June 2, 2008 -- Reports of four organ transplant operations a UCLA surgeon performed on members of a Japanese crime syndicate have sparked debate among ethicists as to who should receive precious donated organs -- and whether wealthy foreigners should be allowed to "buy into" a system to which they do not contribute.
According to a Friday report in the Los Angeles Times, Ronald W. Busuttil, chief of liver and pancreas transplantation at UCLA Medical Center, provided the lifesaving operations to a powerful Japanese gang boss and three other members of a group known as the Yakuza between 2000 and 2004.
The Times report indicates that during this period organs were scarce and more than 100 people in and around Los Angeles died in each of these years as they awaited organs.
In a statement, the UCLA Health System responded that privacy laws prevent it from commenting on specific cases. Nor did the institution reveal to The Associated Press how much the Japanese paid the hospital for its transplant procedures.
Busuttil, in a statement of his own, noted that in his position as a surgeon "it is not my role to pass moral judgment on the patients who seek my care.
"If one of my patients, domestic or international, were in a situation that could be life threatening, of course I would do everything in my power to assure that they would receive proper care," he continued. "I consider that to be part of my responsibility and obligation as a physician."
And the United Network for Organ Sharing distanced itself from the cases in response to the Times article, noting that "the individual transplant center makes all decisions about evaluating and accepting transplant candidates. The [Organ Procurement and Transplantation Networks] role is organ allocation, and we are not involved in any decisions regarding an individual patient's qualification for a transplant. ... Federal law and regulation that guides the OPTN bars us from basing any allocation decisions on personal 'social worth' factors including personal history."
But some worry that the perceived inequality of the case could have a chilling effect on organ donation.
"The biggest risk here is how it might dry up the public altruism that leads to the contribution of organs to the system," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "There is nothing more toxic to this than the belief that an undeserving foreign criminal is getting priority in American transplant centers."
Who Deserves Organs?
Ethicists cite two facets of the case as being potentially problematic for the public when it comes to the fairness of cases such as the one at UCLA. One is the idea that criminals or those with a criminal history would be considered as worthy for a lifesaving transplant than another person who had no criminal record.
But Bill Allen, director of the program in bioethics, law, and medical professionalism at the University of Florida College of Medicine in Tallahassee, noted that as far as this aspect is concerned, the ethical balance is clear.
"The criminal law does not specify that persons convicted of crimes, much less those suspected of crimes, should lose access to lifesaving medical care as a result of their crimes," Allen said. "Social worth criteria as a material principle of resource allocation has always been full of problems, and this is just another example."
The other potentially problematic facet is the fact that the recipients of the organs were not United States residents. Some said this promotes unfairness by allowing these patients to draw from a limited organ pool to which they would never contribute.
UNOS currently allows medical centers to use up to 5 percent of donated organs to save the lives of foreign nationals.
"Whether to allow foreigners to get American organs for transplant is more controversial," said Jeffrey P. Spike, associate professor of Medical Humanities and Social Sciences at the Florida State University College of Medicine in Tallahassee.
"I think the current 5 percent rule is acceptable, but I also think it is acceptable to put some conditions on who we take."
The composition of this 5 percent may be another issue of concern altogether. Caplan noted that those who are in need of organs must first gain admission to the center. And money, he said, is necessary in order to secure this admission. "It's what I call the wallet biopsy," he said.
Admission into some organ transplant centers can cost up to hundreds of thousands of dollars. Those who have the ability to pay get in the door and on the organ transplant list. And when it comes to foreigners, those with the ability to buy in to the system purchase the right to donated American organs.
"The fact that foreign nationals with money can get organs in the U.S. and an American citizen -- who might well be an organ donor him or herself -- without insurance or funds to pay for an organ cannot illustrates the hypocrisy of a system that pushes altruism of the donors," said Joan L. McGregor, professor of bioethics at Arizona State University in Tempe.
"Maybe we should just be honest about the fact that we have a market in medicine and not be shocked by these occurrences," she said.
Policy Change Needed, Some Say
If anything, ethical experts said, the case highlighted in the Los Angeles Times could result in policy changes aimed at increasing the fairness of organ distribution policies.
"A few carefully worded restrictions might be added to the UNOS policies as a result of this case," Spike said.
But whatever the policy, ethicists and doctors agreed that the physicians should not be the ones who are saddled with the responsibility of selecting who gets organs and why.
"Doctors are supposed to care for patients regardless of the lifestyle, likes and dislikes, habits and profession of the patients," noted Ian R. Holzman, chief of the Division of Newborn Medicine at the Mount Sinai School of Medicine in New York. "Last I heard, we provide medical care for prisoners and enemy combatants."
"I don't want doctors making criminal justice decisions," said Jonathan Moreno, director of the Center for Biomedical Ethics at the University of Virginia in Charlottesville. "They have enough problems."