COMMENTARY

How Many Hearts Should One Child Receive?

Arthur Caplan, PhD

Disclosures

August 28, 2015

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I am Art Caplan from the Division of Medical Ethics at the New York University (NYU) Langone Medical Center in New York City. Aiyana Lucas just got a third heart transplant, and that's great for her. It's exciting for her family. She is 8 years old, and pediatric heart transplants are very rare. The good news is that children do not die in motorcycle accidents, diving board accidents, and other circumstances that produce organ donors. The bad news, for people like Aiyana, is that there are not many organ donors available when you need a new heart. She definitely needed a heart and got a transplant. However, it failed. She went right to the head of the transplant list—the national organ system maintained by the United Network for Organ Sharing (UNOS)—and she got a second heart. But that heart didn't work either. In fact, it failed to pump much at all. She went back on a heart/lung machine, and when a third heart became available, she got it because she was the sickest, most desperate person in the United States.

Her physicians at Seattle Children's Hospital fought very hard to get these hearts for her, and it is hard not to do anything but celebrate the fact that she is still here and she was able to be rescued. But there is a tough moral issue when somebody, even a child, gets three heart transplants. The third and fourth heart transplant survival statistics are not good. When you get a heart and then another one, your body starts to build up antibodies, or resistance to tissue that is not your own, and is likely to attack the next heart. Survival statistics after two tries really start to drop drastically (maybe 10% of people survive a year or more.) After the fourth transplant of a heart, kidney, or other organ, survival drops almost to zero.

From the point of view of the physicians taking care of Aiyana at Seattle Children's Hospital, they are going to fight to get every resource they can. There is no doubt that what they consider the right thing to do is to get hearts for their patient. If they could get five, six, or seven, I suspect that they would try to do it. But is that the right use of hearts? When Aiyana gets hers, somewhere there is a kid waiting who isn't going to get a heart, who is not going to get a first chance, perhaps with much better statistics, because we are trying to rescue a particular little girl who is in dire circumstances. So the tough moral issue is, when the doctors are going to try to get their patient all the resources they can, should the system ever set up a rule that limits the number of heart transplants that any patient can get?

The system has to do that. I know that is harsh to say. But after transplant number three, the chances of anyone surviving—even this little girl—are so poor that it makes more sense to let some other child, who hasn't had a chance at any hearts, get a chance. If you turn to doctors to make that decision at the bedside, they cannot do it. They are not going to abandon their patient; they are going to be good advocates for their patient. The only way that we are going to limit the number of hearts that this little girl or anybody can get is if the system has a rule that says, "After X number, we are not sending any more hearts to you. We have to give other people a chance." That is the right thing to do if we value efficacy, if we want to save the most lives using the scarce supply of hearts for kids that we have.

That said, it is a lesson about how we need to think about allocation of scarce resources. If you go to the bedside, you cannot ask doctors to say, "I'm not going to try anymore for my patient." Who would want a doctor like that? We want a doctor who is going to do everything to try to save us. But if we want to make the best use of scarce or very expensive resources, we need a system that can exercise some control regionally and nationally over what resources can be accessed and used. We don't have that now, but the case of this little girl in Seattle should make us think about whether we want to create such a system in the future. I'm Art Caplan at the Division of Medical Ethics at NYU Langone Medical Center.

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