September 25, 2003


Dave Tepper at Interrobang?! had an interesting post today about transplants. Rather than leave an extended comment on his site, I thought I would blog about it on mine.

Dave pointed to this article which is about an HIV-positive man who has been denied a kidney transplant by his HMO, Kaiser.

As many of you know, transplant is a subject that is near and dear to my heart (uh, literally). Due to my recently diagnosed heart condition, I actually spent a lot of time very close to transplant and on the transplant list last year. Fortunately, thanks to modern medicine, my heart has made improvements enough to stave off transplant at least for the immediate future. So I believe I come to the transplant issue with a rather unique and personal perspective.

At first glance, this article seems blatantly unfair. Denied transplant just because of his HIV status? Those damn HMOs! Those cheap bastards! I think we need to move beyond these knee-jerk reactions to the core issues.

Update: This post got very long so I put it in the extended entry. Click on the link below to continue reading "Transplants." Thanks

First, one of the main things I learned about transplant is that transplant selection is not fair. There simply aren't enough organs to go around. In an ideal world, everyone would donate their viable organs and transplants would be a non-issue, but in the world we live in, too many people choose to throw their organs in the trash can instead of saving another life. Because there is this shortage of organs, decisions must be made as to who is eligible for the organ and who is not.

For example, in heart transplants, smokers are not eligible for transplant unless they have been nicotine-free (and agree to random urine tests) for at least 6 months prior to transplant. Is this discrimination against smokers? Sure. But smoking is one of the causes of heart disease. If a person is not committed to stopping smoking how can they be trusted with a heart? Is it fair for them to be given a heart when another person who would take care of a heart dies while waiting for another organ?

This (very long) article on the selection and treatment of heart transplant candidates has some good things to say. Transplants are restricted to: "heart transplantation to patients who are most disabled by heart failure and who are likely to derive the maximum benefit from transplantation." Note that the article said not only the sickest patients, but the patients most likely to derive the maximum benefits from a new heart. Transplants are not automatically given to the sickest person. If a person has one or more comorbid diseases that compromise the life of a patient beyond that of the condition for which the transplant is warranted, then that is taken into account in transplant eligibility.

Sure, we'd love to give everyone, aged 8 or 98 a new organ to give them a shot at life. But we can't. That's a simple fact. Doctors must make the decision as to who can best benefit from a new organ, who is most likely to survive, and who is the sickest. Not who deserves the organ the most. Everyone deserves a chance at recovery, but our present situation makes this impossible.

Organ transplant guidelines are set forth by the United Network for Organ Sharing, or UNOS. UNOS guidelines are made by a committee of doctors, transplant recipients, families of organ donors, and many others to get a well-balanced, as-fair-as-possible guidelines for transplant centers to follow. These are not just medical bureaucrats setting up imperatives. Each individual transplant center has their own guidelines as well for accepting or rejecting patients. I was accepted at the Stanford transplant center. Had I been rejected, I could have applied to the UCLA center and possibly been accepted there. Every potential transplant recipient has the option to go elsewhere to seek treatment.

Okay, now that we have a little background in transplant policy, let's turn to the article at hand. In this case, a man who is HIV positive has been turned down by his insurance company, Kaiser Permanente, for a kidney transplant.

First, what this "turned down" means is not that he's been denied a transplant. Only the transplant center can determine that. It most likely means that Kaiser won't pay for it. For many people, this is the equivalent of being turned down by the doctors, but it really isn't the same thing. He could privately fund his transplant if the transplant center accepted him. I feel that the article is misleading in that it implies that just because the insurance turned him down that means that he can't get a transplant at all. That is not true.

Second, there's the issue of his HIV status. A first reaction would be "of course he's too sick for a transplant--it wouldn't be viable in an HIV positive person." Yet the article states that research shows that: "HIV-positive people have high survival rates after organ transplants, similar to those of people who aren't infected with the AIDS virus. " So HIV status should NOT be a determining factor in the health-related realm of determining transplant eligibility.

So is this a case of an HMO denying an eligible man simply because they don't want to pay out, or is there more that we don't know? I suspect it's the latter. It doesn't seem that HIV status alone should disqualify him for a transplant, but there are many factors that are taken into account in a transplant decision, and none of those other factors are reported on in this article.

Has the transplant center turned him down, or just the insurance company? This is a crucial question. Surely if the insurance is the one who turned him down, and did it based on his HIV status despite research that shows that an HIV positive individual is just as viable as an HIV negative individual, then that is unfair and the insurance is to be condemned.

Still, I suspect there's far more to this story than the media is reporting. I think that they are playing upon people's sense of fairness and homophobia to make a news story here. Would this be a news story if the headline read "Alcoholic denied transplant?" I'm not a big fan of HMOs, certainly, but I think they may be getting a bad rap here. We just don't know. It's too easy to scream "this is unfair!" or "this is just!" Let's think more about these issues before issuing a judgement.

Posted by Shelby at September 25, 2003 12:15 AM

Thanks for adding your perspective, Shelby. That was very insightful.

Posted by: Erica at September 25, 2003 12:42 PM

What I do not understand is why more people are not organ donors.

For me, personally, the thought that my death might bring hope and life to someone else would be such a comfort in my last moments.

I too want to say thank you for sharing your perspective, Shelby.

Posted by: Shelby (The Hang10 One) at September 25, 2003 05:20 PM

Yes, the lack of organ donors is really a shame. Too often a sudden death happens and the family is unsure of what the person would want because they've never talked about it. I would encourage everyone to tell your family about your desire to be an organ donor. If you're not sure about organ donation, read more about it on the Internet. A good place to start is UNOS at Recycle yourself--be an organ donor!

Posted by: Shelby at September 25, 2003 09:23 PM

Great post and very informative article.

Posted by: suzi at September 26, 2003 10:47 PM
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