Dr. Fleck chaired a session titled “Rights, Responsibilities, and Justice.” He also presented the talk “Last Chance Therapies: LVADs AND a Heart Transplant?” Dr. Fleck has provided the summary below of his talk.
In a recent review article [Journal of the American College of Cardiology 2015; 65: 2542-55] the authors assessed expanded dissemination of left ventricular assist devices [LVADs], used in late stage heart failure. About 650,000 Americans experience heart failure annually. About 5.8 million Americans are in some stage of heart failure now with 300,000 deaths annually. A heart transplant would yield more than ten extra years of life for at least half these patients, but only 2300 hearts are available for transplant annually. LVADs are now offered either as Destination Therapy [DT] or as a Bridge to Transplant [BTT]. The ethically troubling proposal suggested by these authors is that individuals in late-stage heart failure [Stage IV] in the future should first be given an LVAD; then, if complications develop, they should be a candidate for a heart transplant. This is, in fact, what was done for former Vice-President, Dick Cheney, who had suffered five heart attacks, starting at age 37. Prior to his LVAD and heart transplant at age 71 he had had bypass surgery, several stents, an implantable cardiac defibrillator, a pacemaker, and numerous cardiac drugs.
What I argued in this presentation is that the proposal in the journal article above is deeply flawed from the perspectives of fairness and health care justice. From a utilitarian perspective more life-years of higher quality would be lost rather than gained because patients needing a heart transplant after LVAD complications have poorer prospects. From an egalitarian perspective only patients with excellent insurance would be able to afford this option, which would likely have overall costs of the two transplants of almost a million dollars. As things are now, fairness is undermined when some patients get both BTT and a heart transplant, two shots at prolonged life at the expense of someone else on the transplant list. This is what happened in the case of Dick Cheney. Some relatively younger individual (who for medical reasons might not have had the LVAD option) died prematurely, having access to neither an LVAD nor a heart transplant, while Cheney had two chances for life prolongation.
I concluded the presentation with a proposal for an ethically preferable alternative. (1) Individuals below age 70 with some form of heart failure could choose either the LVAD as DT or be placed on the transplant list. They could not choose both. If they choose the transplant list, they are rolling the dice. A good match might not be available before they die. If they choose the LVAD, 30% of those patients will die within a year, and 40% will gain 4 extra years of life, though of somewhat diminished quality. The serious complication rate for the LVAD is 70% (stroke, intestinal infections, device failure). (2) Some patients are in experimental protocols with a totally implantable artificial heart. If that device fails, they are immediately moved to the transplant list with top level urgency. They too would have to choose one way or the other. (3) Some patients (often younger) have life-threatening cardiac conditions that cannot benefit from an LVAD. They need to go the transplant list. They should not have to compete for a transplant with individuals who have already had an LVAD. It is essentially unfair that some individuals would get two chances for life prolongation while others would get none.