Give and Take

Rangel's blogging about Todd Krampitz, the 32 year old liver patient who bought billboards and a website ( to advertise his plight. Today, less than a week after his unprecedented blitz, he received a new liver from a cadaver.

Good news? Bad news? I think we can all agree that loved ones should be able to donate kidneys or liver tissue. We can also agree that selling organs is distasteful, at least to armchair philosophers and op-ed columnists.

Todd's case falls in between. Some family was moved by his situation and wanted to help (even though Todd's prognosis with the new liver is still poor). But other people (like Dr. Rangel) have no qualms writing this off as crass commercialism:

Todd Krampitz essentially bought his liver and screwed who knows which patient likely to be far sicker than Todd out of a chance for a cure of their liver disease and the addition of many years of life. Organ donations that specify the recipient are rare (only about 50 out of thousands of transplants each year) because cadaver organ donation is almost always an anonymous process. Unlike most transplant patients and their families, Todd Krampitz (who owns his own digital photography company) had enough money to pay thousands of dollars for billboard and other ads.

Because transplantable organs represent a very finite commodity, rationing is mandatory and the UNOS was supposed to impart as much fairness to the system as possible. Diagnosis, medical condition, and age are the criteria that are supposed to determine who gets to the head of a transplant list. Todd's media campaign for a new liver sets a very disturbing precedent. What happens if more and more patients begin their own ad campaigns? Will the organ go to that patient who spent the most and advertised the most? How will this be functionally and ethically different from allowing organs to go to the highest bidder?

I've sat in on these liver distribution meetings, and it's a grim calculus. Testimonials are read, psychological profiles and support structures are reviewed, and prognosis for the new liver is determined. If you give a liver to a former alcoholic, will he start drinking again? If you wait until the hepatitis patient is sicker, will he become too sick to survive the transplant?

These are tough questions. Rangel thinks the system, as it is, is fair:

According to Life Gift, in 2003 there were over 17,000 patients waiting for a liver transplant nation wide but only 2,771 transplants were done. The waiting list has dramatically increased from only 1,600 patients ten years ago and the average wait time to receive a liver is now almost 800 days! Without a transplant about 10% of those on waiting lists die each year (about 1,300 patients).

So yes, it's fair by the standard of ignoring human preferences. But hardly fair in the sense that hundreds die waiting. What I want to know is: did Todd find a liver from outside the existing donor pool? Did his advertising persuade someone to donate tissue, who otherwise would not have donated?

If that's the case, then good for him. Let others grouse about "dangerous precedents." Rangel worries that soon the airwaves will be crowded with appeals, and soon donors will only want to give to non-alcoholic cirrhosis patients, or only young people, or only specific ethnicities (or, if I may add, only people who 'compensate the donor for their troubles'). In my experience, donors tend to be more altruistic than that, but I'll concede it's a possibility.

So what? The current anonymous system is not getting the job done. People are dying, or waiting until they're so sick they don't do well with the new liver. I'll wager that private advertising and selective donations, while repugnant to some, will actually increase net donations.

And there is the small matter of it being the donor's tissue to begin with. If people want to donate it, or keep it, or drink it into oblivion, it's their choice.

UPDATE: The advertising did indeed bring in a new liver from someone outside the pool. The surgery happened on 8/12. Gruntdoc was all over this last week and has a comment which reads, in part:

A person in Oklahoma saw their story on CNN and decided to donate their son's organs to Todd. They had not previously thought about donating his organs so now many, many people were able to receive transplants last night due to their son.

Yet Dr. Pat Wood, the southeast regional director for Life Gift, calls this "a good day for the Krampitzes but a sad day for liver transplantation." I'm not so sure about that -- though it's certainly a sad day for regional transplant directors.