Innovative Fellowship Focuses on Transplant Medicine

The rapid growth of medical technology is making organ transplantation more viable — and raising more ethical questions — than ever before.

“Organ shortages, allocation issues and informed consent policies for living donors are among the many ethical issues that confront the transplant field on a daily basis,” says Eric D. Kodish, MD, Director of the Center for Ethics, Humanities and Spiritual Care.

Cleveland Clinic is one of the busiest transplant centers in the country, and about 50 of the 400 ethics consults performed each year involve transplantation. The Cleveland Clinic Fellowship in Transplant Ethics was established in June 2013 to address this growing need.

“It’s critical that we develop experts in an area of medicine that will only become more complex in terms of ethics,” says Dr. Kodish.

“Transplantation is a complex field that has the potential to save many lives. Buy as you push the limits to save those lives, more and more ethical issues emerge,” adds Charles Miller, MD, Chair of the Transplant Ethics Fellowship Steering Committee, and Program Director and Surgical Director of Liver Transplantation.

“The brilliance that these young fellows bring to our program and their interest in the whole field of transplantation, from bone marrow to multi-organ transplantation, is extraordinary.”

Program could serve as national model

The one- to two-year fellowship, now the nation’s only transplant ethics-focused program, may serve as a model for other centers.

Ethical issues in transplant medicine are often multilayered. They may affect practice or policy, and involve decisions by clinical teams, patients, families and donors.

Organ scarcity fuels many ethical issues

“The organ shortage is at the heart of many ethical issues in transplantation,” says medical ethicist Kathryn Weise, MD, MA, the fellowship’s program director. “For example, many family members only consider making a live liver donation because of the dearth of available organs.”

Each year in the United States, about 120,000 people await organ transplants, yet in 2012, only 28,051 received them (see reference below).

The program’s first fellow, David Shafran, MD, MA, a fellow in pediatric nephrology with a master’s degree in biomedical ethics, says that perspective is important. “In everyday medicine, patients who are in dire straits tend to be the first priority. In transplant medicine, you have to step back and consider the broader good of the transplant community and how to use a scarce resource to its maximum potential,” he says.

“Medical urgency and the patient’s prospect for success are considered in tandem, representing the tension between justice and utility.”

Informed consent key for donors

“Ethicists of course don’t make any final decisions about who gets to donate,” says Dr. Weise. “But we can help the potential donor and the transplant team — physicians, surgeons and social workers — evaluate whether it’s a good donation process.”

In live organ donation, donors must fully understand their own procedure has no prospect of medical benefit. “We need to make sure that the donor is a willing volunteer who has not been unduly pressured by others and is not being compensated in any way,” says Dr. Shafran.

Higher-risk live donations, such as liver, automatically flag an ethics consult. Kidney donation does not trigger a consult unless donors are younger than normal, do not seem to grasp informed consent information, or participate in “nondirected” donations through an organ donation website, community, church or other source.

“We want to better understand donor motivation in these cases and ensure that they understand the risks,” Dr. Shafran explains.

Setting the stage for success

During the first year of his fellowship, Dr. Shafran conducted and published a review on the issue of organ shortage and observed multidisciplinary transplant meetings. He worked with Dr. Weise to build the fellowship’s curriculum based on emerging clinical developments and related ethical issues.

During the second year of the fellowship, Dr. Shafran will provide consults on ethical issues in transplant. Former U.S. Treasury Secretary Robert E. Rubin and his wife, Judith, provided startup funding for Cleveland Clinic’s program. The goal is to sustain the transplant fellowship with philanthropic funding and with endowments.

This year, two new transplant fellows join Dr. Shafran. Jed Gross, JD, MA, earned his JD and an MPhil in history at Yale. Jonathan Wiesen, MD, a Cleveland Clinic Pulmonary, Allergy and Critical Care fellow, earned his MD from Albert Einstein College of Medicine and has been a resident/fellow representative on Cleveland Clinic’s Ethics Committee.

References

1 U.S. Department of Health and Human Services. Accessed May 5, 2014. Available at organdonor.gov/about/data.html.