New policy changes priorities in allocation of liver donations

Tuesday, November 19, 1996

MED CENTER:

Those most likely to survive will receive transplantsBy Phillip
Carter

Daily Bruin Staff

A change in the way donated human livers are apportioned for
transplantation has UCLA Medical Center ­ the nation’s biggest
liver transplant center ­ scrambling to implement the new
guidelines while keeping patients happy.

In making the case for the new policy, a spokesman for the
United Network for Organ Sharing (UNOS) said that it was trying to
do more with less, by giving livers only to patients who would not
only survive the surgery, but thrive afterwards.

The change takes people suffering from chronic liver disease
­ such as alcohol-induced liver cirrhosis or Hepatitis B and C
­ off the priority list for transplants. It disallows these
patients from entering into the highest priority transplant
category, even when on death’s doorstep.

"It’s truly a dilemma," said University of Minnesota Dr. William
Payne, who is a board member of the UNOS organization. The group
struggled to make its rules, he said, "trying desperately to
balance justice and utility." It decided that since the acutely ill
did best with liver transplants, they should be moved to the top of
the list.

Experts such as Dr. Arthur Caplan, director of the University of
Pennsylvania’s Center for Bioethics, said that this decision
represented a paradigm shift in medical treatment.

"For a long time, our policy has been to try to rescue the
sickest," Caplan said. "But we risk losing lives in our effort to
save the most fragile, damaged, and tenuous lives," said Caplan,
who has studied human transplants for 15 years. "(This new rule) is
the first introduction of a policy of giving organs to those who
are most likely to benefit."

At UCLA, this new policy change has already induced action at
the Medical Center’s liver-transplantation center, which operates
in conjunction with the programs at UC Irvine and Cedars-Sinai,
making it the largest such program in the nation with more than 350
transplants per year.

Since the change, doctors at UCLA have sent out a letter to
their patients explaining the change and telling patients to
contact the Medical Center with any questions.

With the change scheduled to go into effect on Jan. 20, 1997,
hospital officials said they are doing their best to counsel
patients about the new information.

One problem that liver transplant programs have encountered so
far is the "Mickey Mantle syndrome," where patients and families
envision a single list, on which all donors and recipients are
present and where life and death hinges upon a patient’s ability to
move up and down that list. This stereotype is based on the late
athlete’s 1995 liver transplant, in which he was given a liver at
the last minute by the regional organ system in New York.

But in fact, such a "list" system doesn’t exist in pure form,
according to Colleen Devaney, assistant to Dr. Ronald Busattil, who
is the chief of UCLA’s Liver and Pancreas Transplantation
Center.

Doctors make the determination for liver transplantation on a
mixed bag of criteria, ranging from blood type to body size and
similarity.

The new policy change announced by UNOS, she added, is designed
to counteract the distorted view in the public that the process was
inequitable and that celebrities or undeserving patients would
continue to move ahead of more deserving patients.

"This new allocation policy is a direct result of public outcry
because they think the system is inequitable, and the only way they
know about the system is because of the media," Devaney said. "And
what the media has fed them is not necessarily how the transplant
centers work."

One issue that UCLA administrators were concerned with this week
as news of the change spread was how UCLA would cope with the
increased flow of seriously-ill liver patients. As the dominant
liver center for Southern California, UCLA receives most of the
cases which are too serious or too difficult for smaller hospitals
to treat.

"Some centers do not transplant critically ill patients; they
send those patients to us (UCLA), because we can do them," Devaney
said. "For our patient population, we are going to be more
significantly impacted, because we do so many patients per year,
and we have more desperately ill patients than most other
transplant centers."

Nationally, the new UNOS policy on liver allocation will almost
certainly result in a different mortality distribution among those
waiting for transplants.

Doctors from around the country ­ at transplant centers and
in the research community ­ agreed, but added that the real
problem could be boiled down to one issue: an insufficient amount
of livers.

"The real issue is that there are not enough organs and that
people are going to die waiting for livers," said Thistlethwaite,
chief of the liver-transplant program at the University of Chicago.
As a result of that shortage, "the decision has been made to say,
‘Let’s ration to the ones with the greatest chance of being
helped.’"

Indeed, this shortage and need for liver rationing has led the
UCLA Medical Center and other transplant programs nationwide to
launch massive organ-donor programs, where donor cards are passed
out in places from sidewalks to book signings to black-tie
functions.

But for now, with the scheduled change expected to take effect
on Jan. 20, most medical officials have resigned themselves to
implementing the new policy and continuing to practice
medicine.