Even so, Arthur Caplan, a bioethicist at the University of Pennsylvania, said hospitals have a responsibility to inquire about the source of their gifts.

"It starts to defy credulity that you're not going to be curious about who these people are, if only to ask them for more money down the road," he said. "Any development officer who didn't follow up a $100,000 gift with a check of who this guy is and who his friends are would be an ex-development officer."

Wealthy foreigners, he added, are attractive to transplant programs because not only do they pay the full cost for their procedures, but they often make gifts of gratitude later.

Dr. Joseph Tector, chief of transplant at the Clarian Transplant Institute at Indiana University, defended UCLA's actions. The occupations of his patients are not relevant, he said.

"As doctors, you are not a member of the clergy to ascertain someone's worthiness," he said. "You don't want to discriminate. These calls don't come so much into questions with other procedures. But with livers, the water is muddied because not everyone can get transplants. There aren't enough livers. "

But Dr. David Mulligan, a liver transplant surgeon at the Mayo Clinic in Phoenix, took issue with UCLA's statement that it does not make moral decisions when it adds patients to its transplant waiting list. He said transplant professionals make such decisions every day.

"By saying that we don't impose any kind of a moral judgment on people is not entirely complete," he said, "because I think that every transplant center has members of the [selection] committee who are social workers and financial aid advisors and psychiatrists who are intensely involved in the estimation of every potential recipient and their ability to progress with a full and long-standing recovery."

"I don't think that transplant centers can turn a blind eye to patients' social histories and their backgrounds," he said, adding that his center has run criminal background checks on some American patients about whom it has questions.

Transplant rules give hospitals and doctors the final say on which patients get added to their waiting lists, and they have the discretion to refuse patients with unhealthy lifestyles that could compromise the transplant's success. Patients may be refused on other grounds as well, including an inability to pay.

One L.A. doctor said he believes that UCLA's reputation as a first-class transplant center will suffer from the news of the four transplants.

"It's going to have a real negative effect," said Dr. David Boska, an internist in Brentwood who says he has referred 10 patients to UCLA over the last decade. "Their interest is to make sure people know they have a first-rate program. This isn't going to help."

Boska, who said he is a friend of Busuttil, added: "I have lost faith in the system, not the program," he said.

"You have a brother who dies because he doesn't have $500,000 to spend on a liver. That's a terrible thing to think about. Then you learn that we have foreign criminals who come in and get livers. That's not good.

"But it's terrible thing that we don't have any guidelines. We should have them. We have all these people dying in Los Angeles."

charles.ornstein@latimes.com

john.glionna@latimes.com