The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

Oct. 11, 2009
Oct. 13, 2009
Oct. 14, 2009

Contents:
• Dr. Britt chosen as next President-Elect
• ACS Regents and Governors named
• Innovative model for solving organ shortage involves elective surgery patients
• Past-Presidents
• Distinguished Service Award
• Best Scientific Exhibit
• International Guest Scholars
• Surgical Humanitarian and Volunteerism Awards
• Clinical Congress candids
• Nation’s capital to serve as host to 2010 Clinical Congress

Ethics and Philosophy Lecture
Innovative model for solving organ shortage involves elective surgery patients

Improving the supply of living organ donors while maintaining ethical standards was the focus of the Ethics and Philosophy Lecture, which was presented by Mark Siegler, MD, FACP, Wednesday morning. Dr. Siegler, director of the MacLean Center for Clinical Ethics at the University of Chicago, proposed a new model for living organ donation that involves inviting elective laparoscopic abdominal surgery patients to become volunteer, unrelated living donors of abdominal organs (such as kidneys) or organ segments (such as a liver segment.) “Such donors would be surgical patients first, and living donors second, which is a contrast to the current system which creates a surgical patient by operating on a healthy individual,” observed Dr. Siegler.

Efforts to increase the supply of donated kidneys have focused primarily on deceased donors, noted Dr. Siegler. Approximately 12,000 kidneys come from deceased donors each year. Living organ donations usually come from relatives of patients who need the donated organ, but these donations have fallen off in recent years—6,800 in 2003 to the current level of 6,000 a year, and those numbers are expected to continue to decline. “If we ever hope to meet patients’ needs we’re going to have to rely on living rather than deceased donors.”

The surgical procedure would begin with a patient who requires an elective therapeutic procedure (a cholecystectomy, for example) and also consents to donating a kidney during the same operation.

“Given the large volume of elective cholecystectomies performed each year in the U.S., if only 3 percent of patients agree to donate, this proposal could substantially increase—and perhaps even double or triple—the supply of donor kidneys available for transplantation,” said Dr. Siegler.

Inviting elective cholecystectomy patients to consider becoming living donors involves challenges in three specific areas: technical issues (feasibility of combining cholecystectomy with donor nephrectomy, longer anesthesia time, larger incision, and other factors); ethical challenges (informed consent and patient coercion/vulnerability issues, donor risks, and benefits); and practical considerations (who would pay for this innovative form of living organ donation, and would cholecystectomy patients agree to serve as unrelated, altruistic donors?).

General surgeons are the gatekeepers of this model, said Dr. Siegler, and it will be up to these physicians to determine whether or not they will allow their patients to serve as donors. He highlighted the merit of a new research survey currently being conducted by Megan Crowley-Matoka, PhD, and Sarah Olack, which is in the “first stages of qualitative and quantitative research to explore whether the proposed model has any realistic feasibility for general surgeons.”

“The incremental risks assumed by an elective cholecystectomy patient who also agrees to a simultaneous donor nephrectomy procedure are less than the overall risks assumed by a healthy person who accepts abdominal surgery to become a volunteer organ donor,” asserted Dr. Siegler. “This donor risk hypothesis has not been proved as of yet, and can only be established by actually performing these procedures.”

During the presentation, Dr. Siegler periodically asked the audience to respond to various multiple choice survey questions (via a hand-held device) related to his proposal, including questions related to the audience’s general attitude toward what he defined as  ”innovative surgery.” After Dr. Siegler had outlined his proposal, he asked the audience if they were a general surgeon on a cholecystectomy case, would they be willing to consider participating in this approach to organ donation? Nearly two-thirds of respondents said they were “highly likely” or “somewhat likely” to consider participating in this approach. He also asked the audience to rank their potential concerns regarding this proposal from the following three choices: technical considerations, ethical considerations, and practical considerations. Respondents ranked ethical considerations as their chief concern, followed by practical concerns, and then technical considerations. 

In his concluding remarks, Dr. Siegler underscored the use of elective surgical patients as a viable option for replacing healthy persons as organ donors, and he noted that elective surgical patients accept the risks and discomfort of general anesthesia and a surgical procedure for their own needs, but would face the incremental risks of a donor nephrectomy. “Because the procedures have never been performed together, the precise level of additional risks is unknown,” he said.

Additional details regarding this proposed model are featured in an article written by Dr. Siegler and coauthors titled Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation in the October 2009 issue of the American Journal of Transplantation.