Last year a patient at Boston's renowned Beth Israel Deaconess Medical Center was sick enough to be at the top of a liver donation list, but conscious enough to calculate his risks of dying.
When a liver became available, it came with a catch. The donor had a history of risky sexual behavior and the organ could give the middle-aged recipient hepatitis — or worse, HIV/AIDS.
"The patient was not in the ICU and was able to answer questions, but it took him several conversations for him to make up his mind," said Kimberly Sullivan, his nurse and transplant coordinator.
"It depends on what might be transmitted," she said. "But if you look at it from the perspective of a dying patient, would he rather die or have a small chance of developing something like hepatitis B? Most patients take the organ and a chance at life."
More patients and their doctors are struggling with this dilemma as policies for using "high-risk" organs — those that might carry infectious diseases like HIV or undetected cancers — are shifting, according to transplant experts.
Because of the dire need for donated organs, a growing number of the sickest patients are taking the gamble. Though doctors say the risk of later developing an infectious disease or cancer is rare, it does happen, and the consequences can be tragic.
Just this week, Stony Brook University Medical Center in New York revealed that an organ donor, who had been misdiagnosed with bacterial meningitis, had actually suffered from a deadly cancer. His liver and pancreas were transplanted in two people who later developed the same lymphoma and died. Two kidney recipients had the organ removed and were undergoing chemotherapy, the hospital said.
Last year, four Chicago organ transplant recipients got HIV and hepatitis C from a donor who was considered at high risk of carrying the diseases. And in 2004 and 2005, both rabies and West Nile infections were transmitted to transplant patients via donated organs.
The incidents have prompted hospitals across the country to revisit their policies. At New York University Medical Center, where two of the cancer victim's organs were transplanted, stronger proof of bacterial meningitis status is required before a deceased patient can be considered an organ donor. The University of Minnesota, which transplanted the pancreas, has made a similar policy change.
The United Network for Organ Sharing (UNOS), the nonprofit organization responsible for coordinating all organ transplants in the United States, bans the use of an HIV-infected organ or one with acutely spreading cancer or some severe infections.
UNOS only requires a medical assessment of the donor organ, but because the need is so great, it does not prohibit organs from donors with a history of cancer or risky sexual behavior.
As of this week, 98,713 Americans were on the national wait list for organ transplants, according to UNOS. Only 28,354 of them received transplants last year from 14,395 donors. More than 6,000 patients die each year waiting for donor organs.
Today, a blood donor is banned from giving blood just on the basis of their sexual orientation for fear of spreading HIV/AIDS, but an transplant doctors accept organs from donors who have worked as prostitutes or have a history of injecting drugs.