From its inception, the concept of organ transplantation has drilled down to the fundamental ethics of practicing medicine. From initial concerns about donating organs from individuals who died of a cardiac event to the advent of living donation, the medical community questioned if this practice violates the basic tenet of the Hippocratic Oath: do no harm. Now the HCV community is moving steadily toward donation of HCV-positive organs into HCV-negative recipients, and a new set of questions arises.
Raymond T. Chung, MD, vice chief of the gastrointestinal division and director of hepatology at Massachusetts General Hospital, laid out the terms of the discussion. “The notion of donor-positive, recipient-negative transplantation for HCV has been, until now, inconceivable because of the concerns about the natural history of the disease and our inability to completely control it following transplantation,” he said. “When you consider the notion of knowingly introducing an infection into an infection-naive recipient, there is a high bar that has to be surmounted in order to be acceptable.”
Chung said that the arguments against this practice were largely ethical. “This was a threat,” he said. “The potential for allograft disease and infection was high, in addition to the risks associated with less-than-perfect or poorly tolerated antiviral therapies. The notion was off the table.”
But now, with direct-acting antiviral agents, it is possible and worthy of discussion, according Robert S. Brown Jr., MD, MPH, Gladys & Roland Harriman professor of medicine and director of the center for liver disease and transplantation at Weill Cornell Medical College and New York-Presbyterian Hospital in New York. He suggested that a more comprehensive view is necessary when examining the ethical considerations involved.
“It depends on your interpretation of ‘do no harm,’” he said. “If you take the narrowest definition of the phrase, you would never give someone an organ that had a disease. However, if you take a broader definition, giving someone a life-saving organ transplant they might not otherwise receive and then treating them with drugs that have a cure rate of 97% to 99%, it likely can be justified.”
For Brown, it is simply a matter of numbers. “The failure rate of these drugs is 3%,” he said. “The risk of dying on the waiting list is greater than that. It is certainly not an ethical issue in terms of risk–benefit.”
This does not mean, however, one can ignore the ethical questions or those of finances and logistics. Wait times for donor organs need to be considered, as do directions for future research. HCV Next and the experts attempt to tackle these and other concerns related to donor-positive, recipient-negative liver transplantation.