Benjamin Hippen

Association of CD20+ Infiltrates with Poorer Clinical Outcomes in Acute Cellular Rejection of Renal Allografts

We undertook a study to ascertain the relationship between the presence of CD20‐positive B‐lymphocytes in renal allografts undergoing acute cellular rejection and graft survival. We identified 27 patients transplanted between January 1, 1998 and December 31, 2001, with biopsy‐proven Banff 1‐A or Banff 1‐B rejection in the first year after transplantation, and stained the specimens for CD20 and C4d. At least 4 years of follow‐up data were available for each patient studied. Six patients had CD20‐positive B‐cell clusters in the interstitium, and 21 patients were negative for CD20 infiltrates. The CD20‐positive group was significantly more likely to have steroid‐resistant rejection and reduced graft survival compared to CD20‐negative controls. This study supports prospective identification of CD20‐positive B‐cell clusters in biopsy‐proven rejection and offers a therapeutic rationale for a trial of monoclonal anti‐CD20 antibody in such patients.

Incentives for organ donation: proposed standards for an internationally acceptable system.

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to todays conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.

In defense of a regulated system of compensation for living donation.

PURPOSE OF REVIEW The organ shortage is the major problem in kidney transplantation today. Despite aggressive organ procurement efforts, the supply of donated kidneys, living and deceased, has not matched the growing demand; as a consequence, more and more qualified candidates are suffering on dialysis and then dying before being transplanted. Herein, we provide justification for a regulated system of compensation for donation. RECENT FINDINGS The main argument in favor of compensation is simple-financial incentives will increase donation, so fewer transplant candidates will suffer and die while waiting. In addition, development of a regulated system of compensation is the most effective means of crippling the core economic support for transplant tourism. Because dialysis is so much more expensive than a transplant, compensated donation could be cost-neutral to the healthcare system. Importantly, opinion polls suggest that the public would support compensation. As uncompensated kidney donation is widely accepted, persuasive arguments against compensation must explain why such a system would be morally distinguishable from uncompensated donation. SUMMARY We suggest that the potential advantages of a regulated system of compensation for donation far outweigh any potential disadvantages. It is time to advocate for a change in the law so that trials can be done.

Incentives for organ donation in the United States: feasible alternative or forthcoming apocalypse?

Purpose of reviewSeveral factors have generated interest in proposals to offer incentives in exchange for kidneys from living donors, including the growing shortage of available organs, the apparent asymptote of traditional means of organ procurement, and the intimate link between the inadequacies of organ procurement policies in developed countries with the flourishing of underground organ trafficking in developing countries. Recent findingsHerein, we review the scope and dimensions of the growing shortage of organs in the United States, with attention to how each of the proposed solutions to same has proven insufficient. With special attention to the concerns leveled by Gabriel Danovitch in his ‘Open Letter,’ we conclude that each of his concerns are unfounded, and offer a prospectus on how a trial of such systems might be pursued in the United States. SummaryThe failure of current approaches to organ procurement in the United States and other developed countries has led to unnecessary suffering and death, with morally unacceptable consequences for developing countries. For these reasons, a structured trial of incentives for organ procurement in the United States is a moral imperative.

A Case Study in Unethical Transgressive Bioethics: “Letter of Concern from Bioethicists” About the Prenatal Administration of Dexamethasone

On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services (DHHS) Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it.

Transplant tourism and unregulated black-market trafficking of organs.

As transplant professionals and members of the American transplant community, we stand united with the public in strong opposition to transplant tourism and the associated unregulated black-market trafficking of organs, often recovered from desperately impoverished donors. No matter how severe the shortage of organs, there can be no justification for exploiting even a single individual to obtain even a single organ for transplantation.

A Realistic Proposal—Incentives May Increase Donation—We Need Trials Now!

The shortage of organs is a critical problem for patients with organ failure, and has led to a polarizing discussion. Some, including us, have suggested that a regulated system of incentives might increase donation and alleviate the crisis. Others, championed by Chapman, Danovitch, Padilla and Delmonico, have passionately opposed this option. Delmonico et al., representing the Declaration of Istanbul [DoI] Custodial Group (DICG) now write that our proposed guidelines for a regulated system are not acceptable. Our proposal, as stated in the manuscript, was presented as a basis for discussion. Rather than suggesting modifications or improvements, the DICG simply condemns it. [...]

Living Donor Kidney Donation in the United States: Quo Vadis?

After the first successful living donor kidney transplant between identical twins at Harvard in 1954, Joseph Murray, who received the Nobel prize, said of the recipient’s famed nephrologist ‘John Merrill and I had an understandable difference of opinion as to whether or not native kidneys (from healthy living donors) should be removed’ (1). In the subsequent 6 decades, the controversies over removing kidneys from healthy donors remain.

A modest approach to a new frontier: commentary on Danovitch.

Danovitch’s essay expresses a laudable ecumenical sentiment. It is difficult to find fault with the proposition that the international community of transplant professionals ought to identify organ-procurement practices that work and share them with one another in an organized fashion. If the manifest success of the Organ Donation Collaborative in the United States is any indication of the prospects for a global initiative, perhaps we have no time to lose. Indeed, the “sense of restiveness” to which Danovitch alludes would seem to oblige entertaining novel approaches to improving organ procurement. If correctly identifying, understanding, and overcoming cultural barriers to organ donation increases opportunities to liberate still more people from the strictures of dialysis (or for most people in most countries, a tepid annihilation from uremia), even proponents of regulated organ markets (1) can offer enthusiastic support. Still, the identification and promulgation of “best practices” requires some previous agreement on the whys and wherefores regarding variability between countries and between cultures in organ procurement. A casual reflection on the problem quickly demonstrates how inadequate a rudimentary moral vocabulary is in explaining these variations. For example, if organ donation is properly understood as an act of altruism, does it follow that people from countries with low rates of organ donation are generally avaricious? No, because understanding decisions regarding donation within the narrow strictures of “altruism” fails to explain the role of culture in shaping the meaning of organ donation. This approach offers a more textured explanation of organ procurement practices than the dichotomies of altruism and avarice, or enlightenment and ignorance. Those charged with running procurement organizations, in turn, have much invested in correctly comprehending how they cooperate (or compete) with these cultural forces, because these interactions may facilitate or inhibit robust organ donation. As the sociologist Kieran Healy has argued, “. . . we cannot understand why individual donors give without understanding the way collection organizations provide them with opportunities to donate” (p. 87) (2). The corollary to this insight might be: We cannot understand why some cultures fail to facilitate organ donation without understanding why those collection organizations fail to provide opportunities to donate or fail to overcome indigenous barriers to donation. Comparative approaches or general solutions are only helpful insofar as one has an understanding of the problems. Achieving an understanding of the problems within individual countries and cultures turns out to be resistant to the casual generalizations sprinkled throughout Danovitch’s essay. To begin, as Danovitch does, by focusing on these or those means of expanding organ procurement (such as donation after cardiac death or ABO-incompatible transplantation) is to suggest answers before understanding the questions. Danovitch’s brief analysis of organ procurement in Hong Kong and Iran illustrate the weakness of his approach. In the case of Hong Kong, Danovitch traces the decline in the proportion of living donor kidney transplants (from 50% to 15–20%) to the transfer of sovereignty from the United Kingdom to China in 1997, with the implication that opportunities to purchase kidneys in China accounted for the decline. Of course, concerns were publicly raised regarding Hong Kong nationals purchasing kidneys in China before 1997 (3, 4) when it was reported in 1991 that the Hong Kong government was providing care to more than 70 recipients who had purchased kidneys in China. At the time, this represented nearly 35% (70/199) of the total number of transplant patients in the country at the time (5). Cheng and colleagues reported that between 1984 and 1990, 81 patients who had gone to mainland China for a kidney transplant were receiving care in Hong Kong (6). So, recipients who traveled to China from Hong Kong for kidney transplantation predated the transfer of sovereignty in 1997, and this cohort of patients accounted for a substantial portion of the total number of kidney transplant recipients in Hong Kong prior to 1997. What about the decline in the rate of living kidney donation after 1997? Table 1 shows that the absolute number of living kidney donors did indeed decline after 1998, when it reached an all-time annual high of 37 kidneys from living donors. However, Danovitch’s explanation also doesn’t account for the concomitant rise in living liver donors in Hong Kong over the same timeframe, as illustrated in Table 2. In 1998, living donors provided 44% (12 of 27) of all livers for transplantation, and this increased to 68% (49 of 72) by 2006. Why should living liver donation, which ostensibly carries considerably more risk to the donor, not have abated in proMetrolina Nephrology Associates, P.A., Charlotte, NC. Address correspondence to: Benjamin E. Hippen, Metrolina Nephrology Associates, P.A., 2711 Randolph Road, Building 400, Charlotte, NC 28207. E-mail: benjaminhippen@hotmail.com Received 9 April 2007. Accepted 24 April 2007. Copyright

Professional obligation and supererogation with reference to the transplant tourist.

In their essay, Rhodes and Schiano (2010) defend a radical version of professional obligations from beneficence, which comprises the conceptual linchpin for their claims regarding physician obligations to the care of the transplant tourist. They dismiss as “specious” any counterclaims that would limit the duty of an individual physician to treat a transplant tourist under any conditions. They also argue that the duty to treat the transplant tourist arises from a professional duty of “nonjudgmental regard,” which “required us to avoid disparaging this patient, or his choice for transplant tourism, in any way.” They also locate a “positive duty of beneficence,” which entails an obligation to respect patient autonomy that “..requires physicians to accept patients’ views of the good and their patients’ rankings of values” (my emphasis). Elsewhere, Rhodes expands on this point: “The doctor who chooses to avoid personal psychic distress [by declining to provide chronic care to the transplant tourist] declares his willingness to impose burdens of time, inconvenience, financial costs, and rebuke to his patients so that he might feel pure” (Rhodes 2006). To underscore the priority of these values, Rhodes (2006) recommends alternate employment for those who cannot countenance them in practice. Rhodes instead commends an “ethical standard of care” the obligations of which are predicated on the considered judgments of “experts.” I argue that their robust professional obligation of nonjudgmental regard absent any correlative set of patient obligations is a substantive divergence from the historical tradition of medical ethics they seek to revive, and they dismiss contemporary challenges to that tradition without justification. Moreover, the robust positive duties of beneficence they defend fail to distinguish between obligation and supererogation, which entails conflicting and undesirable consequences. In contrast, a clear distinction between professional obligation and supererogation that defines the limits on duties to treat avoids these problems.