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  #21  
Old 02 April 2015, 02:37 PM
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I think you're all missing that this is an update to a previous story. He'd originally been denied for a transplant for having a history of noncompliance with his medical protocol. There were hints that his criminal history were also part of the problem. After a public outcry the hospital reversed it's decision and put him on the list. So yes, it felt very much like he was on the list because of popular opinion rather than sound medical decisions.
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  #22  
Old 02 April 2015, 04:06 PM
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Maybe I'm also missing something, but don't organs that are harvested have to go to the recipients that most closely match them? Meaning that the heart he was given wouldn't have necessarily worked on anyone else. Obviously the fact that he wasn't allowed on the list in the first place meant he had no chance at all, but there's no guarantee that the donated heart he received would have been viable elsewhere. I don't think it's a first-come, first-served scenario where those waiting for a transplant are operated on in a strict chronological order. It's unfortunate that it appears that he threw away his second chance but he didn't deserve what would have been tantamount to a death sentence in the first place for being a 15 year old juvenile delinquent either.
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  #23  
Old 02 April 2015, 04:14 PM
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It is definitely based on compatibility between the donor and recipient and also on size and distance between the donor and recipient (hearts are only viable for 4-6 hours after removal from the donor).

The donor team that made the decision was not the one giving him the death sentence, that was "handed down" when the teen's own heart began to fail. Decisions between best use of limited (very) resources have to be made in medicine. Trauma workers doing triage who decide to not work on a critically injured patient who probably can't be saved aren't handing down a death sentence, they are making an important decision in order to maximize the potential good.

ETA: This document on organ transplant policies (pdf) shows that hearts can be transplanted into recipients who are as much as 2,500 nautical miles away from the donor's hospital. It also shows that hearts can be transplanted based on both a primary or secondary blood match. According to the chart, 9 of the 16 possible donor/recipient combinations would allow for a heart transplant.

Given both the viability distance and the number of potential matches, it would be hard to think of a situation where there wasn't another person who could also have gotten that heart.

Last edited by GenYus234; 02 April 2015 at 04:27 PM.
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  #24  
Old 02 April 2015, 05:07 PM
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Yes, I suppose "death sentence" was unnecessary hyperbole on my part, but as I said, he had no chance at all by being originally turned down as a potential recipient. I know that there are requirements that need to be met but "potential non-compliance" seems to be rather arbitrary at best. How exactly do you determine what someone is going to do or not do in the future? You can't, and there have been many patients who don't comply with their doctors orders. The fact that he came through the operation and survived as long as he did seems to show that there was really no medical reason to deny him the chance, nor did they ever claim that he was medically unfit to be on the list from what I recall. He was 15 and couldn't be expected to take complete charge of his medical care such as getting his medications and going to appointments for a few years at least. We have no way of knowing if another person who might have gotten that heart was more "deserving" somehow or even that someone else died because they didn't get that one. It's rather troubling to think that people may be denied life-saving procedures based upon assumptions about their character and possible actions in the future, especially a minor who isn't considered legally capable of taking care of oneself.
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  #25  
Old 02 April 2015, 06:13 PM
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To put a finer pint on that, I think we may be interweaving two issues. They are related under the large umbrella of "not doing what you are supposed to do" but are not the same.

1. Medical non-adherance
2. Deliquency/ criminal behavior.

Issue 1 is a legitimate reason to at least question suitibility for transplant. The issue there is that if the patient or family in case of a child really cannot or will not take the anti-rejection medications and other adjunct therapies, comply with infection control practices, etc., then the organ transplant would have a high likelihood of failure. It is basically saying that this transplant is not medically suitable. Using other behavior (grades) as a proxy for the prediction that they wil not do what is needed medically is dicey.

Issue 2 gets into the area of "Does this person deserve the transplant?" and it really is not in line with the common values of our society. I agree that in retrospect it sucks that the recipient of a very scarce resource did something unrelated to the transplant that got himself killed, but stuff happens. The one crime I would consider is continued IV drug use if it would harm the organ or the ability to provide care, etc.

In this case, as HL said, it appears that despite his prior deliquency, non-adherence, etc, that he did what was needed medically (e.g. taking meds) as he survived almost two years, apparently without rejection of the organ and ironically with enough energy to commit or participate in the crime that led to his death. So on issue 1, his prior medical-related behavior did not make him medically unsuitable for the transplant.

(All of this is my opinion only of course.)
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  #26  
Old 02 April 2015, 06:29 PM
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Regarding #2, is using criminal behavior based on deserving or is it based on the idea that non-compliance with authority in one area of life may be a predictor of non-compliance with authority in other areas?

Also, I think the only source that says the criminal part was the issue was the family. The only quote from the hospital refers to a history of non-compliance. The NY Daily News article even states that it is the mother who took that to mean his criminal past.
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  #27  
Old 02 April 2015, 08:23 PM
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Quote:
Originally Posted by Hapax Legomena View Post
How exactly do you determine what someone is going to do or not do in the future? You can't, and there have been many patients who don't comply with their doctors orders.
You have too. There are way more people who need transplants than organs available, some are going to get it, some aren't.

How do you decide who gets it? I think the best way is who will benefit the most. That depends on how severe their problem is, but also how effective the transplant can be.

An effective transplant doesn't just depend on the surgery and genetic match, but also how good the person is about getting follow-up care and taking their medications. Ethically, you HAVE to assess compliance in your decision making. And you do that in large part by past behavior: have they been compliant in the past?
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  #28  
Old 02 April 2015, 08:37 PM
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I don't think surviving two years after a transplant is proof of medical compliance. Medical compliance is not a guarantee of health, nor is non compliance a guarantee of mortality. Its impossible to tell how compliant he was based on the information provided.
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  #29  
Old 02 April 2015, 08:54 PM
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Quote:
Originally Posted by GenYus234 View Post
Regarding #2, is using criminal behavior based on deserving or is it based on the idea that non-compliance with authority in one area of life may be a predictor of non-compliance with authority in other areas?

Also, I think the only source that says the criminal part was the issue was the family. The only quote from the hospital refers to a history of non-compliance. The NY Daily News article even states that it is the mother who took that to mean his criminal past.
I think using criminal or delinquent behavior as a predictor of medical adherence is dicey. First, it starts down a road of who is deserving, even if that is not the stated purpose. More to the point, failure to follow authority may have nothing to do with medical adherence if the patient views the medical stuff to their benefit, and breaking laws unrelated to their condition also tho their benefit.

That said, at the outset two years ago I would have have been, and if I read it I think I was, on the side of the hospital's first decision. My only point was that the fact that he then died two years later while fleeing a crime scene is not proof that we were right about his medical adherence.

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Originally Posted by Beachlife! View Post
I don't think surviving two years after a transplant is proof of medical compliance. Medical compliance is not a guarantee of health, nor is non compliance a guarantee of mortality. Its impossible to tell how compliant he was based on the information provided.
True in general, but with a heart transplant if he survived two years and is apparently out and about, he almost certainly at least took his immunesuppressants (anti-rejection). He probably also took at least some antimicrobial prophylaxis or else got very very lucky.

Of course the reverse is not true. Some people take all of their meds and still reject or get other complications.

Again, my point was that if we say "aha- he was a nogoodnik See, we were right!" then we are saying that he should not have gotten the heart because clearly he was going to commit armed robbery. But the reason initially was that he should not get the heart because he was not going to take his meds and come to appointments. Nothing in the article suggests that he did not do those things. Nothing states he did, but see above.
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  #30  
Old 02 April 2015, 10:24 PM
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Quote:
Originally Posted by Dr. Dave View Post
Again, my point was that if we say "aha- he was a nogoodnik See, we were right!" then we are saying that he should not have gotten the heart because clearly he was going to commit armed robbery.
The original article suggested that his problems with the law were a factor in his initial rejection; the fact that he died a mere two years later during a run in with the law certainly seems to point toward the first analysis being correct. It's unfortunate that things ended this way, but the young man didn't die to a freak accident - it was the direct result of his choices. Those choices seem to have been (at least in part) predicted years earlier.
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  #31  
Old 03 April 2015, 03:44 AM
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We have a legal system in place to deal with people who break specific laws. The medical field is not responsible for justice in our society, not should it be. Health care personnel have enough to deal with. I don't think doctors should even be made aware of the criminal history of their potential transplant patients (though as GenYus pointed out, we have no reason to think they were in this case outside of the mother's claim).

Dr. Dave parced it all very well, medical decisions have to be based on science, not according to any scale that includes an assessment of someone's character, lifestyle, or personal choices. That's too subjective.

There are probably a lot of jerks out there who have recieved transplants. This one just happened to make the news.
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  #32  
Old 03 April 2015, 04:01 AM
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Originally Posted by Little Pink Pill View Post
We have a legal system in place to deal with people who break specific laws. The medical field is not responsible for justice in our society, not should it be.
By no means was I suggesting that we use a denial of transplant as a punishment for any crime. I'm only stating that there are factors outside of medical compliance that (IMO, and according to the article, I thought already were) might be considered. If someone is a candidate for a lung transplant should we completely disregard their smoking habits? If they make all their appointments, and take all of their medications, should we allow a lifestyle choice of theirs to ruin the extremely rare commodity they were just handed? An alcoholic who needs a new liver and has no intention of stopping drinking should be placed at the same priority as someone who hasn't voluntarily destroyed their own organ? 6500 people will die waiting on the transplant list this year - we need to make damn sure that those who are given transplants are going to do everything in their power to take care of them.
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  #33  
Old 03 April 2015, 04:19 AM
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Quote:
Originally Posted by Kallah View Post
If someone is a candidate for a lung transplant should we completely disregard their smoking habits?
No, but that would be a medical reason for considering them to be a poor candidate for a transplant.
Quote:
Originally Posted by Kallah View Post
An alcoholic who needs a new liver and has no intention of stopping drinking should be placed at the same priority as someone who hasn't voluntarily destroyed their own organ?
That also is a valid medical reason for denying a transplant and happens all the time. Age is also a factor in transplant priority, and the older someone is the less likely they are to be considered for a transplant as well. I am reminded of the controversy that actor Larry Hagman caused when he was given a liver transplant after many years of hard drinking at the age of 64. Many people accused him of "buying" a liver at the time and it's probably true that his wealth and connections gave him a chance that another 64 year old with a drinking problem likely wouldn't have gotten. He claimed that after the transplant he never drank again, and as it turned out he managed to live another 17 years before succumbing to cancer. I know that organs are a scarce commodity, but making decisions as to who gets them based on things outside of purely medical reasons is a slippery slope that we don't need to go down.
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  #34  
Old 03 April 2015, 01:08 PM
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Yes, as Hapax explains, there's more to medical compliance than taking one's meds and showing up for appointments. No one's suggesting we give new lungs to smokers or liver transplants to people who won't quite drinking.
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  #35  
Old 03 April 2015, 03:24 PM
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Quote:
Originally Posted by GenYus234 View Post
Regarding #2, is using criminal behavior based on deserving or is it based on the idea that non-compliance with authority in one area of life may be a predictor of non-compliance with authority in other areas?

Also, I think the only source that says the criminal part was the issue was the family. The only quote from the hospital refers to a history of non-compliance. The NY Daily News article even states that it is the mother who took that to mean his criminal past.
Also in the case of the family perhaps they/he even used him not taking meds as an excuse for his past criminal activities. I spent middle school through high school in special ed programs because I'm learning disabled (dysleic myself) and often got put in classes with behavior disabled kids. They and their parents would often use "oh he/she didn't take their pill today" as excuses for misbehaving.
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  #36  
Old 03 April 2015, 07:04 PM
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Originally Posted by Kallah View Post
By no means was I suggesting that we use a denial of transplant as a punishment for any crime.
No, but denying someone a transplant because of nonmedical reasons becomes a sort of secondary punishment, doesn't it? I do understand that you didn't mean it that way, but adding non-medical behavior to the scales pushes the whole thing into a different category. Like Dr. Dave said, it becomes about "deserving."

And what kind if criminal behavior counts? Parking tickets or reckless driving? Involuntary manslaughter or first degree murder? We can't ask doctors to make that call, because eventually it becomes about whether or not they think you're a good enough person for a transplant. It can't work like that. The justice system is there to judge lawlessness, not the medical system.
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  #37  
Old 03 April 2015, 10:00 PM
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Quote:
Originally Posted by Little Pink Pill View Post
No, but denying someone a transplant because of nonmedical reasons becomes a sort of secondary punishment, doesn't it? I do understand that you didn't mean it that way, but adding non-medical behavior to the scales pushes the whole thing into a different category.
Non-medical behavior is already being considered, it's just a matter of where the line between "lifestyle choice" and "medically relevant" gets drawn. Should someone who is morbidly obese, and who shows no sign of changing their habits, be thrown in the "that's a valid medical reason" category, or the "did you seriously just suggest fat people don't deserve to live as much as skinny people" category? Smoking and drinking are clear cut, but what if the patient has a history of picking up STIs because of unsafe sexual practices? Surely having to take additional antibiotics - or running the risk of something that can't be cured at all - is going to place additional strain on a transplant patient. Should everyone's sexual history now be considered a medically relevant point? What if someone is just clutzy, and manages to cut/bruise/burn themselves around the kitchen all the time, should we factor their inability to chop onions into antirejection drugs and blood thinners? How about your reckless driver suggestion - if someone freely places themselves in danger, over and over, is it a medical issue (potential injuries, bleeding, trauma) or a mere lifestyle choice?

There is a whole world of gray between the extremes, but I don't think that means it shouldn't be considered along with all the more obviously medical factors. I'm an organ donor, and I really hope that when I'm gone I'm giving folks who need is a second chance on life, not having my body chopped up and handed off to someone waiting to ruin that second chance the same way they ruined the first one. I suppose it doesn't matter either way, as I'll be dead at that point.
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  #38  
Old 03 April 2015, 10:13 PM
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None of what you have described here (except for the reckless driving) is criminal behavior though. Medical establishments should not ever be allowed to make medical decisions based on past or current criminal behavior.

Medical risk is something else entirely that I know absolutely zilcho about. Dr. Dave did give an enlightening post though.
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  #39  
Old 04 April 2015, 07:16 AM
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Originally Posted by LadyLockeout View Post
None of what you have described here (except for the reckless driving) is criminal behavior though. Medical establishments should not ever be allowed to make medical decisions based on past or current criminal behavior.
ETA: My own post was mudding my point. The point I'm trying to make is that "actions voluntarily taken by the potential recipient which might harm their own body" aren't limited to strictly medical reasons. A repeated reckless driving charge is a pretty good indication that someone isn't taking care of their body. Why is drinking your borrowed organ to death wrong, but flinging it into the side of the road at extreme speeds ok?

Last edited by Kallah; 04 April 2015 at 07:31 AM.
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  #40  
Old 04 April 2015, 07:24 AM
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Prisoners are able to be on the transplant list the same as everyone else. While not a definitive source, it is the best I can do at 1 in the morning.

Wikipedia says:

Quote:
In the United States, prisoners are not discriminated against as organ recipients and are equally eligible for organ transplants along with the general population. In Estelle v. Gamble, decided in 1976, the U.S. Supreme Court[6] ruled that withholding health care from prisoners constitutes "cruel and unusual punishment". United Network for Organ Sharing, the organization that coordinates available organs with recipients, does not factor a patient's prison status when determining suitability for a transplant.[7][8] An organ transplant and follow-up care can cost the prison system up to one million dollars.[8][9] If a prisoner qualifies, a state may allow compassionate early release to avoid high costs associated with organ transplants.[8] However, an organ transplant may save the prison system substantial costs associated with dialysis and other life-extending treatments required by the prisoner with the failing organ. For example, the estimated cost of a kidney transplant is about $111,000.[10] A prisoner's dialysis treatments are estimated to cost a prison $120,000 per year.[11]

Because donor organs are in short supply, there are more people waiting for a transplant than available organs. When a prisoner receives an organ, there is a high probability that someone else will die waiting for the next available organ. A response to this ethical dilemma states that felons who have a history of violent crime, who have violated others’ basic rights, have lost the right to receive an organ transplant, though it is noted that it would be necessary "to reform our justice system to minimize the chance of an innocent person being wrongly convicted of a violent crime and thus being denied an organ transplant"[12]
Sounds like the problem you're highlighting is already considered. Those who are violent etc are barred from organ transplants. However, poor decisions and poor peer choice on the part of the OP in question do not have him falling into that category. So far there is nothing to indicate that he was involved in more than petty crime, and therefore less deserving of the heart in question.

ETA: And to my knowledge, death row inmates are not included on the organ transplant list, and never have been. The flip side of that is that they are also barred from being organ donors themselves, which makes no sense to me.
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