Is 79 too old for a heart transplant?
CMAJ 2000;162:390
The University of Alberta Hospital has set off an ethical storm by performing a heart transplant on a 79-year-old man. A transplant team did the surgery Dec. 27 after lengthy debate and following a secret vote taken by members of the transplant unit. Dr. Arvind Koshal, director of cardiac sciences for Edmonton's regional health authority, said the hospital came to a compromise of sorts by transplanting a donor heart that would not have been used by another patient. The patient received a 55-year-old heart.
Usually, a heart that old would be reserved for patients facing death within hours or days without a transplant. But with no one on the waiting list qualified to accept the older heart, U of A staff transplanted it to the older patient. Causing a further wrinkle is the fact that the patient and Dr. Dennis Modry, who heads the U of A transplant centre, are friends. Although Modry was excluded from the decision-making process, Koshal agreed the transplant was considered because Modry argued in favour of the procedure. The patient was in excellent physical condition and Modry was against ruling the patient out simply because of his age.
But ethicists argue that, if the patient was deemed fit enough to receive a transplant, he shouldn't have received a "second-rate heart." The decision sets a dangerous precedent, according to Dr. Douglas Kinsella, a professor of medicine with the University of Calgary and past director of the medical faculty's Office of Medical Bioethics. "This could create a slippery slope where you use the poorer organs for the 'less good' persons, and the interpretation of who might be less good or less worthy could prove to be a very dangerous slope on which to start sliding."
Glen Griner, a philosopher and member of the John Dossetor Health Ethics Centre at the U of A, agrees. "Using less-good organs is like saying, 'Yes, you can ride on the bus but you have to ride at the back of the bus.' The first decision they make is that we will not discriminate on the basis of age and, having made that decision, he is then in fact treated differently than the other people on that waiting list. That looks curious and needs some explanation."
But Eike Henner-Kluge, chair of philosophy at the University of Victoria and a former director of ethics at the CMA, thinks the hospital made the appropriate decision. "If there is a difference between hearts at all, one would try to match a heart to a recipient. If you are looking at lifetime expectancy, you shouldn't give a heart with 70 years on the ticker to someone with 20 years left to live," he said. "It is a relevant difference. You want to make sure you get the appropriate use of the appropriate resources. That is ethically not questionable at all. We do this rationalization of resources in health care every day."
Dr. Koshal said that this is precisely the line of thought the hospital used. In fact, the patient, hospitalized since September following complications from a bypass operation, wouldn't have accepted a younger heart that a younger recipient might have received. The move to break the age barrier for transplant recipients, which is now 65, will force other changes in transplant protocols, Koshal insists. "Ultimately what I think will happen is we'll say, 'He is on the list and he gets whatever is available.' Criteria are going to be expanded more, but you need to be practical. Would you give a 55-year-old heart to 16-year-old patient? We face these decisions from time to time."
The heart transplant was 1 of 32 performed in the province in 1999. — Richard Cairney, Devon, Alta.
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