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The following is a review of what the respectable German press has described as “The worst incident in the history of German transplantation medicine” (Quotation from Criminal Law Professor Hans Lille, University of Halle).In the University Clinic at Göttingen it would appear that medical records have been falsified “big time”. As a result selected patients preferentially received donor livers. The reports indicate that there could be more than a couple of dozen cases. These are now being investigated by the German state prosecutor
In the last week a scandal was uncovered in Germany which promises to have very serious consequences for the medical branch. This scandal relates to liver transplantations carried out in German hospitals. It appears that some patients, including non-German visitors from Russia, have found ways to get to the top of the official waiting list – with a little help from their Doctor.
Background to the Transplantation Waiting List System in Germany
Before I provide more details about the scandal let me first explain the current situation with regards to organ transplantations in Germany.
Generally even with a sick liver it may be possible to survive for a while. The organ has considerable capability to regenerate itself; an important characteristic when dealing with the effects of alcohol or infections from Hepatitis viruses. This regeneration potential was even mentioned in Greek mythology when Prometheus was punished by Zeus, the king of the Olympian gods, for creating man from clay and providing him with fire. Prometheus, through this deed, laid the basis for civilisation and human progress. In his punishment he was sentenced by Zeus to eternal torment by being bound to a rock where, each day, an Eagle would feed on his liver. After each feeding session the liver regenerated but was again eaten each subsequent day by the Eagle.
Even with its ability to regenerate the liver can reach a point in which failure threatens. This can happen, for example, in cases of acute poisoning. In such situations the Doctors in a transplantation centre will place the patient on a waiting list for a donor liver. The medical group ‘Eurotransplant‘ oversees all the requests for transplants and allocates donor livers to patients in its participating countries on the basis of a set of strict medical criteria.
The allocation of donor kidneys in Germany is based on the degree of medical urgency. This uses a so-called MELD score system in which a high score means that without a new kidney the patient will soon die. Bad blood and kidney analysis results and the need for dialysis are reflected in the score. Patients with the highest scores are at the top of the waiting list. As soon as a liver is allocated to a patient the Eurotransplant organisation informs the clinic that registered the patient. The German organisation ‘Organtransplantation‘ then coordinates the removal and transport of the donor kidney. Since there is a shortage of donor organs it is of paramount importance that their allocation is strictly based on the medical urgency of the recipient.
How could a person’s position in the waiting list be ‘improved’?
The ‘tricks‘ which appear to have been used in Göttingen were surprisingly simple. The responsible Doctor just needed to make the patients on the waiting list more sick than they actually were. In this way they could move up to the top of the list and receive their donor organ allocation from Eurotransplant more quickly.
Of course this means that other patients who, based on a correct medical assessment should have been placed higher on the list, need to wait longer. Clearly an important issue for the current investigation is whether these disadvantaged patients actually received their organs in time or whether some actually died as a result of being unfairly ‘leapfrogged’ on the waiting list.
It is suggested that the senior Doctor in Göttingen manipulated the patients records in a number of ways. For example a kidney problem requiring dialysis may have been ‘fabricated‘ or laboratory analysis results may have changed to indicate a raised tendency to form clots or high levels of creatinine (an indication of kidney malfunction). As the liver and kidneys play an important role in detoxifying blood a person with liver disease will be at increased risk if the kidneys are also not performing correctly. One indication that manipulation has occurred is found when the Doctor forgets to also increase the blood urea figures in the records in step with the creatinine levels – being physiologically linked both levels would normally be expected to increase together. Another tell-tale sign of ‘doctored’ records (sorry!) is when the creatinine levels dramatically increase just before the patient is added to the donor waiting list and then abruptly return to normal levels the next day. This can be identified through a simple review of the patient’s medical files.
The Investigation
The German public prosecutor has already started corruption proceedings against the senior Doctor in question. The Doctor’s apartment has been searched and documents have been confiscated. Clearly issues such as deliberately falsifying records and illegal financial transactions will be included in the scope of the investigation. The German press was unable to locate the current whereabouts of the Doctor in question.
The Incentive
Medical centres receive approximately 150,000 euro for each liver transplantation and therefore this is an attractive business for them to pursue. As an incentive senior doctors share in the financial rewards. Historically Göttingen hardly carried out any of these operations. Then the Doctor in question took over the transplantation department and the frequency increased to around 50 per year. In Germany this is a relatively high number, even the largest medical centres only tend to perform about 100 liver transplantations per year.
This was not the Doctor’s first incident in Göttingen
In an earlier report (June 16th 2012) the Süddeutsche Zeitung described another incident involving the same senior Doctor in Göttingen. A person in Russia had serious liver problems after a long period of alcohol indulgence. The Russian doctors were unable to help and so the man came to Göttingen. Apparently, according to the press report, the patient was accompanied by a donor who was prepared to donate part of their liver. This kind of private medical treatment is not abnormal and accepted by the authorities.
However it turned out rather surprisingly that the tissue of the potential donor did not match that of the Russian patient. The press reported that someone close to the case suggested that records had been falsified. According to the documents the patient suddenly became very sick, simultaneously other organs started to fail. As a result it was impossible to put the man in a plane and send him home. He ended up at the top of the waiting list for a donor liver. This he was able to quickly receive from the Eurotransplant group (Russia is not one of the countries belonging to this group).
Upto 5% of the organs transplanted in German clinics can be used for overseas patients on the basis that the patients are not ‘transportable’. Otherwise the patients must return to their home country for treatment.
This was not the Doctor’s first incident in Germany
The same Doctor involved with the above investigations was also involved in an interesting situation in a previous job in a Bavarian university clinic. Here he was able to obtain a Eurotransplant liver for a patient which he then took to Jordan and carried out the transplantation there. Apparently he had told Eurotransplant that the patient was in Regensburg – he gave the patient’s address as that of the clinic.
Following a formal investigation the Bavarian authorities were satisfied with an assurance from the clinic that such a scenario would never be repeated. The Doctor moved and was promoted to a more senior position – in Göttingen.
If you are interested in finding out more about these cases I refer you to the following original German language articles, both in the Süddeutsche Zeitung, here and here.
Chris Duggleby
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Now prepare for an uplifting experience!
Chris Duggleby 