Sweet, Soft Matter: Candy Cotton for the Regeneration of Blood Vessels

I love interdisciplinary journals, but I had not stumbled across Soft Matter, where physics meets chemistry meets biology for fundamental soft matter research, until today when the following story caught my eye:

(Via Red Orbit)

"Scientists are turning to cotton candy as a novel tool to help grow replacement tissues for people. It seems the long-time favorite treat may provide an ideal way to generate a network of blood vessels within lab-grown skin, bone, muscle or fat for breast reconstruction, researchers say.

Dr. Jason Spector of New York-Presbyterian Hospital/Weill Cornell Medical Center in New York and Leon Bellan of Cornell University conducted the research on the new technique.

It works by first pouring a thick liquid chemical over the cotton candy, and waiting for the liquid to solidify into a chunk. The chunk is then put in to warm water to dissolve the cotton candy, leaving small channels where the strands of cotton candy used to be. Eventually, what is left is a piece of material containing a network of fine channels.

These channels are then lined with cells to create artificial blood vessels. The solid chunk can be seeded with immature cells of the type of tissue scientists wish to make.

Since the block is biodegradable, as it disappears it is slowly replaced by growing tissue. Ultimately what remains is a piece of tissue permeated with tiny blood vessels."

Assuming this technique will be refined, it would have incredible implications for organ transplantation, regenerative medicine, artificial wombs, as well as other medical uses.

What can I can say but "Sweet!"?

Art Caplan: And now for the dumbest divorce claim of 2009

Sounds like the start of a corny joke: your money or your wife? When I was a trial attorney (in a previous life), I had my fair share of rancorous divorce cases, but this one takes the cake:

According to a Newsday article,when Dr. Richard Batista's wife needed a kidney, he gave her one of his (how lucky they were a match!) -- and now that Mrs. Batista has filed for divorce, he says he it wants it back -- either that or $1.5 million -- the supposedly value of the kidney transplant.

Aside from the fact that you probably can get a kidney transplant for a lot less, thanks to medical tourism (not that I am advocating it) in China or India, medical ethicists, Art Caplan and Robert Veatch are saying it's just not argument that is going anywhere.

It is just such a shame that the show Boston Legal was canceled ~ they would have had so much fun with this case. (E.g. -- Episode 1 of Season 3 "Can't we all just get a lung?", starring Michael Fox)

Controversial Infant Heart Transplant Redefines Death

Surgeons in Denver are happily announcing a major break-through in infant cardiac transplants: using hearts from infants that have died of cardiac-related deaths. According to the Wall Street Journal,

Until now, it was thought that hearts from those donors were too badly damaged to be transplanted successfully. Only hearts from donors who were brain-dead -- and whose hearts were still functioning after they were declared dead -- have been considered suitable for transplant.

To make the donors' hearts more viable, doctors at Children's Hospital in Denver altered the standards for declaring the patients dead... The Denver researchers narrowed to as little as 75 seconds the time between when the donor was pronounced dead and when the heart was harvested. Current guidelines call for waiting up to five minutes as a way of making certain that the heart does not start beating again on its own. But removing the heart earlier increases the odds of a successful transplant since it limits the damage caused by a lack of oxygen to the organ.

Most professional medical types I know, be they bioethicists, doctors, nurses, etc, agree that there are significant and severe problems with how transplants are handled in this country, and that we need to do something to increase the number of available organs. Many people support Robert Veatch's suggestion that death not be whole-brain death but higher-brain death, opening up a much larger market for available organs; given that he's been advocating this for 35 years, it's not surprising that he's the bioethicist commenting on the NEJM article. Veatch questions whether removal of the heart after such a short period of time is even legal, saying

"If a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria... Removing organs from a patient whose heart not only can be restarted, but also has been or will be restarted in another body, is ending a life by organ removal."

While the law is certainly something to consider, I agree with a former professor of mine who said that the law should be known and acknowledged, but not actually influence consideration of whether or not a practice is ethical.

And so, is it ethical? In the case of the infants who died, the parents had opted to withhold or withdraw life support; all of the infants had severe neurological injuries but were not considered brain dead. So in this very particular, structured situation, parents had agreed to allow their severely injured infants to die - so removing the heart (almost) immediately after cessation doesn't appear to be terribly problematic; even if the heart did restart on its own, they would just allow it to stop again. There is no effort at saving, rather a withdrawal of treatment and then immediate reaction to the intended end result. And I can understand parents wanting to have their child's death mean something positive for someone else; a chance for a bit of their child to live on, a chance for someone else's child to live.

But I worry. I worry about the people who fear that because they are organ donors, they won't be treated the same, that they will be allowed to die so that they can be harvested - people who buy into the very utilitarian idea that one person dying to save many is okay, and that doctors do such calculus on a daily basis. I worry about over-eager doctors realizing that an infant or child will die, and being less willing to perform life-saving medical interventions because they realize it's futile in the long-term, even if it might buy slightly more time in the short term.

Mostly, though, I worry about a redefinition of death that is happening not via committee or discussion, but action. It smacks of asking forgiveness after acting, rather than asking permission. (I should clarify that I am certain the doctors involved followed their ethics and IRB committee's to the letter, and mean more general community discussion.) It seems like an on-the-fly redefinition that actually moves away from the way the discussion was moving - towards refining what it means to be brain dead - and back towards a much more traditional and potentially troubling definition of what it means to die.

-Kelly Hills (who really does remember how to use this thing, honest...)

'Rapid Organ Recovery' ambulance proposed in NY

In the NY Times, a number of bioethicists comment on a plan to deploy a special ambulance to collect the bodies of people who have died suddenly from traumas or heart attacks and try to preserve their organs: "The organ team would wait five minutes after EMTs give up on resuscitation, to create a clear demarcation between efforts to save lives and those to preserve organs. 'The process of resuscitation would be very distinct from the process of organ recovery so that we would be sure that, ethically, there's no potential for an overlap or misconstruing of what's going on,' said Bradley Kaufman, a top medical director for the New York City Fire Department, which operates ambulances."

However, a number of bioethicists, such as Michael A. Grodin, Robert Truog, Art Caplan, Leslie Whetstine, and Nancy Dubler, who is helping vet the plan, have expressed concerns that the plan may undermine public trust in emergency medical care and the organ donor system and aggravate fears of disadvantaged groups that already harbor deep distrust of the medical system.

Access to the full article here.

The God Squad Redux?

There has been a simple problem with organ transplants, for as long as it has been technologically possible to do so: there are never, ever enough organs. And that leads to the simple, painful, difficult question of how you decide who receives a organ, and who is consigned to death that could have been prevented. And perhaps most importantly, how do you make that decision ethically?

For better or worse, much of the debate on who gets to play god has centered in and around the medical facilities in Seattle. Almost everyone knows the history of Dr. Belding Scriber and the hemodialysis God Squad, with the now-infamous headline “They Decide Who Shall Live and Who Shall Die.” And their criteria for choosing who did receive dialysis is almost painful to consider these days: a married Christian white man with children? Worthy member of society, should be saved! Single convict? Let 'im die.

It's a well-known history, in bioethics and Seattle proper. So it was with some surprise that I read, in the morning's news cycle, that the University of Washington was back in the news with accusations that their transplant committee was playing god. Only this time, they're second-guessing other medical professionals in the process.

The situation itself is simple: a man in need of a liver transplant was prescribed medical marijuana use by his physician to control pain, alleviate nausea, and stimulate his appetite.

The marijuana use, according to a doctor at Harborview Medical Center, would prohibit his paperwork for transplanting being processed. He would have to abstain for six months - a ruling eventually dropped in favour of an offer to reconsider after completion of a 60 day substance abuse program. Sixty days that the patient didn't have. On appeal, the University of Washington Medical Center agreed to consider the case again, and a week ago rejected the man from transplant consideration for a second time.

Medical use of marijuana was approved by Washington voters back in 1998, yet use of illicit substances is often grounds for rejecting someone's place on the transplant list. UNOS leaves the specific criteria to each individual hospital, and the information coming out of Seattle seems to suggest that UW's policy is not automatic rejection, but instructions to abstain for six months to then be reconsidered. (And of course, the medical center itself is not commenting on this case, save to say a range of factors play into every decision made regarding transplant cases).

The problem with this is hopefully simple: if a patient is using marijuana under medical supervision, why should it be considered problematic? Or any more problematic than the use of any other addictive substance (such as most pain medications).

The other problem is less simple. Physicians trying to do right by their patients, trying to alleviate pain and suffering (something that is often difficult to even motivate physicians to do, as continued coverage of the dearth of chronic pain management indicates), are inadvertently creating a situation where their patients are actually being denied further medical treatment based on their current treatment.

Peggy Stewart, a clinical social worker in the UCLA liver transplant center, has a simple solution: create a national eligibility criteria, so that everyone is on the same page, and aware of what will and will not increase their chances at actually being placed on the list.

Or, if I may be so bold as to point out the obvious, don't penalize a patient for following the medical advice of a fully licensed physician.
-Kelly Hills

How many organs do we really need?

The Washington Post reports that up to a third of the people on the national transplant list are ineligible for transplant. Why this matters (besides the logistical inefficiencies and delays it could entail): because reports based on a "padded" list would tend to overstate the need for organ donations. As the WaPo story notes, this is bad PR for the transplant world (and for UNOS, the United Network for Organ Sharing, which oversees the allocation of donor organs in the US, in particular)... and bad timing, too, given recent news coverage of the California surgeon accused of hastening a patient's death in order to harvest his organs for donation.

Should Americans be allowed to buy and sell transplant organs?

Another story on organ transplantation ethics, this time from a policy perspective. The libertarian Cato Institute recently hosted a policy summit on the issue of payment for transplant organs. While current US policy prohibits payment for human organs for transplant, based on concerns that poor and vulnerable people would likely be exploited by those who could afford "replacement parts," some argue that it's wrong and unduly paternalistic to stop people from selling their organs. Layer in the substantial shortfall in donor organs and the number of people who die waiting for a suitable transplant organ to become available, and you've got a complicated policy question.

Featured in the panel discussion are (from the Cato Institute website): Arthur Matas, Professor of Surgery; Director, Kidney Transplant Program, University of Minnesota, Immediate Past President, American Society of Transplant Surgeons; Francis Delmonico, Professor of Surgery, Harvard Medical School, Medical Director, The Transplantation Society; World Health Organization; Benjamin Hippen, Transplant Nephrologist, Carolinas Medical Center, At-Large Member of the United Network for Organ Sharing Ethics Committee; and Samuel Crowe, Senior Policy Analyst, The President's Council on Bioethics. You can check out the podcast here.

Photo credit: Aldenbrooke's Hospital Transplant Unit, NHS

Rewarding the Kindness of Strangers (or Friends or Family Members)

While we wrote about Ashwyn last week and whether or not he was unduly influenced to give up a kidney, Sally Satel, a psychiatrist at Yale writes today in the NY Times magazine about desperately seeking a kidney and how her hopes for finding a donor were raised several times only to be dashed at the last moment because the donor changed his/her mind.

As a result of her experience, Sally is urging wherever she can — "in articles, in lectures, from assorted rooftops — that society has a moral imperative to expand the idea of 'the gift'" and to reward the kindness of donors.

She writes, "Altruism is a beautiful virtue, but it has fallen painfully short of its goal. We must be bold and experiment with offering prospective donors other incentives for giving, not necessarily payment but material reward of some kind — perhaps something as simple as offering donors lifelong Medicare coverage. Or maybe Congress should grant waivers so that states can implement their own creative ways of giving something to donors: tax credits, tuition vouchers or a contribution to a giver’s retirement account.

In short, we should reward individuals who relinquish an organ to save a life because doing so would encourage others to do the same. . . But unless we stop thinking of transplantable kidneys solely as gifts, we will never have enough of them."

Seems like a very sensible solution, and something we in the bioethics field having been talking about since the 80's -- but can we convince Congress to do something about it?

Intersecting Human Rights Crises: Organ Transplantation and Organ Trafficking

Seen the Movie "Dirty Pretty Things?"

Some Things Are Too Dangerous
To Keep Secret Like…
Organ Trafficking and Transplant Tourism!

Come to the IHEU-Appignani Center for
Bioethics Panel!

Intersecting Human Rights Crises:
Organ Transplantation and Organ Trafficking

Who: IHEU Appignani Center for Bioethics
What: Panel discussion on organ trafficking and transplantation
Where: 2nd floor, 777 UN Plaza, New York, NY 10017
When: Tuesday, December 11, 2007, 5:30-7:30 PM
Cost: Pay at door: $35 General Public | $20 Students
RSVP: by Dec. 3, 2007
Contact: 212-687-3324 (tel) | 212-661-4188 (fax) |
AnaLita@iheu.org

The speakers will explore the ethical issues of organ trafficking with a focus on shortage of organs for transplantation, lack of organ donors, 'black-market' organ trafficking, some problems
with organ transplantation such as possible immune rejection and keeping organs alive outside the body, among others. The panel will feature keynote addresses by leading bioethicist Art Caplan, and Rachel Mayanja, UN Assistant Secretary-General, Special Adviser on Gender Issues and the Advancement of Women.  The panel will also include medical doctors, experts in gender issues at the United Nations and the Council of Europe as well as the director of New York Organ Donor Network.

Whose Organs are They Anyway...?

The shortage of available and viable organs for transplant both in the U.S., and across the globe, is at a critical mass stage.

We're all aware of the efforts enacted by various states across this country, designed to encourage consistent organ donation on a voluntary basis. In these instances, potential donors have to consent to having their organs harvested. However, the medical community in the United Kingdom is seeking to change that, by moving to an "opt-out" system.

Under the new system doctors would assume that everyone wants to be a donor after death, unless a request has been made ahead of time, either in writing or by notifying relatives, requesting to opt-out.

What do you think? Whose organs are they anyway?

http://tinyurl.com/3bheem

Ewe-terine Transplants

A few months ago, we wondered at the wisdom of going ahead with uterine transplants without doing those simple things like animal trials, seeing what the risks of anti-rejection drugs are on a pregnancy, and how a transplanted uterus would hold up during the duration of a pregnancy. (For example, would a transplanted uterus maintain the necessary elasticity to grow during pregnancy? Would the sutures maintain the bond between uterus and blood vessels?) Without answers to these and other questions, we remained skeptical of the entire concept.

Well, researchers in Sweden have apparently decided animal models would be a swell idea, and have done auto-transplants on 14 ewes. In this procedure, their own uteruses were removed, left out of the body for several hours, then re-transplanted into the body and grafted onto a different blood supply (one providing blood to the legs). Half the sheep developed complications that required euthanization (ewe-thanization?). Of the remaining seven, five were mated naturally and four became pregnant. These ewes are nearing the end of their gestation, at which point the researchers will perform c-sections to deliver the hopefully healthy lambs.

Of course, these are auto-transplants - a good first step to figuring out the complexities of uterine transplants as a whole. Right now the researchers just have to worry about getting the re-implanted uterus working; anti-rejection drugs and their effects on pregnancies can come at a later (planned) stage.

While the New Scientist article wants to warn of the dangers of and inherent risks to non-necessary surgery, I think we're well beyond that. We're a nation of people who take that risk daily, going under the knife for vanity surgeries to fix purely cosmetic issues. Given the huge import placed on bearing biological children, uterine transplants aren't going to be stopped by someone saying it might be dangerous, and the attitude that it's a non-necessary surgery, when biological children are so valued, is just going to offend what I suspect will be a large number of women who would leap at the chance, should technology allow.

(With apologies for the puns. I think Art Caplan is rubbing off on me...)

Surgeons Transplant Ovary

Surgeons have transplanted an ovary from one sister to another, in an attempt to regulate hormonal function and enable pregnany, post-cancer therapy. Apparently the pioneering surgeon, Dr. Sherman Silber, has been working on transplanting strips of ovarian tissue between twins facing similar early menopause situations, but this is the first transplant of a full ovary. Additionally, this transplant was between sisters, not twins.

The point does seem to be twofold: one, to regulate hormones, and perhaps slightly more importantly, to regain fertility. (The patient was not married or involved with anyone at the time of her cancer treatment, so could not bank embryos.) This is slightly different from uterine transplants, in that the surgeons are actually talking about things like the toxicity of immunosuppresent drugs on pregnancy. Right now, they're only transplanting the tissue between twins, or people in the Chaney/Lagos sisters, where there will be no immune response due to shared marrow. (This forgoes the need for the immune response suppressing drugs.)

For better or worse, one of the best things about the article is how it's written. It's not sensationalist or over the top. It's not promising a cure for thousands of distraught women, it emphasizes the trial nature of the procedure, talks (albeit briefly) about the issues around transplants and pregnancies, sets limits, and frankly discusses the emotional motivations behind the principle participants.

Kind of a sad commentary on our media when that's novel, eh?