1. Ethics and Organ Transplantation Richard L Elliott, MD, PhD Professor and Director Medical Ethics and Professionalism Mercer University School of Medicine

2. Thomas Gordon 52 yo AA M with CHF, probable alcoholic cardiomyopathy, CHF, NYHA class 3, arrythmia EF 20% Was considered for heart transplant

3. Organs that can be transplanted Kidney Heart Lung Liver Thymus Pancreas Intestine Face? Tissue grafts: skin, cornea, bone, tendon, nerve, vein

4. A few landmarks in organ transplants Ancient stories of heart transplants 1596 Tagliacozzi skin autografts 1883 Kocher thyroid transplant Nobel 1909 1905 Corneal “transplant” 1912 Carrel Nobel artery and vein transplants 1926 Kolesnikov testis 1954 Murray kidney identical twins 1967 Barnard heart

5. Number of organ transplants- 2012 DeceasedLiving Kidney10,8685617 Heart2378 Lung17531 Liver3553151 Pancreas146

6. 120,000 waiting for an organ 4100 potential recipients added to lists/mo 2300 transplants performed/month 18 potential recipients die each day for lack of donor 1 donor can save eight lives

7. Matching donors and recipients Tissue matching Geography Donor – excluded if HIV, cancer in the affected organ, rapidly spreading cancer Recipient – some infectious diseases, terminal condition aside from condition requiring organ

8. Factors in choosing recipients Age and expected life-span? Productivity and contributions to society? Wealth? Likely adherence? Should recipients who have failed one transplant be allowed to move ahead on list for a second? Should convicted criminals receive transplants?

9. ETOH and Transplants Should patients with a past history of alcohol abuse be excluded from receiving an organ transplant? Should patients with alcoholic cardiomyopathy be excluded from transplant? Should patients currently abusing alcohol be excluded from transplants?

10. Ethics and organ donors Should organ donation be opt-out or opt in? Should donors be paid? Should treating physicians obtain consent or transplant team? Should parents be allowed to conceive to give birth to children who could donate to a sibling, e.g., marrow? Should donors choose recipients outside family? Should children be allowed to donate? Anencephalic infants? Should executed prisoners donate? Without permission? What criteria should be used to determine donor death?

11. Indications for heart transplant End stage CHF, estimated survival <1 year 99% cardiomyopathy, 1% congenital Intractable angina or malignant arrythmias NYHA class 3 or 4 symptoms EF<20%, Pulm Vasc Res < 2 Wood units Age < 65 years preferred Potential for adherence Conventional therapies exhausted

12. Contraindications Pulmonary vascular resistance > 4 Wood units Age > 65 years (relative) Ongoing substance abuse, psychosocial, instability, poor adherence Active malignancy Systemic infection or disease

13. Should Mr. Gordon receive a transplant? Factors associated with successful transplant http://www.uptodate.com/contents/heart- transplantation-beyond-the-basics http://www.uptodate.com/contents/heart- transplantation-beyond-the-basics

14. § 31-10-16 - Criteria for determining death; immunity from liability Listen O.C.G.A. 31-10-16 (2010) 31-10-16. Criteria for determining death; immunity from liability (a) A person may be pronounced dead by a qualified physician, by a registered professional nurse authorized to make a pronouncement of death under Code Section 31-7-176.1, or by a physician assistant authorized to make a pronouncement of death under subsection (j) of Code Section 43-34-103, if it is determined that the individual has sustained either (1) irreversible cessation of circulatory and respiratory function or (2) irreversible cessation of all functions of the entire brain, including the brain stem. (b) A person who acts in good faith in accordance with the provisions of subsection (a) of this Code section shall not be liable for damages in any civil action or subject to prosecution in any criminal proceeding for such act. (c) The criteria for determining death authorized in subsection (a) of this Code section shall be cumulative to and shall not prohibit the use of other medically recognized criteria for determining death. - See more at: http://statutes.laws.com/georgia/title-31/chapter-10/31-10- 16#sthash.liAVigVL.dpuf