For the first time in 15 years, there has been documented transmission of the human immunodeficiency virus (HIV) through solid-organ transplantation.1 Although transmission of infectious agents through transplantation is rare,2 such cases raise important questions about how informed consent for transplantation should be obtained and about the type of resource that transplantable organs represent.
Among the questions raised are the following: Should potential recipients be informed about the general risks associated with transplantation or those specifically associated with an identified organ? Should the risks engendered by the behavior of donors be treated differently from those associated with the medical profiles of donors? Finally, is the supply of transplantable organs a singular public good to be distributed to maximize public health or is it a market of intermittently available goods from which eligible recipients might select in order to maximize their own well-being?
The Chicago Case
A 38-year-old man died after a motor vehicle accident in January 2007. His liver, heart, and both kidneys were subsequently transplanted into four recipients. At the time of the donor's death, all routine tests for transmittable diseases2 were negative. However, the local organ-procurement organization and the transplantation surgeons to whom the organs were sent knew that this donor had a behavioral risk factor that increased the possibility that the antibody-based assays for HIV and other viruses might show false negative results.1,3
All four organ recipients have since tested positive for both HIV and the hepatitis C virus (HCV). At least one of the recipients is considering a suit against the transplantation center and the local organ-procurement organization, charging that she was harmed by not being notified of the donor's above-average risk of HIV and, therefore, was denied the opportunity to decline the donation. Her attorney has declared, "it's up to the patient . . . to make the decision whether to incur the risk."3
Behavioral Risks among Donors
A well-known limitation of the safety of organ transplantation is that antibody-based tests to detect viruses have poor sensitivity within the first few weeks after infection.2 Although more sensitive nucleic acid–amplification tests are now used in some regions, even these tests do not fully eliminate the possibility of a false negative result. Data from studies involving tissue donors show that between 1 of 55,0004 and 1 of 161,0005 donors are infected with HIV, despite negative antibody-based tests, and that the addition of nucleic acid testing reduces the rate of false negative results by two thirds.4,5Certain donors have above-average risks of false negative HIV tests because their behaviors may generate more new infections. Nonetheless, persons with risk factors for HIV that have been identified by the Centers for Disease Control and Prevention (CDC)6 are commonly donors for solid-organ transplantation. Table 1 indicates that during the period from 1995 to 2006, 6% of donors in our donor service area had risk factors that were consistent with the CDC criteria. Read More......