I checked the numbers on this recently. An average heart transplant costs about 1.1 million dollars, and has a mean survival time of about five years (at a very poor QoL). I think there’s a pretty strong case that they shouldn’t be done at all.
Kidney transplants have a much better RoI, but they don’t require the death of the donor.
Cost of finding a donor is under ‘procurement’. As far as I can tell, the immunosuppressant entry only covers the first year of post-transplant care, so factoring in a five-year mean survival time gives the $1.1 million figure I mentioned.
$1.1M was at least an order of magnitude larger than my guesstimate for the price of the transplant itself, so I wondered if that figure included something else. [follows link] OK, the figure for “physician during transplant” was indeed within an order of magnitude of what I expected, but hardly any of the other expenses had even occurred to me.
Correction: the median post-heart-transplant survival time seems to be a little over 10 years now, so the mean is probably close to that.. However, it’s important to note that organ transplants aren’t performed just before the patient dies of natural causes, so there’s overlap between post-transplant survival and the lifespan the patient would have had without a transplant.
Case in point: An acquaintance with COPD had a lung transplant, then died a year later of related causes. His condition at the time of the lung transplant wasn’t good but wasn’t that dire; it’s quite possible he would have lived longer and had a better QoL without the transplant.
The national registry on solid organ transplants is at http://www.srtr.org/, if anyone wants to do some data mining.
What do you mean by ‘shouldn’t be done’? Do you mean it’s imprudent for an individual to spend that much money on a heart transplant, even though she values her own life?
Or do you mean it’s immoral for an individual to spend that much money on herself, rather than on greater utility for others?
Or do you mean it’s imprudent or immoral for medical practitioners and researchers to invest so much time and effort into performing heart transplants and gradually improving the technology? Or do you mean it’s imprudent or immoral for the state to fund such efforts?
Or do you mean it’s imprudent or immoral for the state to permit individuals to purchase heart transplants?
Do you mean it’s imprudent for an individual to spend that much money on a heart transplant, even though she values her own life? Or do you mean it’s immoral for an individual to spend that much money on herself, rather than on greater utility for others?
If it’s moral for someone to spend that much of their money on a house or a yacht, it’s moral for them to spend it on a heart transplant, but it may be a net utility loss for the patient.
Or do you mean it’s imprudent or immoral for medical practitioners and researchers to invest so much time and effort into performing heart transplants and gradually improving the technology?
The first heart transplant was performed 45 years ago. Almost half a century of effort has yielded a state of affairs that could politely be described as ‘dire’. Immoral, no, imprudent yes.
Or do you mean it’s imprudent or immoral for the state to fund such efforts?
Yes and yes. The return on investment is appalling. A back of the envelope estimate I did a while ago, IIRC, showed that public health investment had a RoI 6 to 8 orders of magnitude better than organ transplants.
I also think it’s immoral that the donor’s estate is denied even a tiny share of the revenue.
Or do you mean it’s imprudent or immoral for the state to permit individuals to purchase heart transplants?
But the RoI for the patient himself is great. You present an argument against publicly funded research into heart transplants, but not against doing them at all.
If the patient is spending her own money, the RoI is still terrible compared to comparable interventions like hiring a personal trainer, diet coach, personal chef, etc. that could have forestalled the need for a heart transplant. Furthermore, the actually existing health infrastructure, particularly organ procurement, is so deeply entangled with the state, that it’s difficult to speak meaningfully of strictly privately funded efforts.
the RoI is still terrible compared to comparable interventions like hiring a personal trainer, diet coach, personal chef, etc. that could have forestalled the need for a heart transplant.
Even having purchased all those, a person may need a heart transplant. Genes, disease, accidents, and nurture while young (and unable to choose one’s own lifestyle) all strongly influence the eventual need for a heart transplant. So for many people, even a lot of lifetime investment into their health won’t mean the RoI on a heart transplant will be bad.
Also, at the point where you choose whether to have a heart transplant, the RoI needs to be compared with other things you can do with that money during the time you have left to live without a transplant. If you have a lot of money, and the transplant improves your QALY, then the RoI is likely good.
Point is, these discussions are kind of pointless without quantitative context. If you can give someone 80 years of healthy lifespan for a dollar, few people would object. If you can give someone one day of agony for a billion dollars, few people would support. Most medical interventions fall somewhere in between. Vaccinations are closer to the former, organ transplants closer to the latter.
Then by killing the donor, you get two kidneys and twice as much RoI. Is it worth the death yet?
The benefit is doubled in the second case, but the investment is much larger (obviously), so RoI is not doubled. In fact, the investment is more than doubled (you have to pay for two transplants instead of one, as well as killing someone), so the RoI plummets.
What IainM said. RoI is the ratio return/investment. The return is doubled, the investment is (substantially) more than doubled, thus the ratio decreases.
Does it means “8 people saved (for unspecified time)” or “the saved people gain 8 times as much QALYs as the donor lost”?
AFAIK, the there are some problems with transplanted organs which require repeated medical attention and sometimes a lot of painkillers, so we convert X years of a healthy person to Y years of people with bad health.
On the other hand, a person willing to follow this advice and kill themselves probably suffers from depression, so we should reduce their remaining years estimate by a probability of suicide (other than the specific one recommended in this thread).
a person willing to follow this advice and kill themselves probably suffers from depression, so we should reduce their remaining years estimate by a probability of suicide
And if they don’t actually commit suicide but still suffer from depression, or dislike living for any reason so much that they want to die, we should reduce their QALY in the equation.
I mean, if every suicidal person saves the lives of up to eight people who want to live, it might be worth outright encouraging this approach, rather than having suicidal people kill themselves in ways that damage their bodies for this purpose, and then spend effort and money trying to bring them back.
Once a certain number of people is reached, though, there might be a degree of overabundance of organs compared to the needs, and unless you want to make the jurisdiction that allows this some sort of exporter of literal human resources, you should probably stop there.
You can give a small part of the liver, which grows to a functioning liver in the recipient. Presumably that means that you could get multiple liver transplants from one suicide by organ donations.
Yes, to my knowledge that was only done with living donors, but you are correct:
The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients. A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child. Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients. [wiki]
Interestingly, “living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver”, but you can’t just take any 20% unfortunately.
If only there were more focused, high-scale, no-holds-barred research efforts on growing organs in the vat, xenotransplants from engineered e.g. pigs, for all of which proofs-of-concept and actual human trials by isolated low-funded groups exist (e.g. artificially grown trachea for a swedish girl if I recall correctly)! We have the technology, as they say, we’re just too reluctant to use it.
I’d realized as much, but that still left me wondering what actual average “Up to 8” signifies. After allowing for different suicide methods and such, that “Up to 8″ might be 8, or it might be something like 1.1. The result of a utilitarian calculation would probably be sensitive to the real world average being ≈8 versus ≈1.
Is the expected number of people you’d save by doing that actually greater than 1?
I checked the numbers on this recently. An average heart transplant costs about 1.1 million dollars, and has a mean survival time of about five years (at a very poor QoL). I think there’s a pretty strong case that they shouldn’t be done at all.
Kidney transplants have a much better RoI, but they don’t require the death of the donor.
Does that include the cost of finding a donor?
There are other estimates available on the web, but I worked off this one:
http://www.transplantliving.org/before-the-transplant/financing-a-transplant/the-costs/
Cost of finding a donor is under ‘procurement’. As far as I can tell, the immunosuppressant entry only covers the first year of post-transplant care, so factoring in a five-year mean survival time gives the $1.1 million figure I mentioned.
$1.1M was at least an order of magnitude larger than my guesstimate for the price of the transplant itself, so I wondered if that figure included something else. [follows link] OK, the figure for “physician during transplant” was indeed within an order of magnitude of what I expected, but hardly any of the other expenses had even occurred to me.
Correction: the median post-heart-transplant survival time seems to be a little over 10 years now, so the mean is probably close to that.. However, it’s important to note that organ transplants aren’t performed just before the patient dies of natural causes, so there’s overlap between post-transplant survival and the lifespan the patient would have had without a transplant.
Case in point: An acquaintance with COPD had a lung transplant, then died a year later of related causes. His condition at the time of the lung transplant wasn’t good but wasn’t that dire; it’s quite possible he would have lived longer and had a better QoL without the transplant.
The national registry on solid organ transplants is at http://www.srtr.org/, if anyone wants to do some data mining.
What do you mean by ‘shouldn’t be done’? Do you mean it’s imprudent for an individual to spend that much money on a heart transplant, even though she values her own life?
Or do you mean it’s immoral for an individual to spend that much money on herself, rather than on greater utility for others?
Or do you mean it’s imprudent or immoral for medical practitioners and researchers to invest so much time and effort into performing heart transplants and gradually improving the technology? Or do you mean it’s imprudent or immoral for the state to fund such efforts?
Or do you mean it’s imprudent or immoral for the state to permit individuals to purchase heart transplants?
If it’s moral for someone to spend that much of their money on a house or a yacht, it’s moral for them to spend it on a heart transplant, but it may be a net utility loss for the patient.
The first heart transplant was performed 45 years ago. Almost half a century of effort has yielded a state of affairs that could politely be described as ‘dire’. Immoral, no, imprudent yes.
Yes and yes. The return on investment is appalling. A back of the envelope estimate I did a while ago, IIRC, showed that public health investment had a RoI 6 to 8 orders of magnitude better than organ transplants.
I also think it’s immoral that the donor’s estate is denied even a tiny share of the revenue.
See above, re: houses and yachts.
But the RoI for the patient himself is great. You present an argument against publicly funded research into heart transplants, but not against doing them at all.
If the patient is spending her own money, the RoI is still terrible compared to comparable interventions like hiring a personal trainer, diet coach, personal chef, etc. that could have forestalled the need for a heart transplant. Furthermore, the actually existing health infrastructure, particularly organ procurement, is so deeply entangled with the state, that it’s difficult to speak meaningfully of strictly privately funded efforts.
Even having purchased all those, a person may need a heart transplant. Genes, disease, accidents, and nurture while young (and unable to choose one’s own lifestyle) all strongly influence the eventual need for a heart transplant. So for many people, even a lot of lifetime investment into their health won’t mean the RoI on a heart transplant will be bad.
Also, at the point where you choose whether to have a heart transplant, the RoI needs to be compared with other things you can do with that money during the time you have left to live without a transplant. If you have a lot of money, and the transplant improves your QALY, then the RoI is likely good.
Why? What’s the mean survival time and QoL for people who need a transplant but don’t get one?
Then by killing the donor, you get two kidneys and twice as much RoI. Is it worth the death yet?
The information is available, but takes time and work to interpret. I gave a link with data. From that page, you can get to http://publications.milliman.com/research/health-rr/pdfs/2008-us-organ-tisse-RR4-1-08.pdf which provides much more detail. Please consult it, and if you need more, I’m available starting at $100/hr.
Point is, these discussions are kind of pointless without quantitative context. If you can give someone 80 years of healthy lifespan for a dollar, few people would object. If you can give someone one day of agony for a billion dollars, few people would support. Most medical interventions fall somewhere in between. Vaccinations are closer to the former, organ transplants closer to the latter.
That’s not how RoI works.
Why not? The investment here being the death of the donor.
The benefit is doubled in the second case, but the investment is much larger (obviously), so RoI is not doubled. In fact, the investment is more than doubled (you have to pay for two transplants instead of one, as well as killing someone), so the RoI plummets.
Thanks, it’s clear to me now. It seems obvious but I didn’t understand it correctly the first time around.
What IainM said. RoI is the ratio return/investment. The return is doubled, the investment is (substantially) more than doubled, thus the ratio decreases.
AFAIK yes. Up to 8 people.
Does it means “8 people saved (for unspecified time)” or “the saved people gain 8 times as much QALYs as the donor lost”?
AFAIK, the there are some problems with transplanted organs which require repeated medical attention and sometimes a lot of painkillers, so we convert X years of a healthy person to Y years of people with bad health.
On the other hand, a person willing to follow this advice and kill themselves probably suffers from depression, so we should reduce their remaining years estimate by a probability of suicide (other than the specific one recommended in this thread).
And if they don’t actually commit suicide but still suffer from depression, or dislike living for any reason so much that they want to die, we should reduce their QALY in the equation.
When do we hit diminishing returns?
Let’s find out.
You mean by calculation, right?
I mean, if every suicidal person saves the lives of up to eight people who want to live, it might be worth outright encouraging this approach, rather than having suicidal people kill themselves in ways that damage their bodies for this purpose, and then spend effort and money trying to bring them back.
Once a certain number of people is reached, though, there might be a degree of overabundance of organs compared to the needs, and unless you want to make the jurisdiction that allows this some sort of exporter of literal human resources, you should probably stop there.
Do you mean saving figuratively? (Also addressed at drethelin who used “save a life”.)
Heart, lungs, liver, left kidney, right kidney = 5, and that’s being generous.
Pancreas and corneas certainly improve quality of life, but aren’t life savers. For skin grafts there’s alternatives AFAIK.
Is there a stash of secret organs I’m missing?
You can give a small part of the liver, which grows to a functioning liver in the recipient. Presumably that means that you could get multiple liver transplants from one suicide by organ donations.
Yes, to my knowledge that was only done with living donors, but you are correct:
Interestingly, “living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver”, but you can’t just take any 20% unfortunately.
If only there were more focused, high-scale, no-holds-barred research efforts on growing organs in the vat, xenotransplants from engineered e.g. pigs, for all of which proofs-of-concept and actual human trials by isolated low-funded groups exist (e.g. artificially grown trachea for a swedish girl if I recall correctly)! We have the technology, as they say, we’re just too reluctant to use it.
I have no idea where to find quantified data on average lives saved. Most of the people involved have an incentive to exaggerate.
Up to?
Not all of your organs will be usable or near enough to save a life. A lot depends on the way you choose to kill yourself.
I’d realized as much, but that still left me wondering what actual average “Up to 8” signifies. After allowing for different suicide methods and such, that “Up to 8″ might be 8, or it might be something like 1.1. The result of a utilitarian calculation would probably be sensitive to the real world average being ≈8 versus ≈1.