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TRANSPLANTS: ETHICAL THICKET
LEAD: HEART transplants are ''reaching the point where major decisions must be made'' on who gets a chance to live and who does not, says Dr. Jacques G. Losman, a former director of the transplant program at Beth Israel Medical Center here.
HEART transplants are ''reaching the point where major decisions must be made'' on who gets a chance to live and who does not, says Dr. Jacques G. Losman, a former director of the transplant program at Beth Israel Medical Center here.
Dr. Losman, who left the center on Jan. 1, wants to raise public awareness of some of the profound moral dilemmas he says he has seen in modern medicine, especially in heart transplants.
Among the questions Dr. Losman poses are:
* ''How do we select patients?'' Of 500,000 to 600,000 coronary patients in the United States, perhaps 150,000 to 200,000 could be eligible for transplants, yet no more than 5,000 hearts are available yearly. ''There is no satisfactory system to screen patients,'' Dr. Losman said.
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* Should criminals receive transplants? Should they be barred from optimal coronary care because of their incarceration and the expense to taxpayers?
* Should the hearts of children born without brains be ''harvested''?
* Should doctors give a donor heart to a new patient or to one who needs a second transplant?
* What about children who may need ''three or four little transplants''?
His program at Beth Israel was permitted to lapse last spring because of the mortality rate; from January 1986 through March 1987, there were 15 transplant patients, of whom 10 died, according to Tom Casey, a hospital spokesman.
Beth Israel is currently seeking regulatory approval to restart the program, which must maintain a 73 percent survival rate to meet insurance reimbursement requirements, hospital officials said.
Mr. Casey said that the hospital was looking for a replacement for Dr. Losman. The surgeon, he said, was brought to Beth Israel in 1984 to supervise the transplant program, with the first procedure done in 1986.
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Mr. Casey said that Beth Israel had not been displeased with Dr. Losman's work and that he was eligible to apply again to run the transplant program.
According to Mr. Casey, another program will get under way once approval is received from the state's Health Department. He added that Beth Israel had based its decision to ''put the program on hold'' on mortality tables provided in a 1986 issue of The Federal Register.
Dr. Losman said he would seek the directorship role again, adding that, even if someone else is chosen, he would continue to perform transplants at Beth Israel. He said that the hospital had ''voluntarily suspended'' his program as a result of a professional disagreement he had had with Dr. Victor Parsonnet, the hospital's chief of surgery.
Dr. Parsonnet, a cardiovascular surgeon, said he had suspended the program because ''we obviously had a very difficult time.''
He said that Dr. Losman's directorship had been replaced by a co-directorship ''troika'' consisting of himself, Dr. Losman and Dr. Isaac Gielchinsky, head of thoracic surgery.
Dr. Parsonnet said that Dr. Losman's program, with a 67 percent first-year survival rate, ''wasn't a disaster, it just wasn't good enough.''
He said that Dr. Losman was very deeply concerned for his patients and had ''tended to take on patients who were very, very high risk.''
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A new program, he said, could not afford to take such risks.
Dr. Parsonnet agreed that selecting patients was a ''wrenching'' experience and that selection in the future must be done by committee.
Although Dr. Losman agreed that most transplant centers were able to achieve a survival rate of at least 73 percent during the first year of their programs, he insisted that many complicating factors had to be considered. These include standards for screening patients and the availability of suitable patients, who tend to be drawn to more well-established centers.
Dr. Losman, editor of The Journal of Heart Transplantation, the official publication of the International Society for Heart Transplantation, cited research that showed typical survival rates ranging from 70 percent to 85 percent for the first year.
However, he noted that the University of Chicago's first-year survivial rate was reported at 50 percent and that of the University of Illinois at 25 percent.
Dr. Losman has faced difficult ethical situations since having performed heart transplants with Dr. Cristiaan Barnard at Groote Schuur Hospital in South Africa.
Was it premature for Dr. Barnard to gamble with the life of 55-year-old Louis Washkansky on Dec. 3, 1967, by planting the heart of a 24-year-old woman into him?
''I really don't think so,'' Dr. Losman said.
Although Mr. Washkansky died three weeks later, apparently because of mistaken radiation therapy, Dr. Losman said, the patient was someone whom ''no cardiologist would ever offer for a heart transplant today.''
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In fact, five of Dr. Barnard's early patients were more than 56 years old, which today is considered the cutoff age for transplant eligibility, Dr. Losman said.
In a speech before the Society of Professional Journalists at the University of Medicine and Dentistry of New Jersey last November, Dr. Losman said he had ''had the privilege'' of getting to know very well a patient who lived 12 1/2 years after one of Dr. Barnard's early transplants.
''The alternative for these people was to die in a matter of days or weeks,'' said Dr. Losman, who worked with Dr. Barnard from 1970 to 1978 before coming to the United States.
Since the introduction early in this decade of Cyclosporine, which fights the body's natural rejection process, thousands of heart transplants have been performed. The ethical problems, Dr. Losman said, stem from the medical reimbursement system and the shortage of donor hearts.
Dr. Losman believes that a vigorous public debate is essential to effect change because, without ''a public better informed and more demanding, we will come to a bottleneck.''
The debate, he said, should deal with such questions as the definition of death and ''when to harvest hearts.'' Lack of brain function is not universally accepted as a definition of death, he said, and so the question arises whether it is proper to remove a brain-dead person's heart to try to save another person.
Dr. Losman said that he had become less and less comfortable with transplant operations on newborns. Parents, he said, might be better advised to let the baby die and be urged to try to have another child.
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''There is very little likelihood to give the child a normal life,'' he said, and most such children will need another transplant within 5 to 10 years.
''We don't know enough to see that that kid goes to college and leads a normal life,'' Dr. Losman said.
Deciding whom to treat and whom to turn away can evolve into purely technical considerations, with human compassion secondary, he said.
For example, Dr. Losman said, specialists who reject too many patients may harm their reputations while, on the other hand, insurance programs pressure doctors to keep mortality rates down. This, in turn, pushes the doctors to turn away the seriously ill, he said.
However, the mortality figures used by insurers make little sense when lumped together, Dr. Losman said. For example, he said, patients who are carried into the coronary unit have much less chance of surviving than those who walk in.
Dr. Losman partly attributes the shortage of hearts to fewer deaths on the highways, which he attributed to the speed limit of 55 miles an hour, and in recent years, he added, the number of brain-dead people has become ''limited.''
Of 18,000 brain-dead people annually, only 2,000 to 5,000 are potential heart donors. This is because the organ must be transplanted within five hours of death.
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Another impediment to available hearts, Dr. Losman said, is ''the large number of people in the medical business who don't want the hassle of recovering organs,'' despite the increased willingness of relatives to donate body parts.
To be eligible for medical insurance reimbursement, Dr. Losman said, he must maintain an annual patient survival rate of 73 percent, a standard he calls ''very far from realistic.''
''The best way to achieve excellent results is to operate on less-ill patients,'' he said. ''You will achieve those results and be considered a center of excellence. But does that represent medicine?
''What do you do with a patient who was a suitable candidate for two or three months, but later deteriorates and then must be dropped from the program? It's very difficult.''
Dr. Losman said there had been ''a lot of noise made'' about the amount of money involved in transplants. Typically, he said, the argument runs that a bypass operation for clogged arteries costs $30,000, while a transplant costs $60,000 to $70,000.
Dr. Losman called the comparison ''totally unfair'' because, with complications, bypass costs could rapidly escalate to more than $100,000, he said.
''Our society can provide good medical care,'' Dr. Losman said, if ''our way of distributing wealth'' were modified. He did not offer specific suggestions; however, to a question on the efficacy of British socialized medicine, he indicated that the issue in the United States was more a matter of fairness than of money.
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''We are not giving everybody the same opportunity,'' he said.
Noting that ''Americans don't want to die more than any other people in the world,'' Dr. Losman cited the practice in the United States of performing coronary bypasses on people in their late 70's or 80's, whereas in Europe the elderly are routinely denied such operations.
''Is is logical for a system to have 80-year-olds occupying beds,'' he asked, while turning away younger patients for inability to pay?
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