Paying Living Donors for a Kidney

Arguments against paying living donors for a kidney generally focus on two ethical concerns; 1) that payments might induce a potential donor to ignore the risks associated with kidney donation, and 2) that payments might exploit poor people, who would have a greater incentive to donate than wealthier persons.

To test these concerns, a team of researchers polled 342 potential donors in Philadelphia. The study found that potential donors’ perception of the risk of kidney donation is completely unaltered by how much money is offered for their kidney ($0, $10,000, or $100,000). The study also found that although a potential donor’s willingness to donate is influenced by money (more money, more willingness to donate), the effect of money was the same across all income strata. In other words, there was no evidence that payments would either induce donors to ignore risk or specifically exploit poor people.

Based on these data, perhaps payments should be offered to donors on a trial basis. It’s worth knowing whether potential donors’ actual choices would be the same as their hypothetical choices on a survey.

Steve Jobs' New Liver

It’s not official, but there are reports in the news media that Steve Jobs, CEO of Apple computers, received a liver transplant recently at an undisclosed location in Tennessee (The New York Times, June 23; “A Transplant That is Raising Many Questions”).

Normally, patients who need an organ transplant place themselves on the transplant list of one of eleven regional Organ Procurement Organizations (OPOs) in the U.S. Waiting times can vary. When an organ becomes available the regional OPO offers it to a patient already on its list, with the highest priority given to the sickest patients and those who have been on the list the longest time.

Most patients sign up for the transplant list at only one OPO, because insurance companies will only pay for an organ transplant performed in a person’s “home” OPO. Nevertheless, patients who are willing to pay for the transplant themselves (and with access to a plane so they can get to the hospital within six hours) can increase their odds for a transplant by placing themselves on the transplant lists of several different OPOs simultaneously. No one has said whether or not Mr. Jobs was on more than one list at the time of his transplant, or how long he waited for his new liver.

For a discussion of whether the current organ allocation system is fair, see “How Should We Allocate Scarce Organs?” in Human Biology 5th ed., pp. 368-369.

The Dark Side of Gender Preference

In China, 120 boys are born for every 100 girls. Experts think that the recent trend (since 1980) is the result of China’s “one-child” population-control policy, combined with a traditional society in which the eldest boy inherits the family land and is responsible for taking care of aging parents. So if a couple is planning on having just one child, usually they will decide it should be a boy. The boy/girl sex ratio is highest in rural areas; in cities, the earning power of women tends to be accompanied by a more normal sex ratio.

What can be done about it? One approach is educational programs to encourage couples to value daughters equally with sons; another is to allow families whose first child is a girl to have a second child; still another is to encourage young couples to live with her parents rather than his. The government is even offering cash payments for girls in some regions.

8 Babies - How Did It Happen?

Last week a 33-year-old unwed California women gave birth to octuplets. Experts say that there are only two plausible explanations; they could have been conceived naturally if the woman had taken heavy-duty fertility drugs and had ovulated eight eggs at once, or an IVF clinic deliberately implanted eight embryos, against all current IVF treatment guidelines.

The woman’s mother has said that the woman had frozen embryos left over from previous IVF cycles, and that she had embryos implanted last year. But who would implant eight embryos?! It’s no surprise that the woman’s doctor has not yet come forward to take “credit” for this feat. Ethicists and fertility specialists are in agreement that implanting eight embryos during one IVF cycle would be unethical and irresponsible. Doctors apparently offered the woman the opportunity to reduce the number of embryos early in the pregnancy, but she refused.

This one is likely to be debated for awhile by ethicists and fertility experts. It might even be discussed on Oprah's show some day soon, if the woman can get enough money to appear! Reports are that she is holding out for several million dollars. Good luck.

Note added April 20, 2009: Apparently six embryos were implanted, but two split into twins. The maximum number of embryos which should be implanted is two, according to voluntary guidelines established by the American Society for Reproductive Medicine.

Incentives for Organ Donations

There are now over 100,000 patients waiting for an organ transplant. Over 6,000 of them will die this year because they will not find a suitable organ in time. The problem, as discussed in Human Biology 5th ed. (pp. 368-369), is simply too few available organs for too many patients. Aside from the fact that finding a good match among unrelated donors is relatively rare, healthy people are often reluctant to donate an organ for emotional reasons and there is no financial incentive for organ donations. In fact, current federal law states that a person can go to jail and be fined $50,000 if “valuable consideration” is given to a donor. The law was meant to discourage commercial trafficking in human organs (considered to be exploitive of the poor), but it has also had a chilling effect on altruistic giving.

But that may soon change. Senator Arlen Specter of Pennsylvania will introduce a bill next year that would allow states to offer certain “incentives” to donors and their families, such as tax credits, contributions to 401K retirement plans, and tuition vouchers. The bill still would still prohibit the direct buying and selling of organs, however, so you won’t be able to buy a kidney on eBay any time soon.

One patient’s emotional odyssey as her kidneys began to fail is described in “Desperately Seeking a Kidney” published two days ago in the New York Times. It might make an interesting additional reading assignment for your students.

Frozen Embryo Dilemma

Fertility treatments and IVF procedures generally produce more viable embryos than are needed in order to achieve a successful pregnancy. So after a couple has a child by IVF, they must decide what to do with the “leftover” embryos. There are at least five choices: 1) freeze and save them for several years in case they choose to have more children, 2) discard them, 3) donate them for research, 4) donate them to another couple, and 5) leave them frozen until some other decision is made.

A recent survey published in the journal Fertility and Sterility (online Dec. 5) indicates that the decision is a difficult one, even for couples that do not want any more children. Over 40% would not feel comfortable discarding the embryos. And even though they no longer needed them for themselves, over 50% would not consider donating their embryos to another couple. Common reasons given were because they wouldn’t want their child brought up by another couple or because of the fear that their child might meet an unknown sibling someday. Forty percent would consider donating their unused embryos for research, but that option is not available at all IVF clinics. Faced with what they view as unacceptable options, twenty percent say they will keep the embryos frozen indefinitely. However, frozen embryos may not be viable after several decades, so this may ultimately be a decision to let the embryos die.

There are now more than 400,000 frozen embryos at IVF clinics. The authors of the survey suggest that potential parents need to be counseled thoroughly about the choices ahead of them before they choose IVF, not after.

What would your students choose to do if they had leftover embryos?

A Screening Test for Ovarian Cancer?

Here’s an ethical dilemma for you:

A promising new screening test for ovarian cancer called OvaSure can correctly identify ovarian cancer 95% of the time. Ovarian cancer is one of the most deadly cancers if it is not detected early. The company marketing the test says that the test has a false-positive rate of only 0.6%. (A false-positive is when the test indicates that cancer is present when in fact it is not.) Should the test be made widely available as a screening test for ovarian cancer?

Let’s see; 95% success rate at detecting ovarian cancer versus a 0.6% false-positive rate – it doesn’t sound like much of a dilemma, does it? You might try it out on your students to see what they think. But it is an interesting dilemma, and the reason is that ovarian cancer is rare; its prevalence is only about 0.06%. So among 100,000 women screened with the new test, 60 (0.06% of 100,000) would have ovarian cancer and 57 of them (95%) would be diagnosed correctly. Many of these 57 might be saved. However, 600 women (0.6%) would be told they had ovarian cancer when they did not. In the absence of any good corroborating tests to confirm the diagnosis, many of those 600 women might choose to have a surgery they actually didn’t need. And almost certainly they'd suffer emotionally from the belief that they had a deadly cancer.

Sometimes you have to run the numbers carefully to see the full effect of what is being said. It pays to be a skeptic.

ADDENDUM: Ovasure was pulled from the market in October, 2008, after the FDA sent the company a letter saying that the kits required FDA approval before they could be marketed and sold.

Testing Fingerprints for Illicit Substances

Could your fingerprints tell more about you than just who you are? A brief report in Science this month describes a technique that could allow crime investigators or even employers to analyze fingerprints for a variety of chemicals, including explosives and substances of abuse, such as cocaine. And since the chemicals would be determined from a single fingerprint, there would be no doubt as to who had handled the substances.

Law enforcement officials and crime investigators will welcome the technique as another weapon in their arsenal against crime. But the ability to test fingerprints for certain chemicals could also raise some privacy concerns for us all. Would we consider it ethical for an employer to enter workers’ offices to check for fingerprints containing traces of illegal drugs, without the employee’s knowledge or consent?

Reference: “Latent Fingerprint Chemical Imaging by Mass Spectrometry”. Science 321:805, August 8, 2008.

Merck Settles Vioxx Lawsuits

The news media are reporting this morning that Merck has agreed to settle 27,000 lawsuits against the company for damages related to its painkiller, Vioxx, for $4.85 billion dollars. (See the New York Times online at nytimes.com, Nov. 9 - "Merck Agrees to Settle Vioxx Suits for $4.85 Billion"). Since the lawsuits cover about 47,000 plaintiffs, the average plaintiff will get around $100,000 before paying his/her lawyers 30-50%.

The issue of what Merck knew and when they knew it regarding the potential health damage that could be caused by Vioxx is highlighted in Human Biology 5th ed., pp. 182-183. Merck had vowed to fight each and every lawsuit over Vioxx in court, a strategy that seemed to work for the company. Because Merck won most of the first 20 cases, plaintiffs began to realize that their best hope was for a modest but guaranteed settlement, rather than the chance of nothing at all if they sued individually for huge amounts.

For Merck, $4.85 billion was less than Wall Street had anticipated, and less than one year’s profit.

Can a Physician Refuse to Treat a Patient?

Yesterday I wrote about two Washington pharmacists who are suing for the right to refuse to sell the morning-after pill because of their religious and moral beliefs. What rights do physicians have when it comes to offering certain services or choosing to treat certain patients?

According to the Guttmacher Institute, 46 states specifically allow doctors to refuse to provide abortion services if they wish. Sixteen states allow doctors to refuse to provide sterilization services, and at least 8 states allow doctors to refuse to provide contraception. These policies have stood up to challenge as long as the doctor does not offer the service to any of his/her patients.

Well, okay, doctors certainly should have rights, too. The problem arises when a doctor provides the service to some patients but then refuses it to others. Patients’ advocates say that such doctors are hiding behind religion while violating anti-discrimination laws. For example, if a physician prescribes Viagra for a straight guy, should he/she be allowed to refuse it to a gay patient? What about a doctor who refuses artificial insemination to lesbian couples and single women, but offers it to married couples?

The California Supreme Court is about to hear a case in which a lesbian woman is suing two doctors for refusing to provide artificial insemination to her on religious grounds. The case is generating a lot of interest, with over 40 groups asking to be heard. Doctors’ attorneys are likely to argue that if physicians are forced to violate their religious or moral beliefs they may be driven out of certain specialties. But is it right that they should be able to force their beliefs on others instead?

What do you think? Whose rights should take precedence here?