The market of human organs: a window into a poorly understood global business.

The global demand for human organs has set the stage for an exploding and poorly understood global business in human organs. Whenever there is demand for a product, the opportunity for business arises. The form that a business takes is dependent on a complex network of inputs and outputs, each affecting the others. Historically, the details of any specific market are drastically underestimated. Nowhere is this truer than in the market of human organs. The drivers, which propel the "goods" of human organs, form a flourishing business. Critical analysis is essential to understanding of the supply and demand sides and to determine the role of government in regulating the industry. Governmental groups have dismissed formation of a regulated market for organ sales. The concept is nonetheless a topic of active discussion, motivated by the suffering of patients in need of organs and exploitation of the victims of human trafficking. Ethical principles have been invoked on each side of the ensuing debate. Theory in the absence of sufficient data is shaky ground for enactment of new policy. The Aristotelian concept of "practical wisdom" and the pragmatism of William James illuminate the importance of scientific investigation as guide to policy formation. How will stakeholders benefit or lose? What impact might be anticipated in regard to organized medicine's social contract? What can we learn about cross-cultural differences and their effect on the global landscape?

Immunological response to stress in agoraphobia and panic attacks.

The authors studied in vitro immune function as measured by lymphocytic proliferative response to mitogen stimulation in 36 patients with agoraphobia and panic attacks who were participating in a double-blind placebo-controlled psychopharmacological study of anxiety disorder. No significant difference in immune status was observed between panic patients and healthy controls.

Psychiatric aspects of organ transplantation.

Technical advances in surgery and the new antirejection agents cyclosporine and muromonab-CD3 have led to improved outcome for organ transplantation. Allograft rejection and complications of immunosuppressant therapy are often associated with considerable stress, so availability of psychiatric consultation is a necessity. As a transplant team consultant, the psychiatrist treats perioperative anxiety, depression, and organic brain dysfunction and addresses medical and ethical aspects of patient selection. Studies indicate that many patients with psychopathological conditions have good postoperative results and that most living kidney donors participate spontaneously and consider donation a positive experience.

Panic disorder in genotypic HLA identical sibling pairs.

The authors describe two HLA identical sibling pairs with panic disorder. To their knowledge, this is the first report of histocompatibility testing in patients with anxiety disorders.

Panic attacks and the dexamethasone suppression test.

Of 51 patients with panic attacks, 11.8% (7.8% with a correction factor) had a positive dexamethasone suppression test. This is significantly lower than the rate for melancholia. This difference suggests that panic attacks and major depression may be associated with different biological mechanisms.

Neuroendocrine correlates of lactate-induced anxiety and their response to chronic alprazolam therapy.

Lactate infusions are anxiogenic in patients with panic disorder or agoraphobia with panic attacks, but few neuroendocrine profiles of this effect have appeared. The authors measured the number and intensity of panic symptoms and blood hormone levels during double-blind lactate infusions in 25 patients and 10 normal subjects and during placebo infusions in another five patients. Each patient was rechallenged with an identical infusate after chronic double-blind outpatient treatment with alprazolam or placebo. The results confirm the effectiveness of lactate infusions in evoking anxiety, extend previous hormone profiles of this maneuver, and indicate that chronic alprazolam treatment minimizes the neuroendocrine response to lactate challenges in patients with panic disorder or agoraphobia with panic attacks.

Monoamine oxidase inhibitors in obsessive-compulsive disorder.

The authors describe the use of monoamine oxidase inhibitors (MAOIs) in eight patients with severe obsessive-compulsive disorder. In four cases, the MAOIs produced rapid and sustained remission of symptoms; no response was seen in four other patients. All patients who responded to MAOIs, but none of the nonresponders, had phobic anxiety and/or panic attacks. Thus, a trial of MAOIs is indicated in obsessive-compulsive disorder, especially when phobic anxiety or panic attacks form part of the clinical picture.

Unusual lymphocyte subset distribution in some depressed patients.

Depression has been previously associated with immunologic dysfunction. The lymphocyte subsets of 10 patients with major depression were found to show a mean T4-T8 (helper-suppressor) ratio lower than that of controls, a difference attributable to increased numbers of suppressor cells in the depressed group. One possible cause of increased suppressor cells is prior or current viral infection.

Use of hypnosis in patients receiving hemodialysis for end stage renal disease.

Dialysis patients experience considerable psychologic stress, but practical issues impede delivery of psychiatric care. The authors describe five cases in which the use of hypnosis for symptom reduction provided the basis for beneficial psychiatric intervention.

Ethical dichotomies in organ transplantation. A time for bridge building.

Rapid advances of the past 15 years have resolved many of the technical and immunologic limitations to organ transplantation. With the success rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remaining obstacles to wide application of organ transplantation. Competition for organs and for funding demands greater focus on patient selection and resource allocation. As Charles Taylor, philosopher and political scientist, has written, ethical formulations inevitably conflict when each is taken to its logical end point. In the 1960s, a life boat ethics framework predominated for selection of transplant recipients. The opposing egalitarian framework of recent decades has allowed for enrollment of older transplant recipients and those with histories of substance abuse. In the United States, alcoholic liver disease has been the most common indication for orthotopic liver transplantation since 1987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are young and who appear relatively stable die while waiting. Despite the shortage of cadaveric organs, physicians and ethicists have for the most part eschewed rewards or reimbursement for living related organ donation. Such conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioners are immersed in the trends of the day and the approach at each moment seems preferable to that of the moment preceding. From a practical standpoint it may be possible to bridge disparate ethical constructs. For example, in the wait for solid organ transplantation, a bicameral approach could alternatively accommodate time waiting and urgency. Selection of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and posttransplantation quality of life. Living organ donors and families of nonliving donors could receive incentives of a noncoercive nature that would stimulate participation without sacrificing altruism. Creative approaches are needed to improve fairness and efficacy in solid organ transplantation.

Microcomputer-assisted relaxation.

The present pilot study was designed to test the effectiveness of a microcomputer program developed by the authors to induce relaxation and focused attention, which are common to most clinical stress-reduction and hypnotic procedures. A nonclinical sample of 20 adults used the program on an APPLE IIc computer in two 30-min. sessions in a within-subjects design. Repeated measures analyses of variance showed significant decreases in the Spielberger State Anxiety Scale and on a visual analog anxiety scale. Limitations and implications of the study are discussed.

Informed consent: what the patient heard.

UNLABELLED: Transplant Psychiatrist: "Why is it important to take (routine) medications after transplantation?" Transplant candidate: "To protect the liver." Doctor: "How?" PATIENT: "I don't know." Doctor: "Think about it for a moment." PATIENT: "To prevent rejection and infection." Doctor: "Which one: rejection or infection?" PATIENT: "Both." This article reports significant conceptual limitations in patient medical knowledge. In the course of customary comprehensive psychiatric evaluation, patients with end-stage renal and/or hepatic disease were asked about knowledge of benefits and side effects of required post-transplant medication. Liver transplant candidates were asked about their understanding of primary organ function and instructed in reference to components of Model for End-stage Liver Disease status on the deceased donor transplant list. Candidates for renal transplantation were selectively asked about risks regarding medical dietary compliance, including dangers of hyperkalemia. PATIENTs had less than expected understanding of required immunosuppression. Liver transplant candidates, with infrequent exception, described the organ as a filter. Those with medical compliance problems related to end-stage renal disease had limited understanding of the kidney's role in homeostasis and impact of hyperkalemia on neurologic function. Additional teaching centered on narrative and analogy specific to individual life experience and skills. Historical reference to Sir Peter Medawar's Nobel Prize-winning work on skin allograft failure for treatment of World War II burn victims effectively illustrated the primacy of immunosuppression for successful organ transplantation. PATIENTs were receptive to this teaching approach. Many expressed gratitude for improved understanding. Clinical awareness of patient skills and life experience can enrich understanding of transplantation objectives and importance of medical compliance.