Steven's voice filled with emotion when he talked about his long road to surgery. When he got to the part where his friend Michael offered him half of his liver, that's where he had to pause and collect himself.
"Having someone give you your life back -- it's hard to just say you're grateful," says Steven. "Gratitude doesn't do it. I don't know what the right word is."
The two men became friends over 20 years ago when Michael worked at a company managed by Steven. A few years later, Michael left his job and moved away. They stayed in touch, talking on the telephone a couple of times a year.
It was during one of those conversations that Michael learned that Steven had terminal liver disease brought on by hepatitis and needed a transplant. Steven was depressed because doctors had just disqualified a high school friend who had volunteered to be a donor.
"Right there in the middle of that conversation, I knew without a doubt what I was going to do," Michael recalled months later. "Something just came over me. It just felt right. I know it sounds strange, but that is just the way it was."
Without a word to Steven, Michael had his blood type tested and discovered that he matched his friend. "I called and asked if he'd like to have half of my liver," Michael says. "He said, 'You're crazy.' But I told him I wanted to do it."
The Rise in Living Donors
Just over a decade ago, this gift of life between two close friends would have been impossible. Partial organ transplants between adults were unheard of: People's immune systems typically rejected organs from nonrelatives, and doctors, for the most part, considered such operations not only risky but unethical. But today, Michael could be the poster boy for a trend that's changing the course of transplant medicine in the United States. There are more living donors today than deceased ones. And many of the living donors are unrelated to the patient in need; sometimes they don't even know them.
"Illustrating the altruistic nature of family, friends and even strangers, living donation rates have steadily increased. This increase has helped bring awareness to the critical shortage of organs." says Annie Moore, spokesperson for the United Network for Organ Sharing (UNOS), the nation's organ clearinghouse that matches donors to recipients. Consider the numbers: There were 6,618 live donors in 2002, a 230% increase over 1989, according to UNOS. By comparison, there were 6187 deceased donors, people who have died, often in the prime of life in an accident. Living kidney donors now account for nearly 52% of all kidney donors and the number of living donor liver transplants has doubled since 1999, according to UNOS.
Clearly attitudes are changing. A survey in 2000 by the National Kidney Foundation showed that 90% of Americans say they would consider donating a kidney to a family member while alive. That same survey reported that one in four Americans would consider donating a kidney to a stranger. Indeed, UNOS reports that living donors unrelated to the patients increased tenfold between 1992 and 2001.
Battling "The List"
Science can take some credit for this shift. New surgical techniques let doctors remove a kidney through small incisions that leave little scars and are easier to recover from. New anti-rejection drugs let patients receive organs that aren't close genetic matches.
But there has also been a shift in medical thinking. While anti-rejection drugs have been available since the 1980s, until several years ago doctors routinely rejected donors who weren't immediate family members. Placing a healthy donor at any risk from surgery -- no matter how small -- violated the physician's obligation to "first, do no harm," they argued.
So what has changed? It can be summed up in two words -- The List. As medical technology keeps people alive longer and improved transplant techniques offer new hope, the number of people on the waiting list for organs has swelled. Today, more than 83,000 people are waiting -- and hoping -- for an organ, compared to 60,000 six years ago.
"Living donors are a desperate move to compensate for the lack of organs," says Amadeo Marcos, MD, clinical director of transplantation at the Starzl Transplantation Institute and professor of surgery at the University of Pittsburgh School of Medicine. He was one of the first doctors to transplant a partial liver from one adult into another.
Officially, more people on the waiting list today need kidneys than livers. But experts predict our need for livers will soon explode, triggered by the Hepatitis C virus. Some health officials estimate that 75,000 Americans may need a liver transplant by the year 2010, compared with just 15,000 today. And many, like Steven, will turn to their friends for a portion of the most vital organ in the human body.
The New World of Transplant Medicine
Most people don't realize the number of body functions dependent on the soft, reddish-pink organ. Damaging your liver is like tipping over the first domino in a line. Energy levels fall, blood fails to clot, concentration is lost, and heart and lung problems develop. A person with kidney failure can survive on dialysis treatments while awaiting a kidney transplant; a patient with liver failure has no such recourse.
"Every organ starts to shut down around the liver," Marcos says.
But unlike kidneys, each person has only one liver. Until partial liver transplants became possible in 1989, people couldn't donate their livers while alive. That year, the first parent-to-child partial liver transplant was performed, and after its success, surgeons began experimenting with adult-to-adult partial transplants. Still, the procedure didn't really take off until 1998. By May 2000 there were 2,745 partial livers transplanted between adults, and the number grows each year.
Liver transplants from living donors are actually safer for recipients than transplants from deceased donors, according to research presented in 2003 at the 68th Scientific Meeting of the American College of Gastroenterology. But they do pose some risk to the healthy donor.
The human liver is an atlas of tiny blood vessels and vital arteries that must be severed and sealed off or the donor can bleed to death. Marcos likens the surgery to a plumber fixing a leak without turning off the water. The donor must give up at least half of his or her liver, which means surgery can last up to 14 hours. And while the liver apparently fully regenerates in about two weeks, there are other risks. Donors face a 20% chance of a complication. Typically, these will be minor, such as developing an infection or catching a cold while in the hospital. However, 4% may face a serious complication requiring a second surgery, such as hemorrhage or the development of an abscess.
Therefore, there's no question that the surgery could potentially "do harm" to a healthy donor. Do the donors and doctors have the right to agree to take the risk? In today's world -- where medicine promises so much if only organs are available -- bioethicists increasingly say yes.
"There are trade-offs, and people should have the right to weigh the trade-offs," says Arthur Caplan, PhD, a medical ethicist and director for the Center for Bioethics at the University of Pennsylvania. "As long as the donor 'gets it,' they should be allowed to participate in risky things. Doctors are not doing evil by doing small harm."
The bigger question, says Caplan, is whether transplant centers require enough psychological counseling to make sure the donors truly understand the full risks. In his experience, many don't, and on that point, many doctors agree. In the August 10, 2000, issue of The New England Journal of Medicine, editors warned that while a donor may receive the "altruistic satisfaction of having assumed a risk in order to help another person," strict rules are needed to ensure that people aren't pressured into becoming donors and are fully informed of the risks.
Doing a Favor for a Friend
Although Steven accepted Michael's offer before hanging up the phone that fateful day, he worried that his friend didn't fully understand the pain and risks he faced by donating half his liver. He also worried that once Michael understood the risks, he would change his mind. "I didn't want him to say 'I want to do this' and change his mind a month later when we were down to the wire," Steven recalled after the operation.
But Michael knew what he was getting into. His friend, Ken, had given a half of his liver to a woman Ken saw in a TV news report. "I thought, man, that was a damn noble thing to do," Michael says. "I wondered if I would have the courage to do something like that."
If Ken could do that for a stranger, Michael decided, he could surely do it for a friend.
But first, he had to convince his wife, who flat-out opposed the plan. Then he had to discuss his decision with his teen-age son. He told them both that donating part of his liver was not only important to him but something he felt he was supposed to do.
"I don't go to church but I have an inner vision," he says. "It's a gut feeling I get, and I believe it is the true voice of God speaking to me."
Next, he checked into the University of Virginia Medical Center in Charlottesville for four days of testing: a thorough physical, a liver biopsy, a tissue typing, and a mapping of his liver's arteries and veins. His tissue matched Steven's more closely than anyone had expected. "It was so close it was almost as if we were brothers, which was kind of strange," Steven says.
Michael met three times with the transplant team's psychiatrist. And each time the psychiatrist asked the same core question: Why did he want to give half of his liver to his friend? Michael gave the same answer each time: It feels right.
The night before the surgery, the two men shared a room. At 3 a.m., Michael was prepared for surgery. "When they took Mike away, I was just laying there, dazed, not really thinking too much about anything," Steven says. "I was nervous." Michael, on the other hand, was totally relaxed. His blood pressure was an unbelievable 100 over 70 with a pulse rate of 55 beats a minute.
More than 14 hours later, Michael woke to searing pain. "Someone asked me what it felt like, and I said it felt like they cut me in half and put me back together," he says.
The pain would last for weeks. Still, Michael says, he went home three days after surgery and felt well enough to host a cookout three weeks later. Steven was discharged a week after surgery but had to be readmitted for a second surgery to drain an abscess that had formed.
The men say their families grew closer after the transplant, though they were always friends. They try to get together every couple of months for dinner or a barbecue. In the past, they would have knocked back a few drinks to relax; no longer. Michael quit drinking a decade ago, and Steven credits his friend's healthy liver, in part, to that decision. So he's joined the diet-soda club, too.
"I want to treat Mike's liver as good as he treats it," Steven says. And I want to keep it as long as possible."