WMed Blog

There has been much media attention about the death of a 17-year-old girl with relapsing leukemia denied insurance coverage for a liver transplant.   This tragic event should offer an opportunity for an intelligent discussion of transplant policies.  Instead there has been the threat of criminal charges against those involved in the transplant decision process.  Another big problem is those people with knowledge; experience and perspective are remaining silent because of fears of being drawn up in an irrational debate.  Politicians have jumped into the debate with little knowledge of transplant issues but offering lots of draconian and impractical solutions.

There is no storage shelf of organs awaiting handout after insurance company approval.  At any given time, there are 100,000 Americans waiting for donated organs.  Due to a chronic shortage, only a small fraction of those will ever get a transplant.  For liver transplantation, there are more than 17,000 people on the waiting list with only about 5,000 liver transplantations available each year. After years of experience, there has evolved a fair but painful system to deal with transplantation issues.   The transplantation selection process takes place thousands of times a year by volunteer committees trying to fairly pick the best patient for each donated organ.

The goal of transplantation is to give replacement organs to patients with the best chance of survival and a long productive life.  With major breakthroughs in surgical technique and anti-rejection drugs, this miracle can be delivered.  In otherwise healthy patients, the one-year survival for liver transplantation approaches 90% and five-year survival is over 75%.  Patients who are extremely sick with multiple organ failure or other diseases are often denied. It’s not to play God, but a necessity to give the limited supply of donor organs to patients with the best chance of survival.
 
Deciding who needs a transplant and how to procure donor organs offers a major ethical challenge.  There has evolved a process of compartmentalization of each step of the transplant evaluation.  The process starts when the patient’s doctor believes a transplant will help.  A formal Transplant Committee reviews the request and determines if the patient will be put on the transplant waiting list.  It also assigns a priority score reflecting the urgency of the need.  The patient’s doctor usually does not sit on this committee because each doctor should naturally favor his own patient.  The transplant committee may be separated into organ donation and procurement sections.  The procurement section does public education for the need for organ donation and sponsors events  showcasing transplant recipients.
 
After the transplant committee has carefully reviewed each case, it decides whether or not to place the patient on a list of those awaiting a transplant usually through central organizations like the United Network for Organ Sharing.  The transplant committee also creates a score for each patient indicating how critical the need is.
 
Insurance companies including Medicare have a less well-defined role in the transplant process.  They don’t directly decide who needs a transplant or who will get one.  Their decision is to agree to cover the cost of the transplant if they have a contractual obligation to do so.  This does indirectly exert great influence on the transplantation process
Cynics will say insurance companies only decide transplant issues on the basis of economics.  Proponents say decisions are necessary to spend money wisely and to keep health care cost down.  Bankruptcy of the medical system would occur if every possible transplant need were met without regard to outcome.
Many would argue that the transplant system crisis shows the need for government control.  Statistics don’t support that.  Countries with government-controlled health care appear to do far less transplants than the United States. The United States is the transplant leader in the world doing about 52 kidney transplants per million population.   Canada does about 33 kidney transplants per million, Europe does only about 27 per million, and Asia does only 3 per million.

There is no question that a medical education is a rigorous experience with tough mental and physical challenges. The training period is great preparation for the real world life of a physician. Working long hours compacts years of experience into the training period. There is also no question that many physicians in training are chronically fatigued and overtaxed beyond the point of diminished performance. No one can argue with the adverse effects of fatigue on performance. Experts point out the impressive safety record achieved by the airline industry that limits pilots to about 80 flight hours a month. In an effort to combat the negative effects of fatigue on the training experience, academic medicine has now limited physicians in training to 30 consecutive work hours and an 80-hour workweek.

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