Liver transplantation has evolved rapidly from an experimental procedure to standard therapy for patients with end-stage liver disease. One- and five-year patient survival for deceased donor liver transplants has reached 86 and 72 percent, respectively, and for living donor liver transplants, 90 and 78 percent, respectively, due to advances in surgical techniques, immunosuppression, and organ preservation . While the number of liver transplants performed in the United States has reached approximately 6000 per year, the demand for donor organs far exceeds the supply. As a result, there are more than 1800 deaths per year on the liver transplant waiting list . The relative shortage of donor organs provides the basis for many of the ethical issues associated with liver transplantation.
The current system of organ donation in the United States is based on the Uniform Anatomical Gift Act of 1968 and is referred to as "opting in" or "expressed volunteerism" . This statute authorizes competent adults to specify their preferences regarding organ donation. Procurement agencies generally exceed the provisions of the statute and ask for consent from the next of kin/legal decision-maker even when there is a signed donor card or online organ donation registration, to be sure that the family/legal decision-maker is in support of donation. More frequently, there is no signed donor card or other evidence of an advanced directive about organ donation. In this circumstance, the family is asked to make a judgment about the wishes of the deceased. Donation is carried out in the absence of a donor card if the next of kin/legal decision-maker is in agreement. However, asking a grieving family member to make a difficult decision in a time of crisis poses a significant barrier to donation. Further efforts are underway to enhance the process of obtaining advanced directives about organ donation.
A number of states adopted a revised Uniform Anatomical Gift Act (1987) stipulating that the next of kin/legal decision-maker need not consent to organ donation if the deceased made his or her wishes known in writing to a clinician prior to death. Many states have enacted a "first person consent" law making a person's wish to be an organ/tissue donor legally binding. The position of the Council on Ethical and Judicial Affairs of the American Medical Association is consistent with this legislation. The Council stated: "It is ethically preferable for the individual, rather than the family, to decide to donate organs" . A further iteration of the Uniform Anatomical Gift Act proposed in 2006 contained a provision prioritizing organ donation over other end-of-life care in an effort to increase organ availability. The Act raised ethical concerns that organ donation should not trump other end-of-life management decisions such as refusal of cardiopulmonary resuscitation and intubation . A revised version was proposed subsequently that provides for resolution of any conflict between end-of-life care and organ donation.
Efforts to increase donor organ availability — The organ donation process is relatively inefficient for a number of reasons. Organs are lost when clinicians fail to recognize criteria for brain death. Educational programs for health care providers could be helpful in clarifying the laws regarding the declaration of brain death. Requests for donation often have been handled by inexperienced personnel, a factor associated with a reduced consent rate. Regulations from the Centers for Medicare and Medicaid Services (CMS) require hospitals to report pending deaths and deaths to their local organ procurement organization. Now, only persons approved by the organ procurement organization are authorized to request organ donation from the next of kin/legal decision-maker. Finally, families decline to consent to donation for reasons including lack of awareness about donation and difficulty in making a rapid decision at a time of emotional turmoil.
Other systems for organ donation have been proposed:
Mandated choice — "Mandated choice" is an alternative system that would require competent adults to record their preference for organ donation. According to this approach, all persons would be asked to complete a standard document, perhaps at the time of applying for a driver's license or filing a tax return. Decisions would not be subject to reversal by family members. Advantages of mandated choice include removing the burden on family members to make decisions about organ donation, while respecting individual autonomy, and ameliorating fears that organs might be harvested from non-consenting individuals.
- UNOS 2008 Annual Report www.unos.org (Accessed on April 22, 2009).
- OPTN/SRTR 2008 Annual Report http://optn.transplant.hrsa.gov/ar2008/ (Accessed on April 22, 2009).
- Gundle, K. Presumed consent for organ donation perspectives of health policy specialists 2004 surj.stanford.edu/2004/pdfs/gundle.pdf (Accessed on April 22, 2009).
- Ethical considerations in the allocation of organs and other scarce medical resources among patients. Council on Ethical and Judicial Affairs, American Medical Association. Arch Intern Med 1995; 155:29.
- DeVita MA, Caplan AL. Caring for organs or for patients? Ethical concerns about the Uniform Anatomical Gift Act (2006). Ann Intern Med 2007; 147:876.
- Martin DK, Singer PA, Siegler M. Ethical considerations in liver transplantation, Chapter 11. In: Progress in Liver Disease, 1994. p.215.
- Reich DJ, Mulligan DC, Abt PL, et al. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation. Am J Transplant 2009; 9:2004.
- Wall SP, Kaufman BJ, Gilbert AJ, et al. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city. Am J Transplant 2011; 11:1417.
- Lancet 2012; 379:1275.
- Lederer W, Lichtenberger C, Pechlaner C, et al. Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest. Resuscitation 2004; 61:123.
- Nagao K, Kikushima K, Watanabe K, et al. Early induction of hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who undergo emergency cardiopulmonary bypass and percutaneous coronary intervention. Circ J 2010; 74:77.
- Massetti M, Tasle M, Le Page O, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005; 79:178.
- Nielsen N, Sandhall L, Scherstén F, et al. Successful resuscitation with mechanical CPR, therapeutic hypothermia and coronary intervention during manual CPR after out-of-hospital cardiac arrest. Resuscitation 2005; 65:111.
- Thiagarajan RR, Brogan TV, Scheurer MA, et al. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults. Ann Thorac Surg 2009; 87:778.
- Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010; 81:1219.
- Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829.
- Bernat JL, Capron AM, Bleck TP, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010; 38:963.
- Peters TG. Life or death. The issue of payment in cadaveric organ donation. JAMA 1991; 265:1302.
- Whitington PF. Living donor liver transplantation: ethical considerations. J Hepatol 1996; 24:625.
- Malagó M, Burdelski M, Broelsch CE. Present and future challenges in living related liver transplantation. Transplant Proc 1999; 31:1777.
- Singer PA, Lantos JD, Whitington PF, et al. Equipoise and the ethics of segmental liver transplantation. Clin Res 1988; 36:539.
- Mayer AD. The argument against live-donor liver transplantation. J Hepatol 1996; 24:628.
- Anderson-Shaw L, Schmidt ML, Elkin J, et al. Evolution of a living donor liver transplantation advocacy program. J Clin Ethics 2005; 16:46.
- CMS Federal Register, Vol. 72, No. 61, Rules and regulations. p.15236. March 30, 2007.
- Griffin J. Organ donation new strategies for finding organs. The Hastings Center. Garrsion, NY. 2007.
- UNOS Ethics Committee. Ethics of organ donation from condemned prisoners, 1998 www.unos.org/resources/ (Accessed on March 08, 2005).
- Bobbert M, Ganten TM. Liver allocation: urgency of need or prospect of success? Ethical considerations. Clin Transplant 2013; 27 Suppl 25:34.
- Schaffer RL 3rd, Kulkarni S, Harper A, et al. The sickest first? Disparities with model for end-stage liver disease-based organ allocation: one region's experience. Liver Transpl 2003; 9:1211.
- Ahmad J, Bryce CL, Cacciarelli T, Roberts MS. Differences in access to liver transplantation: disease severity, waiting time, and transplantation center volume. Ann Intern Med 2007; 146:707.
- OPTN/UNOS Liver and Intestinal Organ Transplantation Committee. Redesigning Liver Distribution to Reduce Variation in Access to Liver Transplantation. http://www.hrsa.org (Accessed on September 06, 2015).
- Moss AH, Siegler M. Should alcoholics compete equally for liver transplantation? JAMA 1991; 265:1295.
- Shelton W, Balint JA. Fair treatment of alcoholic patients in the context of liver transplantation. Alcohol Clin Exp Res 1997; 21:93.
- Lumeng L, Crabb DW. Genetic aspects and risk factors in alcoholism and alcoholic liver disease. Gastroenterology 1994; 107:572.
- Lucey MR. Liver transplantation for alcoholic liver disease. Nat Rev Gastroenterol Hepatol 2014; 11:300.
- Lucey MR, Merion RM, Henley KS, et al. Selection for and outcome of liver transplantation in alcoholic liver disease. Gastroenterology 1992; 102:1736.
- Hoofnagle JH, Kresina T, Fuller RK, et al. Liver transplantation for alcoholic liver disease: executive statement and recommendations. Summary of a National Institutes of Health workshop held December 6-7, 1996, Bethesda, Maryland. Liver Transpl Surg 1997; 3:347.
- McCurry KR, Baliga P, Merion RM, et al. Resource utilization and outcome of liver transplantation for alcoholic cirrhosis. A case-control study. Arch Surg 1992; 127:772.
- Kumar S, Stauber RE, Gavaler JS, et al. Orthotopic liver transplantation for alcoholic liver disease. Hepatology 1990; 11:159.
- Pageaux GP, Michel J, Coste V, et al. Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism. Gut 1999; 45:421.
- DiMartini A, Dew MA, Day N, et al. Trajectories of alcohol consumption following liver transplantation. Am J Transplant 2010; 10:2305.
- Addolorato G, Mirijello A, Leggio L, et al. Liver transplantation in alcoholic patients: impact of an alcohol addiction unit within a liver transplant center. Alcohol Clin Exp Res 2013; 37:1601.
- Forster J, Bartholome WG, Delcore R. Should a patient who attempted suicide receive a liver transplant? J Clin Ethics 1996; 7:257.
- Rhodes R, Aggarwal S, Schiano TD. Overdose with suicidal intent: ethical considerations for liver transplant programs. Liver Transpl 2011; 17:1111.
- Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med 2002; 347:284.
- Roland ME, Lo B, Braff J, Stock PG. Key clinical, ethical, and policy issues in the evaluation of the safety and effectiveness of solid organ transplantation in HIV-infected patients. Arch Intern Med 2003; 163:1773.
- Locke JE, Durand C, Reed RD, et al. Long-Term Outcomes After Liver Transplantation Among Human Immunodeficiency Virus-Infected Recipients. Transplantation 2015.
- Kim WR, Wiesner RH, Poterucha JJ, et al. Hepatic retransplantation in cholestatic liver disease: impact of the interval to retransplantation on survival and resource utilization. Hepatology 1999; 30:395.
- Zarrinpar A, Hong JC. What is the prognosis after retransplantation of the liver? Adv Surg 2012; 46:87.
- Ubel PA, Arnold RM, Caplan AL. Rationing failure. The ethical lessons of the retransplantation of scarce vital organs. JAMA 1993; 270:2469.
- ORGAN DONATION
- Efforts to increase donor organ availability
- Other systems for organ donation have been proposed:
- - Mandated choice
- - Presumed consent
- Controlled donation after cardiac/circulatory death
- - Uncontrolled donation after cardiac/circulatory death
- - Economic incentive
- - Living donor liver transplantation
- Altruistic/stranger donors and the use of social media
- - Prisoners
- TRANSPLANTATION FOR SPECIFIC POPULATIONS
- Alcohol-related liver disease
- Convicted criminals
- Suicidal overdoses/attempts
- Transplantation in HIV-infected patients