Should Unvaccinated People Be Allowed to Get Organ Transplants?

Arthur L. Caplan, PhD


April 14, 2022

This transcript has been edited for clarity.

Hi, I'm Art Caplan. I'm at the Division of Medical Ethics at New York University's Grossman School of Medicine.

For many years — longer than I care to remember — I have been involved with transplantation and transplant ethics, trying to think about how to persuade people to give their organs when they die, and how to make that more attractive to people.

It's still something that many people don't do and are reluctant to do, and it leaves us with a shortage of organs. We simply do not have anything close to the number of kidneys, hearts, livers, and lungs that we could transplant because people just don't agree to give them when they die.

At the same time, the demand keeps going up for organs. We have a population that's older, and that leads to more organ failure. That leads to more demand. People need transplants because there's more diabetes, there are people with high blood pressure, and there are people still smoking and drinking. As sad as it may sound, attempts at suicide drive up the transplant ranks because you can damage your liver if you binge drink or swallow a bottle of pills and you don't succeed.

There are many different variables at work about why demand is big and growing. Also, the competency of transplant teams in the US is growing. They can take on tougher cases.

Every day in the US, people will die because there aren't organs to give them, and every day in the US, there are going to be very tough decisions about who is going to get one of the scarce hearts or livers that is available to transplant.

The process of deciding who's going to get one of those organs involves two steps. The first is whether the transplant center will take you in as a candidate for a transplant, whether it's NYU, Penn, Stanford, or Nebraska. Wherever it is, they have decisions to make in their transplant programs at these institutions about who needs a transplant and whether they think they have the skill or the ability to give them that transplant.

If they take the patient in, then we have a national waiting list that distributes organs, mainly according to blood type, tissue type, geography, and need in terms of who might be sickest, and with some attention as well to who might benefit the most. There is a delicate balance off the national list.

Now, I want to talk to you about the status of people who are trying to get into a transplant center and what factors drive that decision. Well, obviously, you have to be in organ failure, and if you're so sick that they don't think you could survive the operation, you won't get on a transplant list.

People who have access to good medical care and good primary care are advantaged in our society over people who don't. To be blunt, homeless persons are less likely to show up on anybody's transplant list than wealthy persons. That's just the reality of how medical care and healthcare are distributed in our society.

Transplant centers pay attention to other things like lifestyle. They ask, "Are you drinking? Are you smoking? Are you someone who is a high suicide risk? Are you in a situation where you are abusing drugs?" And most recently: "Are you vaccinated?"

This is a topic that really sets off argument and dispute: vaccination status as a condition for admission to transplant centers. My own position is if vaccination, before a transplant, helps the transplant to work because it builds up immunity to infectious diseases — COVID-19, flu, measles, whatever we can vaccinate for — that might kill you post-transplant because you're immunosuppressed, then that is a reasonable thing to take into consideration in deciding who's coming in to get a transplant.

It is a reasonable thing to use to decide who has priority for a transplant. It's not punishing people who choose not to vaccinate any more than saying you can't smoke if you're going to get a heart transplant. It's a decision based on what's going to work and what increases the chance of a good outcome. If vaccination does that, then COVID-19 vaccination status or any other vaccination status — including potentially shingles, the zoster vaccine — is relevant to take into account.

Is it the only thing to take into account? Probably not. Is it something that transplant centers appropriately, ethically, can weigh knowing that there are many people who are vaccinated who are eligible for transplants? I'm going to say yes.

If you do things that diminish the chance of success with a scarce, lifesaving resource like a heart, lung, or liver, then I think the doctor's duty is to try and steward those organs to get the best results and to save the most lives with the scarce supply.

Vaccination bears on that, and as it does, it becomes morally relevant to who's going to get access to a transplant. I know there are many who would say, "Demanding vaccination is just an example of bullying people who don't want to do it." I would defer and say no. What vaccination status indicates is one more fact, a lifestyle choice, that bears on whether you're likely to survive or not if you are lucky enough to get a transplant.

Overall, saving the most lives is what we want to happen with our scarce supply of organs. Even more, we want more people to donate organs so that these hard choices don't have to be quite as hard. Nonetheless, they are, and I think you have to take into account what's medically relevant.

I'm Art Caplan at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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