Encourage Even HIV Patients to Become Organ Donors?

Arthur L. Caplan, PhD


February 07, 2017

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Hi. I'm Art Caplan from the Division of Medical Ethics at the New York University Langone Medical Center. Everybody knows that there is a huge shortage of organs for transplant. We have appealed year after year to people to donate organs when they die or when a loved one dies. It's important to raise this topic with your patients, both young and old. It is important that we encourage and support organ donation when people die.

Nowadays, many kidneys come from people who are living. We don't get nearly enough kidneys for those who need them, so we are turning to living sources. There is nothing wrong with that as long as the people understand what they are doing and have good informed consent.

Sometimes it's even necessary for a physician to provide [a patient who doesn't want to be a donor] with an excuse. It's hard to tell a family member that you don't want to be a donor. I have long argued that, in this area, you may need to do a little bit of coloring of the truth or stretching the truth to say that a person cannot be a donor. It may be psychological or emotional reasons instead of physical.

What else can we do to increase the supply of organs? An idea that has been around for a long time is to take high-risk organs and give them to high-risk people. Recently, Johns Hopkins University took an HIV-positive donor—someone who would never even be considered as a possible organ donor—and transplanted his liver and a kidney into two individuals who were also HIV positive.[1] A high-risk donor's tissue went to a recipient for whom the risk might be less.

Other programs are underway at some transplant centers to use older donors (> 60 years of age), to transplant their organs—if they are healthy enough upon inspection—to older recipients. As one wise guy said to me, "If we transplant a 65-year-old heart into a 75-year-old recipient, they don't need the same warranty as you would if you were giving it to a 30-year-old." There may be ways to explore this.

On the other hand, the National Institutes of Health has said that there are some tough ethical issues when you are using high-risk donors, whether they are dead or living, in the case of kidneys. First of all, do the patients need to know that they are high-risk? I would argue that they do. Even HIV-positive to HIV-positive. You don't know that it's not going to retrigger HIV infection or make it worse for the recipient. It's a bit of an experiment. You have to get a strong consent, even if you are telling your patients who need a transplant to consider an older donor or someone who might have an infectious disease like HIV.

We also need to make sure that these people are carefully followed. Transplant centers and the doctors who care for these patients need to make sure that they understand the importance of keeping the doctor informed about rejection, the effects of immunosuppression if they get an HIV-positive organ, and so on. You have to track them very carefully.

Ultimately, we may get to a point in time where we say, "Even though I'm not HIV positive, if I can't get an organ, I will take one from an HIV-positive person because an HIV-positive heart or liver is much better than the alternative, which is death. Maybe I can take my immunosuppressive drugs and the HIV drugs and get a good quality of life for many years by accepting a very high-risk organ." Shortage makes us think hard about how to stretch supply.

It is almost an ethical obligation if we are going to ration. What can we do to get more organs? I think that using high-risk organs makes sense. However, patients have a right to know. Patients also have a right to say no if they don't want to do it. Until we establish whether this is safe and effective, we have to treat it as research, not just as rescuing someone from death.

I am Art Caplan at the New York University School of Medicine. Thank you for watching.

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