Challenging issues associated with organ transplantation for Jehovah’s Witness individuals

Organ transplantation is one of modern medicine’s stunning but incomplete successes. Since renal transplantation was first practiced in the 1950s, advances in surgical technique, organ preservation, immunosuppression, and ongoing meticulous treatment of medical complications after transplantation have led to a 5-year survival after transplantation of 50% to 90% for all solid organs. Because of the great expense involved ($100,000 to 300,000 easily for solid organ transplantation in the United States) and the limited supply of organs, organ transplantation remains an elective and selective choice in modern health care. Considering the present state of the art and science of medicine, it cannot and should not be performed on every candidate. Every transplant program operates with a list of indications and contraindications for transplantation. Candidates must have organ failure (usually single organ) with a reasonable chance to survive the waiting period, the transplant procedure, and the initiation of immunosuppression so that a return to physiologic function is probable. As a general rule, gender, ethnicity, and religious belief are considered to be irrelevant to candidacy for organ transplantation. On the other hand, almost all programs require that the recipient have some resources prior to and after transplantation—financial to offset the considerable costs of transplantation and after-care and personal or psychosocial to handle the responsibilities and the inevitable stresses of transplantation. The paper “Lung Transplantation in a Jehovah’s Witness” by Conte and Orens1 in this issue raises a number of fundamental issues in the candidacy for lung transplantation. Although there is some variation in practice among individuals of the Jehovah’s Witness (JW) faith on medical matters, most adults willfully decline transfusion of blood products based on the particular and idiosyncratic JW interpretation of certain biblical texts.1 A review of the literature indicates that individuals who subscribe to the JW faith have undergone successful transplantation of kidneys,2 hearts,3 and livers.4 Success can be attributed to boldness and respect for patient preference from individual transplant surgeons, careful attention to techniques to minimize hemorrhage during surgery, and improvements in transfusion medicine. The introduction of erythropoietin therapy5,6 and antifibrinolytic agents such as aprotinin7,8 have reduced the likelihood and risks of excess hemorrhage to the patient. Nonetheless, the stipulation of the JW patient imposes a restriction on routine supportive therapy that may impact the potential success of organ transplantation. Conte and Oren1 indicate that the patient in question and the transplant team were “willing to accept a poor outcome.” Herein lies the crux of the difficult calculus of decision-making for any candidate regardless of religious belief. If a potential recipient is wealthy, appealing, and young, is it ethical to utilize scarce resources even if the chances of a good outcome—survival with reasonable physiologic function—are lower than in most other candidates? How objective does our decisionmaking need to be? How much risk of a poor outcome would be acceptable? If the patient had been grossly obese at 200% of her ideal body weight, most transplant programs would be reluctant to accept her as a candidate because of concerns about Associate Professor of Clinical Pediatrics, Washington University School of Medicine, St. Louis, Missouri. Submitted June 19, 1999; accepted July 27, 1999. J Heart Lung Transplant 2000;19:119–120. Copyright © 2000 by the International Society for Heart and Lung Transplantation. 1053-2498/00/$–see front matter PII S1053-2498(99)00073-X