Three Heart Transplants for One Child While Others Get None?

Neil Chesanow

Disclosures

November 04, 2015

How Many Hearts Should One Child Receive?

In a recent Medscape video, bioethicist Art Caplan, PhD, of the Division of Medical Ethics at the New York University Langone Medical Center in New York, addressed one of the most difficult ethical and moral issues in medicine: Should a child whose heart transplant failed receive another heart, when the odds of success a second time are significantly less and many more children need organ donors than hearts are available?

Dr Caplan focused on the case of 8-year-old Aiyana Lucas, who received not one heart but three. "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," Dr Caplan said. "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."

"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," Dr Caplan concedes. "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."

This isn't a question for a patient's doctors to grapple with, Dr Caplan asserts. "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."

The video prompted dozens of thoughtful, poignant, often impassioned, and sometimes angry comments from doctors—including a number of edifying responses to those comments.

"Art raises a very challenging issue," a cardiologist wrote. "If early rejection is a major factor in nonsurvival of repetitive organ transfers, that must have a deterrent effect. Obviously, a not-yet-transplanted recipient must have a higher claim in choices, unless there are 'local' factors that limit eligibility. If ever there were an urgent need for total transparency in making such matching decisions, this may be it."

"Without a doubt, such a system must be instituted," a urologist agreed. "However, it will be hated. We already have a similar system at the VA. It is not well-liked."

"I agree that we need to consider resources when allocating any kind of medical care," a pediatrician opined. "What I object to is creating blanket rules regardless of the situation. What should happen is that when a need is discovered, the scenario and risk/benefit ratio should be entered into the needs analysis. There is already a needs analysis pool being used. It is the benefit analysis that needs to be added to the consideration. And we do obtain that information. What we don't need is some rule like 'three hearts and you're out.'"

"Rationing is never easy, but meeting the needs of as many children as possible needs to be given utmost priority," another pediatrician insisted. "However, you must allow each physician to advocate for their patient and have an unbiased body of experts make the final call. As a physician, it is not ethical for me to say 'You take it' to another patient if there is a remote possibility that this organ could save my patient."

"Just as prospective liver and lung transplant recipient patients are 'scored' using many eligibility factors before being deemed a candidate for a transplant, I believe that the risks of success of multiple cardiac transplants should also be taken into consideration as a 'negative score,'" a radiologist stated. "The first-time cardiac-transplant child waiting for a heart might then receive a higher eligibility score and move up in the queue. We must begin to address the ethical issues associated with the most limited of our precious human resources, and pediatric hearts must be one the most limited of these resources."

"I don't think physicians fail to understand the concept of limitations; I think they are uncomfortable telling the patient in front of them that that person is the one who will have to accept those limitations," an otolaryngologist wrote. "A national consensus would be useful, but only up to a point. People are more than ready to keep someone else's medical costs down, but they balk when it is their own care that is being denied."

"I worked for many years in pediatric liver and gastrointestinal transplantation," a surgeon commented. "I did that after working in the jungle in Africa for few months. I have seen both extremes of medical care, in terms of limited resources and waste of resources."

The surgeon continued, "Every doctor should spend some time in the jungle. When a premature baby or newborn baby comes to life with major life-threatening conditions, very often they cannot be saved. This is socially accepted, and few months later a new, healthy baby will come to life. In America, we are able to save a 600-g baby who lost his gut; wait months for a transplant or sepsis-induced liver failure, whichever comes first; and then give him a multivisceral transplant if he's still alive. However, this will destroy the lives of the two often very young parents, will cost the baby years of tremendous suffering, and will cost the community millions of dollars. Sometimes medicine needs to stop, and doctors should write fewer papers about the craziest interventions."

In response to the surgeon's comment, a radiologist wrote, "I agree. We play God every time we 'save' a 600-gram baby who would not have lived if not for the interventions we provide. Our technology has progressed beyond our ability to use it rationally. There needs to be a discussion of outcomes, not just survival. I have seen patients who would have died except for heroic medical interventions, only to be left with severe debilities or no cerebral function but who were considered a 'success' because they lived. Life at all costs is not acceptable, and quality of life needs to enter into decision-making."

"The limitations of medicine are no longer technical; they are financial," a family physician maintained. "We cannot afford to do what we know how to do for everyone, every time. If you agree with this proposition, the only conclusion is that we have to ration. The truth is that we already do, but in an arbitrary and irrational fashion. As unpalatable as it may be. We need to come to grips with this problem and learn to ration in a thoughtful and rational way."

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