Public plea spurs new liver, and debate over technique
■ UNOS is exploring the ethical issues related to public solicitation for organs.
By Andis Robeznieks — Posted Sept. 6, 2004
A billboard advertising a Houston man's desperate need for a liver helped save his life but raised ethical questions regarding the allocation of donated organs.
Thanks to billboard and Internet advertising and the media coverage his campaign received, Todd Krampitz, 32, has a new liver. The attention helped shine more light on the shortage of available organs, but some transplant experts wonder whether a new standard was set by the use of advertising and the media to get a specific organ for a specific person. They also question whether the practice of "directed donation," where one gets to choose who will receive a deceased family member's organs, unfairly bypasses a system designed to distribute organs to the patients who need them the most.
Catherine Burch Graham, director of communications for the Houston-based LifeGift Organ Donation Center, said the liver came from an out-of-state donor whose family requested that it be given to Krampitz.
"Interestingly, it wasn't the billboard itself that got him the organ, it was the media coverage of the billboard," Graham said.
Annie Moore, spokeswoman for the United Network for Organ Sharing, said although directed cadaveric donations are allowed by federal law, only "a handful" take place each year. Moore said UNOS had previously decided it was time to study public solicitation.
"At the June board meeting, [members] did acknowledge that it's an emerging issue, and a special committee was formed to make recommendations on that topic," she said.
AMA policy states that allocation of limited medical resources should be based on "ethically appropriate criteria" such as likelihood of benefit and urgency of need. The Association does not have a position on directed donation or public solicitation, said Robert Sade, MD, a member of the AMA Council on Ethical and Judicial Affairs and a former member of the UNOS ethics committee.
But Dr. Sade said his personal opinion is that "people have the right to be directed donors. It's not encouraged, but it's not against policy, so what happened is OK, but it leaves a bad taste for all the people on the waiting list who were jumped."
Dr. Sade added that it appeared that direct donations have not had a significant impact on organ donations as a whole, but warned that "there is the potential for this to become a competitive business about who has the best story to tell."
As a result of the Krampitz campaign, Graham said, LifeGift received about 100 calls from people seeking information on organ donation, including some who requested an organ donation card to place in their wallets. But not all the calls were positive. "We received a few from other transplant candidates who are not entirely happy with the campaign," she said.
The Krampitz family did not respond to telephone and e-mail requests for an interview.
Raymond Pollak, MD, professor of surgery and head of the abdominal organ transplant program at the University of Illinois in Peoria, said a happy day for the Krampitz family was a sad day for liver transplantation.
"By using the media and a directed donation by the donor family, the patient successfully bypassed the organ allocation system," Dr. Pollak said. "In so doing, he violated the principles of equity: Every person waiting should have an equal chance of receiving a liver; justice: The sickest person with the highest MELD [model for end-stage liver disease] score should be offered a donated liver first; and utility: The best use should be made of the donated liver."
Dr. Pollak does support some directed donations of cadaveric organs but says UNOS should allow the practice only within families.
Joining in the criticism of the liver-seeking campaign was Charlie Fiske, founder of the Family Inn in Brookline, Mass., a place where family members of patients awaiting an organ transplant can stay. In 1982, Fiske waged a successful media campaign to get his then 11-month-old daughter a liver.
This was an era before the UNOS allocations system. "She was kind of on the top of the list because there really wasn't a list," he explained. Now that there is an allocation system in place, Fiske argued that it should be followed.
"Was [the Krampitz transplant] done at the expense of someone else?" he asked. "Should I have to know the assignment editor at 'ABC News' to get good health care?"
The Krampitz Web site does offer information on how to become an organ donor, and some experts say that might lead to an increase in the number of organs available. "The Krampitz's plea has certainly turned attention to donation, and, in the long run, it will potentially generate more donors," Graham said.
"It does bring a face to the 17,000 people waiting for a liver," Moore said.
Dr. Pollak disagreed. He said awareness of the shortage is not the problem -- what's lacking is family awareness of a person's desire to donate organs. He said family refusal to donate a deceased patient's organs is based on not knowing what the patient wanted and not being able to handle the question in the immediate aftermath of a tragedy.