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This week on The Editors, The Medical World examine new ethical standards concerning the supply and demand of donors for liver transplant surgery.

The controversy over white families caring for black foster children continues.

And Brian O'Neill brings us the last word.

The University of Pittsburgh Medical Center gives liver transplants priority to the sickest patients.

But around the country, that's not the case.

How should transplant recipients be chosen and which center should receive the organs?

In our first segment, John Craig and Jane Blotzer meet Doctor John Fung, chief of transplantation at the University of Pittsburgh Medical Center, to explore these ethical questions.

Doctor, nice to hav you here with us on The Editors.

So we're going to talk a little bit about transplantation and specifically availability of organs and what institutions should get them.

Jane, I suppose that we really are constructing the situation and responsibl because of a series of articles that ran the Post-Gazette and what's what's the principal issue?

Well there's there's several issues, but they all come together.

One is how are organs allocated?

What centers do they go to?

What?

You know, what it's related to.

That is what patients get the organs to.

Do you give it on the basis of who is the sickest patient and in the most immediate need?

Or do you give the organ on the basis of who has the best chance of surviving, and who has the best chance of having a good quality of life after the transplant?

And another related issue is what centers should do transplants.

There's been a huge proliferation of organ transplantation centers in the country, and they have sucked away some of the very precious organs, because there aren't enough to go around from the bigger center that have the sicker patients.

So as chief of transplantation at the Pitt Medical Center, Does, you know, the answer to all these questions, right?

Well, I wish I knew the answers.

No, I, I think I have different I have a perspective, I think, which was brought ou in the last series of articles in the Post-Gazette, which may differ, though, from other centers that have different philosophies now.

Okay.

From your point of view, let's take the first thing.

Do we have a limited supply?

So there are more people who want livers than there are livers.

How do you decide who gets them?

I think that's one of the key issues, is do you, try to obtain the best results on paper, you know, in terms of patient and grass survival?

Or do you try and treat the patients that, are in the mos need for organ transplantation?

It would be nice to think that they were the same, but they're not.

We know that sicker patients will have worse results.

I think as a, a physician, what we try to do in as a research scientist, what we try to do is to make the results for those worst class patients better.

But there will always be some kind of a penalty for for being sicker.

I think, as a physician I look at treating the sickest patients as being my, priority.

And so at Pitt at the University of Pittsburgh, our philosophy has been, and this is Doctor Starrs was teaching to treat the patients that would benefit the most from it.

Now, how do you look at benefit the most?

Well, if you are in, in jeopardy of dying, sooner than if you were able to be saved from that, from impending death then it's going to be much more, the benefit is going to be much more, obviou than if you were somebody who's relatively healthy has much longer period of time, before you get sick and then undergo a transplant.

So I think, you can argue from either way, but I how would you.

I would argue that the patients that are sickest should be transferred.

Let me give you, before you hop in and let me ask you just the same question in a different way, just so people watch this, have the sense of what you think.

You have two people.

One person is 40.

One person is 60.

They're both obviously equally ill.

It's hypothetical.

And so we give.

We only have one liver.

Do we give it to the person who's 40 who will live for 40 years?

Or do we live to give the person who's 60 who will live for 20 years?

We obviously don't come back and say, I don't know how long they're going to live, but how do you decide if that's the choice to be?

Do you go, do you make a choice on the basis of the prognosis that one person is going to live longer than the other?

No.

And why not?

Because we can't predict what their outcome will be.

There's just there are so many factors and variables in the perioperative period, that will have a more immediate impact on survival than the long term, age prognosis.

No, but I was just suggesting that, you know, your your prognosis of survival is longer in one case than the other.

So do you give the liver to the person who's got the prognosis for longer survival?

I think that's, That's certainly goes into the decision making process.

I think if you have a patient who, you know, is not going to have do well long term, then, if you continue to transplant those patients as a bulk of what you do, then of course, you you'll you'll suffer in the long term.

Statistics.

And unfortunately, statistics have a lot to bear because of Medicare, insurance company.

And these registries that we that we all subscribe to, that, you know, published the results of, of giving centers, luckil that most of the patients that, end up having a transplant have equal long term prognosis.

In other words, plus or minus 5 or 7%.

The different diseases that we normally transplant, for liver disease have very similar outcomes.

But there are some group of patients that won't do well.

I think that those rather than saying don't transplant those patients, what we should be doing is saying, what can we do to make those patients have a better prognosis?

Some of those are viral, certain viral, diseases.

Some of those are certain, liver cancers.

And we know that by, developing new drugs and new therapies that we might be able to, you know, greatl improve their long term outlook.

That's where I think Pitt, University of Pittsburgh has an obligation to the transplant community by virtue of what we do and our philosophy to make the prognosis of the patients that normally wouldn't get the transplant better to the poin where they will get transplant.

And what we do then is create an increasing shortage of organs, are increasing disparity between those that but between the patients that need a transplant and the availability of organs.

But I don't know that it's our responsibility to to then single out or starting start to trim the patients.

That shouldn't be to identify patient that shouldn't be transplanted.

That's my philosophy as a, as a physician is to provide, the, the best possible care to, as many patients as possible.

And that includes, and if that creates an increasing organ shortage, then it's going to require society to decide who who should be transplant should and an equitable way to do that.

If there were enough livers to go around for all the patients who needed them.

Would you advocate transplanting patients before they got too sick?

I mean, that would that change your philosophy before they got sicker?

I think there's got to be a point where, you still have to use judgment whether or no somebody should be transplant.

There are a good number of patients that you can obviously predict.

We'll need a transplan in several years or five years, or even ten years.

And.

But if you transplant them too early there is a penalty to be paid.

There's a 20% mortality in the first year after transplant.

And you can't predic in many cases who they will be.

So to take someone who's relatively healthy and then subjecting to a procedure of that magnitude with that kind of risk, I, I find it hard to defend.

And that's going o now.

Well, that happens a lot.

It doesn't it's happening somewhat less and less only because the, the, the the disparity between those are waiting and the organ shortage has created a gradual shift to transplanting more ill patients.

The problem is it's not going far enough.

What we're saying is that patients are really desperately ill, are still not having access to transplant.

I think we should probably define a little bit about how that's allocated now.

It's within a certain region.

The sickest patients in that region get the organ right.

But if there are sicker patients outside that region, the region where the liver is procured still get the the patients in the region where the livers procured still get the advantage, even if they're less sick than patients outside that region.

Right.

The allocation of organs currently is done in a local, priority first and then increasing to a regional priority, then to national priority.

People argue that the reason for that is that it keeps the local organs locally.

Well, I don't know that there's a lot of data support.

That organ donation is is related, connected to where those organs go.

Certainly I think it's mor altruistic in terms of donation than thinking that it's a local benefit.

The the proble is that there are 65 local areas defined arbitrarily by, the government, starting about five years ago.

And these organ, these areas serve different population bases.

The regional allocations and is there are 11 different regions in the United States, again, arbitrarily geographically defined with different population bases that don't take into account, racial in, in differences.

The differences in, the illness in that particular population, urban populations have much higher incidence of disease than the rural populations.

And then, the last thing, it doesn't take into account is the attraction of patients to given centers.

Be it Pittsburgh or or Nebraska or Los Angeles, places that have research programs or, for instance, that attract patients that otherwise would not have access to transplant, that would be have been turned down at at smaller centers.

And I think it's that problem that that referral basis to the national programs, to the larger programs that have these, research programs that has created some of this, this, conflict between larger centers and smaller centers.

The patient, we look at organ allocate the flow of organs that should be in proportion to where the patients want to get transplant.

In other words, if you have somebody from, Florid who gets turned down in Florida by their local program, and yet there are other programs in Nebraska that are aggressive and they feel, well, this guy can be transplanted and they've already proven they can do reasonably well with those patients.

There should be no reason that when that patient goes to Nebraska, that there shouldn't be some access to the, the, the base from which that patient came from.

And that's I think one of the thing that's the counterargument to that is that, okay, it's true that these people in Nebraska will will give this case a shot where that wasn't going to occur in Florida.

But the fact of the matter is that their mortality rate is twice as high, say, and and what we're doing is, yes, they're they're taking shots, but they're a dealer in lost causes.

Let's keep this liver but send this liver, keep it in Florida.

Or better that, let's send it to Texas.

Where they they treat people like they do in Florida.

And they and they're not they don't have so many bad cases.

Is that is that the nature in sort of lay terms?

This is the way these things are debated.

That's one argument, but I don't what's your what's your rebuttal?

I don't really if you actually look at, centered by center analysis of, the results.

There are a large number of centers, and this is the last report.

There's a more current report coming out this year.

But in the last analysis in 1992, the patient, the programs, there were a number of programs that did relatively small number of transplants that took that only very good risk patients whose results were less than the larger programs that did the worst case patients.

So, in other words, their their results with the best patient case patients was worse than the programs that did the, you know, that group of worst case patients.

And so you can argue that it's really not the national statistics that you're looking at, because everybody knows in the national statistics the the sick you are the worse you're going to do.

What we're saying is if you compare center to center, there is big discrepancy in terms of the results that you get.

That's not politically possible.

To really do that though, is it?

Is is there too much resistance to really doing it there?

There is already that trend to being done.

You know, but is beginning to do these analysi of, of, center results for both, you know, for transplantation for, coronary artery bypass.

And what they're beginning to do is pick out centers that have better results, than others and that will go into decision making of where those send patients.

And how do you believe there are too many centers?

Right now There are 112 liver transplant centers.

And, they're just it' impossible for me to understand how what the need is for 112 programs.

Do you think the federa government should control that?

I don't think that, I always hat when government gets involved.

And I hope the Democrats aren't hearing, I hate when governmen gets involved in medical issues because, then, you know, it's not medically based.

It's become.

But if the government doesn't decide this, how are you going to decide?

Well, what they ought to be doing is saying these are certain criteria that you have to obtain for each program and then le the programs decide what it is that they want to do.

In other words if they want to do easy cases, that are relatively inexpensive, and still maintain reasonable results, then, you know, comparable to other large programs that do those cases, I think that's fine.

But if they're not going to be doing the sicker patients and that's where it is, if they don't want to take the risk on doing sicker patients because they're more expensive, the results aren't as good, and those patients will still be picked up at another program.

What ought to be done is that the organ allocation shouldn't be done on the basis of of geography.

But where do the patients go?

And I going back to the question of organs, should follow where the patients go a doctor we get we're just about out of time I think one last question for people very parochial is is a is the University of Pittsburgh program going to maintain about its current size and European for the next, say, decade, or is it going to keep shrinking?

I think, I can't see tha the number of liver transplant centers are going to grow any more than this.

I mean, there are there may be some changes, small programs falling out and then new programs starting.

But about 110 is where I see.

So I don't see that the it's going to be a much change in our and our referrals and our IT.

It'll be about its present level.

Right.

But what we're trying to do i is to look at different sources of organs.

In other words the taking patients or donors.

In the past, we're not considered donors and expand now and see if we can increase the the donor pool from which we draw from.

And if we can do that, then then a lot of thi controversy that we talk about may be at least dampene in temporarily until eventually, if we use those organs up for I will watch with interest.

Thank you very much.

Thank you Jane, Thank you.

The case of baby Byron raised the issu of interracial foster families.

And weeks later, the controversy continues.

Next, John Craig and Barbara White Stack welcome Richard Wexler, assistant professor from Penn State Beaver, to examine what's in the best interest of the children.

Baby Brian has got the issue before the house, and it just won't go away.

And so here we are back again, talking about another aspect of this business, about foster care.

And, professor, you don't think that the problem is so much, finding adequate foster families and, and issues of race the like as much it is we've got too much foster care to begin with.

Is that correct?

Exactly.

At least half there.

About 450,000 children in foster care nationwide, I believe, based upo the best experts in the field, that at least half of those children could be safely in their own homes if proper services were provided.

And you have you have you've talked to professor about this and what's the situation in Allegheny County?

Well, Allegheny County does not use the program that he's interested in.

It's called homesteading.

At this point.

They are looking at something similar to that.

But if you could describe homesteading, it's somethin that's sort of a novel approach.

And it this is the alternative to foster, right.

The idea is this many, many cases of children needlessly placed in foster care are situations where a family's poverty has been confused with neglect.

Now, in some cases, something as simple as a rent subsidy or a daycare slot will do where more intensive services are needed, a homebuilders intervention is done in which you spend only six weeks with a family, bu it's a very intensive six weeks.

Homebuilders workers have caseloads of only two, so they are in the home for several hours a day.

They respond to the needs of the family they see the family interacting, and they combine the traditional counseling and parent education with services designe to ameliorate the worst effects of poverty emergency cash, perhaps a rent subsidy, even they will even help fix up a home.

If a homebuilders worker sees a messy home, she will not immediately conclude.

There's some deep psychological problem here, and we'd better take the children away.

The homebuilders work like our house, but the home builders worker will roll up their sleeves and help clean the place up.

Okay, now, what about this?

This is.

But this is more expensive, isn't it?

It's less expensive because although the intervention is intense, it is very short.

A homebuilders intervention is typically about one third the cost of a year in foster care.

The problem is the way the government, federal and state finance.

So these kinds of services in most Pennsylvania counties, on average, every time you put a child in foster care, the county gets back $0.87 from the federal or state government.

There isn't comparable reimbursement in most cases for family preservation programs.

So although it is cheaper in total dollars, it may not be cheaper for the county.

Making the decision what happens after the six weeks if it doesn't work out well, first thing that has to happen after the six weeks i you have to link the family up with more conventional services to make sure that the gains made are maintained.

If it doesn't work at the end of the intervention, the home builders worker writes a report and makes a recommendation.

If it doesn't work.

If things are still bad, then you should move to remove the child.

And in fact, home builder even succeeds when it fails in that if you try this and it doesn't work, you have a much better case to terminate parental rights sooner, so you can move the chil into a permanent adoptive home.

So let me ask you about that issue.

Now what what you're saying, point numbe one is if we had more attention to families, we wouldn't need as many foster families.

Absolutely.

Right.

So we cut that about in half.

According to here, I have at least.

All right, now let's tak the let's take the foster half.

Okay.

What do we do to make that better?

Is by just by cutting it in half.

Do we on average, improv the quality of the foster care?

Absolutely.

Because as soon as one of the reasons that foster care is not as good as it should be.

Now, most foster parents are excellent dedicated, hardworking people.

However, the best evidenc we have is that there is abuse in one quarter of all foster homes.

Not always by done by foster parents.

Sometimes it may be one troubled child assaulting another, but we have this image of foster care as a safe haven.

And it's not family preservation programs are not just less expensive than foster care.

They are safer than foster care.

So if we get a lot of these children out of foster care, yes, the quality of foster care will improve.

There'll be fewer marginal foster homes.

There won't be a shortage.

What d you do in situations where the the problem with the family is, is a drug addiction.

And they're saying in Allegheny County, 80% of the children removed from families are because of drug addiction.

Can a six week intervention really work?

First of all, you have to be cautious about what is meant when you use those figures in some communities.

And I am not saying Allegheny County is one of them.

The phrase drug involvement can be anything from a crack baby to a mother who smoked one marijuana cigaret to ease the pain of labor.

And there's an actual case in Long Island, New York, where a mother lost her baby for that.

Initially.

So you have to be careful about what is meant by drug involvement.

Homebuilders programs are successful in substance abusing families.

Obviously, they have to be combined with drug treatment.

Imagine what would have happened in the Baby Byron case if instead of taking him away at six days, placing him in foster care, then trying Unconscionably to move Byron to still another foster home, and only then discovering he had a mother.

Imagine what would have happened if they had gone and helped LaShawn Jeffrey immediately and immediatel placed her in Sojourner house.

All of this tragedy could have been avoided, but you know, one thing that that people say about that case in particular and in other drug cases is you you can try to intervene.

But if the person doesn't want your help and if it's not the right tim for them to get off the drugs, it's not going to work anyway.

It isn't always going to work.

However, what people who have worked with substance abusing mothers have found is that very often, childbirth is the right time, the threat of losing a child, the experience at that point of childbirth is very often a turning point, and very often the best time to intervene.

The problem is, not only is there a lack of drug treatment in general, there is very little drunk drug treatment available for pregnant women and very little available for new mothers that does not require separating mother and child.

There were very few Sojourner.

Wouldn't it be true that in this instance you would have had the leverage?

That is, whether or not the mother liked it or not at that exactly that time that she did have a drug problem and somebody intervened.

The question is, what' the nature of the intervention?

Yeah but you're you're in there now, you and you and you say your choice would have been going to Sojourner House or doing something else.

And apparently that choice was not offered in this case.

All they did was thro the child into into foster care.

And that happened so often in this county, and there is so much needless harm to children done as a result, compounded by what you wrote about.

It is utterly unconscionable to have a deliberate policy to move children around from one foster home to still another foster home after five and a half months.

In some circumstances, even inexcusable.

Not in the what you'd call correct housing situation, in the sense that you want black children with black families.

The best way to keep black children with black families is to move heaven and earth, to keep those black children in the black families they were born with, not to bounce them around like sacks of mail dropped on another doorstep.

Okay, well, I think on that point we've got answers to all the questions.

We've got to cut the foster care down, and we're going to keep children in their same, environment, and we're going to end we're going to treat the problem which is either drug addiction.

Like, right.

Okay, I hope so.

All right.

Thank you, Barbara.

Thanks very much.

Brian O'Neill takes a look at new art form with the last word.

Judy Panzer has what every artist dreams about a rich patron.

Her brothe Richard buys downtown buildings.

The way I buy shirts.

Only he doesn't mind getting paint on them.

You've probably seen his Wood Street building with her mural of Pittsburgh sports gods.

I like seeing Mario and Roberto together, but I'm a little wary of the Panzers latest idea.

The city of the Mays.

They'd like to use 30 building to tell the story of Pittsburgh through murals.

Would be like a WQED special that never went off.

Visitors would go from one end of the Golden Triangle to the other, looking up in the air.

Kind of dangerous around Gateway Center.

And how honest do we want to be here?

Some murals could be breathtaking.

George Washington kicking the croissants out of the French.

Andrew Carnegie's discovery a library card the first time the brothers put fries on a sandwich.

You're classics.

But who's going to do the mural on smog?

We live in a cit getting ready to open a museum dedicated to Andy Warhol, the local boy who fled to New York to erase the line between high art and popular culture.

But Warhol's ghost i being upstaged by a New Yorker who may exact a terrible revenge.

Or she may make art history more like Warhol.

She may do both.

I wonder how a Campbell's soup can would look on the side of the USX Tower anyway.

Brian O'Neill's ha the final word, and so have we.

Thank you very much for being with us.

If you have any suggestions or comments, please write to John Craig, care of the editors, WQED TV 4802 Fifth Avenue, Pittsburgh, PA 15213.

The Editor is brought to you by the people of Duquesne Light Company, dedicated to providing customer service and to caring for the environment.