What's the matter with liver transplants? Nothing -- if you're Steve Jobs

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By now, we all know that Apple (AAPL) founder Steve Jobs underwent a liver transplant in April. Following reports of his increasingly gaunt appearance and sudden retirement from Apple, The Wall Street Journal on Saturday solved a mystery that's been brewing for months, if not years. Jobs's surgery is good news, of course, but it raises major concerns about the way the business of organ transplants is conducted in America.

After his bout with pancreatic cancer, Jobs has been notoriously tight-lipped about his health, so it's difficult to know how long he's been waiting for a transplant, or the extent to which his liver has been damaged. But liver-transplant candidates routinely wait years to get a working organ. Many die waiting.
That's not to say that Jobs somehow skipped to the top of the list, or that he purchased an organ -- both illegal practices are well-nigh impossible, at least in the U.S. But the fact that he had a transplant in Tennessee reveals how much easier this process is if one happens to be richer than Croesus.

Organ allocation works like this: transplant patients get on a list in their "transplant region" (There are 11 in the U.S.). Based on their degree of need (which is measured by a MELD or PELD score), their blood and tissue types, and the organs available, their wait may range from a few days several years. For richer patients with connections and means of travel, it's possible to vastly increase your odds of getting an organ fast by cherry-picking a region with a shorter list, or getting on the list in multiple centers. The alleged location of Jobs's transplant suggests that he went this route.

Jobs's cancer is another odd variable in his transplant story. Some experts say that tumors metastasize and spread to other organs in 75 percent of pancreatic cancer patients. This makes them less-than-ideal candidates for transplantation -- leading some to wonder how Jobs managed get an organ.

When it comes to the odd relationship between transplantation and wealth, the poster boy is probably former Pennsylvania Gov. Robert P. Casey, who received both a heart and a liver within days of getting on the transplant list. Officially, Casey got his organs quickly because, while the heart list and the liver list were both extremely long, the heart-and-liver list was very short, so Casey shot right to the top. Interesting explanation ... if true.

In 2003, St. Vincent Medical Center in Los Angeles took the wealthy transplant problem one step further. Breaking protocol, the hospital catapulted a Saudi citizen over nine other patients. The transplant netted the hospital $340,000 (not including surgeons' fees), 25 percent to 30 percent more than normal. Ultimately, the windfall wasn't worth it: after the story broke, the hospital shut down its liver-transplant program.

Canadian companies have taken another tack: according to some reports, they send patients to underdeveloped countries where they can buy kidneys from poor people. Seemingly the stuff of urban legend, Canadian organ-outsourcing has been the subject of numerous investigative reports.

Livers are a little bit more touchy: while one kidney can easily be taken from a living patient, most liver transplants are done with "cadaver" livers, harvested from dead people. Partial liver transplants are possible but are far from common.

Over the past year and a half, my family has gotten a sharp glimpse of this -- and of the difficulties surrounding transplantation. Early last week, my youngest sister, Ella, received a little over 40 percent of my sister Jen's liver. This came at the end of a long struggle with waiting for a cadaver liver, dealing with Medicaid, and various other horrors of contemporary medical care.

My sisters are both doing well, and their liver team at New York's Columbia Presbyterian Hospital has done a wonderful job. But there's little doubt in my mind that my sister was ill-served by both the transplant list and the transplant protocols. Had she been forced to wait for a liver, it seems likely that she would have died.

While I have a great deal of respect for Steve Jobs and endless admiration for his company, I'm not sure that creating the innovative iPhone merits preferred transplant status. Until commerce and transplantation are firmly separated, this program will be a blight on the record of American healthcare.
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