Surgeons at St. Vincent Medical Center bypassed nine of the hospital's own patients on a regional liver transplant waiting list before they inappropriately gave the organ to a Saudi national who ranked 52nd, hospital officials said Tuesday.
But hospital officials said they were at a loss to explain why St. Vincent staff allegedly violated basic rules governing organ transplants in the September 2003 procedure and then falsified documentation to cover up their actions.
"They have not provided us with a motivation," hospital President and Chief Executive Gus Valdespino said at a news conference, referring to the two physicians who ran the liver transplant program. The Los Angeles hospital has terminated the program's relationship with the doctors, he said, and has indefinitely suspended liver transplants.
What is clear is that the Saudi national received a liver that should have gone to a patient at UCLA Medical Center who was much higher on the transplant list. Moreover, the Royal Embassy of Saudi Arabia paid St. Vincent $339,000 for the Saudi patient's transplant and hospital care, plus undisclosed fees to the doctors, according to the hospital. That amount is about 25% to 30% higher than the hospital would have been paid by insurance companies and government programs.
The embassy routinely pays for medical care for Saudi residents in the United States, though fewer nationals have sought care in this country since Sept. 11, 2001, because of the difficulty in obtaining visas, embassy spokesman Nail Al-Jubeir said. He said the embassy would "absolutely not" try to move a patient up the waiting list.
Meanwhile, on Tuesday, the Medical Board of California indicated that it had opened an investigation of Dr. Richard R. Lopez Jr., the St. Vincent program's former director, and Dr. Hector C. Ramos, the former assistant director. Both retain privileges at the hospital, although hospital officials said their status was being reviewed by the medical staff.
An attorney for Ramos said her client had done nothing wrong.
"In Dr. Ramos' mind, he transplanted a patient who was sick and was in the hospital, and as far as he knew, was the only sick person in the hospital who needed a liver transplant," said the attorney, Evelina M. Serafini. "The first time he had heard about the patient's position on the list was when the hospital launched its investigation."
An attorney for Lopez has declined to comment.
The allegations at St. Vincent have renewed calls among some bioethicists and transplant experts for stricter curbs on the number of foreigners allowed to receive transplants in the United States.
With nearly 90,000 patients on U.S. organ transplant waiting lists, "it ought to be Americans first," said Dr. Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "That's why people donate."
Hospitals should resist the temptation to prioritize foreign nationals who in general pay more for organ transplants because they do not qualify for insurance discounts, Caplan and others said.
"I do think that when we have a shortage, that we are probably obligated to take care of our own citizens and residents first," said Dr. Douglas Hanto, chief of the transplant division at Beth Israel Deaconess Medical Center in Boston.
He added, however, that the United States had an obligation to help foreign countries set up their own transplant centers and to serve visitors who find themselves unexpectedly in need of transplants while in this country.
Others said transplants in the United States are the only hope for some foreign nationals whose countries do not offer those procedures. In addition, foreigners donate organs to U.S. patients in about the same proportion that they receive transplants.
"Part of what makes our country a great one is that we're willing to share our expertise," said Jeffrey Kahn, director of the Center for Bioethics at the University of Minnesota, and vice chairman of ethics for the nation's transplant oversight agency. "Obviously, we can't allow people from outside the country to swamp the system ... so there needs to be a balance struck, and that's the trick."
According to national data, St. Vincent has allocated about 8% of its donated livers to foreign nationals since the program was created in 1995, slightly higher than the 5% guideline set by the national organ oversight agency. That group, the United Network for Organ Sharing, spells out no punishments for exceeding its guideline but says that it audits out-of-compliance programs.
Overall, St. Vincent has allocated fewer than 5% of its organs -- including kidneys and pancreases -- to foreign nationals. Hospital spokesman Paul Silva said he knew of no organized outreach by the hospital to find foreign transplant seekers.
This would not be the first time that a scandal had led transplant experts and others to call for limits on transplants to foreign nationals. In the 1980s, the University of Pittsburgh Medical Center was forced to defend itself over transplants given to Saudi residents, including members of the royal family.
Integris Baptist Medical Center in Oklahoma similarly was asked to justify its actions the following decade, when a quarter of its livers in one year went to foreigners. The hospital has not performed a transplant on a foreign patient since 1999.
Congress considered legislation in the mid-1990s that would have created two lists of patients seeking organ transplants -- one for U.S. citizens and one for foreigners, said Joel Newman, a spokesman for the United Network for Organ Sharing. The legislation, which would have allowed a foreigner to be considered only if no American needed an available organ, did not pass the Senate.
In response to the concern, the group said no more than 5% of organs should go to foreign nationals, a reduction from the previous 10% cap, Newman said.
St. Vincent officials are reviewing whether any of its nine bypassed patients in September 2003 were foreign nationals and whether any were hospitalized then, as the transplanted Saudi patient was, Silva said.
In any event, he said, the line-jumping was wrong.
"Anybody who is in this profession knows that every patient on that list has a reason to be on the list," Silva said. "The integrity of the list is the order that it's in."
The liver was initially offered to St. Vincent for a patient who was near the top of the regional waiting list and also happened to be a Saudi national.
Because that patient was out of town, the liver should have been sent to UCLA Medical Center to be transplanted to the next patient in line, Valdespino said.
Instead, he said, St. Vincent doctors used the organ for the Saudi patient who was 52nd on the list.