COMMENTARY

Is an Organ From a Diseased Person Better Than Nothing?

Arthur L. Caplan, PhD

Disclosures

July 31, 2017

Hi. I'm Arthur Caplan at the Division of Medical Ethics at New York University (NYU).

Everybody is well aware that there's a chronic shortage of organs to transplant for people who need them. We don't have enough kidneys. We don't have enough hearts. We don't have enough livers or lungs. Many organs are plainly in very short supply. The waiting lists continue to grow. Unfortunately, many people die without getting a chance for a transplant.

That said, there are some interesting ideas about how to expand the pool of organs. One recent idea is that even if someone has hepatitis C, maybe we could give that organ to an individual, knowing that we're likely to transmit hepatitis, but also knowing that we have medicine that seems to be able to cure hepatitis.

There are now powerful new drugs, antivirals, that appear to cure hepatitis. If you die with hepatitis, it will have been too late to cure you; there's nothing that can be done to handle the organ from the deceased person. But if it's donated, should we say that it's right to give it to someone else, knowing that we would give them a very serious disease?

I think the answer is yes, but I would put a number of qualifications on the practice. For one, there ought to be informed consent. People should know, I'm getting an organ that has this disease; maybe they want to try a living donor if it's a kidney or a liver that they need. Maybe they are going to say, I'll just wait for another cadaver donor, although it is enormously risky to do that, because of the shortage; the odds that they are going to get another offer are probably low.

We also have to consider that there are drugs that cure hepatitis. We've got the wonders of these medicines. If we do a transplant in someone who has to then take immunosuppressive medicines, which knock the immune system down, we don't know whether those medicines are going to do the same thing they do in a healthy person who has hepatitis.

People who need transplants frequently have other healthcare problems; they are weaker, and they may be older. Are other drugs that we now have for hepatitis C going to work well in them? That's experimental, and that's how I think we should treat this idea.

Obviously, we are creating financial toxicity. The drugs that cure hepatitis are very expensive; not everybody can get them covered. In some states, Medicaid programs say no. Some parts of the Veterans Administration have been pushed really hard to cover hepatitis C treatments because the price tags are so high. An insurance company might say post-transplant, "I don't know whether we are going to pay for that." We have to think about these things.

There are many instances where the desire to do good creates a set of unexpected problems. I think this is one of those instances. We might see this idea expand into such areas as HIV: I have HIV, I'm going to make my organ available and not just give it to someone else with HIV, but give it to a healthy person and then put them on a regimen of medicines that we know can significantly prolong life, even for someone who has HIV.

We can imagine the desire to expand these programs being huge, because we are in such short supply of organs. These programs have to be treated cautiously and carefully, and with an eye toward the categorization that they are experiments. Just because something works in one set of circumstances doesn't mean it's going to work in another set of circumstances. Even though people are desperate and might take something, while not worrying about the long-term consequences, part of medicine's job is to keep in mind what they need to know, what they need to understand. We also have to make sure that when something novel is initiated, we fully study it to make sure that what we think will be good is actually good.

I'm Art Caplan. I'm at the Division of Medical Ethics at NYU School of Medicine. Thanks for watching.

Talking Points: Is an Organ From a Diseased Person Better Than Nothing?

Issues to consider

  • Every 10 minutes, someone is added to the national transplant waiting list. On average, 20 people die each day while waiting for a transplant. One organ donor can save eight lives.[1]

  • Waiting times for kidney transplants exceed 3-5 years in many parts of the United States.[1]

  • More than 500 high-quality kidneys from deceased donors with hepatitis C virus (HCV) infection are discarded annually.[2]

  • Only 37% of hepatitis C-positive kidney donations between 2005 and 2014 were transplanted. The discards could have helped more than 4000 patients during that period.[3]

  • In a pilot trial at the University of Pennsylvania, researchers found that transplantation of HCV genotype 1-infected kidneys into HCV-negative recipients, followed by the use of direct-acting antiviral agents, can provide potentially excellent "allograft function with a cure of HCV infection."[2]

  • New antiviral therapies for hepatitis C virus infection have cure rates exceeding 95%.[4]

  • Some healthcare professionals reason that some Medicaid programs and insurance companies will not pay for costly hepatitis C drugs for organ recipients who get the disease.

  • Some say it is cruel to give desperate patients an organ that will give them hepatitis C, because they don't fully understand the implications of the disease.

Comments

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