Ethics of split liver transplantation: should a large liver always be split if medically safe?

Abstract

Split liver transplantation (SLT) provides an opportunity to divide a donor liver, offering transplants to two small patients (one or both could be a child) rather than keeping it whole and providing a transplant to a single larger adult patient. In this article, we attempt to address the following question that is identified by the Organ Procurement and Transplant Network and United Network for Organ Sharing: ‘Should a large liver always be split if medically safe?’ This article aims to defend an answer—‘not always’—and clarify under what circumstances SLT is ethically desirable. Our answer will show why a more dynamic approach is needed to the ethics of SLT. First, we discuss a case that does not need a dynamic approach. Then, we explain what is meant by a dynamic approach and why it is needed.

A retrospective analysis of outcomes and complications of living- and deceased-donor split-liver transplantation in Johannesburg, South Africa

“…argument for splitting livers, it is crucial to consider the principles proposed by Vulchev et al (quoted by Kim et al [23] ) which emphasise the importance of maximising the number of patients receiving organ transplants, provided that individual patients do not suffer disproportionate costs for societal benefit and that individual patient survival is maximised without society suffering disproportionate costs. Historically, SLT often led to less favourable outcomes for individual recipients, even though it increased the number of patients receiving organ transplants.…”

“…The argument further aligns with the principles of the Organ Procurement and Transplantation Network (OPTN) and the UNOS, as well as the Joint Ethics Committee's white paper, which emphasises the ethical obligation to maximise organ outcomes while promoting equity. [23] The ethics committee recognises the fairness and efficiency of splitting the liver for both children and larger candidates, aligning with the utilitarian principle of maximising societal benefit. [23] While the debate between LDLT and DDSLT is narrowing as outcomes improve, the utilitarian argument for split LT overall is gaining strength as a result of improved long-term outcomes and the potential to save more lives.…”

“…[23] The ethics committee recognises the fairness and efficiency of splitting the liver for both children and larger candidates, aligning with the utilitarian principle of maximising societal benefit. [23] While the debate between LDLT and DDSLT is narrowing as outcomes improve, the utilitarian argument for split LT overall is gaining strength as a result of improved long-term outcomes and the potential to save more lives.…”

Current Understanding of Marginal Grafts in Liver Transplantation

“…Hence, a comprehensive evaluation of suitable donor organs for splitting and a careful selection process for prospective SLT recipients become paramount. Moreover, to enhance the number and safety of SLT procedures, it is imperative to adapt the logistical framework of the splitting procedure and fine-tune organ allocation policies [114]. In selected patients and experienced transplant centers, the outcome of SLT can approach those of whole organ LT under certain circumstances.…”

Split liver transplantation with extended right grafts on adult recipients: A propensity score matching analysis

“…Split liver transplantation (SLT) has increased the number of donor livers available for transplantation while also increasing the discussion around the ethics and logistics of splitting an organ. 1 First reported in 1988, SLT was initially described to split a whole liver graft into the left lateral segment, segments II and III, for a pediatric transplant and then utilizing the remaining segments, an extended right graft, in an adult. 2 This technique then further evolved into potentially splitting a whole graft into a full right and a full left lobe for two adults.…”