The idea of having a convicted murderer receive a heart transplant before a law-abiding citizen is one that has caused great debate among the general public and lawmakers. But for corrections agencies that must abide by laws mandating that inmates receive the community standard of care, transplants those who qualify are not necessarily controversial.

Corrections officials in California, for example, okayed a heart transplant for an inmate in early 2002 and in Ohio that same year, a U.S. District Court ruled that an inmate was eligible for a liver transplant, although he died before he could ever receive it.

Clearly transplants are becoming available for those who need it, regardless of their inmate status. But this issue may cause more of a stir as inmate populations age.

“The majority of people I have talked to [in the medical profession] say it is not for us to decide if someone is more worthy than another. It opens a whole can of worms – will we [next] overlook people who are older to choose those who are younger? [Instead] we allocate on a value-neutral basis. You get points based on how sick you are and how long you have been waiting,” said Jeffrey Kahn, Director of the University of Minnesota's Center for Bioethics.

Kahn said that the public, in many cases, has moral objections to inmates receiving transplants before others, much like some members of the public dislike that inmates receive better health care than some law-abiding citizens.

“One of the issues is, if they were out of prison, How likely would they be to get a transplant? Arguably many people are better off in terms of health care in prison,” he said.

This is because of the Supreme Court ruling almost 30 years ago that said inmates were entitled to adequate medical care while incarcerated.

“When you are incarcerated you give up certain rights, but you don't give up your right to get a transplant to save your life. If you say people have a right to health care [while incarcerated] that generally includes life saving treatment,” Kahn added.

Yet not all agencies approach the transplant issue the same way.

Discretion by State

A Prison Health Care Survey conducted for the federal Bureau of Prisons in 2000 http://www.nicic.org/pubs/2000/015999.PDF asked state departments of correction about a variety of issues that reflected health care costs per inmate, including how each responded to the organ transplant needs of inmates.

Of the 50 agencies, eight said they evaluated transplant needs on a case-by-case basis, 10 said they had done no transplants, and the remainder reported they had done a bone marrow transplant, kidney transplants, conducted transplants based on a doctor's discretion, followed community standards or had not yet implemented a plan for providing for transplants.

With inmate populations aging fast and many becoming sicker as they age, it is likely that transplants will become more common in the future.

Kahn said that corrections agencies may have a tough time with these decisions as they face budget crises that cause them to make cuts in operations and in health care. And with transplants costing anywhere from $250,000 to $500,000, this may be one of the areas that is targeted for trimming.

“It's very expensive and if there is a budget allocation for health care within the prison, I would guess they are coming up against those resource issues,” said Kahn.

Kay Northrup, Deputy Director of the Office of Correctional Health Care for the Ohio Department of Rehabilitation and Correction agrees that the graying of the population may cause agencies to see a rise in the number of inmates needing high-cost care and transplants.

“As the population is gradually aging we are seeing a greater demand for a wide range of specialty medical care also the increased incidence of hepatitis C. You [now] have a population that is specifically subject to liver failure because hepatitis C was not known as a separate entity until fairly recently,” she said. “I would see it continue to be an issue for DOCs across the country.”

Even if an agency decides to go forward with a transplant operation for an inmate, the costs do not subside after the surgery. In the case of the California inmate who received a heart transplant in 2002, the surgery cost $850,000, according to press reports, but the follow-up care cost about $150,000 – nearly $1 million in total. And then, the inmate, who did not follow doctors' recommendations, died 11 months later when his body rejected the transplant.

In the end it is up to each state agency to decide what the criteria will be for organ transplants for the inmate population.

Physicians Make Transplant Decisions in Ohio

The Ohio DRC generally receives its input about transplant-eligible inmates from the specialists who work with chronically ill inmates at the Ohio State University Hospital, according to Northrup.

“It's a list maintained by the Ohio State University Transplant Center and they make all the decisions about whether the inmate patient should be placed on that list. Any one with that kind of diagnosis would be seen by a specialist at OSU,” she said.

Northrup said that the department's criteria for medical care of inmates is not specific to transplants rather it is a general criteria for care that is medically mandatory to preserve life and care that is medically necessary.

“For transplants it would be passing the criteria that it is medically necessary. These are OSU physicians and if they see an inmate and they believe the only option is a transplant they would notify us and refer them to the OSU transplant team to see if they are a viable candidate,” she said.

Northrup said the majority of transplants done for inmates have been bone marrow, but at least one inmate has received a liver transplant. Others have been placed on the list for a liver transplant, but have either been released or died before an organ became available.

In all transplant cases, the cost is the financial responsibility of the department, although recent state legislation does allow the department to bill third party insurance if an inmate happens to have it, which very few do.

Regardless of cost, Northrup said the department looks at transplant recommendations from specialists as being medically necessary procedures and as such, the department must do what it can to sustain an inmate's life.

“Our policy says it is care without which the inmate could not be maintained without serious medical risk or [significant reduction of the chance of possible repair after release] or without significant pain and discomfort,” she said.

Kahn said that as the issue becomes more prominent, perhaps it will cause society as a whole to think about how we provide health care and who we provide it to.

“The prison population is marginalized in lots of ways; they are just by their incarceration [But] what do we owe those who are more vulnerable [in our society?] The same person outside may not have access. So should we look at doing better for everybody?,” Kahn said.

Resources:

To reach the University of Minnesota Center for Bioethics, call 612-624-9440  or visit http://www.bioethics.umn.edu/

For information about Ohio DRC, contact  614-752-1150.