February 08, 2013

Stell's medical ethics class meets in Charlotte at Carolinas Medical Center, allowing students to attend rounds and hear guest lectures from top medical practitioners.

Thatcher Professor Lance Stell has provided Davidson students with an insider's view of America's health care system for many years through his association with Carolinas Medical Center. Now he is providing them with a new window into the complex issues surrounding organ transplantation through his appointment to a national committee charged with designing policy for that high-stakes medical procedure.

Stell's two decades of service as ethicist at Carolinas Medical Center in Charlotte prompted his surgical colleagues to nominate him for the appointment to a three-year term as one of 11 regional representatives on the United Network for Organ Sharing (UNOS). That private, non-profit organization manages the nation's organ transplant system for hearts, livers, kidneys, intestines, corneas, and lungs under contract with the federal government.

UNOS maintains a national database of available organs and patients needing them, and establishes equitable policies for distribution of organs based on a scoring system for potential recipients. Scores are assigned based on factors such as candidate age, time on dialysis, and diabetes status.

When an organ donor is identified, a transplant coordinator at the hospital or other procurement facility enters medical information about the donor into the system. The system uses this information to match donor information with the medical characteristics and scores of the candidates on the waiting list. The system then generates a ranked list of patients who are suitable to receive each available organ.

A patient's ranking on the list is determined by a UNOS points system based on factors such as medical urgency, tissue match, blood type, a patient's waiting time, organ size, immune status, and distance between the donor and potential recipient.

UNOS created the system to maximize efficiency and equity in the process, but questions and incidents regularly arise that require reevaluation. Stell serves on the UNOS ethics committee that fields such questions. At his first committee meeting, Stell and the other committee members considered two thorny issues - the degree to which a recipient's age should affect ranking on the list, and procedure for asking terminally ill patients and their families to consider organ donation.

Molly Crenshaw '13 leads a discussion for Prof. Stell and her classmates.

The scarcity of transplantable organs intensifies the importance of UNOS guidelines for patients. Stell referred to the UNOS web site, which displays a constant update of the numbers of people on the waiting list, transplants completed, and donors. He noted, "More than 115,000 people nationwide are waiting for organs today, and as many as 20 of those people per day will die waiting."

The most striking need is for kidneys. There are currently almost 90,000 patients requesting kidneys, while less than 20,000 kidney transplants are performed each year.

Stell's committee was asked to consider how the age of recipients should affect their ranking to receive the healthiest kidneys available. He explained, "There are cases where someone as old as 78 has received a transplant of a kidney. But is that ethical when an 18-year-old could gain many more years of healthy living from that organ?"

Historically, waiting time and blood type were the primary determinants of kidney allocation. UNOS first asked for a review of the system in 2003, and several ideas were explored in committee meetings and public forums. At one point the committee considered recommending that frank preference should be given to younger recipients. However, the U.S. Department of Justice rejected that idea as illegal age discrimination.

The committee eventually ended up proposing changes that would not affect many candidates, but would result in longer graft survival, which would indirectly favor younger candidates. The committee's mathematical calculations estimated the new system would result in 8,380 additional life years for patients.

But that recommendation is not the final word. The committee's suggestions were opened to public comment, and then needed approval by the Department of Justice as well as the Centers for Medicare/Medicaid Services.

Stell says bringing his committee work back to students in his classroom add rich detail to the issues of medical ethics.

"The details are very important in medical ethics," Stell said. "The subject shouldn't be engaged from 20,000 feet. Student interest increases when they consider the nuts and bolts of policy and surgical procedures."

Ramiz Hamid '14 speaks up as Ashley Parker '14 and Seth Saylors '14 look on.

Through his long-time service as resident ethicist at Carolinas Medical Center in Charlotte, Stell has arranged access there for his students. They get a first-hand look at the medical decision-making process by meeting there each Tuesday afternoon to attend rounds, hear guest lectures, and discuss their reading assignments.

Stell said, "Because of Davidson's institutional affiliation with CMC, students have the opportunity to be at the elbow of physicians and surgeons as they engage in ethically complex discussions. Seeing how professionals engage with each other over very dramatic choices makes an impact. They learn tremendously more."

Stell's course is not limited to premedical students. It provides all students with valuable access to study important societal issues that will affect them. As Stell likes to say, "they're not all going to be doctors, but they will all be patients."

In addition to his new UNOS responsibilities, Stell has been involved in other medical ethics scholarship. He and a colleague from Harvard, Thomas Stossel, MD, have written several articles defending physicians' complex relationships with the medical products industry. "Physicians would have very little to offer patients," Stell says, "were it not for drugs and devices they obtain from industry." He has also recently published a book chapter titled "Responsibility for Health Status: Essays on the Distribution of Health Care," in the new Oxford University Press book Medicine and Social Justice.

Davidson is a highly selective independent liberal arts college for 1,900 students located 20 minutes north of Charlotte in Davidson, N.C. Since its establishment in 1837 by Presbyterians, the college has graduated 23 Rhodes Scholars and is consistently regarded as one of the top liberal arts colleges in the country. Through The Davidson Trust, the college became the first liberal arts institution in the nation to replace loans with grants in all financial aid packages, giving all students the opportunity to graduate debt-free. Davidson competes in NCAA athletics at the Division I level, and a longstanding Honor Code is central to student life at the college.
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