How can we justify a heart transplant?

A 40 year old male presents to the emergency department with shortness of breath, swelling in his legs, feeling generally unwell. He is not sure exactly when he last felt himself, but certainly for the past few weeks he has not been able to take his children out to ride their bikes or keep up with the gardening at home. The doctors in the emergency department scratch their heads, concerned, questioning him about his medical history. After a series of investigations, being reviewed by multiple medical specialists and many long and emotional conversations, he is diagnosed with dilated cardiomyopathy and acute heart failure. The diagnosis carries with it a poor prognosis, without a heart transplant, the quality and quantity of his life are likely to be reduced significantly. More tests, more specialists, and more difficult conversations take place. He is listed for a heart transplant. The waiting game begins. He lives in anticipation, waiting for the call telling him a donor has been found. The call comes, a Friday morning just after his kids have caught the bus to school. His wife rushes home, and he is whisked off. Mere hours later he waits in the anaesthetic bay nervously. His life is about to be changed forever. 

Across the globe on the same morning a mother nurses her child. She is sick, she has been for about a week now. Undulating fevers, increasingly pale skin and lethargy have transformed her daughter from the little girl chasing chickens around the yard, to a docile vulnerable child battling a microscopic war within her own body. She takes her daughter to the health centre, some two hours walk away, swaddled in cloth to her back. By the time they arrive her daughter is listless. A rapid malaria test is positive. As is a urine test for protein. She has severe malaria, and her kidneys are taking a hit. The clinical officer on duty searches for a vein, and vein, to insert an intravenous line to administer the antimalarial drugs and antibiotics she needs to stay alive. She is admitted to the ward. No specialists arrive, there are no more investigations. The sun sets, and rises again the following morning. The woman sobs, as her daughter’s breathing becomes irregular, then stops. Her life is changed forever. 

A heart transplant exemplifies just how far modern medicine has brought us. From the medical science necessary to surgical excise and implant the vital organ from one person to another, to the logistical challenges of coordinating the transport of the organ from donor to recipient, every heart transplant attests to just what humanity is capable of if we set our mind to it. It is also incredibly resource intensive. The pre-transplant workup, admission for transplantation, follow-up and management of complications present a significant volume of work. One US review of heart transplantation and mechanical assisted pump devices (LVAD) usage estimated a combined cost of $2.5 billion USD for the period 2005-09, with 9369 transplants and 6414 LVAD procedures taking place, placing costs at ~$158 000 per episode (1). These costs accounted only for the inpatient episode of care, excluding initial workup, and post operative care. An Australian review of pediatric heart transplantation calculated the mean cost of heart transplant at $278 480 USD (95%CI $219 282 – 337 679 USD), with follow up costs quoted at $55 823 USD (95%CI  $47 631 – 64 015 USD) for the first year, and $12 119 USD (95%CI $8 578 – 15 661 USD) for each following year. The cost per QALY gained was calculated at $29 161 – 44 481 USD (2). The 1 year survival post heart transplant is 84.5%, and 5 year survival is 72.5% (3). The quality of life amongst surviving heart transplant recipients seems to be similar to that of the background population (4). Median survival post transplant is approximately 12 years (5). 

In addition to the costs of the procedure and care required directly to the patient, there exists additional reservoirs of cost. For instance, significant biomedical research is necessary as a precursor to the procedure of transplantation being physically possible. Surgical technique, complex immunosuppressive regimens and perfusion systems have all had to be developed for the purposes of successfully carrying out the procedure. Or consider the infrastructure which provides support for the logistics of the transplantation. It must be operative 24 hours a day, and requires staffing from specialist medical and nursing staff. Cost estimates accounting for the direct costs associated with an individual patient’s care fail to account for the significant and costly foundation this care is based upon.

Many high-income countries are willing to invest in heart transplant services, with around 5000 transplants occurring across the world every year. Thresholds quoted by national governments for what constitutes a cost-effective intervention vary worldwide, the US has a threshold of approximately $50 000 USD per QALY gained. From the cost perspective of the individual patient encounter, the investment for each QALY for a heart transplant patient is cost-effective. This is where most analyses stop, and where our policy decisions draw the line in terms of evaluation. What would be our view on the cost effectiveness of a heart transplant if we considered all of the investment they have brought us to the point of being able to successfully add some 12 years of life to each beneficiary of the process? With some 3500 transplants being performed a year, and assuming a quality of life comparable with the background population, the efforts and investments associated with heart transplantation offer 42 000 QALYs to patients every year. 

To put these 42 000 QALYs in a more global context, consider the years of life lost (YLL) associated with malaria across the world each year. According to WHO estimates in 2019, 30 855 000 years of life were lost due to malaria alone (6). 95.5% of YLL were on the continent of Africa. Findings from the Gallup World Poll suggest a positive relationship between life satisfaction and income, with members of high-income countries reporting satisfaction levels between 6 and 8, and members of low-income countries reporting satisfaction levels between 3 and 5.5 (7). Let us therefore assume, as a conservative estimate, for each absolute YLL to malaria 0.5 QALYs are lost. There are therefore some 15 427 500 QALYs lost to malaria every year. This is the same number of QALYs as are produced from more than 367 years of heart transplantation. GiveWell’s cost effectiveness analysis suggests that a death from malaria can be prevented for as little as $3 845 (8). This is far cheaper than the $29 000 – $44 000 cost per single QALY gained from a heart transplant. How then can we justify as a society the investment, costs, and opportunity costs associated with heart transplantation, given the availability of interventions, such as malaria prevention, that are so much more cost effective, and so much more vast in terms of scale?

There are a range of potential justifications for the practices of high-income countries and expensive, innovative medical treatment more broadly. Let us consider a few such justifications, and in doing so appreciate some of the complexities involved in performing this style of moral calculus:

1. The intrinsic value of innovation: A heart transplant represents the pinnacle of human progression. The broader trajectory of society toward healthier, happier and longer lives built on the foundation of scientific progress is nowhere more aptly exemplified than in the procedure of transplanting a human heart to give an identifiable individual another shot at life. Innovation in the broadest sense is valuable to all, albeit to some more than others, and in acting out innovation for the benefit of an individual, all involved have a tangible sense of connection to the good society has produced.
   1. Spillover effects: Connected to this may be arguments around the interconnectedness of health progress, how innovations in one area may benefit those in adjacent fields. Could a heart transplant give us insights about the management of cardiovascular disease, which may benefit the increasing numbers of those being burdened by similar conditions in low and middle income countries?
   2. Potential for cost reduction: Whilst innovative treatment modalities may be expensive initially, by accepting a high initial cost we are accepting the likelihood of lower costs in the future, improving the cost effectiveness of effective treatments over the long term.
2. Moral prioritisation of one’s own community: Many believe in the moral obligation toward those of their own family, community, and country. This may involve ideas of reciprocity, or more common-sense-morality related to the connection shared with those around them, and the direct observability of their impact. We may feel that although a heart-transplant is resource intensive, at least we can be more convinced these resources are being utilised for a qualitatively ‘positive’ purpose. 
3. Local economic considerations: A heart transplant is a complex undertaking that not only requires the input of specialist knowledge, but the labour of many non-specialised workers. The economic remuneration from undertaking the procedure benefits all involved, whether directly or indirectly, and contributes some part to economic activity in society. 

Conclusion

A bias exists toward innovative activities that in our society is morally and economically acceptable. On closer examination, it appears that a bias toward innovation and common sense morality underlies our current resource allocation. If what we truely seek to optimise is the health and wellbeing of all people, we would be wise to shift our focus from the margins of what is humanly possible, to innovation that ensure the basic needs of all people are met

References 

1. Mulloy DP, Bhamidipati CM, Stone ML, Ailawadi G, Kron IL, Kern JA. Orthotopic heart transplant versus left ventricular assist device: a national comparison of cost and survival. J Thorac Cardiovasc Surg. 2013 Feb;145(2):566-73; discussion 573-4. doi: 10.1016/j.jtcvs.2012.10.034. Epub 2012 Dec 13. PMID: 23246055; PMCID: PMC3707397.
2. Ye XT, Parker A, Brink J, Weintraub RG, Konstantinov IE. Cost-effectiveness of the National Pediatric Heart Transplantation Program in Australia. J Thorac Cardiovasc Surg. 2019 Mar;157(3):1158-1166.e2. doi: 10.1016/j.jtcvs.2018.11.023. Epub 2018 Nov 16. PMID: 30578063.
3. Lund LH, Edwards LB, Kucheryavaya AY, Benden C, Christie JD, Dipchand AI, Dobbels F, Goldfarb SB, Levvey BJ, Meiser B, Yusen RD, Stehlik J; International Society of Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: thirty-first official adult heart transplant report–2014; focus theme: retransplantation. J Heart Lung Transplant. 2014 Oct;33(10):996-1008. doi: 10.1016/j.healun.2014.08.003. Epub 2014 Aug 14. PMID: 25242124.
4. Politi P, Piccinelli M, Fusar-Poli P, Klersy C, Campana C, Goggi C, Viganò M, Barale F. Ten years of “extended” life: quality of life among heart transplantation survivors. Transplantation. 2004 Jul 27;78(2):257-63. doi: 10.1097/01.tp.0000133537.87951.f2. Erratum in: Transplantation. 2012 Aug 15;94(3):e22. Poli, Paolo Fusar [corrected to Fusar-Poli, Paolo]. PMID: 15280687.
5. Khush KK, Cherikh WS, Chambers DC, Goldfarb S, Hayes D Jr,, Kucheryavaya AY, Levvey BJ, Meiser B, Rossano JW, Stehlik J; International Society for Heart and Lung Transplantation. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-fifth Adult Heart Transplantation Report-2018; Focus Theme: Multiorgan Transplantation. J Heart Lung Transplant. 2018 Oct;37(10):1155-1168. doi: 10.1016/j.healun.2018.07.022. Epub 2018 Aug 10. PMID: 30293612.
6. WHO methods and data sources for global burden of disease 2000-2019. Global Health Estimates Technical Paper WHO/DDI/DNA/GHE/2020.3.Geneva: World Health Organization; 2020 (https://www.who.int/docs/default-source/gho-documents/global-health-estimates/GlobalBurden_method_2000_2019.pdf).
7. Deaton A. Income, health, and well-being around the world: evidence from the Gallup World Poll. J Econ Perspect. 2008 Spring;22(2):53-72. doi: 10.1257/jep.22.2.53. PMID: 19436768; PMCID: PMC2680297.
8. Givewell’s cost-effectiveness analyses. GiveWell. (2023). https://www.givewell.org/how-we-work/our-criteria/cost-effectiveness/cost-effectiveness-models. Accessed 27 May 2023.