The dilemma and reality of transplant tourism: An ethical perspective for liver transplant programs

Abstract

Transplant programs are likely to encounter increasing numbers of patients who return after receiving an organ transplant abroad. These patients will require ongoing medical care to monitor their immunosuppression and to provide treatment when the need arises. Transplant societies have condemned transplantation with organs purchased abroad and with organs procured from executed prisoners in China. Nevertheless, transplant programs require guidance on how to respond to the needs of returning transplant tourists and to the needs of patients who may choose to become transplant tourists. This discussion presents a case that raised such issues in our program. It goes on to offer reasons for considering a program's responses in terms of the most relevant principles of medical ethics, namely beneficence and nonjudgmental regard. This is the first in a series of case-based discussions of ethical dilemmas facing liver transplant programs and physicians. In caring for extremely ill patients with complex medical problems, liver transplant teams are on the front line when it comes to making difficult decisions. Many such decisions are made during meetings of the program's recipient review committee, a forum that seeks perspectives from a variety of professionals, including transplant coordinators, social workers, psychiatrists, and medical/surgical subspecialists. At times, however, a clear consensus on whether or not to perform transplantation for a patient may be difficult to obtain. What follows is such a case that we encountered at our center. THE CASEH.Q., a 46-year-old Chinese accountant, was placed on the liver transplant waiting list with a Model for EndStage Liver Disease score of 18 and an O blood type. He had hepatitis C with refractory ascites requiring biweekly paracentesis, type 2 hepatorenal syndrome, and hepatic encephalopathy. He had no potential live donor and no close family living outside the New York City area, and he did not want to consider dual listing outside United Network for Organ Sharing (UNOS) region 9. After he had waited on the list for a year, his Model for End-Stage Liver Disease score had risen to 21, and he had received no donor calls despite several recent hospitalizations. H.Q. was then unable to be contacted for several weeks, and a family member subsequently told us that he had undergone liver transplantation in China. Friends had suggested that he travel to China, where he could obtain a liver transplant for a fee. He then investigated the option through relatives in China and made the necessary arrangements to stay with them. He received a liver transplant 2 weeks after arriving in China.Three months after his liver transplant, H.Q. returned to our program, requesting follow-up care. He explained that he had received a liver transplant in China, but when questioned, he stated that he knew nothing about the source of the transplanted organ. He came with scant medical records and was about to run out of the immunosuppressive medication that he had been given by the transplant center i...

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