Harvest of Corneas at Morgue Questioned
A renowned eye bank has paid more than $1 million during the last five years to the Los Angeles County coroner’s office in exchange for thousands of corneas, harvested without the permission or knowledge of the families of the dead.
Although the practice is permitted under a little-known state law, officials of the coroner’s office and Doheny Eye & Tissue Transplant Bank have used the statute so extensively that critics say the morgue has become a virtual cornea mill.
“Totally immoral,” is how former Doheny technician Julia Brain described what is happening behind the coroner’s doors--and behind the backs of families.
“Repugnant,” said former coroner supervisor Peter Linder.
Under the 14-year-old state law, coroners are allowed to remove corneas in cases targeted for autopsy if there are no known objections from the next of kin.
When the law was passed, there was a shortage of corneas and long waits for people seeking transplants of the dome-like tissue that covers the eye’s colored iris. Speed was of the essence because corneas usually disintegrate within 24 hours after death. For that reason, coroner officials are not specifically required under the law to seek time-consuming permission.
There is no doubt that the wide availability of corneas has helped thousands of people overcome a variety of vision-impairing maladies. But a mounting number of medical experts say the law is unnecessary today because corneas are so plentiful that none need be procured without the blessings of loved ones.
San Francisco Medical Examiner Boyd Stephens, for one, said he will not allow cornea removals without family approval. He said surveys by his office have shown that even people willing to donate internal organs draw the line at eyes.
“When you think of somebody you know, you envision their face, their eyes and nose,” Stephens said. “You don’t identify anybody by their liver.”
In Los Angeles, that has not deterred coroner’s and eye bank officials, who say they have been guided only by humanitarian concerns and the dictates of the law.
An investigation by The Times has revealed that the coroner’s office and Doheny are invoking the state measure on an unprecedented scale. This has generated a cheap source of corneas that the eye bank resells for a markup of more than 1,200%. In return, the cash-strapped morgue receives payments of about $250,000 a year.
In all, at least half of Doheny’s corneas--more than 1,000 annually--come from coroner cases in which consent has not been obtained, a number unmatched by any eye bank in the state.
Along the way, critics and medical experts say, ethical lapses and procedural breakdowns have occurred.
Internal documents, a computer analysis of hundreds of coroner cases and scores of interviews disclosed that:
* Employees of the coroner’s office and the eye bank say they have been discouraged by superiors from asking permission of family members, even when easily accessible at death scenes, through the police or by telephone. In that way, no objections can be lodged and the corneas can be harvested under the state’s so-called Coroners Law.
* The eye bank’s employees are under such intense pressure to procure corneas that their productivity has been charted on monthly bar graphs. Earlier this year, when the numbers dipped, a veiled warning of possible “downsizing” was issued by the president of Doheny’s management organization, Tissue Banks International, a driving force behind the 1983 Coroners Law.
* The ties between Doheny and the coroner’s office are extremely close--some say incestuously so. The morgue’s former director is now a key executive of Tissue Banks International. In recent years, Doheny has hired relatives of pathologists working for the coroner’s office. At times, full-time morgue employees have moonlighted for Doheny. Some of the eye bank’s technicians have their own keys to the coroner’s office, giving them free run of the facility and its investigative files.
* Contrary to federal health-safety guidelines, Doheny technicians have removed corneas from people recently incarcerated and from drug users--high-risk candidates for infectious viruses, including hepatitis and AIDS. In addition, no family or medical histories are sought to discover other possible health dangers. Although chances of disease transmission through corneal transplants are extremely remote, most eye banks and coroners outside Los Angeles say they prefer to err on the side of safety.
Doheny and the eye bank’s management firm, both of which are listed as nonprofit organizations, say they not only have complied with the law but have been motivated solely by a genuine desire to help those with vision that has been impaired by such things as cataract surgery and scarring from accidents and infections.
The Coroners Law, according to Doheny Executive Director Jeffrey A. Thomas, “enables everyone with need [for] the rapid access to sight-restoring corneas.”
Officials of the Los Angeles County coroner’s office also say their extensive use of the law has been justified by the long-standing demand for corneas in Southern California. Nonetheless, they say, the time has come for a change--prompted, they acknowledge, by internal dissension and recent questions from The Times.
“There were some employees feeling they should inform the families,” said the coroner’s top administrator, Anthony T. Hernandez. “We took a look and said maybe we should.”
Hernandez said a policy requiring employees to seek family consent was drafted about eight months ago, but “fell through the cracks” until inquiries from the newspaper revived the issue. Hernandez said he expected that the new policy would be in place within days.
Former state Sen. Robert Presley (D-Riverside), who wrote the Coroners Law, said he is proud that the measure boosted the number of corneas available for transplants, but he never anticipated that family members would be disregarded in the process.
“Technically, legally, they’re OK to do that,” Presley said of coroner officials. “But you would think, if the family is right there, they would say, ‘Do you have any objection?’ ”
Relatives Shocked by Disclosures
As part of its study, The Times examined 572 cases for a 12-month span beginning in July of 1996, as well as a scattering of others from years past in which corneas were taken under the Coroners Law--meaning families were unaware that the procedure had been conducted. When contacted by the newspaper, some responded with anger, others with understanding. All, however, were shocked that they had not been asked or told.
Yolanda Aguirre’s son Mitchell, 18, was killed in a gang shooting Feb. 3. When his body arrived at the morgue, his corneas were promptly removed.
“It makes me want to cry,” the El Monte mother said. “How come they don’t send letters to tell us what they’ve done?”
Aguirre, unlike some others, said she finds no comfort in the knowledge that her son has possibly provided the gift of sight to another.
“A lot of people need a lot of things,” she said. “I need a million dollars but I don’t take it from somebody. . . . Those were my eyes. Those were my creation.”
Frank Casias also was infuriated to learn that the corneas of his 20-year-old daughter, Christina, had been secretly removed.
He said he could have been asked for permission at the death scene--the family’s Canoga Park apartment, where he found Christina dead from breathing complications shortly before 1 a.m. on Feb. 15. Had he been asked, Casias said, he would have answered no.
“I had just gotten finished looking into her eyes. I tried to give her CPR. It would have been hard enough to donate anything at all,” recalled the father, who said he is now at peace with what was done.
Ken Brondell said permission could easily have been sought from him too. His 40-year-old daughter, Christy Lynn Hamilton, was a rookie Los Angeles police officer who was gunned down three years ago in the line of duty. She was the oldest woman to graduate from the Police Academy.
Brondell said he was in constant contact with the Police Department. As the official next of kin, he was chauffeured to the hospital and stood vigil before Hamilton’s body was delivered to the morgue. He then returned home, where he said he could have been reached at any time.
“If they would have asked me, and I had a few minutes to think about it, I probably would have said yes,” Brondell said. “But it kind of bothers me that it was done without any notice.”
Said Hamilton’s brother: “Good manners dictate that a thank you note be sent. You do that for a wedding gift.”
Even families with the presence of mind to register objections on their own sometimes are too late for the quick work of Doheny’s technicians, who are allowed to peruse paperwork of unfinished cases and remove bodies from the coroner’s crypts.
Carlos M. Gudino, a 24-year-old Wilmington gang member, died shortly before 9 p.m. on March 26 from 12 bullet wounds to the chest and head. His sister called the morgue the next day.
“My parents told me to let them know they didn’t want any organs donated or anything,” Maria Gudino said during a brief interview at her family’s apartment. She said she was told: “ ‘Don’t worry, honey, we’re not going to do that. Thanks for letting us know.’ ”
A coroner’s investigator dutifully noted the objection on a supplemental note to his report: “Family is profoundly against ANY organ or tissue donation per conversation with multiple family members 03-27-97.”
By then, it was too late. Gudino’s corneas had been removed three hours earlier.
A similar circumstance prompted a lawsuit against Doheny and the county by the family of Carlos Lopez, a 20-year-old man shot while eating at a fast-food stand. After Lopez died at County-USC Medical Center, the family refused a nurse’s request to harvest some of his skin. Lopez’s body was then transported around the corner to the morgue, where Doheny employees removed his corneas--two days before the autopsy.
The case was settled for an undisclosed sum.
The failure to request permission in these and other cases was no mere oversight but, rather, common practice.
Robert Iwan once ran Doheny’s Central Coast office. He now is a freelance illustrator and substitute teacher in Alhambra.
“We were, under no circumstances, to call the family or approach the family,” he said. “If we were to approach the families, we risked the possibility of the family saying no. Then we would lose the corneas, at the very least, and that was something they [eye bank executives] didn’t want.”
Veteran coroner investigator Pam Eaker said she received the same message from her top boss.
“I was told not to ask [families],” Eaker said, because coroner administrators “didn’t want us involved in that aspect.”
And if the families weren’t asked, there was no reason for them to wonder.
“If you take the cornea, no one knows it’s gone,” said Lisa Karlan Rasgon, who once operated a local tissue bank. “That’s how they’ve gotten away with it . . . because who goes up to a dead person and opens their eyes? There’s no disfigurement when the corneas are removed.”
Cornea removals are disclosed on public autopsy forms, but those documents usually are not available until long after burials. What’s more, the documents, by design, are worded to minimize potential problems from family members, records obtained by The Times show.
In 1991, the vice president of Tissue Banks International asked the coroner’s office in a letter to stop calling corneal removals “donations” on its official paperwork.
“The question arose in our minds,” he wrote, “that describing the cornea removal . . . as a donation might trigger responses from the reader which could be of concern.
“In cases where corneas are removed the NOK [next of kin] upon reading the Autopsy Report might object to the term ‘donation’ when in fact the ‘donation’ was authorized by statute.” He suggested this change: “Corneas removed (CGC)"--an acronym for the California Government Code.
“We feel this statement would address the issue in a positive and completely honest manner,” the executive wrote.
The coroner’s office agreed, noting in its procedural manual: “Please do not use terminology such as, ‘The corneas were donated,’ or, ‘The eyes were removed,’ as this could lead to misunderstanding and concerns for the next of kin.”
Information about the legislatively authorized removals also is contained in a single paragraph of a pamphlet titled “Information from the County of Los Angeles Department of Coroner.” The three-page pamphlet is kept in the morgue reception area, along with a variety of others on various health issues.
Tissue Banks International contends that coroner employees provide the pamphlet to everyone identifying a body at the morgue. But coroner officials say the truth is that employees are not required to give the pamphlet, and many do not.
Coroner administrator Hernandez said distribution has been on a “catch-as-catch-can” basis. He said that, under the new policy, investigators will be required to hand the pamphlet to family members.
Eye Bank Employees Under Pressure
Doheny’s county contract has paved the way for it to become one of the most productive eye banks of 111 in the nation, according to statistics compiled by the Eye Bank Assn. of America.
Last year, Doheny supplied 1,846 corneas for transplants, second only to an eye bank in Tampa, Fla., which does seek family consent, despite being in one of 21 states with laws similar to California’s. Doheny also has the right to recover skin, bone and heart valves from the coroner’s office on behalf of other tissue banks--taken only with family consent.
Insiders say Doheny employees have taken full advantage of their access, driven by productivity goals set by Tissue Banks International, which runs a nationwide network of eye banks.
Tissue Banks is widely credited with transforming cornea acquisitions from what used to be a small volunteer effort pioneered by the Lions Club into a highly professionalized operation with big salaries, executive perks and high overhead.
Tissue Banks International runs the administrative side of its 11 eye banks across the country, buying supplies, hiring workers and ensuring that the network has a ready supply of corneas that can be shipped on a moment’s notice where the need arises. In return, Tissue Banks charges its affiliates a management fee based on the amount of money each generates on corneas and other tissues. Last year, Tissue Banks collected $600,000 from Doheny, records show.
Efforts to keep the system working--and the money flowing--are intense.
Earlier this year, when workers at Doheny and its affiliated eye banks picked up their paychecks, they also were handed a letter from Tissue Banks President Richard Fuller, urging them to work harder. The reason: “Corneal Tissue Volumes are under budget by 9%, or 376 corneas.”
“This is a very serious concern since ocular programs [represent] 80% of our ‘business,’ ” Fuller wrote.
“It is up to each of us to put forth extra effort to ensure that tissue volumes are met and costs are contained. . . . ‘Re-engineering,’ ‘reduction in force’ and ‘downsizing’ are all common terms these days. Let’s make sure we do not have to use them to solve the problems we face.”
In an interview, Fuller said the letter was intended to “nudge people a little bit. . . . We don’t pressure nor do we threaten our employees.”
Fuller also defended his firm’s extensive use of the Coroners Law. “What we’re doing is in the public good. . . . We believe it’s the right thing to do.”
But those on the front lines say those lofty goals, coupled with a push for productivity, can often create an almost ghoulish environment.
“We were swooping down on the dead to make money. We were feeding off the dead,” said one former Doheny employee, who still remembers the glares he and others suffered from rankled county workers.
“You’d walk by and there would be a sardonic look on their face and they would flap their wings, like, ‘Uh-oh, here come the vultures.’ ”
At one point, Doheny workers offered--and morgue attendants began demanding--food to expedite cornea cases, prompting an official memo halting the “inappropriate and unethical” practice.
“While it might seem that a doughnut here or a piece of pizza there is no big deal, it is demeaning and calls into question the integrity of the entire Department,” wrote the chief of coroner investigators.
“If you don’t think that a person doesn’t or won’t expect something in return for their ‘gratuity,’ you’re sadly mistaken. Behind your back, you’re a ‘simpleton’ and a ‘chump’ in their eyes.”
Before they remove corneas, Doheny technicians routinely obtain permission from coroner officials in cases likely to require autopsies, such as homicides, thus ensuring compliance with the law.
On occasion, however, corneas have been harvested when no autopsies were conducted because of communication foul-ups or subsequent decisions not to perform them.
Former death investigation supervisor Peter Linder said he recalls about a half-dozen instances in which unnecessary autopsies were performed because corneas had been removed under questionable circumstances.
“If . . . you’re afraid of a family complaint, to protect the coroner against a lawsuit, you did an autopsy,” Linder said.
“The autopsy now makes the taking of the eyes legal. . . . Some of the doctors were very angry about it because their workload is heavy.”
In a case last year, a Doheny technician requested a belated autopsy on a West Hills woman who had drowned in her apartment complex pool.
“Dr. Liang [a Doheny technician] requests at least a partial autopsy, as [Tissue Banks International] took corneas,” according to a notation in coroner files. “Case held for tomorrow.”
The autopsy was performed, despite an earlier determination that it was unwarranted. Liang said Friday that he did not recall the case.
Chief Medical Examiner Lakshmanan Sathyavagiswaran acknowledged in a recent interview that there have been “rare” instances in which such autopsies were performed. “I don’t think it happens anymore,” he said.
Corneas Resold at Substantial Profit
One reason Doheny and Tissue Banks International have so aggressively mined the coroner’s office for corneas is because it is much easier--and more profitable--than going to the trouble and expense of seeking family approval or obtaining them from hospitals, according to eye bank experts.
Doheny, using money supplied by the Baltimore-based Tissue Banks, pays the coroner an average of about $250 for a set of corneas, which are then sold to transplant institutions for a “processing fee” of $3,400--among the highest in the nation.
Records show that the coroner’s office has collected nearly $1.4 million from Tissue Banks during the last five years. Tissue Banks also has donated two vans and upgraded an autopsy room where technicians perform the 45-minute corneal removals.
County officials say the payments are merely reimbursement for the time it takes for coroner employees to consult with Doheny technicians and for the space used by the eye bank.
Tissue Banks International officials put a different spin on the payments with the state’s Registry of Charitable Trusts. In public filings, they called them “grants” intended to accelerate tissue removal.
“Due to budget constraints, the Los Angeles County Coroner’s Office was unable to achieve its potential for tissue donations,” the filing states. “Delays to the necessary timely release of tissue arose because of staffing shortages.”
Coroner administrator Hernandez said that, although the extra money each year has been helpful, it has not been crucial to his department, which he said has suffered budget cuts of 25% over the last several years.
“If we lost our 250,000 bucks, big wow,” he said. “After losing $3 million [in cuts] over six years, $250,000 is not going to be a big deal.”
But some say the issue transcends the amount of money being funneled to the coroner’s coffers.
“The way this has been done, with them buying things for the coroners, it’s implied that they are going to get something in return,” said Linder, who retired from the coroner’s office last year. “It makes for an incestuous relationship.”
Linder and other critics say that relationship is cemented not only by money but by personnel connections.
The most conspicuous is Ilona Lewis, who was in charge of the coroner’s office from 1991 until her retirement in 1993 after 26 years of county service. She promptly joined Tissue Banks as a high-ranking executive with oversight of Doheny operations.
One year earlier, while still employed by the county, Lewis authorized an extension of the eye bank’s contract and later encouraged her charges to help eye bank workers meet their goals.
In a 1993 memo to coroner staffers, two months before her new job was announced, Lewis wrote: “Tissue Banks International (TBI) reported a marked increase in the number of cases for harvesting in the month of March and early April. . . . Once again, thanks for a job well done.”
Lewis acknowledged in an interview that she had a “brief discussion” with Tissue Banks about a job during her last days with the county. But she stressed that, in her current position, she does not have contact with members of her former department.
The hirings did not stop with Lewis. Within a week after morgue doctor Nine Liang was laid off in a 1993 budget purge, he was hired as a Doheny cornea technician. At least three other coroner’s employees have worked full time for the county while holding down part-time jobs removing corneas for Doheny.
Doheny also has employed the children of two coroner pathologists. Last year, the tissue agency hired as a laboratory assistant the nephew of Sarah Ahonima, the coroner administrator currently in charge of Tissue Banks’ county contract.
Ahonima said she had nothing to do with the hiring of her relative, whom she said had heard the organization was “looking for laboratory assistants, or lab boys.” She declined to say whether she provided the tip.
Asked if the employment of her nephew posed a conflict because of her oversight of the tissue bank contract, Ahonima responded bluntly: “No, it does not.”
Agreeing with her are coroner administrator Hernandez and Medical Examiner Sathyavagiswaran, who said in interviews that such hirings do not violate county policy.
James Childress, a nationally recognized expert on medical ethics, sees things differently. He said the financial ties between the eye bank and the coroner’s office could provide “the temptation to cut ethical corners.”
“At a very minimum, [families] ought to be informed and have a right to say yes or no” to corneal removals. “That’s what we do on other organs. But if you think the family might be too upset or would have other problems providing the corneas, you might just skip [seeking permission] altogether.”
Childress, a University of Virginia professor of biomedical ethics who has served on national task forces on organ transplants and cloning, said the coroner’s extensive use of the California law “amounts to something very close to expropriation or conscription of corneas.”
Use of High-Risk Donors a Concern
Beyond the ethical questions, concerns have been raised over whether Doheny executives are in step with counterparts elsewhere in the nation on public health issues.
The chance of contracting life-threatening illnesses through corneas, which are bloodless, is extremely remote. To date, for example, there has been no documented case of HIV infection by that route. Still, federal regulators have issued a series of rules to play on the safe side.
Among them: Corneal tissue should not be removed from people who have been incarcerated, who have used drugs intravenously or who have engaged in homosexual sex--all of which put them at risk for AIDS and hepatitis.
Doheny officials say they have done their best to comply, based on the paperwork available to them at the time. Moreover, Executive Director Thomas said blood tests are conducted on every cornea donor and their bodies are examined for telltale signs of drug abuse or fresh tattoos.
Safety, Thomas said, “is paramount. I think we put tremendous efforts at having talented people, training and really following the respective guidelines.”
But several former Doheny employees said their experience showed otherwise. They said they were compelled to take corneas from bodies they considered suspect because of high-risk health factors.
Ex-Doheny employee Julia Brain, now a graduate student at McGill University in Montreal, said eye bank officials transferred her out of the morgue and into a phone job when she balked at removing eye tissue from a two-time prison inmate with tattoos.
“I said, ‘I’m sorry, I’m not going to take this case,’ ” Brain recalled. “After that, they decided I shouldn’t be a [technician] for them anymore and they wanted me to take donor calls.”
In a sampling of several dozen cases from earlier this year, The Times found at least 10 in which corneas were taken from people who had been jailed three days or longer within the prior year. Their criminal identification numbers were listed on autopsy reports.
One of them was Michael Wayne Marshall, whose unidentified body was brought to the morgue Feb. 27. Two months earlier, he had been released from the California Institution for Men in Chino. His autopsy report noted that he had “multiple drug violations.”
Doheny executive Thomas said he doesn’t remember any technician being told to take corneas from high-risk donors, but acknowledged that mistakes can happen. “I think there’s a risk whenever the donor can’t talk,” he said.
In the hopes of minimizing that risk, federal health authorities also require that social histories on donors be obtained by interviewing family members and friends. The exception: cases in which corneas have been removed under state statutes, such as those obtained by Doheny.
Thomas said that such social histories often are unreliable. “In any situation where you’re asking next of kin or asking medical personnel or professionals about a certain case,” he said, “you’re going to get not 100% accurate information.”
Sometimes, however, you do get enough to prevent mistakes.
Jason K. Woody, director of the Central Florida Eye and Tissue Bank in Tampa, knows how important a relative can be--as do eye bank officials in California and across the country, who routinely compile social histories.
“I had a [donor] who was 65 years old and he hadn’t had sex with his wife in 20 years,” Woody recalled. He said the case looked like a slam-dunk until he interviewed the man’s wife.
“She said, ‘Honey, he probably slept with two or three prostitutes a week,’ ” Woody said, adding: “I had to decline that case.”
Woody’s state, like California, has a coroners law. But unlike here, he said, his employees remove no corneas without family consent--"whether the patient is 1 day old or 100 years old"--or from anyone considered at risk for infectious diseases. “If you’re in a motor vehicle accident in Tampa, if I don’t find your next of kin, I don’t take your tissue.”
In his view, the practices occurring in Los Angeles border on theft.
“Would you want it to happen to your son or daughter? . . . You have to live with it for the rest of your life,” he said. “A part of your loved one is gone, there’s nothing you can do about it, and you never knew about it. . . . There’s not even the courtesy of telling the general public that it’s happening.”
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Those Who Gave
Under the California Public Records Act, The Times examined all 572 cases in which corneas were removed without family consent or knowledge during a 12-month span ending in June.
Here, based on a computer analysis of that information, are some characteristics of the donors.
* Seventy-two percent were homicide victims, who are most likely to have young, “healthier” corneas that transplant banks seek. Accident victims accounted for the next largest group at 16%.
* Nearly 60% were Latino, 21% were African American and 16% were white. The number of minority cornea donors was disproportionate compared to the number of minorities autopsied. Only 44% of all autopsies performed during the last year were of Latinos and African Americans, while 42% were of whites.
* The average age was 27.7 years, much younger than the average age of all those autopsied. Eleven of the donors were 5 years old or younger; the oldest was 69.
Eye bank officials say that they base their selection of donors purely on mode of death and that race is not a factor.
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Under a little-known state law, the Doheny Eye & Tissue Transplant Bank has harvested thousands of corneas from bodies at the county morgue without notifying the next of kin. The county receives about $250 per pair--money county officials say recovers public costs. The corneas later are resold for considerably more.
* THE CORNEA: A transparent thin-walled dome forming the front of the eyeball. To remove the tissue, a technician opens the eyelid with a speculum and cuts around the thin membrane in a circle, extending three to four millimeters into the sclera, the white part of the eye. The cornea is then lifted and preserved in a culture medium. Including preparation, the entire
process takes about 45 minutes.
Pushing for More Corneas
This memo from the president of Doheny’s management firm, Tissue Banks International, was distributed with January paychecks of eye bank employees. Some former workers say this kind of productivity push has led to overzealousness inside the county morgue. Tissue Bank’s president characterized the missive as a “nudge,” not pressure.
The Autopsy Factor
California law states that corneas can be taken without family consent only in cases targeted for autopsy. But coroner officials acknowledge that there have been occasions when unnecessary autospies were performed to justify cornea removal. Documents in this 1996 drowning case show that a Doheny technician, working for Tissue Banks International, requested “at least a partial autopsy” because eye tissue had been removed. Morgue doctors complied, reversing an earlier decision that an autopsy was not needed.