After digesting the Wall Street Journal’s 2,500-word opus on the breaking scandal at the University of Pittsburgh Medical Center’s renown transplant center, my emotions are stirring violently this evening. “Disappointed” is an understatement. “Shocked” is an overstatement. “Angry,” “betrayed,” “saddened,” “curious,” and “determined” all come to mind, but none alone fits.
More than anything, I feel protective. I think about this amazing community that the Greatest Gift Foundation exists to serve, and I want them to be protected, not only from unethical behavior, but also from misinformation and false perceptions that will surely follow the resulting media blitz. So this post is my effort to help move people toward enlightened, in-context conversation.
First, the scandal summarized in one paragraph: Dr. Amadeo Marcos is accused of unethical practices to inflate the number of liver transplants performed at UPMC under his leadership, including questionable use of “expanded criteria” cadaver donor organs and living organ donor organs. He is accused, per the WSJ article, of three primary abuses: 1) falsifying (or, at least, misrepresenting) the frequency of negative outcomes of his surgeries to make his program seem more successful than it was; 2) putting donors and transplant patients at unethical risk by performing transplants on patients whose low MELD scores suggested that the risks of the procedure would outweight the benefits; and 3) having romantic affairs with his co-workers. A prominent motive, the article suggests, is financial.
Second, a plea for informed discussion — enveloped in context — from here: I hope every reader who encounters the WSJ article (and other related news items) will be alert and judicious — that they will carefully distinguish between proven facts and unproven assumptions, and that they will be wary of statements that could be lacking context.
But I know they won’t (people don’t). They will need our help. Because living donation can be such a positive force in people’s lives, and because it is such a viable part of the solution to the awful organ shortage that causes so many people to suffer, we need to do our best to constantly increase our world’s understanding of living donor risks and benefits, truths and myths, ethical problems and very real successes. In the wake of such high-profile news, we need to do this now more than ever.
Below are some of my personal thoughts, presented in the order they occur to me as I read the article sequentially. Pass them on, debate them, add your thoughts to comments, whatever helps keep an informed conversation going with the people around you! (And thanks, as always, humbly, for reading.)
Opinion 1: Transplant surgeons, governing bodies, administrators, and other key leaders should face the hard and ugly facts head-on. If Marcos truly was acting unethically, and doing so for reasons beyond the best interest of donors and recipients, there should be severe consequences. We should all insist upon strict adherence to ethics, quality governance to enforce ethics, and justice for any crimes or abuses. This is the only way living donor and expanded-criteria transplantation can succeed as a part of our solution to the organ shortage.
Opinion 2: The WSJ article offers no context to support the claim that Marcos or UPMC went overboard on the use of expanded criteria donors, which the article defines as “deceased people who had been older or sicker than preferred liver donors.” So the public should take this accusation with a grain of salt. Research is ongoing about the impact of donors who are older than 50 or who have had certain illnesses. It is pointed out that the average age of Marcos’ deceased donors (47) was nine years above the national average in 2003. But considering that UPMC is one of the most experienced and advanced transplant centers in the country, it might be reasonable for it to be pushing the envelope in the name of innovation. So much goes into any worthy assessment of the ethics of the age of the donor; we should be cautious about forming an opinion just on the basis of this one article.
Opinion 3: Marcos’ former co-workers say some damning things, in direct quotes, in the article. Be wary of the fact that they may have been taken out of context or misrepresented by the article’s author. Case in point is this excerpt:
“At times, according to [Dr. Howard Doyle, now director of surgical critical care at Montefiore Medical Center in New York], patients healthy enough to walk into the hospital before being transplanted died ‘because they had a high-risk liver put into them.’
If we take that quote literally, it’s outrageously worthless. The general public does not know the background of this enough for the assertion to hold any water with us. Consider these questions:
* What criteria is Doyle using to define “healthy enough” — MELD score? Likelihood of dying within three days or three months? Did the patient have a say in what “healthy enough” meant?
* Did those patients know what they were going into? Did they have an opportunity to weigh the risks and benefits, and decide to try the transplant? If so, does that make the decision to go forward any less unethical?
* What criteria is Doyle using to define “high-risk liver” — the age of the donor alone? The arbitrary choice of 40 years old, 50 years old, the national average… it’s all debatable as a standard (and being debated at the highest levels of leadership in the U.S.A.). A healthy and fit 55-year-old donor with a six-for-six antigen match to the recipient could be, in some cases, a much lower risk than some 30-year-old donors with a three-for-six match.
Opinion 4: Of all the horrible accusations in the article, this one angered and saddened me most:
[Dr. Thomas Starzl’s review of 121 living donor liver transplants] concluded that about 10% of the living donors had suffered serious complications, belying Dr. Marcos’s claim that this number was zero.
If Marcos truly concealed complications experienced by his living donors, I am furious — and we all should be. Our system does far too little as it is to care for living donors who experience negative consequences (mental or physical). Ignoring them or covering them up is an injustice of inconceivable proportion. But let’s also be curious about what “serious complications” are, about how that 10% compares to known averages and likelihoods, and about how well those living donors were informed about the risks ahead of time. Personal input: Had I known there was a 10% chance I would have serious complications, and were those serious complications clearly explained to me ahead of time, I want to believe I would have still gone ahead with my gift of my liver to my brother.
Opinion 5: I could give two shits about the affair stuff. Yes, I want to believe that the businesses I patronize — especially the specialists I rely on, like, oh, hospitals — are promoting ethical behavior that protects consumers from conflicts of interests and compromised quality of service. I insist on it, in fact. If Marcos broke hospital policy or was harassing women, he should be tried and disciplined. But it should be a separate discussion from this bit about the ethics of his transplantation choices.
Hm. I have many more where these thoughts came from. But this post is almost as long as the Journal article, and I don’t want to bore my poor blog readers.
I’d sure like to hear what you all think of this story. Comments???