Should patients waiting for an organ transplant be required to get a COVID-19 vaccine to be considered for the life-saving procedure?
That question is being debated at Ontario transplant centres, now facing the tricky ethical dilemma of whether to limit donor organs to only those who have been fully vaccinated against the virus.
The University Health Network, which runs the largest organ transplant centre in Canada, has decided patients must be fully vaccinated before being put on a wait list for a solid organ transplant, including a heart, lungs or liver. Hospital leaders say the policy — the first to be implemented in Canada — is needed to protect vulnerable patients and ensure the donated organ goes to those with the best chance of survival.
But other transplant centres in the province are taking a different approach.
St. Michael''s Hospital, which only offers kidney transplants, is not turning away unvaccinated patients listed for a new organ.
Instead, the hospital — which strongly recommends COVID vaccines ahead of transplant — is evaluating patients on a case-by-case basis and educating those who are hesitant about the benefits of vaccination, said Dr. Ramesh Prasad, director of the kidney transplant program at St. Mike’s, a part of Unity Health Toronto.
“Every attempt is made to educate patients about vaccinations, and the decision to proceed or not in the current COVID situation is a clinical one,” Prasad said.
“There is a clear benefit to getting a kidney transplant. The ethical dilemma is that the mortality of waiting for a kidney transplant is high. We don’t know at the moment — there is not enough data — whether it’s higher than the mortality of COVID.
“Until that is sorted, we’re not denying anybody a transplant.”
Transplant recipients are among those at highest risk of severe complications and death from COVID infection because of the powerful immune-suppressing medications they must take to prevent their body from rejecting the new organ. Research has shown COVID vaccines — including the third shot — reduces those risks for transplant patients.
Kevin Smith, UHN president and CEO, said requiring transplant recipients to be fully vaccinated is critical at the hospital given the large number of complex transplant procedures it does every year. Not only does the policy help protect individual transplant recipients, it also ensures the collective safety of other vulnerable patients, Smith said, noting UHN has made COVID vaccination mandatory for its staff.
“These are extremely high-risk patients,” he said. “They are patients who, if they get COVID, are at profound risk of serious illness and death.”
UHN bioethicists and physicians at the hospital’s Ajmera Transplant Centre also considered the limited supply of donor organs in creating the vaccine policy, Smith said. Currently, there are 796 patients on UHN organ wait lists.
“We have a fidelity and a responsibility to this very scarce resource,” Smith said. “We want the likelihood of success after transplant to be the very best in the world.”
So far, UHN is the only Ontario hospital to mandate COVID vaccines for patients waiting for transplant, though other centres are considering the issue.
St. Joseph’s Healthcare Hamilton is reviewing its policies for patients waiting for a kidney transplant and will be sharing its decision in the coming days, Dr. Christine Ribic, the hospital’s medical director of transplant, said in an email to the Star.
“Our program uniformly supports the recommendation of COVID-19 vaccine prior to transplant to reduce the increased risk of severe COVID post-transplant,” she said. “We are balancing this with the principle of equitable access to care for patients awaiting transplant.”
The Trillium Gift of Life Network, the provincial agency in charge of organ and tissue donation, has not mandated COVID vaccines for potential organ recipients. (TGLN transferred into Ontario Health on April 1, 2021.)
In a statement to the Star, Ontario Health (Trillium Gift of Life Network) said it is “in the process of developing a clinical guidance document supporting vaccination while recommending each transplant centre proceed case by case, based on medical urgency and an evaluation of risks to the patient.”
The statement said the agency recommends COVID vaccines for transplant recipients and points to data showing the risk of death is “two to five times greater in transplant patients than in the general population” from COVID.
The statement also noted that transplant recipients must already take recommended medications, including vaccines, and that “donated organs are scarce and publicly entrusted gifts.”
Smith said UHN’s vaccine policy for transplant recipients is not at odds with Ontario Health’s current recommendations. However, he said, the agency has expressed worry that a COVID vaccine policy could lead to fewer people consenting to be organ donors.
For UHN, Smith said the proven benefits of requiring COVID vaccination to protect vulnerable patients outweighs the theoretical risk of losing potential organ donors.
While the ethical debate over mandatory COVID vaccination is fraught, Ontario has long had rules in place for transplant recipients to ensure organs are allocated to those who would benefit the most, said Alison Thompson, an associate professor of bioethics at the University of Toronto.
“We treat donated organs like they are precious resources, because they are so scarce,” she said. “We do ask people to show that they will benefit, even if that means changing their behaviour, so they can maximize the benefit of that organ, of that gift.”
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie