Transplant Injustice and the Response:Which Is The Greater Injustice?
From today's Los Angeles Times comes a story regarding St. Vincent Medical Center, a Los Angeles liver transplant center hospital, that in 2003 (just discovered now by the hospital doing a routine evaluation required by UNOS, the federal transplant agency) performed a liver transplant paid for by the Royal Embassy of Saudi Arabia. "The patient who received the successful transplant was, [however], actually 52nd on the list, which covers much of Southern California and takes into account such factors as who is sickest and who has been waiting longest."
The CEO of St. Vincent stated "A patient at UCLA Medical Center was entitled to receive the organ and St. Vincent should have declined it." The St. Vincent liver transplant program has now been suspended The involved director and assistant director surgeons associated with the liver transplant program were now no longer affiliated with the program.
"Suspending the program means that 75 patients on the waiting list for livers may have to seek care at other hospitals, possibly delaying their chances for a life-saving transplant. Patients who need livers typically suffer from end-stage liver failure, cirrhosis and other liver and metabolic diseases."
I see the ethical issue: the injustice of the original act vs an injustice to those 75 patients by the suspension of the liver transplant progrram. How does one work out this ethical equation? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:31:00 PM
16 comments
16 Comments:
I think we would need to know how many people need liver transplants. Right now it's 17,398.
If you suspend your liver surgeons, who would perform the liver surgery??? Would you actually want to continue to have these surgeons doing transplants at your hospital???
Regulators are quick to re-affirm their authority over the process and slow to consider the 75 waiting, dying, suffering patients. That's preserving power by contributing to the harm of others: that's decidedly immoral.
I am still trying to think this issue out ethically. These surgeons who are alleged to have produced an injustice to a UCLA patient by their use of that liver for a foreign patient much lower on the recipient list is said to have done this 3 years ago. If in the meantime, till the deed was discovered, presumably they have performed professionally and have, through their skills, extended the life of many other liver failure patients, shouldn't that be taken into consideration? My ethical concern is whether the hospital administration, by suspending the program, now is simply adding to the ethical injustice by making it difficult for other patients who want to recieve the life prolonging benefit of these particular surgeons' and liver transplant team skills. It would seem that the injustice was administrative and not a deficiency of surgical skills or a surgical technical problem. Therefore,unless there were other factors not as yet made public, it would seem the "right thing" if the program was not suspended and the skilled surgeons and transplant team continue to do their work while the administrative system is analyzed. My advice:
Throw out the bath water but keep the baby, at least for the present. ..Maurice.
There's a practical issue you are overlooking here. The 2 surgeons that run the Liver Program at St Vincent have been terminated from their positions at SV. This makes sense -- what they did was a breach of ethics and possibly criminal. You can't have them working for you. Now, the Liver Program has been suspended by the hospital itself pending an investigation -- not by UNOS. There isn't anyone in charge of the liver program anyway now, and there are no liver surgeons to perform surgeries.
That the program has been suspended is bad for the patients on the list out in the cold, I agree, but there is no practical alternative at this point. there's no one there to do the transplants anyway.
The comment I first posted on your blog above is in today's LATimes.
http://www.latimes.com/news/opinion/letters/la-le-friday30sep30,0,3535797.story?coll=la-news-comment-letters
Trapier
www.isemmelweis.com
I should expand on my post. With over 17000 people on the liver transplant list, the 75 people at this hospital represent less than 0.5% of the program. My sense is that some of the patients could afford to transfer to another hospital in the event a matched organ came available. The hospital should eat the cost of transfer for those who can't afford it. How long was the program suspended for? How many of these patients are above or below the typical wait time for a liver transplant? Where did the surgeons go? Are surgeons available on staff to backfill in the immediate future? Is the program suspended because the surgeons were dismissed and now the hospital is looking for replacements? As usual, it's more complicated than it seems. From a leadership perspective it is not unusual to increase the burden of a small percentage of a group in order to evaluate, maintain, or repair a program. Remember, however, that leaders are human too, and would have a very difficult time, morally, transferring the burden to these unfortunate 75 patients. Were the 75 offered other access to care?
I had a liver transplant 2 years ago. I assure you that very little of this kind of thing goes on, but I also know from experience that there are some hospitals and doctors that exclude some patients from the list on little more than personal dislike.
Personally I had to move to a different area to receive my transplant, a place with a shorter waiting list and with doctors that cared about me. The other place (it starts with UC and ends with SF) was horrible, overcrowded and completely lacking in empathy. I too was told I was on the list and to wait patiently, but when I checked through an hospital insider I found out that I was not on the list as I was assured repeatedly.
Was it a mistake or intentional? In my case it was a mistake, but it shows how easy it is to mess with the records, since "the List" is not an actual, published document patients can see. "The List" also might have 200 people ahead of you in sickness, but the available liver may be a match just for you because of blood type, size and many other factors. In reality your position on the list is given by how good a match you are to the next donor.
That said, the real victims of what went on at St. Vincent's are the people currently waiting. Some of them are going to die.
I'd be really curious to know what went on. there is more to the story than we know so far. Saudi patient, Saudi transplantee, overpayments.. It stinks. So far it does not make a lot of sense, there are some areas in the US where it is far easier to receive a liver transplant than LA, a notoriously overcrowded area. I know of people that moved from the major metropolitan lists to a smaller "market" and received their organ within weeks or even days. Why would the Saudis and the Doctors at St. Vincent's risk so much? It would have been easier to falsify the eventual recipient's medical records than to let someone else die.
I'll make sure to keep an eye on this one.
I recieved a liver transplant last year. The group that I was with in the post transplant clinic had a mean age of 50. Most of them have HCV, and most will be asking for a retransplant within 5 years. If retransplanted, %35 will not leave the hospital. The long term survival rate for the rest is all over the grid.
Should retransplant even be reconsidered? If so, who gets one?
I have put up on this blog today another example of a medical center unjustly performing their liver transplant program. Although these incidents like the one in todays posting and the St. Vincent issue are probably and hopefully uncommon in the entire U.S. transplant program, those which have occurred have the potential of affecting the lives (and deaths) of many patients. Each event should be carefully scrutinized, evaluated and prevented in the future. ..Maurice.
I got this! There is still much unfairness in the organ transplant system. If there were enough organs available, this would no longer be a problem. ..Maurice.
I don't have an answer, but all I can think every time I read about such abuses or horrible outcomes that seem so common at the "big name" centers and cities I say another prayer for the great surgeons I had, the great hospital I was at and the fact that I'm in a state with a small list! Thank God for MUSC.
Mr Buck not meaning no disrespect to you.
Medical University of South Carolina my a-- all the transplants drs. down there can go straight to he-- for all I care. They are the reason I don't have my husband here with me now.
In 2004 he found out he had hep c with cirrhosis (no he did not drink)his drs. here sent him to Dr.Ira Willner at MUSC for the liver clinic in May of 2005. After several visits he set him up with Dr. Ken Chavin of the transplant team. They explained everything and then told my husband after his testing they would get back with him. He was a 9 on the MELD score and he had to be a 12. 2 weeks later we get a letter saying he would not be put on the transplant list because his quality of life wasn't bad enought yet to put him thru a transplant.
We kept going every 3 to 6 months for check-ups and every time we done the test they still said he wasn't bad enought yet.
By Dec.of 2006 he had gained so much body fluid that it was coming out his legs as water blisters the size of quarters. In Oct 2006 he was put on disability because he had encepholopathy. His ammonia level was at one time 135. He would fall asleep trying to eat, he couldn't go anywhere because he took so much lactulose to keep his bowels moving. He too about 15 pills a day just to keep everything working.
In Dec. 2006 when we went for check-up his Meld was 13 we felt sure he would go on the list but then they told us he had to be a 15
In Jan & Feb he was put in our local hospital 4 times for fluid buildup so bad that he couldn't walk thay were so swollen. In Jan, Feb, Mar, he developed dibetes, had to have a Turp to relieve his kidneys for they were only working at a 40% level but they never offered him any dialysis. In Mar he went back to MUSC, his MELD was a 18 but he still couldn't go on the list because they felt the test was giving them a false reading. Early July he went back to MUSC to see if he needed a liver and a kidney but then they decided he didn't for some reason, His MELD was a 19 then.
Finally on July 20 they decided to list him, but before he got his call he fell in the bathroom and had to be put in the hospital with 2 cracked ribs.
On Aug. 11 he got the call for his liver and came thru the operation, was taken out of CCU after 4 days doing good to the 6th floor to recover and some crazy dr. hooked him up to a machine that forced oxygen into your lung and he thru up in it only to send him back to CCU where he developed sepsis.
They had to hook him up to a respirator and a ECMO machine to filter his blood. Then they let the blood vessels in his throat bust it took 9 bands to get them to stop bleeding.
After 10 days on the ECMO they felt he was getting better so they took him off it and was going to put him on a dialysis machine but guess what they couldn't get it to stop clotting and he swelled up on all his organs quit working and he died on Sept.1st.
So again I say to He-- with MUSC and their Doctors.
Drs made my husband believe he would die without the Heartmate II operation. My husband was doing well, he felt better than he had in a long time. He had quit smoking and should have been listed on UNO's list for heart transplant. He was evaluated in Sept, and talked into this operation in Oct. he died of Sepsis in Nov. Dr. Toole operated, closed the chest after three days and then went on vacation. My husbands ICD unit was shocking him, the Dr. overrode the computer to pace him more and not fire so soon. I heard him say he had to override to accomplish this because of the saftey feature. he even laughed about it to the dr who had tried to get to the settings and could not, this was after I was told my husband had TB . was transferred to another room with outflow of air only, was left in a chair for ten hours with a fever and chills, had his dressing changed in the chair, upright and slouching , with the nurse straddling him. his tray brought to him with liquid and NO ONE helped him with it. he did not have even a sip of water while he sat there. That night he was put back on the ventilator at 3am. I was wakened to be told. the following monday Toole returned, told me they were working to remove the ventilator again, that day the nurse pulled my husband up in the bed and walked out..the ventilator came apart, alarms going off and no one came in ...i went out to get someone...I was told my husband did not have tb. NO more masks great. next day husband waking up,not responding.Not knowing me. that night he knows me. squeezes my hand,under the sheet, my hand comes out full of blood, the heart pillow they give all patients is full of blood. the floor full of blood , sheets full of blood, his iv had opened blood flow freely.I had to go and find a nurse, ICU?... He already had a low blood count. I kept asking for two days about the differnce in the heartrate and asking what it meant by, pacer not pacing. And the alarm and the nurse saying..hmm it says his heart isnt beating..hmm something wrong with monitor. Two days later Im awakened at 3am. I am told my husbands status has changed, ICD was not working properly, heartrate had changed. Doctors were with him, Dr. came out said it did not look good...went back, came out said sorry hes gone...Death certificate says.SEPSIS..no one ever said...SEPSIS ....yes MUSC CAN GO TO ...they killed my husband as far as I am concerned.
To the lady who's husband died at MUSC. There are several websites that I found where you can tell your story. I myself have posted on it about my husband. I want to warn everyone I can about them. The web is: timesunion.com/healthylife/http://www. or chron.com either site will get you to the place. When you get there on the right side of the screen click on a topic called Dead By Mistake when there it will have a place where people have shared their stories. An another site that you can go to is: Rate MD.com I hope this gives you a little information so you can get it out. I still have nights like tonight that I can't sleep and they are days sometime I can't seem to eat a thing. I will be thinking you you. S.C.
POLICY NOTICE: I want material written to this blog to comment mainly on general ethical issues and not specific cases of named persons or institutions unless the names have already been presented to the general public through the documented research of the news media or through other public records. It was on the basis of a news media report on liver transplant that this thread was started. Experiences of my visitors which are pertinent to the topic can be written about but I don't think that it is fair or indeed ethical (or legal?) to name names (to name persons or institutions)in stories about misdeeds when those persons or institutions are not themselves made aware of such specific accusations written here and an opportunity given for them to present their views of the issue.
Discussing ones own experiences without naming names but in terms of an example regarding the ethics topic of the thread would be appropriate.
I have set this same requirement already in other topics on this blog and request that it be followed. ..Maurice.
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