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Journal Club – Ethical Issues in Renal Medicine: ‘Transplant Tourism’. Transplant Tourism in the United States: A single-centre experience. Gill J, Bhaskara R et al c JASN 3: 1820-1828. 2008 Matthew Graham-Brown LGH August 2013. Introduction - Ethics. ‘Ethos’ – meaning character

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journal club ethical issues in renal medicine transplant tourism

Journal Club – Ethical Issues in Renal Medicine: ‘Transplant Tourism’

Transplant Tourism in the United States: A single-centre experience. Gill J, Bhaskara R et al cJASN 3: 1820-1828. 2008

Matthew Graham-Brown

LGH August 2013

introduction ethics
Introduction - Ethics
  • ‘Ethos’ – meaning character
  • Ethicsis the philosophy of morality that involves systematizing, defending and recommending concepts of right and wrong
  • The study of moral behaviour in humans and how one should act
  • Ethics seeks to resolve questions dealing with human morality—concepts such as good and evil, right and wrong, virtue and vice, justice and crime
introduction morals morality
Introduction – Morals (Morality)
  • Moralitas, meaning manner, character, proper behaviour
  • Morality is what ‘you’ believe to be right or wrong – informed by ethics, (religious) beliefs, experiences and observations.
  • ‘What is believed to be right or good’
  • Immorality: active opposition to morality
  • Amorality is an unawareness of, indifference towards, or disbelief in any set of moral standards or principles
ethical theories
Ethical Theories
  • Utilitarianism – greatest good for the greatest number


  • Immanuel Kant – ‘categorical imperative’ - reason is the source of morality, ‘universal right and wrong’, ‘cannot use a person as a means to an end – they must be an end in themselves’


  • Situation ethics – what is the most loving thing to do in any given situation
medical ethics historical
Medical Ethics - Historical
  • Formula ComitisArchiatrorum – (Early 5th century) It demands from physicians that they widen and deepen their knowledge and enacts the consultation with other physicians
  • Hypocratic Oath – Honesty (Physicians only!) 
  • Declaration of Geneva (1948, 1968, 1983, 1994, 2005 and 2006) – Post Nazi Germany. ModernisedHypocrates
medical ethics key tennants
Medical Ethics Key Tennants
  • Autonomy
  • Beneficence
  • Non-maleficence
  • Justice
so this study
So… This Study (!)
  • Transplant tourism – ‘The practice of travelling outside the country of residence to obtain organ transplantation’
  • Implications of this are largely unknown
  • This study described the characteristics and post-transplantation outcomes of patients who sought transplant abroad and returned to be followed up at UCLA
study design methods 1
Study Design & Methods 1
  • Single Centre (UCLA)
  • Retrospective, observational, comparison study, including a comparison against a ‘matched’ cohort
  • Included - Allliving and deceased-donor kidney transplant recipients followed up at UCLA who underwent transplantation outside the US as of April 2007 – Total number 33 patients
  • Excluded – patients who had moved to US after transplant and all non-kidney patients (1 kidney pancreas transplant was included)
study design methods 2
Study Design & Methods 2
  • Looked at:
    • Demographic recipient data
    • Donor data (where available)
    • Transplant data (where available)
    • Clinical events
    • Graft survival
    • Patient death
    • Acute rejection
    • Serum creatinine after transplant
    • Infectious events
  • Data verified with transplant staff + physicians, NOT patients (attempting to negate recall bias)
study design methods 3
Study Design & Methods 3
  • Compared ‘tourist’ demographics, transplant characteristics and outcomes with:
    • ALL adult patients who had transplant at UCLA during the study period (graft survival, patient survival, incidence rejection at 1 year, serum Cr at 1 yr)
    • A matched (Age, race (Asian vs non-Asian), transplant year, previous transplantation, dialysis time, donor type) cohort of 66 adult patients who had transplant at UCLA (graft survival, patient survival, incidence rejection at 1 year, renal function and infectious events)
hospital stay and d c meds
Hospital stay and D/C Meds
  • Average length of stay was 15 days (info unavailable for 47%)
  • All D/C’d on CNI
  • 90% D/C’d on Pred + Mycophenolate
  • Only 24% received induction immunosup (info unavailable in 39%) vs 60% of UCLA patients
  • Only 12 patients received co-trimoxazole and no patients received CMV prophylaxis
results arrival post transplant
Results – Arrival post transplant
  • Median time to initial visit to UCLA post Tx was 35 days (13  2796 days)
  • 4 patients needed immediate admission, 2 lost grafts, 1 recovered function after prolonged period of Gram –ve sepsis and 1 died of fulminant hepatic failure on ITU (presumed Hep B contracted from unscreened donor)
results infections
Results - Infections
  • Overall no difference in infection rates 52% vs 48%
  • But….
  • Marked difference in severity
  • 27% tourist group required hospital admission, vs 9% of matched cohort
  • More than twice as many CMV positive patients (30% vs 12.1%) with one CMV pneumonia in tourist group
  • ??Increased incidence of bacterial infections in matched cohort group ??Incomplete records of infections from transplant centres
discussion general points
Discussion – General Points
  • Supply and demand an underlying problem
  • More and more common
  • Predominantly American-Asian patients sought transplants abroad – Cultural aspects poorly understood…..
  • Reasons for travelling abroad not sought, not clear and certainly multifactorial
  • Why go abroad for live related… ?cost in US
discussion a fair bit lacking
Discussion – A fair bit lacking
  • Live donors most common – lack of documentation on where kidney comes from – vendor-driven, executed prisoners, open market….
  • Lack of information from transplant centers
    • Health, age, viral status of donor
    • Cold/warm ischaemic time
    • HLA matching
    • Post-op issues
    • Drug levels
discussion reasonable outcomes not without risk
Discussion - Reasonable outcomes, Not without risk
  • No statistical significance between one year graft and patient survival, even in matched group, but low patient and event numbers limit power (NB only patients that return included…)
  • Discursive results section wanting to demonstrate experience that when things went wrong they went very wrong!
  • Inferior graft function and patient survival described elsewhere in literature (refs 5,7,9,14,15)
  • Higher episodes of acute rejection
  • Generally higher rates of (severe) infections and less prophylaxis. CMV a particular problem
discussion a public health issue
Discussion - A public Health Issue?
  • Potential infectious diseases
  • Unclear donor selection
  • Further work required
dicsussion trust
Dicsussion - Trust
  • Of the 29 ‘transplant tourists’ evaluated at UCLA prior to Tx ‘few’ discussed plans to go abroad
  • Can you council patients on transplant tourism? Can you give information on risks? Should you mention it’s an option? Should you ask if they’re thinking about it?
  • Does it damage the Dr/patient relationship when patients return with grafts
more e thical stuff to think about
More ethical stuff to think about
  • Right or wrong?
  • Incredibly complex mixture of social, political, economic, cultural factors underpinning decisions of people willing to sell organs and those willing to buy them. Desperation on both sides
  • Are we supporting this practice by looking after patients when they return? We can’t not look after them!
  • Can we affect practices happening in a far away land??
  • Way forward? – continue striving to improve transplant services here (including numbers of organs) so people don’t ‘need’ to go abroad…
  • Small study, low power
  • Retrospective and observational (selection bias)
  • Only returning tourist included – no evidence about peri-operative deaths/deaths from complications in those not returning
  • ‘Matched’ group contained no matching for nature of underlying renal disease or co-morbid illness
  • Lots of incomplete data from transplant centres