As young Alyssa Leanne Smith continued her steady recovery Wednesday, researchers predicted that living-donor liver transplants such as that performed on her Monday may have their greatest impact in foreign countries where cadaver organs are not readily available because of legal and cultural restrictions.
The technique might also provide a way for foreign nationals to circumvent restrictive U.S. laws that limit them to receiving only 10% of available cadaver organs from this country.
Both possibilities raise a host of new ethical questions, however, including possible overuse of the technique in the United States and the technical competence of Third World surgeons to perform the intricate procedure and the possibility that individuals would be paid or otherwise coerced into making donations.
In the United States, the wide publicity given to Alyssa’s apparently successful operation has brought parents clamoring to the doorsteps of major transplant centers seeking to become liver donors for their own children. Many experts agree that the operation will soon be carried out at other centers as well--a prospect that some see as premature.
Meanwhile, both 21-month-old Alyssa and her mother Teresa were doing well. Alyssa was removed from her respirator Wednesday, according to Dr. Peter F. Whitington, and her liver function “is average for a pediatric liver transplant patient at this stage.” That seemed something of a disappointment, however, because her physicians clearly had hoped that a transplant from the mother would function better than one from a corpse.
But, he added, the liver has “a recovery capacity that is profound. We are still on course for a good outcome.”
Teresa Smith, a 27-year-old schoolteacher from Schertz, Tex., walked around her room Wednesday and was drinking water through a straw, according to her husband, John, but she has not yet had a chance to see Alyssa.
Whitington also had encouraging news about 15-month-old Sarina Jones, whose liver transplant from her mother, originally scheduled for Wednesday, was canceled when she developed a life-threatening infection. Her condition has stabilized, Whitington said, and the odds are even that she will receive the liver transplant next Wednesday.
The liver is vital to human health. It secretes bile that helps digest foods in the intestines, helps break down and store sugars and detoxifies many poisons in the blood. As many as 250 children die in the United States each year from liver failure, mostly as a result of biliary atresia, a blockage of the bile ducts.
The new living-donor liver transplant technique pioneered by Dr. Christoph E. Broelsch, of the University of Chicago, could improve the odds for many children.
In the first such transplant in the United States on Monday, Broelsch removed a fist-sized section of Teresa Smith’s liver, about a third of it, and transplanted it into Alyssa. Teresa’s organ is expected to regenerate itself, while the transplanted segment in Alyssa will grow with her if it is not rejected.
But critics, charging that the new technique is unnecessary in this country, argue that other techniques pioneered by Broelsch are sufficient to meet the demand for infant transplants. Those techniques include paring down adult livers from cadavers so that they will fit into the small chests of infants and dividing one adult liver to treat two children.
And they argue that the threat to the donor is substantial. “There is not an insignificant risk to the donor,” said Dr. Ronald Busuttil of the UCLA Medical Center. “This is not as simple as taking out a kidney.”
“If this operation is performed with any frequency, there will be a higher incidence of mortality and morbidity than with other surgical procedures,” added Dr. Robert Gordon of the University of Pittsburgh.
“I think we can do a lot to increase the number of donor organs in this country without resorting to living-donor transplants,” said Dr. Byers (Bud) Shaw Jr. of the University of Nebraska Medical Center, the only other U.S. surgeon to have divided up adult cadaver livers for children. “This technique may increase the number (of children successfully treated) slightly, but at what cost in terms of pain and suffering” of the parents?
But there are many other countries where cadaver organ donations are almost impossible to come by. In Sweden and Australia, for example, vague laws governing brain death make it virtually impossible to harvest organs for transplant before they deteriorate irreversibly. In Japan, cultural mores make the mutilation of corpses taboo.
Living-donor operations could have a major impact in such countries, Whitington said. In fact, the first four attempts at living-donor liver transplants were made in Brazil, Australia and Japan.
Some critics, such as Shaw, argue that the technique should be left to those countries. “The Japanese have a great deal of experience with liver surgery,” he said. “They have a lot of kids with biliary atresia that they are sending around the world for transplants. They ought to start doing this, and we ought to wait until we see their results before we start doing it more widely.”
But others question whether many foreign physicians have the technical expertise to carry out the complicated procedure--which surgeons agree is more difficult even than a heart transplant. Broelsch said that “only five to 10 surgeons around the world” are competent to perform the sophisticated hepato-biliary surgery he has pioneered, and that others will have to develop many years of experience before they try it.
Even some sophisticated U.S. medical centers, such as the UC San Diego Medical Center, have stopped performing normal liver transplants because of the difficulty. In light of these problems, “who is better than us to try to perfect the operation?” Whitington asked.
The use of the procedure overseas could also raise new ethical issues. According to ethicist Arthur Caplan of the University of Minnesota: “It would be unfortunate if this procedure was used to avoid the need to wrestle with brain death laws,” which need to be revised to make wider use of cadaver organs possible, he said.
Caplan also noted that some transplant programs abroad have had problems with potential donors who were paid to claim that they were relatives. In one case, he added, a Japanese gangster reputedly “allowed” a man who owed him money to donate an organ instead. This problem will become more severe, he noted, as research on new drugs to minimize transplant rejection reduces the need to rely on family as organ donors.
The living-donor procedure could also be used to circumvent U.S. laws governing transplants to foreign nationals, according to some doctors. Because of a scandal at the University of Pittsburgh Medical Center a few years ago in which foreigners were, in effect, buying their way to the top of organ waiting lists, new laws prevent more than 10% of donor organs from going to foreign nationals. Many U.S. residents resent even that percentage because of the overall shortage of organs. As many as 50% of U.S. children on waiting lists for organs die before receiving one.
Parents who donated a liver fragment to their children would be exempt from these regulations and would have the advantage of using sophisticated U.S. medical technology. Whitington notes that one candidate for the new procedure is the child of two Turkish physicians who live in Paris.