Editorial: Where monsters hide

The report served to establish the “ethical” foun-dation for initiating a series of surgical procedures inwhich a living adult would be subjected to partial hep-atectomy to obtain a segment of liver for transplanta-tion to a child. At the time, the mortality for infantsawaiting liver transplantation was said to be 50%. Asevidenceoftheirqualiﬁcationstoproceed,theChicagogroup cited two distinct accomplishments. First, in thelaboratory, 8 of 9 recipient dogs and all 9 donor dogswerealiveandwellafterundergoingproceduressimilarto the planned clinical surgery. Second, a retrospectivereview of the group’s experience in performing partialhepatectomies in patients without cirrhosis showed nodeaths in 35 patients.The current report (the authorship of whichincludes Siegler and Broelsch from the 1989 report)represents a similar effort to examine the ethical issuesrelated to extending the use of live donation to providelivertransplantationforadults.Theauthorsbeginwiththe traditional justiﬁcation, namely the shortage ofcadaveric organs and the alarming risk of death foradults awaiting a cadaveric donor liver. Additional jus-tiﬁcation is necessary, of course, because the risk to adonor is believed to be greater when a larger portion ofhis or her liver is removed for transplantation. Notunexpectedly,theiranalysisleadsthemtoconcludethat“the high risks taken by donors undergoing a hemi-hepatectomy seems to be justiﬁed by the steadilyincreasingmortalityofadultrecipients(sic)waitingfortransplantation.”Eschewingamoretraditionaldiscussionoftheethicsinvolvedinlivingorgandonation,theauthorschooseamore practical analysis of the level of expertise and thetypes of facilities they believe are required. A section oftheir manuscript is entitled “Who Can or Should Per-form ALDLT?” and, within it, the authors list “Opti-mal Institutional Requirements.” Clearly, the intent isto provide a starting point for self-regulation, an admi-rable and timely goal.Unfortunately, in developing their recommenda-tions, the authors bring their considerable reputationsbut little objective data. More than apparent is theirconﬁdence that by setting the bar high for entry quali-ﬁcations, they are protecting the unwary public fromuncontrolled participation by unprepared surgeons.Equally unapparent is their recognition that by speak-ing out now, well after their own programs are estab-lished, their credibility courts parochialism. That thequaliﬁcations cited are those that each of their centerspresently meets does little to discourage such anunhappy union.Thatsaid,oneneedstobeginsomewhereindeﬁninghow best to deal with the specter of untrained surgicalhordes bearing down on a public all too willing to giveapieceofitslivertosaveitssoul.Theauthorsdowelltoadvocate self-regulation within the profession, speciﬁ-cally through implementation of authoritative qualiﬁ-cations.Perhapsourgreatestchallengegoingforwardisdeﬁning those qualiﬁcations on the basis of sound evi-dence whenever practical. The political pressures tomake them either too restrictive or too liberal wouldseem considerable.The authors also examine some of the ethical andphilosophicalissuesarisingfromthenearlyoverwhelm-ingtemptationstoextendtheindicationsforlivertrans-plantationbeyondthosegenerallyacceptedfortheallo-cation of cadaveric organs. But while the authors laterstatethat“healthprofessionalsareexpectedtomaketheﬁnal determination on the appropriateness of the indi-cations,” they stop short of suggesting that health pro-fessionalshaveanobligationtoprotectthepublicfromitself.Instead,theauthorsbelievethattheneedforgoodpublic stewardship in decisions governing allocation ofcadaver organs need not necessarily apply to live dona-