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Special-Needs Girl Denied Kidney Transplant in Phila.

Myriad

The Clarity Is Devastating
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Chrissy Rivera, a New Jersey woman, reported in a blog post that a doctor and social worker at Children's Hospital of Philadelphia told her and her husband that their daughter Amelia would not be given a life-saving kidney transplant, even if the kidney were donated by a relative as they had intended. This was because of "quality of life issues" and also because "brain damage" and "mental retardation" were on a printed list of contraindications for that procedure. Amelia has Wolf-Hirshorn Syndrome, a genetic condition (though usually not hereditary) that affects multiple aspects of development.

Here is her original blog post: http://www.wolfhirschhorn.org/2012/01/amelia/brick-walls/

Word spread in the special-needs community, and the hospital, which has an overall good record of care for special-needs children, is now facing a storm of criticism, including on its own Facebook wall. An online petition is now past 20,000 signatures. The "petition updates" tab at that last link now has dozens of media and blog links.

For me, this story is like a flashback to the struggles my parents went through in the 70s to get proper schooling and medical care for my developmentally disabled brother. They were once told by a doctor, "He [my brother] has pneumonia; he'll die if we don't give him antibiotics. Do you want us to give them to him?" Quizzical raised eyebrow, nudge-nudge. Those attitudes have changed, but it seems there are still some shameful holdovers in the medical community.

Of course, Chrissy Rivera's account is only one side of the story; the hospital cannot comment due to privacy rules. However, there are details in the blog account that ring true to me based on my parents' experiences, and that a parent who had not been through it would be unlikely to invent. Such as, the social worker writing notes with every expression of anger or disagreement; the implied threat of the parents being "diagnosed" as neurotic or hysterical or whatever terms they use nowadays, to destroy their credibility or even challenge their custody if they dare to make trouble. That's an old game. (The difference, today, is the Internet.)

If this were a matter of Amelia's priority on a donor list, I agree that there's a legitimate medical issue. There are too few donor organs, and the surgery Amelia needs is more difficult and more dangerous than the same operation on a "normal" child. But to those of us who share our lives with developmentally disabled friends and relatives, the doctor's remarks on "quality of life" come across as ignorant and outrageous.

Respectfully,
Myriad
 
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I'd like to know the reason for the contraindication before commenting or jumping to any conclusions. Severe mental retardation is an absolute, rather than a relative contraindication.

Contraindications for Kidney Transplantation

There are certain absolute contraindications to renal transplantation:

Disseminated or untreated cancer
Severe psychiatric disease
Unresolvable psychosocial problems
Persistent substance abuse
Severe mental retardation
Un-reconstructable coronary artery disease or refractory congestive heart failure
http://www.umm.edu/transplant/kidney/indkidny.htm

However these research papers indicate it shouldn't be precluded:

http://www.ncbi.nlm.nih.gov/pubmed/20215391

http://www.ajkd.org/article/S0272-6386(05)01811-1/abstract

ETA: And here's a relevant paper on mental retardation and organ donation in general:

Abstract: We reviewed the literature on accessibility and outcomes of organ transplantation in individuals with mental retardation (MR) and on the prevalence of organ donation in this population. Six centers have published outcome data on renal transplantation in 34 individuals with MR. The one- and three-yr patient survival rates were 100% and 90%, respectively. The studies reported good compliance with post-transplant medications due to consistent support from family members or caregivers. The outcome studies for liver and heart transplantation among these individuals are limited. The literature on organ donation in individuals with MR is mostly concerned with legal issues. The courts generally permit organ donations when such is in the best interests of the donor.
http://nisonger.osu.edu/papers/LWSarticle.pdf
 
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Sounds a bit peculiar. Do we have a seperate source for the information?
 
It looks like in the past it has been denied because of concerns about keeping to the post transplant medicine regimen, but research has now shown that with good carer/family support, this needn't be a great issue. Looks like the guidelines (and the doctors in this case) haven't kept up with their research.

ETA: This is in addition to the general attitudes about quality of life mentioned above
 
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I don't know the details of the hospitals decision, but I can tell you that CHOP is a treasure. I have met people from all walks of life who have moved to the area simply because of CHOP and the care their children receive, as opposed to prior experience at other institutions. I have never met a soul who has taken a child to CHOP who did not rave about it.
 
I'd like to know the reason for the contraindication before commenting or jumping to any conclusions. Severe mental retardation is an absolute, rather than a relative contraindication.

http://www.umm.edu/transplant/kidney/indkidny.htm

However these research papers indicate it shouldn't be precluded:

http://www.ncbi.nlm.nih.gov/pubmed/20215391

http://www.ajkd.org/article/S0272-6386(05)01811-1/abstract

ETA: And here's a relevant paper on mental retardation and organ donation in general:

http://nisonger.osu.edu/papers/LWSarticle.pdf


Thanks for looking into the medical literature. Some of the press articles have checked with doctors and so far none have revealed any physiological reasons that the transplant could not succeed.

The concerns, rather, appear to be the reliability of long-term post-operative care, and "quality of life." Just as the doctor told the Riveras (according to Mrs. Rivera). Those are the same reasons Down's Syndrome heart patients are denied any access to heart transplants.

For the former, every developmentally disabled person I know of any age (from children to geriatric) are under far more strict medical supervision than the average person. So that leaves quality of life.

Respectfully,
Myriad
 
Another relevant paper I found has this extract:

Despite abundant evidence of substantial health needs that exceed those of the general population, it is clear that impediments to appropriate health care continue to confront individuals with intellectual disability13. Educational deficiencies and unsupported prejudices are prominent in maintaining those impediments. To illustrate further, parents have reported that it has not been unusual for their sons or daughters to be disallowed recipient status for organ transplant surgery, with disability given as the reason for exclusion:

“I was told by her cardiologist that she is not eligible for a transplant because of her Down syndrome.”

“We were told that if he was ‘normal’ like us he would be a great candidate for a corneal transplant.”

“The first doctor we saw told us that no transplant could be done because our son was ‘retarded’”.

“I was told that at the university hospital they will transplant a kidney but not even consider a heart transplant for someone with Down syndrome”14.

While people with intellectual disability are no longer universally excluded from transplant surgery (when organ transplantation was first introduced, intellectual disability was grounds for automatic exclusion), many people with intellectual disability still do encounter discrimination when it comes to referral, evaluation, and actually receiving a donor organ15. In one case, a doctor who was compelled by U.S. antidiscrimination legislation to evaluate a woman with Down syndrome concluded that her explanation--- that she “wanted to live”--- was not sufficient reason to qualify her for transplantation16. In another case, a woman with intellectual disability was denied life-saving transplant surgery by two California transplant centers. The decisions were not the results of careful examination and medical judgment (one of the centers had never met with nor examined the woman), but reflected a categorical view that people with Down syndrome were not appropriate candidates for heart/lung transplants. In Canada, a 17-year old boy with Down syndrome had his application for a lung transplant turned down because he did not meet the hospital’s written criterion of “satisfactory intelligence”. It wasn’t until his parents “went public” that the hospital revised its policy and placed the boy on the transplant waiting list (this, incidentally, caused a flood of telephone calls with callers accusing the hospital of “wasting organs” on the intellectually disabled)17.
http://www.ispub.com/journal/the-in...individuals-with-intellectual-disability.html
 
I don't know the details of the hospitals decision, but I can tell you that CHOP is a treasure. I have met people from all walks of life who have moved to the area simply because of CHOP and the care their children receive, as opposed to prior experience at other institutions. I have never met a soul who has taken a child to CHOP who did not rave about it.


I agree, for the most part. (I tried to give them their due in the OP but in fixing some awkward sentence structure, I ended up understating it.)

I (and tens of thousands of others) am waiting to see how CHOP handles this going forward. They might have recruited a physician who's world-class in pediatric nephrology but a few decades behind in northeastern U.S. attitudes about developmental disabilities. Things like that can happen.

It's also possible that Ms. Rivera misunderstood, or is lying. I don't believe that for reasons I mentioned, but I can't rule it out for certain.

Respectfully,
Myriad
 
Thanks for looking into the medical literature. Some of the press articles have checked with doctors and so far none have revealed any physiological reasons that the transplant could not succeed.

The concerns, rather, appear to be the reliability of long-term post-operative care, and "quality of life." Just as the doctor told the Riveras (according to Mrs. Rivera). Those are the same reasons Down's Syndrome heart patients are denied any access to heart transplants.

For the former, every developmentally disabled person I know of any age (from children to geriatric) are under far more strict medical supervision than the average person. So that leaves quality of life.

Respectfully,
Myriad

Could it not be that after interviewing the parents, and grasping the situation the child is in, the doctor simply does not have reason to believe that they would be able to stick to the post op regimen?

There are some **** doctors out there to be sure, but considering that this is an otherwise raved about hospital, could the case not be that there is simply factors we do not know?

I know the instant reaction to someone denying something to someone who is in a bad situation is ire, but there could be much more to this than we know.
 
Well said.

It seems that "quality of life" issues generally come down to the "I can't see myself wanting to live like that" perspective.

I say that a lot of the time this branding is unfairly placed, especially when it is an issue of being on a wait list ( which this is not, but it is a broad reaching topic. .)

It is more of a case of " With this organ, person A could lead a normal healthy life and be able to make the most of the organ. But person B, will lead a less normal, healthy life and not gain as much of a benefit from the organ." if you have to give one person the organ, it simply makes sense to make it the person that will get the most benefit out of it.

In fact i find in general, the attitude to things like this is " This person already has a **** life, why not give them something good?" and that is a nice standpoint to take. But when we have a limited supply of organs, the person who can make the best use of them, should be the person getting them.

It would be like if one was in charge of designating which troops get which weapons. Are you going to give a state of the art , costly, effective sniper rifle to the gent who can barely hit a target, or the gent who can hit the bullseye 9/10 times?
 
I have to say this is usually the right decision. I have seen it in patients I am familiar with, too. And so I have done some reading;

If a person is so profoundly disabled that they cannot FULLY cooperate with the process, there are nearly always bad outcomes and unnecessary pain and suffering. Plus an irreplaceable opportunity to save the life of somebody who could actually have benefitted was lost.

ETA: Even if, as will very soon be the case, human kidneys can be manufactured out of cell cultures, giving one to a person who cannot do what is needed to survive the process is not a mercy.
 
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I have to say this is usually the right decision. I have seen it in patients I am familiar with, too. And so I have done some reading;

If a person is so profoundly disabled that they cannot FULLY cooperate with the process, there are nearly always bad outcomes and unnecessary pain and suffering.


You mean, people who cannot cooperate with the process the way normal three-year-old children fully cooperate with the process?

And what research shows those "nearly always" bad outcomes, in cases where developmental disabilities (as opposed to suicidal behavior, substance abuse and other factors that are also weighed) are concerned? Studies were cited above showing otherwise.

Plus an irreplaceable opportunity to save the life of somebody who could actually have benefitted was lost.


The case at hand does not involve any such opportunity, unless you think the relative who would have donated his or her kidney to Amelia should be compelled to donate it to someone else instead.

I agree that there's more justification for your position in cases like heart transplants, but only because in that area no one is guaranteed a chance to begin with, not because a developmentally disabled person is not able or less able to benefit.

ETA: Even if, as will very soon be the case, human kidneys can be manufactured out of cell cultures, giving one to a person who cannot do what is needed to survive the process is not a mercy.


You mean, like a three-year-old child? This is a children's hospital, so I suspect that giving treatments to people who cannot (without assistance) do what is needed to survive the process, is rather routine there.

Respectfully,
Myriad
 
You mean, like a three-year-old child? This is a children's hospital, so I suspect that giving treatments to people who cannot (without assistance) do what is needed to survive the process, is rather routine there.

Indeed. I think my niece may have struggled somewhat with the medications etc given that she was only 5 months old when she had her heart transplant.... I don't think she would manage much better by herself now that she's 4, either.
 
Could it not be that after interviewing the parents, and grasping the situation the child is in, the doctor simply does not have reason to believe that they would be able to stick to the post op regimen?


Possible, but highly unlikely. The family had been able to stick to regimens sufficient to keep Amelia alive for three years, which not all with her condition manage to do. That includes the post-op regimen for at least one other major surgery.

However, "the parents wouldn't be able to handle it" has been employed as an excuse to deny rights to parents of developmentally disabled children often enough in the past (usually accompanied by the snide implication that to have borne a defective child they were probably a bit on the dim side themselves), so it's possible that someone at CHOP will attempt to make that claim, but I certainly hope not.

There are some **** doctors out there to be sure, but considering that this is an otherwise raved about hospital, could the case not be that there is simply factors we do not know?


Again, it's possible. But all the evidence we do have is consistent. As to the hospital's rave reviews, I've been reading the decidedly mixed comments by other parents of developmentally disabled children who have been treated there (or for various reasons were not), and contrasting them with the near unanimous raves by the proud happy parents of potential future professionals, taxpayers, and breeders, and there is an interesting difference. It appears that the most likely "factor we do not know" is frequent (though not universal or pervasive) medical prejudice against the developmentally disabled, and their parents.

I know the instant reaction to someone denying something to someone who is in a bad situation is ire, but there could be much more to this than we know.


More to it than I knew before, certainly. Like I said in the OP, I thought that **** ended with the reforms of the mid to late 70s.

Respectfully,
Myriad
 
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What is not clear here is how profoundly or not this child is brain damaged. Are people suggesting it would have been ethical to give Terry Shiavo a kidney transplant? OTOH, at the end of the personal anecdote the mother says the child is developmentally delayed, quite a different scenario.

I need to know how brain damaged before I'm willing to condemn the medical exclusion. Yes there are times where it is a judgement call, but there are times when a medical decision is not agreed with by parents in denial that their brain dead child will never improve.

It depends on how severe this child is affected. Also, hep C is mentioned. That could mean a liver transplant would also be needed in the future. Livers and kidneys are both in short supply. Sometimes that has to be taken into account and yes, we make judgements about quality of life.

Then there is the problem of the parents not hearing everything the physicians said. A parent might hear the mental disability when the doctor also said the immunpsuppressing drugs a kidney transplant entails could worsen the hep C. I'm just rather skeptical of these personal testimonies by distraught loved ones. I've seen some doozies out there in the anti-vaxxer community.
 
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Fascinating thread. I had heard that Downs syndrome people were denied transplants but I'd thought that was because of "physiological" complications arising from their condition, which I could understand. So I am surprised to learn that it because of an unfounded discrimination.
 
I'm afraid I'm not. It's not all that long since they were still called the M word as a matter of course.
 

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