Is it ethical to transplant a kidney in an 85-year-old dialysis patient?
Before answering, consider that unlike heart and liver transplants—which go to the patient most likely to die without them—kidney transplants go to the next person on the list. Whomever’s been waiting longest is next up.
That’s one of the reasons I’ve declined several kidneys during my six year tenure on dialysis and have placed myself on “hold” on the waiting list. I have not, however, removed myself from the list entirely.
For a Denver nephrologist, cited in Alan Zarembo’s special report in the Los Angeles Times, a kidney transplant for an 85-year-old patient was both unreasonable and unethical. The organ would likely last much longer if given to a younger patient.
The 85-year-old patient was removed from consideration for the available organ. A few weeks later, ethical considerations presumably aside, he was removed from the waiting list completely—he was too old. He died of a heart attack 2.5 years later. Dialysis is extremely hard on the body’s systems. Maybe he would have lived longer with a transplant. But maybe not. Life’s like that.
According to Zarembo, “With little public scrutiny, transplant doctors and administrators are discussing who should receive life-extending kidneys—and support is growing for a national system that would favor the young.” The United Network for Organ Sharing (UNOS), the organization that oversees organ allocation in the US, already gives preference to patients younger than 18. “Last year,” Zarembo writes, “it moved them to the front of the line for high-quality organs from donors younger than 35.”
While UNOS oversees allocation of transplant organs in the US, individual hospitals set their own policies with regard to patient viability.
UNOS will hold public hearings on the issue of rationing organs next year, although the final decision lies with the Health Resources and Services Administration (HRSA).
The idea, based on an analysis of more than 300,000 kidney transplant waiting list patients since 1987, is to dole out available organs with maximum efficiency. Maximum efficiency as measured by maximum longevity—of the kidney, not the patient. The analysis factored age, body mass index, diagnosis, health, race, number of years on dialysis, and number of years of post-transplant survival.
Today more than 70,000 dialysis patients are waiting for a kidney—more than double the number waiting 10 years ago, and some researchers estimate that it could reach 100,000 by 2010. The average wait for an organ is now more than three years (and up to seven years in some cities).
“The growth has been driven by older patients—over 50, and increasingly over 65—who are joining the waiting list in record numbers and claiming an unprecedented share of kidneys,” writes Zarembo, who claims “from a statistical standpoint, kidneys are being squandered.”
“Nearly everybody, at least up to age 70, lives longer with a transplant than with dialysis. But the young gain the most extra years of life. In the mathematics of transplantation, they have the potential for the most ‘net lifetime survival benefit.’”
So, that’s what it’s come down to. Mathematical analysis and computer modeling will determine who’s a viable transplant candidate and perhaps more importantly, who’s not.
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