An appeals court has ruled that people who donate bone marrow through a newer and less invasive technology can be paid for doing so, overturning a decades-old law that makes it a felony to pay donors for bone marrow and organs.
A three-judge panel of the 9th U.S. Circuit Court of Appeals in California ruled unanimously that because the process of donating bone marrow is now so similar to that of donating blood plasma -- which people are paid for -- bone marrow should no longer be considered an organ for which payment is illegal under the National Organ Transplant Act.
A newer method of marrow extraction called peripheral blood stem cell apheresis removes stem cells from a donor's bloodstream in a process similar to donating blood, except that patients must take medication to spur greater production of hematopoietic stem cells, the donation process takes several hours, and instead of collecting bags of blood, the hematopoietic stem cells from the donor's bloodstream are filtered out and collected.
The 1984 National Organ Transplant Act included bone marrow in its list of "organs and parts thereof" for which donors could face criminal charges and five years in prison for providing them in exchange for money or other "valuable consideration."
Though bone marrow is naturally replenishable, unlike livers, kidneys and other whole organs, its sale was barred because the extraction method used at the time the law was passed was painful and risky for the donor and authorities feared the poor would be induced to submit to the procedure to earn money.
In the last 20 years, though, medical advances have brought about a less intrusive method by which the life-saving marrow stem cells are harvested from a donor's bloodstream in much the same way as blood is drawn at a blood bank. The new process, known as apheresis, filters out excess marrow stem cells that circulate in the bloodstream, as opposed to the surgical extraction method, known as aspiration, which inserts a large needle into the hip bone and siphons out the cells.
A unanimous three-judge panel of the 9th U.S. Circuit Court of Appeals ruled that the marrow cells taken from a donor's blood were blood parts, not organ parts, and that a donor is therefore free to accept compensation for a donation.
"This is a fundamental change to how deadly blood diseases will be treated in the country," said Jeff Rowes, the Institute for Justice attorney who argued the case before the 9th Circuit panel in February. "Compensation will expand the donor pool by at least hundreds and potentially thousands each year."
More than 3,000 Americans die each year waiting for a suitable marrow donor, Rowes told the court, representing a group of cancer patients and their families, a Minnesota doctor specializing in bone marrow treatments and the California nonprofit MoreMarrowDonors.org.
The lead plaintiff in the case is Doreen Flynn of Lewiston, Maine, a single mother of five trying to ensure that a broader field of potential donors is available when her three daughters suffering from Fanconi anemia need marrow transplants after treatment for the potentially fatal genetic disorder.
"That is, like, the best Christmas news ever!" said a jubilant Flynn upon hearing that the 9th Circuit had ruled to exclude marrow from the compensation ban. Her 13-year-old daughter is already on medication to stave off the need for a marrow transplant while waiting for a well matched donor, and Flynn must decide soon whether to put one of her 7-year-old twins on the same medication, she said.
MoreMarrowDonors.org wanted the organ transplant law struck down or amended to allow the nonprofit to offer $3,000 scholarships or housing payments to attract new registrants to the National Marrow Donor Program. The registry has more than 7 million members, but many joined years ago during donor drives for friends or family members and are often reluctant to donate to a stranger.
Although the extraction procedure has been greatly simplified, it remains difficult to find the right genetic match between donor and recipient, the plaintiffs argued. Unlike blood, of which there are only four types, marrow comes in millions of types.
The plaintiffs sued U.S. Atty. Gen. Eric H. Holder Jr., alleging that the federal law treating bone marrow in the same way as organs that can't be regenerated violates the Equal Protection Clause of the Constitution. The appeals court panel ruled that the older extraction method directly drawing cells from the marrow was reasonably included in the ban on compensation but that the marrow cells filtered out of a donor's blood were blood parts, not marrow parts.
"We construe 'bone marrow' to mean the soft, fatty substance in bone cavities, as opposed to blood, which means the red liquid that flows through the blood vessels," said the opinion written by Judge Andrew J. Kleinfeld, an appointee of President George H.W. Bush. "The statute does not prohibit compensation for donations of blood and the substances in it, which include peripheral blood stem cells."
Justice Department spokesman Charles S. Miller said the government hasn't decided yet whether to appeal.
"We're going to have to review it to make a determination about what the government's next step will be," Miller said, declining to comment on the ruling.
The 9th Circuit interpretation applies to its nine-state jurisdiction, but because it is the only federal appeals court to have ruled on the question, its judgment could guide future decisions nationwide.
Formerly conjoined twins Maria and Teresa Tapia should return home to the Dominican Republic by Christmas, their doctors say. The toddlers are currently recovering from separation surgery in Virginia.
PICTURES - Conjoined twins Maria & Teresa Tapia: Before and after
For the nearly daylong surgery on Nov. 8, doctors at the Children's Hospital of Richmond at Virginia Commonwealth University divided the twins' liver, pancreas, and other shared organs, and reconstructed their abdominal walls.
How are the twins doing?
"They are enjoying life now that they're separated," their mother, Lisandra Sanatis, said. "They enjoy seeing themselves as individuals."
But they're still getting accustomed to exploring their surroundings separately, and stay near each other and hold hands when they walk.
Dr. David Lanning, a surgeon and head of the girls' medical team, says both children have been recovering well.
Maria, the smaller of the two, weighs about 19 pounds, and Teresa weighs about 26 pounds. The disparity in their weight, caused by the configuration of their small intestines and blood flow from the liver, will gradually even out, Lanning said.
Maria's pancreas is slow to produce digestive enzymes, so she is taking replacement enzymes. Teresa is undergoing treatment on the incision where the girls were separated.
After being in Richmond for several months now, Sanatis says she and her daughters are more than ready to leave the confines of the hospital and are anxious to return to their family in their native country. "We're missing our family, and the girls miss their little brother, Lisander," she said.
The family also hasn't acquired a taste for American food - including hospital meals - and they order takeout Dominican dishes, including traditional beans and rice.
They will be staying at the Hospitality House, which provides temporary lodging for patients and their families while in Richmond to get medical care, while continuing physical and occupational therapy and medical follow-up before going home to the Dominican Republic, possibly by Christmas.
"It's great to see the girls happy and out the door," said physician David Lanning, the lead surgeon on the operation that took months to coordinate and plan.
In all, more than 100 people — doctors, nurses, therapists and other staff — were involved in the care of the girls and their family, said Leslie Wyatt, executive director of the Children's Hospital.
Other partners include the Rotary Club of South Richmond, which helped cover the family's living expenses while in Richmond.
"This is a tremendous culmination of a lot of teamwork," Lanning said.
The girls are adjusting to life as separate people. Their birth in April 2010 as conjoined twins was a medical rarity, occurring in one in every 50,000 to 100,000 births worldwide.
"All cases of conjoined twins can be very different even though on the outside they appear similar," Lanning said.
"Because the girls had a lot of organs that were conjoined, it really required a prolonged, complex operation with a lot of reconstruction, lots of different teams involved. I think we're really delighted with how they've done and to leave the hospital doing so well," Lanning said.
The girls are on aspirin therapy, a recommendation from the liver specialists, Lanning said.
"The aspirin is a little bit of a blood thinner" to minimize any risk of clotting, Lanning explained. "Even though they didn't have any liver tissue removed, they split it in half." They will be on aspirin therapy for a year, he said.
Maria, the smaller twin whose reconstructive surgery was more complex, is also taking oral medication that helps with digestion. Lanning said tests show that Maria's pancreas, the organ that produces insulin and other hormones, is working fine but may not be producing enough of some digestive enzymes.
"We anticipate it will recover, but in the meantime we are just giving her supplements," Lanning said. "They are enzymes that help break down carbohydrates. We think that will eventually recover because she has an adequate amount of pancreatic tissue."
The oral medications are cheap and easily available and will not hurt her, Lanning said. If lab tests on stool samples show inadequate digestive enzymes, she may be on the medication for several months while her pancreas ramps up.
There may be one more medical procedure, a surgery to create cosmetic belly buttons for the girls, Lanning said. Originally, they had one that was underneath their conjoined belly.
"Dr. (Jennifer) Rhodes could do it as an outpatient procedure with a little sedation," Lanning said. "Their focus was to get the belly closed, and they've done that."
The weeks leading up to their discharge have been marked by incremental milestones — first sip of water, first bowel movement, first bite of solid food, first independent step.
Still ahead for the girls is learning to get around on their own.
Before the surgery, the girls toddled around easily, with each twin providing balance for the other.
After surgery, they have had to relearn many things — to sit up, to go from sitting to standing, to stand assisted, to walk assisted. The girls, once on their feet, are good at pushing around a stroller.
"Once they are standing and holding on to something, they will walk forward," said occupational therapist Audrey Kane.
"They need to be able to get up and down from standing, from the floor. That's one where they are still trying to figure out what to do. When they are sitting on the floor, they are not quite sure yet how to go about getting up," Kane said. Both girls made gains in that area this week, Kane said Tuesday.
The girls still turn to their mother and aunt with outstretched arms for help, which is still there but in measured doses.
On Friday, Sanatis thanked everyone who made the surgery possible and who supported them but added that she was looking forward to going home.
"It is sad for me. I fell in love with everyone here," she said while holding Teresa, who grabbed at the microphone and, when prodded, leaned over and gave Lanning a kiss on the cheek.
Lanning, who has taken care of other children while on World Pediatric Project missions to Caribbean countries, said there is satisfaction in caring for children who might not get needed medical care otherwise.
At the same time, what they learn from such cases allows them to help many others.
"We may not necessarily have another set of conjoined twins come along, but we certainly learned a lot from this operation to take care of other kids," Lanning said.
"Just a month or so ago I had a baby born here with … all the intestines outside the belly. I knew I could close it a certain way because of a baby I had taken care of in St. Vincent on one of my mission trips. … We learn a lot … when we do these complex, unusual operations."
A statement from Asheville's Mission Hospital on Saturday afternoon said Graham's pulmonologist reports he is maintaining the improvement he showed on Friday.
The 93-year-old evangelist will continue physical therapy to help his strength and mobility. Doctors said Graham stood and walked Friday during a physical therapy session.
Doctors at the hospital in Asheville said Graham was able to stand and walk Friday during a physical therapy session.
Dr. Mark Hellreich, a pulmonologist treating Graham, said he's making good clinical progress and looks better since treatment with antibiotics began.
Graham has suffered from several ailments in recent years. He was admitted to the hospital Wednesday night after suffering from congestion, a cough and a slight fever that was later diagnosed as pneumonia.
Graham was able to take meals on Friday sitting in a chair while talking with hospital staff. No discharge date has been set. .
Whether it is housework, cooking or childcare, women do about 10 hours more multitasking in the home each week -- 48.3 hours compared to 38.9 -- which researchers say constitutes an important source of gender inequality.
"When you look at men and women in similar kinds of work situations they look very similar," Barbara Schneider, a professor of sociology at Michigan State University and a co-author of the study, said in an interview.
"But when they come home it is very clear that women are shouldering much more of the responsibilities of housework and childcare."
Schneider and Shira Offer, an assistant professor at Bar-Ilan University in Israel, used data from the 500 Family Study, which looked at how families in eight U.S. urban and suburban communities balance work and family life.
Their research, which is published in the American Sociological Review journal, is based on responses from a subset of 368 mothers and 241 fathers in dual-income families, which they said reflects the most time-pressured segment of the population.
"This (the findings) suggests that working mothers are doing two activities at once more than two-fifths of the time they are awake, while working fathers are multitasking more than a third of their waking hours," Schneider said.
In addition to doing more, the jobs women perform at the same time in the home are more labor intensive,
such as housework and childcare, than what men tackle.
The study showed that 52.7 percent of all multitasking for working mothers involved housework, compared to 42.2 percent for fathers, and 35.5 percent was taken up with childcare, as opposed to 27.9 percent for men.
"Fathers, by contrast, tend to engage in other types of activities when they multitask at home, such as talking to a third person or engaging in self-care. These are less burdensome experiences," Schneider explained.
Multitasking may feel productive, but psychological research suggests our brains aren't at their best when divided between two or more tasks. One 2010 study published in the journal Science found that the brain can juggle two tasks at once, but adding a third is a recipe for disaster. Even practiced multitaskers struggle with the overload. According to research by Stanford University professor Clifford Nass, the people who multitask the most are the worst at it.
But for modern families, multitasking is a way of life. Schneider and her colleagues wanted to know how much time moms and dads spend doing two or more things at once, and just as important, how they felt about it.
As part of a large 1999-2000 study of mostly middle-class families called the 500 Family Survey, researchers asked parents to wear pre-programmed wristwatches that would beep eight times each day. When the participants heard the beep, they stopped everything to record in a diary what they were doing, whom they were with, and their emotions at the moment. This method, called "experience sampling," was developed by Hungarian psychologist Mihaly Csikszentmihalyi.
"What we're really learning is not only how people are spending their time, but how they're feeling about it at a very deep and personal level," Schneider said.
With a total sample of 16,878 diary entries of 368 moms and 9,482 entries of 241 dads, the researchers found that multitasking is very common. Fathers multitask for more than a third of their waking hours, while mothers multitask for two-fifths of their waking lives.
Paid work puts a lot of multitasking burden on both moms and dads, with work-related multitasking making up 36 percent of multitasking episodes for dads and 23.4 percent of multitasking episodes for moms. At home, however, mothers are more likely than fathers to engage in two housework activities or two child care-related activities at the same time, the study found. Housework and child care combos accounted for 10 percent of moms' multitasking time and only 4.4 percent for dads.
Modern family
Though moms piled on more multitasking at home than dads, they were also less cheery about it. They reported a lower sense of well-being when multitasking than did multitasking dads, Schneider said. Moms reported more negative emotions and more stress when they multitasked at home compared with when they did a single task, while fathers did not show this increase in negative emotions.
"Basically, that's telling you that when dads are at home and they multitask, they pretty much are thinking it's a good thing," Schneider said. "This is less so in the case of moms."
Some of the emotional discrepancy may have to do with who juggles what tasks. The study found that for working moms, 52.7 percent of multitasking episodes at home were housework-related, compared with 42.2 percent for working dads. Likewise, 35.5 percent of home multitasking for moms involves child care, compared with 27.9 percent for dads.
The results highlight the stress that middle-class families face in the modern work force, Schneider said.
