Doctors have an ethical obligation to treat complications from a transplant operation performed abroad

Originally published in MedPage Today

by Kristina Fiore, MedPage Today Staff Writer

Patients who travel to foreign countries for organ transplants may return with more problems than they left with — and physicians here have a moral responsibility to treat them, researchers asserted in a transplant journal.

Doctors have an ethical obligation to treat complications from a transplant operation performed abroad “Medical tourism” has been on the rise as demand for organs outpaces supply and U.S. healthcare costs skyrocket, Thomas D. Schiano, MD, and Rosamond Rhodes, PhD, of Mount Sinai School of Medicine, reported in Liver Transplantation.

Researchers have estimated that 300 medical tourism transplants occurred between 2004 and 2006, with more than 40% of transplant tourists residing in New York or California, which have only 18% of the total U.S. population.

Yet physicians have had little guidance on delivering care to these patients, and some transplant centers may turn them away, based on their actions, Schiano and Rhodes wrote.

Their questions about treatment arose with a 46-year-old Chinese patient who had been put on a waiting list for a liver transplant here because of end-stage liver disease.

The patient waited on the list for a year as his disease progressed from 18 points to 21 points on a 40-point severity scale.

Rather than wait any longer, the patient flew to China and had a liver transplant there.

Many transplanted organs in China come from executed prisoners, raising concerns about disease. Also, foreign transplants may be compromised by poor organ matching, unhealthy donors, and post-transplant infections, while some transplant centers abroad may use substandard surgical techniques, the researchers said.

Foreign centers are also less likely to send patients home with adequate records and education than centers here, they asserted.

Three months after his transplant in China, the patient came back to the clinic at Mount Sinai for follow-up care because he was about to run out of imunosuppressive medication.

Two months after that, the patient developed sepsis due to diffuse intrahepatic biliary stricturing related to hepatic artery thrombosis.

He required three additional hospitalizations for biliary sepsis, and at that point, retransplantation was the only viable option, Schiano said.

However, members of the medical team had conflicting views about giving the patient another new liver.

“He was a medically suitable candidate,” Schiano and Rhodes wrote, “but there was disagreement about whether it was morally right to provide him with a transplant.”

The clinicians had few ethical guidelines to refer to in making their decision because many deal solely with moral issues related to donors and foreign medical standards.

For example, the International Society for Heart and Lung Transplantation issued a statement against accepting organs from prisoners in April 2007, and the American Association for the Study of Liver Diseases and the International Liver Transplant Society endorsed similar policies.

The American Medical Association’s guidelines on medical tourism focus on best practices — for example, the procedure must be voluntary, it can’t limit the alternatives offered to patients, and patients should only be referred to accredited institutions.

While the United Network for Organ Sharing (UNOS)’s statement on medical tourism does maintain that the medical community has an obligation to provide care for these patients, it stops short of offering further direction to transplant programs.

“Little guidance is provided for dealing with the specific problems of patients who choose to become transplant tourists,” Schiano and Rhodes wrote.

Instead, they created some ethical guidance for the “moral quandary.”

Physicians have a “professional obligation to promote the good of patients” as well as a “professional responsibility to adhere to medicine’s commitment to nonjudgmental regard,” they wrote.

“Taken together, the moral principles of beneficence and nonjudgmental regard direct us to treat potential or returning transplant tourists as we would treat other patients under our care by focusing on providing the medical treatment and support they need,” they continued.

Physicians shouldn’t deny patients post-transplantation care, and they ought to provide emergent care at the very least. They may refer the patient to another transplant center for long-term follow-up if they regard it as unethical to continue treatment.

Patients should also be informed about the possibility of transplant tourism when they are not eligible for a transplant in the U.S. or when they are likely to die before reaching the top of the transplant list, Schiano and Rhodes wrote.

“Patients should not be threatened with abandonment by a center’s refusal to provide care upon their return,” they added.

As for the 46-year-old patient who was transplanted in China, the Mount Sinai team decided a transplant program must treat all patients on the basis of their need “regardless of what they might have done or how they secured their transplant organ.”

“Although [the patient] had a long, complicated transplantation course,” they wrote, “he is currently doing well.”

Mount Sinai has seen a total of nine patients who pursued transplants in China. Three of those had post-transplant problems but had been turned away elsewhere “because several transplant centers in our region do not render care to transplant tourists,” the authors wrote.

Seven of those nine patients have hepatitis B. Another three had had a renal transplant in India, and subsequently developed liver failure, the authors reported.

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