As uterine surgeries are planned, transplant system’s ‘gaming’ can’t be ignored

Let’s give credit where it’s due: Transplant surgery, in popular lore, has become one of modern medicine’s most miraculous practices, not only saving individual lives but also blazing new frontiers about the functions of organs in the body and providing insights of large significance into the workings of the human immune system. This progress hasn’t come without considerable cost to health care as a whole — and recent developments should prompt some deep thinking on how transplants work now.

First, let’s look at the disturbing study that suggests that wealth gives patients needing a transplant an edge when it comes to getting an organ. As the Associated Press notes in describing the research just presented to the American Heart Association, “You can’t buy hearts, kidneys or other organs but money can still help you get one. Wealthy people are more likely to get on multiple waiting lists and score a transplant, and less likely to die while waiting for one …[This work] confirms what many have long suspected — the rich have advantages even in a system designed to steer organs to the sickest patients and those who have waited longest. Wealthier people can better afford the tests and travel to get on more than one transplant center’s waiting list, and the new study shows how much this pays off.”

Who is to blame for this seeming inequity or gaming of the system? The United Network for Organ Sharing, or UNOS, has a government contract to run the system that decides who among 100,000 Americans waiting for various organs will get one suitable for transplant. The independent body “considers medical urgency, tissue type, distance from the donor, time spent on the waiting list and other factors.” Despite criticism of its practices, such as occurred when Apple tycoon and California resident Steve Jobs got on the liver transplant list in Tennessee, UNOS allows patients to traverse the country seeking the optimal situation for themselves and possible procedures. To even get on the lists, however, the patients–each time–must fork over, depending on the organ the need, anywhere from $23,000 to $51,000 for various suitability tests. Ouch.

Popular accounts about transplantation — feature stories with winsome kids or huggable grandmas — often also don’t describe the monetary toll of the procedures. In 2014, for example, almost 2,000 patients had heart transplants, procedures with an estimated, billed cost of $1.2 million each; 29 patients had complex heart-lung transplants, with a price tag of $2.3 million each.  Further, patients typically need to spend time before and after their transplant in serious, hospital care; they then face a lifetime of health challenges, including extensive medication regimens. They spend their own money (for example, to get to and from care) but insurance and government programs often must pick up a big portion of these hefty tabs. In other words, all of us bear a share.

It’s also only rarely discussed but, as current practice holds, the transplant approval process tries to minimize judgments as to how individuals arrived at their need for an organ; those who abuse alcohol or drugs and damage their livers, for example, must demonstrate sobriety for a period while under consideration for transplant — but they are not denied access to the life-saving receipt of an organ.

So are cost-conscious and ethical considerations already weighty enough in this field? Just wait. As the New York Times has reported, surgeons at the Cleveland Clinic hope to pioneer uterine transplants to address infertility in select patients who can meet some hefty prerequisites, including the ability to pay, at least, for their travel and stay in the Midwest for the preparation, five-hour surgery, and recovery. Doctors who considered whether to pursue the challenging process of making uterine transplant a more standard procedure recognized, they say, that it will not be life saving. But they said this type of surgery “has broadened to include improving quality of life, with for example, face and hand transplants.”

The physician who has driven the effort to try uterine transplants, which have been performed elsewhere but rarely and with mixed success in terms of patients bearing healthy children, is quoted in the Times as saying: “There are women who won’t adopt or have surrogates, for reasons that are personal, cultural or religious. These women know exactly what this is about. They’re informed of the risks and benefits. They have a lot of time to think about it, and think about it again.”

Good thing. It’s something all of us who are part of and pay for the healthcare system need to join.

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