The D&T Report

Christian Longo murdered his wife, MaryJane, and three children 10 years ago in Waldport, Oregon. The police finally caught up with him in Cancun, Mexico, where Longo was living undercover with a young woman who thought he was a journalist named Michael Finkel, on assignment to write about Mayan ruins.1, 2 Even after being convicted and sentenced to death in 2003, Longo continued to maintain his innocence. However, he's since dropped that charade and has owned up to his crimes. Since 2009, Christian Longo has a new mission: He wants to be an organ donor. As he wrote in a New York Times op-ed piece in March, “There is no way to atone for my crimes, but I believe that a profound benefit to society can come from my circumstances. I have asked to end my remaining appeals, and then donate my organs after my execution to those who need them. But my request has been rejected by the prison authorities.”3

At first glance, the question of whether or not prisoners should be permitted to become organ donors appears straightforward. If the prisoner is healthy, and it can be ascertained that no coercion was involved, why not allow him to atone for his misdeeds by prolonging someone else's life? No law specifically prohibits prisoners from becoming organ donors but, as Longo discovered, no state in the union currently allows it among deathrow inmates. It turns out that the issue of prisoner organ donation, particularly when that prisoner faces a death sentence, is fraught with troubling ethical and logistical questions for which there are no easy answers.

Some of the controversy surrounding the issue of inmate organ donors concerns the nature of their crimes and their sentences. For example, people not on death row can ask that their organs be harvested should they die while in prison. However, it is illegal to offer a potential donor any kind of valuable incentive, monetary or otherwise, in exchange for their organ. That has not stopped people from suggesting that sentences be reduced somewhat for prisoners to become live kidney donors, and there are indeed cases on record of people being released from jail early so that they can give an organ to a family member. Perhaps the most recent, and prominent, was the decision by Governor Haley Barbour of Mississippi to release two sisters, Gladys and Jaime Scott, who were serving life sentences for a 1994 robbery that netted them $11.00, with the understanding that Gladys would give a kidney to Jaime, whose dialysiswas costing the state $200,000 a year (it turns out that neither woman was healthy enough to undergo the surgery).4

Governor Barbour's actions were controversial: Some observers praised him for being compassionate, while others thought he was simply trying to save the state some money, perhaps while garnering some good publicity. Whatever the governor's motivation might have been, his decision was illegal. “In this case, the right strategy would have been to parole the women, then let one sister donate her kidney to the other,” says Robert M. Veatch, PhD, professor of Medical Ethics at the Kennedy Institute of Ethics at Georgetown University in Washington DC.

Not that Dr. Veatch is necessarily against the concept of shortening a sentence in exchange for a kidney. “I am on record as favoring limited experiments in rewarding people for organ donation and seeing what that does to the donation rate, so I wouldn't be unalterably opposed to rewarding a prisoner with a modest reduction in their sentence,” Dr. Veatch tells “The D&T Report. “But it would require judicial review. I wouldn't just leave it up to the prisoner to make a deal with the warden.”

It is precisely the redemptive nature of organ donation that gives many people pause, says bioethicist Arthur L. Caplan, PhD, Emanuel and Robert Hart professor of bioethics and philosophy at the University of Pennsylvania in Philadelphia. “If someone is being executed for a capital crime, what will [the victim's] next of kin think? When we talk about heroes who make the gift of life, I'm not sure you'd want to hear anybody use that phrase about the guy who just got executed for murdering your wife. I'm very sure we'd hear quite a bit from friends and family members who would say that they have no interest in his ‘ift.”’

Others fear that viewing condemned prisoners as potential sources of organs could ultimately lead to their being seen as little more than living petri dishes. This might bring us a little too close for comfort, ethically speaking, to the Chinese jailers who, earlier in the decade, allegedly killed imprisoned members of the FalunGong spiritual group with impunity, simply to get their organs. According to one account, “mobile organ-harvesting vans run by the armed services were routinely parked just outside the killing grounds to ensure that the military hospitals got first pick.”5 The Chinese government insists that the donations are voluntary, but as of now, China remains the only country that permits organ harvesting from executed prisoners.6

Finally, the issue of organ donation among prisoners challenges one of the fundamental principles of medical ethics: the notion of patient autonomy. Some ethicists believe that no prisoner can be considered completely autonomous as long as they are incarcerated, so “in a technical sense, Christian Longo is not an autonomous agent,” says Dr. Veatch. “He is externally constrained by the prison environment. My suspicion is that he might not want to donate his organs were he not on death row.” According to this argument, even if no one actively pressures a prisoner to consider organ donation, the very fact that he is in prison changes his circumstances—and most likely his mind—in so many subtle ways that such a decision should not be considered autonomous.

Ethical issues aside, there are huge practical barriers to obtaining organs from people on death row. “People on death row who get executed are usually older, because they've had a lot of appeals; they're usually in poor shape, because their food usually has been bad and they don't exercise much, and there's a lot of infectious disease risk in prison,” says Dr. Caplan. “And the technical problems of executing somebody and moving them somewhere you can quickly remove their organs are daunting.” In otherwords, prisoners would have to be executed in a way least harmful to their organs, which would give the state a new level of interest and complicity in their deaths.7 That fact makes some people queasy.

Questions regarding pressure and autonomy can be resolved by removing any external incentives, such as a reduction in sentence, says Dr. Etzioni. In any case, he sees autonomy as only one part of the issue. “Some people are concerned only with autonomy, but I'm concerned with doing good. We also have to take into account the person who is going to be the beneficiary. If you start arguing about autonomy, you can say the same thing about poor people, or about people who are under pressure from their families. None of us is completely autonomous. If you consider that they may be giving someone eyesight, or a kidney, the fact that they don't have perfect autonomy should, in my opinion, be considered less significant than the good they can do.”

Dr. Etzioni calls the idea that condemned prisoners should be denied the satisfaction of giving away their organs “preposterous” and says, “In bioethics, people can get extremely fancy. I don't think that someone who needs a heart or kidney transplant wants to hear a crime victim tell them that they would not save that patient's life because they don't want the prisoner who's about to be executed to have a moment of satisfaction.”

The ethical and practical objections for allowing prisoners to be organ donors are understandable, particularly regarding people on death row. However, perhaps some kind of protocol could be devised to ascertain that prisoners wishing to donate are making the decision of their own free will. As renal patient Venturia Scales, 33, says, “Why shouldn't they be able to donate a kidney? It would save another person's life, and, depending on why they're in prison, it may be a way of letting them give back what they have taken from someone else.”

According to the U.S. Renal Data Service (USRDS), hospitalization rates for infection among hemodialysis patients have risen 45.8% since 1994. Since hitting a low in 2001, hospitalization rates for bacteremia and sepsis in this patient population have been on the rise and, overall, the odds that a dialysis patient will be hospitalized for an infection are 18% higher today than they were in 1997–98.1 Sepsis from catheterrelated infections (CRIs) is the secondleading cause of death among patients on hemodialysis, with the average cost to the healthcare system for each episode of CRI ranging from $4,000 to a whopping $80,235.2

The reasons for this increase in infections are not completely clear, but are thought to be related in part to the use of longer-term cuffed catheters. Indeed, the Centers for Medicare and Medicaid Services (CMS) considers fistulas the first choice of vascular access largely because they are associated with the lowest risk of infection, while catheters are the last choice, mostly due to their high infection rate.3 These infections have various sources, but one of the most prominent is tapwater. Unless they carefully seal off the access site, dialysis patients with catheters run a high risk of contracting an infection every time they take a shower. In fact, some doctors warn their patients with catheters not to shower at all.4

Several companies have developed special dressings that allow dialysis patients to protect their catheter access sites so they can shower with impunity. For example, CoverCath, made by CGB Enterprises of Longs, S.C., is a singleuse, disposable catheter cover that can be used by people with peg tubes, central lines, and chemotherapy catheters, as well as patients with hemodialysis catheters.5 A larger and sturdier dressing, the CD-1000, is made by the Open Access Vascular Access Center of NorthMiami Beach, Fla., and has been associated in at least two trials with a lower rate of bloodstream infections by as much as 75%.4,6 The question is: Who will pay for them?

Medicare hasmade it clear that dressing changes, including protective coverings that allow dialysis patients to bathe, shower, or perform any other activities of daily living, are to be covered in the composite rate it pays dialysis centers.3 The centers, however, do not seem to see things that way, and have been insisting that patients pay extra for them since bundled payments went into effect. “Medicare used to pay for it,” says Sanford Altman, MD, director of Open Access Vascular and developer of the CD-1000. “Our dressing costs Medicare about $600 per year, while one catheter infection is estimated to cost about $35,000. However, this wasn't something that the dialysis centers typically provided [before the expanded composite rate went into effect], and they aren't used to dealing with it, so they are still trying to get their arms around it. And meanwhile, patients are caught in themiddle.” Many of these individuals are poor enough to qualify for Medicaid, says Dr. Altman. “They don't have extra money to spend on anything.”

“I understand that there's only so much money to go around,” he adds, “but from my perspective, this is inexpensive, it saves lives, it will save money for the dialysis providers because they will be able to lower infection rates among their patients, and it will save Medicare hundreds of millions of dollars a year by preventing catheter infections.” Some advocates for renal patients have suggested that Medicare continue to reimburse for the dressings separately while presenting them to the dialysis centers as a tool for lowering infection rates, but so far, Medicare has been immovable.

“At the end of the day, it's not the dialysis centers who are getting stuck with the cost of caring for these infections; it's Medicare,” says Dr. Altman. Until Medicare comes around, however, he believes dialysis centers should step up to the plate.