Splitting Deceased Donor Livers to Double the Transplant Benefits: Addressing the Legal, Ethical, and Practical Challenges
Evelyn M. Tenenbaum and Jed Adam Gross,
Splitting Deceased Donor Livers to Double the Transplant Benefits: Addressing the Legal, Ethical, and Practical Challenges,
33 Health Matrix
Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol33/iss1/5
Liver transplantation is different from transplanting other solid organs because some recipients can achieve good long-term outcomes with only half of a donor’s liver (or less). This means that some deceased donor livers can be split, saving two lives instead of one. However, although more than 10 percent of cadaveric livers meet the criteria for splitting, only about 1.5 percent are actually split in the United States. This article identifies a set of ethical, legal, and logistical challenges to a more extensive use of split liver transplantation (SLT) within existing legal frameworks. We then discuss how each of these challenges can be overcome with a set of realistic clarifications and changes to the current liver transplant architecture. Three guiding values shape liver allocation policy in the United States: maximizing expected outcomes, ensuring broad access, and prioritizing the sickest patients. While the last value is in tension with SLT (because the sickest patients often need a whole liver), we maintain that greater adoption of SLT is consistent with this normative balance. In addition, the distribution infrastructure is not designed to facilitate splitting. When a surgical team is offered a liver for a specific patient, they feel duty-bound to give that specific patient the whole organ. Further discouraging SLT, performance metrics, including those used to determine a transplant program’s eligibility for Medicare and Medicaid funding, focus on surgical outcomes rather than waitlist mortality. Our preferred remedies entail clarifying the informed consent requirements for SLT, using a national clearinghouse to identify livers that are prime candidates for splitting, offering these livers to qualifying programs for SLT only, and establishing a separate regulatory reporting and outcomes evaluation pathway for SLT. Together, these reforms, many of which have precedents in the transplant field, will support the expansion of SLT in carefully controlled conditions and save more lives.