Did a rich sports team owner jump the line for a liver transplant?

Did a rich NHL team owner game the organ transplant system to save his own life?

Eugene Melnyk isn't well-known in the United States. But he's a household name in Canada, where he has been the owner of the Ottawa Senators of the National Hockey League since 2003. Since earlier this month, he has also been at the center of a remarkable and much-debated medical and ethical saga.

The public side of the saga began May 14, when Melnyk's NHL team issued a public appeal, via a press conference, for a live liver donor to step forward to save the 55-year-old businessman's life. Melnyk had been suffering from an unidentified disease since January, the team revealed. His rare blood type made it almost impossible to find a liver from a deceased donor in time. His friends and family had been tested, but none was deemed suitable. 

The appeal worked; an anonymous donor emerged within days, and Melnyk promptly received a portion of his liver. The donor asked nothing of Melnyk, doctors reported, except that he "bring the Stanley Cup home to the Ottawa Senators." Both donor and recipient were reported to be doing fine.

At the time, 1,500 people were waiting for a liver transplant in the province of Ontario. One-third of them are expected to die on the waiting list.

"A public solicitation raises a lot of ethical considerations," observes ethicist James F. Childress of the University of Virginia.

There are no indications that Melnyk did anything illegal. But his case underscores that transplant medicine, like so many other aspects of healthcare, functions under a "double standard," says bioethicist Arthur Caplan. "The rich," Caplan says, "do better."

Caplan says the existing transplants systems in the United States and Canada "do fairly well at distributing organs," but loopholes abound. One is that rich or celebrated patients have advantages in accessing the system. The other is that there are few rules governing live transplants, like Melnyk's.

Until the late 1990s, Caplan says, kidney and liver transplants from live donors almost always involved family members, often a parent donating to a sick child. Questions of donor motivation or financial gain rarely emerged.

Arrangements between strangers are much different. For one thing, they're private. No one can really be sure what Melnyk's donor, who is unknown to the public and supposedly to Melnyk himself, asked in return for a portion of his liver. Was his motivation purely altruistic? Emotional? Psychological? Or, indeed, financial?

Without standards governing donors and recipients and a publicly transparent process, Caplan says, the opportunities for abuses multiply. "Do you really want to set up circumstances where you're winking at a black market?" he asks.

The system of postmortem organ donations certainly isn't immune from being gamed by the wealthy. The best-known case is that of Apple co-founder Steve Jobs, who used his wealth to take advantage of a perfectly legal, if burdensome, procedure known as multiple listing to obtain a liver transplant in 2009.

The procedure allows patients to place their names on waiting lists in multiple communities, enhancing their chances of obtaining an organ in one place or another. But one must have the resources to travel cross-country at a moment's notice and to recuperate far from home. Jobs registered in California, where competition for available livers was fierce, and in Memphis, where it was lower and where he soon received a liver.

Occasionally an ordinary person with a heartbreaking story can break through with a public appeal for an organ donation through local or social media. "Statistics of how many people are on a waiting list won't generate quite as much interest as a compelling story," says Childress. The most compelling, he observes, involve children. The problem, of course, is that the most compelling stories may not involve the people with the most need.

In Canada, the debate over Melnyk's transplant has been largely sympathetic; discussions of the health of generally admired public figures usually are. His defenders argue that he wasn't jumping the line of liver patients so much as creating a line of his own, and that the publicity attending his case might well inspire more people to volunteer parts of their own organs in life and sign up as post-mortem organ donors.

The first is undoubtedly true: Melnyk's doctors say about 500 potential donors came forward after the Senators' appeal, most, if not all, of whom would not have offered to become organ donors otherwise. The second claim, however, is dubious. The evidence falls on both sides, Childress says.

"One could argue that, yes, this does highlight the need for more donors," he says, "but the perceived inequality of someone being able to make a public appeal could make people less likely to donate into a system that's already flawed." Nor is there any certainty that any of the people who came forward as live donors for Melnyk will hold themselves available for other candidates.

The Melnyk case does underscore the biggest flaw in the transplant system: "We're falling far short of the number of organs we need for transplants," Childress says. In the United States, the waiting list for transplants (mostly kidney, heart, liver and lung) is currently more than 123,000. Each day, about 21 people die while waiting, according to federal authorities.

Why is the gap growing? One reason may be that the success rate of transplantation encourages more doctors to see it as an option for their patients. Another is that public campaigns have failed to make people comfortable with the role of an organ donor. Some countries, such as Spain, have a higher donation rate because their system is "opt-out" -- one must ask to be taken off the donor list, rather than volunteer to join it. But an opt-out system is considered politically unpalatable in the United States.

"It's a complicated problem," Childress says. "I'm not sure we'll be able to solve it."

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