New liver-transplant rules causing anxiety, misgivings Priority will go to those who have the best chance of a relatively long life

November 17, 1996|By LOS ANGELES TIMES

LOS ANGELES -- Within the next day or two, Dr. Ronald Busuttil will sit down and compose a letter to the 250-plus patients on the University of California, Los Angeles Medical Center's liver transplant waiting list to explain why some of them will no longer be considered favored candidates for the life-saving operation.

Busuttil's department -- one of the largest liver transplantation units in the country -- has been swamped with calls from anxious patients since Thursday's announcement of changes in the rules defining who gets priority for a liver transplant.

In that announcement, the United Network for Organ Sharing said that thousands of people with chronic liver failure can no longer be among the first in line for a transplant.

Previously, the criteria for deciding who got a transplant were based purely on how close a person was to death.

The new guidelines will give priority, called "status one," to those who have the best chance of living a relatively long life.

Those would include children and patients with sudden illness -- for instance, liver failure caused by poisoning or a virus -- who are critically ill.

Busuttil is one of several high-profile liver transplant surgeons who have misgivings about the rule change.

"The thing that I am concerned about," he said, "is there are very legitimate candidates who have been status one, and because of these new rules, they will not be considered status one anymore."

Busuttil operated on one such candidate Nov. 10. Shelly Silva, a 31-year-old single mother from Sacramento, was near death when she was flown to UCLA Medical Center. Silva suffers from a rare life-threatening condition called secondary biliary cirrhosis, a result of successful treatment for pancreatic cancer.

Silva, whose recovery is progressing uneventfully at UCLA fTC Medical Center, said, "I'm so glad I got my liver. If they had already passed this rule, I would only have had a month and a half to live. Now, my life has completely turned around."

Silva added, "But with this new rule change, they'll be cutting people like me off from getting a transplant."

Others, however, applaud UNOS for facing the delicate issue of how to best allocate a scarce resource.

About 7,200 people are awaiting liver transplants. Last year, 3,922 such transplants were performed, and, according to UNOS, eight to 10 people die each day awaiting a liver.

"This is a real test case for what is fair and efficacious," said Dr. Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania.

"For many years, we've allocated livers in this country according to urgency: Who is, literally, at death's door?

"When liver transplant surgery first began, it was so risky, so dangerous, that to [select] someone who wasn't at death's door was almost immoral. But as liver transplant has evolved to better efficacy, that policy doesn't make as much sense."

Because most people survive transplant surgery, the priority will go to those with the best chance for a long life.

"We're trying to select out the smallest group of patients who could benefit the most," said James Wolf, UNOS' director of medical affairs.

While many cases of chronic liver failure are caused by alcoholism or hepatitis (which can be contracted from intravenous drug use), the rule change is not meant to punish those with lifestyle factors that might have caused the disease, said several experts.

"This policy has nothing to do with sin. It has to do with outcome," Caplan said. "It is true, however, that if you have many other diseases, you are not as likely to do as well with a transplant."

Lower status patients will still get liver transplants under the new rule, experts noted. Children, even if they have chronic liver failure or are not facing imminent death, will receive priority for transplants because children tend to have good outcomes, according to the new policy.

While controversial, the UNOS policy changes might reignite a much-needed public discussion about organ donation, experts said. "I think it will do more good than bad," said Dr. James Williams, director of transplantation at Rush-Presbyterian-St. Luke Medical Center in Chicago. "Maybe the people who make a big deal out of allocation can turn their energies to how to get more organ donors."

Pub Date: 11/17/96

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