Subscribe to one of our feeds
Print
“Who says the life of an 82-year-old isn't as valuable as the life of a 32-year-old?”
Clint Eastwood was pushing 70 when he hit his stride as a director. But if Dirty Harry had needed a new lung, he might have had a hard time finding a surgeon to make his day. Historically, the cut-off age for lung transplants has been 60 to 65.
Now, just in time for the rapidly aging baby boom juggernaut, surgeons have been rethinking the lung-transplant paradigm. In the past decade, the number of U.S. hospitals performing lung transplants on 65-and-older patients has increased to about two dozen. The University of Pittsburgh Medical Center transplanted a lung into a man born before the 1929 Wall Street crash. And a 78-year-old is alive today thanks to a lung transplant at UCLA Medical Center. As people live longer and enjoy healthier lives, and as medical science improves, surgeons expect that lung transplants for the Social Security crowd will become even more commonplace.
The historical age limit came about for reasons that made sense at the time. Older folks are often less tolerant of immunosuppression therapies and beset by chronic ailments such as renal and heart problems that complicate recovery. Moreover, good lungs are a scarce resource. People with end-stage lung disease die every day for lack of donor organs. The consensus among transplant surgeons and medical ethicists was that it wasn’t fair to save the life of someone with a shrinking life horizon while sacrificing the life of a younger person.
“That concept is noble and ethically justifiable. But we have many patients over the age of 65 who are otherwise very healthy and leading very productive lives,” says Dr. Abbas Ardehali of the Division of Cardiothoracic Surgery at UCLA. “Who says the life of an 82-year-old isn’t as valuable as the life of a 32-year-old?”
Ardehali and colleagues at UCLA have been transplanting lungs into 65-and-older patients since 1999, with three-year outcomes as good as those seen in younger patients. Of 50 UCLA transplant patients age 65 and older who received donor lungs between 2000 and 2006, 73.6 percent survived at least three years, compared to 74.2 percent for those under 65. Results of the UCLA study were expected to be published in the February issue of the Journal of Thoracic and Cardiovascular Surgery.
The age paradigm is shifting across the board in the transplant world. The 65-plus population, whose need for kidney transplants has tripled in the past decade, is getting a new lease on life with kidneys that would have once been discarded because donors suffered from high blood pressure, stroke, or other conditions. And more livers are being transplanted into older patients as medical experts find that age alone is not a good predictor for survival.
Dr. Kenneth R. McCurry of the University of Pittsburgh Medical Center, which has performed nearly 100 lung transplants on 65-plus patients, says he looks at physiological age and overall health rather than mere chronological age when deciding whether a patient is a good candidate for a new lung. “If we feel there’s a reasonable chance for a good outcome, we’ll do it,” he says.
As with once-rejected donor kidneys, many of the lungs being transplanted into the over-the-hill gang would have been considered unusable in years past. Today, old lungs and lungs with 20 or even more years of tobacco use are giving a second wind to patients with end-stage lung disease, with surprisingly good results. Most of these organs are simply unsuitable for younger patients who need low-mileage, high-quality lungs.
The increase in organ transplants in oldsters is not without its critics. Transplants are expensive. A lung procedure carries a price tag of $100,000 to $200,000, not counting the cost of medication once the recipient returns home. Utilitarians argue that it doesn’t make sense to throw so many resources at someone who can reasonably expect to live only a few years. Ethicists at the United Network for Organ Sharing (UNOS), the facilitating organization for transplants performed in the United States, recommend that surgeons “carefully consider” accepting patients whose reasonable life expectancy is significantly shorter than the expected life span of the donor organ.
But the utility argument is a slippery slope. “If our goal is to get as much benefit as possible, it seems like we would want to give organs to the people who are the most useful, so society would get the best payout,” notes Robert Veatch, professor of medical ethics at Georgetown University. “Is the president of a corporation or a poet or a mother of three the most useful member of society? You can see that that can get very messy very quickly.”
The opposing principle argues that everyone should get a fair shot at a life-saving organ, regardless of age. As Veatch notes, ultimately, the debate may not come down to a transplant or even a medical issue. “It’s a question about your theory of public policy,” he says.
