Case example

The clinical staff of the liver transplantation program at a major US academic medical center is having its monthly meeting to determine which of the candidates recently evaluated by the program will be added to the program's waiting list for liver transplantation. Among the patients under consideration today are the following three:

Mr. Hale is an 18-year-old university student who suffered acute liver failure as the result of an overdose of acetaminophen (thirty-seven tablets within one hour). He states that he took the tablets for an unrelenting headache and had no suicidal intent. He has a history of attention deficit disorder, depression, and cannabis use. His parents appear to be quite willing to support his medical care.

Mr. Irving is a 32-year-old inmate of Central Prison. He was convicted on a murder charge at age 19 and has eight more years to serve on his sentence. He has liver failure due to cirrhosis, and his cirrhosis is a result of juvenile hemochromatosis, a rare genetic condition causing severe iron overload in the liver and other organs. Mr. Irving also has ascites (fluid accumulation in his abdomen) and encephalopathy (loss of brain function due to liver failure). He has a history of drug abuse prior to his incarceration. His father has petitioned the Governor for early release due to his illness.

Mrs. Nguyen is a 73-year-old Vietnamese immigrant with cirrhosis caused by chronic hepatitis C infection. Her condition was stable until she took a Chinese herbal remedy that resulted in acute liver failure. She has no other illnesses and, until the present acute illness, worked full-time in a clothing store. She is a widow, but has a large and supportive family.

Which of these patients, if any, should be added to the program's waiting list for a liver transplant?

Success and scarcity

Success

On December 23, 1954, surgeons in Boston performed the first successful human organ transplant, transplanting a kidney from a healthy identical twin into his dying twin brother. Since that time, surgeons have developed techniques for transplantation of multiple organs, and investigators have discovered effective therapies to prevent immune system rejection of transplant organs. Many nations have developed sophisticated systems for recovering transplant organs from patients after death and distributing those organs to waiting patients.