Steve Jobs' Reported Liver Transplant Stirs Debate

The rich may have advantage with 'multiple listings' on liver waiting lists.

June 22, 2009, 6:08 PM

June 23, 2009— -- Reports that Apple CEO Steve Jobs traveled to an unidentified hospital in Tennessee for a liver transplant this March have sparked a debate over whether the wealthy are able to use their resources to game the national organ donation system.

Representatives from Cupertino, Calif.-based Apple declined to answer specific questions from or confirm the Wall Street Journal report that Jobs, 54, received a liver transplant. However, Apple released this statement: "Steve continues to look forward to returning to Apple at the end of June and there is nothing further to say."

But if Jobs did indeed get a transplant at one of the three designated liver transplant centers in Tennessee (Le Bonheur Children's Medical Center in Memphis, Vanderbilt University Medical Center in Nashville and Methodist University Hospital in Memphis) experts agree that he would have cut his waiting time for an organ.

Jobs couldn't pay for an organ. Nor could he pay to cut the queue. But what someone with Jobs' resources could do, according to liver transplant surgeons and ethicists, is to use money and mobility to improve the odds either by going to an area of the country where there are more organ donors, or by signing up at multiple transplant centers.

"It's not for anybody but the rich. It's called multiple-listing, a practice some would say is unethical," said Arthur Caplan, co-chair of the United Nations Task Force on organ trafficking and chair of the department of medical ethics at University of Pennsylvania.

When a person needs a liver in the United States, the patient must go to a hospital with a transplant center for an extensive medical, mental and financial consultation. Then if he or she is determined a good candidate, the patient will be put on that transplant center's waiting list.

When a liver becomes available, the nearest of the 49 national Organ Procurement Organizations (OPO) will run a database search and algorithm to match the liver to people on all the transplant centers within that OPO's designated local and regional area.

"The local area is not a state, it's that donor service area of that OPO," explained Anne Paschke, spokesperson for the United Network of Organ Sharing (UNOS). "For a liver they're going to look in the local and regional areas before they look nationally."

According to the Organ Procurement and Transplantation Network, 15,771 people are currently waiting for a liver in the United States. Last year, 1,481 people died waiting for a donor liver, almost all of which come from the recently deceased. The national average waiting time for a transplant is about a year, but it can average as little as a few months at some centers, organ experts said.

Paschke said UNOS requires transplant centers to encourage patients to do "multiple listings" at transplant centers in multiple geographic areas to increase the odds of being matched to a liver. The only catch, Paschke said, is that health insurance policies often cover only one medical evaluation to get on one transplant center list. Most people simply don't have the money to pay for multiple extensive evaluations at far-flung locations.

Money Can Influence Chances on Liver Recipient Lists

"[Multiple listing] is not common. I think you have to have the means to do it and most centers are looking for patients that have a support system within the area," said Dr. Michael Porayko, medical director of Liver Transplant at Vanderbilt University in Nashville, Tenn.

"So, most people don't travel all around the country to get on a liver transplant list," he said.

The fact that anyone with Steve Job's level of wealth could use money to get a numerical advantage within the national system irks ethicists like Caplan. According to Caplan 3 to 5 percent of the names on organ waiting lists are "multiple listing," including U.S.citizens and wealthy foreigners who moved to the United States for medical treatment.

"Obviously the supply of organs is controlled as a public resource by UNOS," said Caplan. "Multiple listing undermines the fairness of the listing, in my opinion."

While Jobs and Apple have refused to speak about the matter, doctors say what Jobs has publicly revealed about his health makes his case more unusual in the organ donation system.

Jobs stated in 2004 that he was diagnosed with an uncommon islet cell neuroendocrine tumor in the pancreas. Doctors say under some circumstances the islet cell tumors cancer can metastasize to the liver, thus necessitating the need for a transplant. However, Apple has not commented on whether Jobs' cancer ever metastasized.

"Islet cell tumors are an unusual but an accepted indication for liver transplantation when the primary tumor has been addressed and the metastatic disease is limited to the liver," said Dr. Michael Millis, chief of transplantation at the University of Chicago Medical Center.

In years past a person needing a liver transplant from islet cell cancer would have to join a local waiting list with patients suffering liver failure from multiple reasons from alcohol abuse to hepatitis C. For years the liver recipient lists were managed by wait time and other factors such as age.

But in 2002 a new metric called MELD, (Model for End Stage Liver Disease) was supposed to level the playing field and make the wait for an organ purely associated with biology.

An Objective Way To Make Liver Recipient Lists?

"It's an objective score that is generated from patient's blood test to better be able to rank people in the severity of their illness," said Dr. Ari Cohen, a transplant surgeon with the Ochsner Health System in New Orleans.

"The MELD score makes it purely objective, and it's the same between centers," he said.

MELD scores range from 0 to a severe near-death score of 40. The sicker one gets, the higher the MELD score goes. At a MELD score of 15 or above, doctors begin to recommend a transplant.

But once the MELD score was implemented a clear geographic difference among waiting lists began to appear, according to Dr. Michael Porayko, medical director of liver transplant at Vanderbilt University in Nashville, Tenn.

"There are differences in wait times for livers," said Porayko. "I know for instances at the Mayo Clinic down in Florida, there are so many donors they can transplant somebody at a MELD of 17, 18, 19."

At Vanderbilt the average MELD score at time of transplant ranks around 24. But on the East and West Coasts, Porayko said the average transplant is done with a person who has a MELD score of 30.

But the original MELD score isn't always used to gauge a patient's needs if the disease that's causing the liver failure won't show symptoms in the MELD blood tests. In the rare case of someone with islet cell cancer, for example, the patient would be reviewed by a regional board that would then assign an "artificial" equivalent MELD score, said Cohen.

It's unknown whether Jobs fell into this category and what such a score might have been since he is not releasing his medical records.

Despite the cases of the wealthy benefiting from multiple listings, Cohen said he thinks the MELD system has so far proven the best method for fair organ transplants.

"People are constantly looking at ways to improve upon organ availability," said Cohen. "None of them are proven yet, so they haven't been applied. This system is the best system we have right now. "

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