I agree with most advice given by the affable TV character Ted Lasso. "Every choice is a chance," he said. Pandemic-era physicians must now consider whether a politically motivated choice to decline COVID-19 vaccination should negatively affect the chance to receive an organ donation.
And in confronting these choices, we have a chance to educate the public on the complexities of the organ allocation process.
A well-informed patient's personal choice should be honored, even if clinicians disagree, if it does not affect the well-being of others. For example, I once had a patient in acute leukemic crisis who declined blood products because she was a Jehovah's Witness. She died. Her choice affected only her longevity.
Compare that decision to awarding an organ to an individual who has declined readily available protection of that organ. Weigh that choice against the fact that said protection is against an infectious disease that has killed over 5.5 million worldwide.
Some Institutions Stand Strong, Others Hedge Their Bets
Admirably, Loyola University Health System understands that difference. They published a firm stand on transplant candidacy and COVID-19 vaccination status in the Journal of Heart and Lung Transplant in January. Daniel Dilling, MD, medical director of the lung transplantation program , and Mark Kuczewski, PhD, a professor of medical ethics at the Stritch School of Medicine, wrote that, "We believe that requiring vaccination against COVID-19 should not be controversial when we focus strictly on established frameworks and practices surrounding eligibility for wait-listing to receive a solid organ transplant."
The Cleveland Clinic apparently agrees. In October 2021, they denied a liver transplant to Michelle Vitullo of Ohio, whose daughter had been deemed "a perfect match." Her daughter, also unvaccinated, stated, "Being denied for a nonmedical reason for someone's beliefs that are different to yours, I mean that's not how that should be".
But vaccination status is a medical reason, given well-established data regarding increased mortality among the immunosuppressed. Vitullo then said, "We are trying to get to UPMC as they don't require a vaccination."
The public information page on transplant candidacy from UPMC (University of Pittsburgh Medical Center) reads (my italics):
It is recommended that all transplant candidates, transplant recipients, and their household members receive COVID-19 vaccination when the vaccine is available to them.
It is preferred that transplant candidates are vaccinated more than two weeks before transplantation.
I reached out to UPMC for clarification and was told by email that "We do not have a policy regarding COVID-19 vaccination requirement for current transplant candidates." Houston Methodist shares the same agnostic stance.
Compare these opinions to Brigham and Women's Hospital, where the requirements are resolute:
"Like most other transplant programs across the country, the COVID-19 vaccine is one of several vaccines and lifestyle behaviors that are required for patients awaiting solid organ transplant."
They add that
"Transplant candidates must also receive the seasonal influenza and hepatitis B vaccines, follow other healthy behaviors, and demonstrate they can commit to taking the required medications following transplant."
Last month, Brigham and Women's Hospital declared 31-year-old D.J. Ferguson ineligible for a heart transplant because he declined to be vaccinated against COVID -19. According to the New York Post and ABC News, his physicians resorted to left ventricular assist device support. His mother, Tracy Ferguson, is quoted as saying, "He's not an anti-vaxxer. He has all of his vaccines." I'll just leave that right there.
Unfortunately, Michelle Vitullo's obituary was published in December 2021. Regardless of whether she received her liver transplant, the outcome is tragic, and whatever you think of this family's battle playing out in the glare of the national spotlight, their loss is no less devastating.
The directed-donation aspect of this case poses an interesting question. A news anchor asked the mother and daughter, "If you both accept the risks, why doesn't the hospital just let you try?" The answers are obvious to us clinicians: Performing a transplantation in an unvaccinated patient:
Could lead to their early death if they became infected because of their immunocompromised state
Puts other vulnerable hospitalized patients at risk during the initial transplant stay and follow-up.
Not to mention the potential legal suit. Never has a consent form dissuaded any party from lodging an accusation of wrongful death or medical malpractice. In the face of strong data on higher mortality in unvaccinated, immunocompromised patients, a good lawyer could charge that the institution and transplant surgeons should have known better, regardless of the donor and recipient's willingness to accept the risks.
The Vitullo and Ferguson cases are among many similar dilemmas surrounding transplant candidacy across the United States.
UVA Health in Charlottesville, Virginia, denied 42-year-old Shamgar Connors a kidney transplant because he is unvaccinated, despite a previous COVID-19 infection. In October 2021, Leilani Lutali of Colorado was denied a kidney by UCHealth because she declined vaccination.
As Ted Lasso says, "There's a bunch of crazy stuff on Twitter."
Predictably, social media is full of public outcry. "Some cold hearted people on here" tweeted one. "What if it was one of your loved ones who needed a transplant?" Another tweeted the Hippocratic oath with the comment that "They all swore under this noble 'oat', but I guess it's been forgotten." (This was followed with a photo of a box of Quaker Oats in a failed attempt at humor.) These discussions among the twitterati highlight the depths of misunderstanding on organ transplantation.
To be fair, unless you have been personally involved in the decision-making process for transplant candidacy, there is little opportunity to be educated. I explain to my anxious patients and their families that a donor organ is like a fumbled football. There may be well over 100 patients at all levels of transplant status in many geographic locations diving for that same organ.
The transplant team is tasked with finding the best match, determining who is the sickest, assessing time for transport of that organ, and, above all, who will be the best steward of that organ.
Take heart transplantation, for instance. Approximately 3500 patients in the United States are awaiting one each year. Instead of facing an almost certain death within 5 years, a transplant recipient has a chance at a median survival of 12 to 13 years. The cost of a heart transplant is approximately $1.38 million, according to Milliman, a consulting firm. This is "an incredibly resource intensive procedure," including expenditures for transportation, antirejection meds, office visits, physician fees, intensive care unit stays, rejection surveillance, and acute rejection therapies.
Transplant Denial Is Nothing New
People get turned down for organ transplants all the time. My patient with end-stage dilated cardiomyopathy was denied a heart transplant when it was discovered that he had scores of outstanding parking tickets. This was seen as a surrogate for an inability to afford his antirejection meds.
Another patient swore that her positive cotinine levels were due to endless hours at the bingo hall where second-hand smoke swirled. She was also denied. Many potential candidates who are in acute decline hold precariously to newfound sobriety. They are denied. A patient's boyfriend told the transplant team that he couldn't be relied upon to drive her to her appointments. She was denied.
Many people who engage in antisocial behaviors have no idea that these actions may result in the denial of an organ transplant should their future selves need one. These are hard lines, but everyone should agree that the odds of survival are heavily in favor of the consistently adherent.
We should take this opportunity to educate the public on how complicated obtaining an organ transplant can be. More than 6000 people die each year waiting for an organ because of the supply-and-demand disparities in the transplantation arena. I'm willing to bet that many of the loudest protestors in favor of unvaccinated transplant recipients have not signed the organ donor box on the back of their driver's license. This conversation is an opportunity to change that and remind people that organ donation may be their only opportunity to save a fellow human's life.
Again, to quote Ted Lasso, "If you care about someone and you got a little love in your heart, there ain't nothing you can't get through together." That philosophy should apply to the tasks of selecting the best organ donors as well as the best organ recipients.
And every organ should go to the one who will honor their donor and their donor's family by taking the best care of that ultimate gift of life, including being vaccinated against COVID-19.
Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband and daughters, and sidelines as a backing vocalist for local rock bands.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Melissa Walton-Shirley. Organ Transplantation: Unvaccinated Need Not Apply - Medscape - Feb 10, 2022.