I am Art Caplan from the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. Anthony Stokes was 14 years old when he wound up in an Atlanta area hospital in need of a heart transplant. His heart had been attacked by a virus and the virus was eating away at the heart muscle. Anthony was going to die if he didn’t receive a heart transplant.
The hospital, however, initially rejected the 14-year-old, saying that he was not a good candidate for a transplant. He has had brushes with the law and was wearing an ankle bracelet because he had been convicted of breaking and entering. He has had problems at school. The hospital said that the waiting list for hearts is very long. Acquiring a heart to transplant is very unusual. It is difficult to get a heart, and we are worried that you are not a good candidate because you may not comply with what needs to happen if you do receive a heart. You have to take all your drugs every day. You have to do it reliably. You have to monitor your health and make sure that at the first sign of fever, or some other symptom that you might be rejecting the heart, you get right to the hospital. They thought that this particular 14-year-old, because of his uneven behavior, wasn’t the best candidate for transplant.
His mom did not agree, nor did many of her friends at church and her other neighbors. They appealed and said, “You shouldn’t penalize Anthony. He should get this heart. Just because he has had some run-ins with the law and has had behavioral issues at school, you shouldn’t kill him. He should be considered for a transplant.”
This all took place about 3 years ago. I happen to agree that Anthony should have been on that waiting list. Part of my reasoning is that we are not good at predicting who will be compliant. Furthermore, teenagers as a group are poor at compliance. They are teenagers. They don’t do what they are told. They don’t like the appearance changes that sometimes occur with immunosuppression. The drugs that must be taken after the transplant are generally pains in the neck. If you were going to penalize Anthony, you wouldn’t be transplanting any teenagers because the likelihood that they are going to be noncompliant, reject the heart, or experience side effects and problems is much higher. The data show that teenagers, generally, do worse, but we cut them slack because we know that teenagers are teenagers. I didn’t see any reason to treat Anthony Stokes differently.
Well, Anthony Stokes recently wound up dying—not because his heart was rejected. He was compliant. He took his medicines. But he died in a police chase. He crashed his car and died, in the middle of committing a crime in which there was violence and he used a gun. I don’t think he had killed anyone, but it was definitely a violent crime, and in fleeing the police he crashed his car and died.
So many people will say, “The hospital, initially, was right. That young man should not have been on a waiting list. Hearts are scarce. What are we doing? Why wouldn’t we give them to people who are more deserving?”
But I don’t agree. I know that is a hard position to accept but I still believe that teenagers have to be treated as teenagers. Many of them are going to have brushes with the law. A lot of them are going to be in trouble at school. A lot of them are going to act out. A lot of them are going to try drugs. A lot of them are going to use alcohol. Teenagers get into all kinds of problems.
Our ethical duty is to be a little forgiving. It is hard when they go out and do terrible things, but I don’t think we should exclude them from organ waiting lists just because they are at higher risk. The high risk is related to being a teenager and everything that goes along with that.
How many of us got into trouble or went down the wrong road for a while when we were teenagers? I don’t think we want to exclude that group. Yes, the heart that Stokes got when he died in this police chase could have gone to someone else, but that is looking through the retrospective scope. Teenagers, even the ones who are showing signs of trouble, like Anthony Stokes, should be considered for organ transplantation.
Doctors should not sort the saints from the sinners. They often don’t have enough information to do it. In fact, if you look at the transplant waiting list, there are plenty of sinners on it anyway. There are people on the list who have tried to kill themselves. There are people on the list who abused alcohol. There are people on the list who used injectable drugs, have hepatitis, and have destroyed their livers. There are people who didn’t control their blood pressure, and people who are far too obese. The list of sinners is very long. Making judgments about who is and who isn’t worthy is not the doctor’s role.
Doctors should try to figure out who might benefit and who can be helped, and leave the social and policy decisions about whether to accept someone who is a bad person, or a potentially socially undesirable person, to the legislators and politicians. It is not the doctor’s job. It is all of our jobs if we want to make restrictions on who can get a transplant because of their criminal or drug history or any other problems they might have.
I am Art Caplan at the NYU Langone Medical Center.