Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a mother should be allowed to assume 25% risk of death in donating part of her liver to her daughter. Here are the results:
Yes: 75%
No: 25%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his book, :
Living donor liver transplantation (LDLT) has been controversial since Christoph Broelsch performed the first such operation at the University of Chicago Medical Center in 1989. A handful of high-profile deaths, most notably that of donor Mike Hurewitz at New York's Mount Sinai Medical Center in 2002, have heavily influenced the availability of the procedure. Yet such transplants can and do save lives.
With a chronic shortage of available organs, donors are often willing to take substantial risks to help their loved ones.
A serious concern in the consent process for such donors is that they may underestimate the dangers. Following the unexpected death of Paul Hawks in 2010, another supposedly healthy donor, surgeon James Markmann, chief of transplantation at Massachusetts General Hospital, told the Boston Globe, "You can quote 1 in 1,000 people will die and they think it's not going to happen to me because it's such a small number."
While such underestimates can occur with any medical intervention, the difference here is that the donor is healthy and receives no medical benefit from the surgery; any advantage she garners is entirely psychological or social. Since most LDLTs occur between close relatives, there is also the risk of duress. Ascertaining whether a brother really wants to give a liver to his sister or feels obliged to do so (by family pressure, guilt, etc.) is a determination that doctors are particularly ill-equipped to handle.
When the risks jump from 1 in 100 to 1 in 4, doctors are faced with an additional challenge: How much risk should they allow any individual person to accept? If one is willing to permit this parent to assume a 25% chance of death to save her daughter, what about a 50% chance or a 75% chance? What if the odds were 1 in 200 that she might survive the surgery? One can easily imagine a mother willing to risk her life at significant odds, or even sacrifice her life entirely, to save a beloved child.
Those desires may be sincere and heartfelt. To what extent a person should be allowed to act on these feelings is one of the challenges of modern transplant ethics.
Oddly enough, the degree of risk that any potential donor may accept is often influenced by the nature of the system for evaluating transplant programs. Teams and hospitals are rated, in part, on the mortality of both donors and recipients -- and those institutions which fare poorly can ultimately be shut down. Any transplant team willing to permit a patient with a 25% chance of dying to donate a liver to her child would certainly want to consider the impact on its program's overall success rate.
In addition to the risk of government sanction, the optics of a mother perishing under such circumstances would look awful for the hospital and its surgeons; on the other hand, a successful transplant would likely generate substantial positive publicity.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Would You Amputate Healthy Patient's Foot?