Physicians Must Treat 'Transplant Tourists'

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.

"Medical tourism" has been on the rise as demand for organs outpaces supply and health care costs in the United States skyrocket, Dr. Thomas Schiano and Rosamond Rhodes of Mount Sinai School of Medicine reported in Liver Transplantation.

"If there were enough organs to go around, no one would go abroad to get transplanted," Schiano said. "In our practice, it clearly has increased over the last three to five years."

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

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

"One of the liver transplant centers in our region, their policy is not to take on care of these patients, even if they were known to them before the transplant," Schiano said.

His 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. And some transplant centers abroad may use substandard surgical techniques.

Foreign centers are also less likely to send patients home with adequate records and education than centers here, the researchers said.

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, he developed septic shock, requiring three additional hospitalizations for a serious complication known as biliary sepsis. At that point, re-transplantation was the only viable option, Schiano said.

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

"The concern was that ... by re-transplanting him we're going to take a liver away from another patient on the waiting list who may die because they didn't get the organ," Schiano said. "That was the main ethical issue."

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.

Because of the dearth of guidance for dealing with specific problems that arise with transplant tourists, Schiano and Rhodes created some basic ethical principles.

They based their ideas on the understanding that 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."

"We're supposed to take care of everybody, whatever their lot in life," Schiano said. "That has to be the overriding principle. We can't blame these people for trying to save their lives and getting transplanted."

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.

"To turn your back on patients, especially if you know them before the transplant -- I don't agree with that," Schiano said. "It's the same thing in war. We treat the enemy soldier."

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.

Schiano said that he'd rather have more information about centers abroad before referring patients there. He does, however, recommend that patients travel to other areas in the U.S. to get their transplant if they live in high-demand areas such as New York or California.

"There are geographic differences in terms of organ availability. For instance, you can go to Florida with the same [severity] score and blood type and be transplanted a lot sooner than you can in New York," Schiano said. "It's probably because more donors become available in certain areas of the country."

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," Schiano and Rosamond 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.

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

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