 Juliano Testa. Juliano is the surgical director of living donor liver transplant at Baylor University Medical Center. He was here for a number of years. I had the great opportunity to work with him as a colleague and great to welcome you back Juliano. Well first of all, Mark, thank you so much for the invitation. It's one of the highlights of my otherwise insignificant career to be part of the McLean family and to have trained with you. So this is really, really deeply appreciated. I feel better because usually in the past I've been the one who presented a little bit of a controversial issues. So thank you guys for starting with this. That makes everything else very, very easy. We are now thinking about transplanting anything that you may have related in your mind, especially the male mind to cosmetic surgery. So that's not the issue of this what we're discussing today. What the premise for whoever doesn't know where my ethical training has brought me is trying to understand from the guy on the field because I'm a transplant surgeon and I will always be a transplant surgeon. What are the issues that have to do with my profession and also try sometimes to counteract other great ethicists that speak about transplant but don't leave the profession like I do. So there is a little bit of bias in anything that I say and I do about my profession. And one of the things that you may not be aware of or you heard a lot is that the premise to everything that we speak about ethics in transplant is a simple demand and offer. There is a huge gap there and we can feel it. And no matter how much I study about that and no matter how I read about that, the gap is there and there is no solution to that. We've all the beautiful articles have been written and how we should do this and that. If you look at the curve of the donors in the United States coming from a disease source, that curve, that number has been steady and unchanged for the past probably 10 to 12 years. And so if you think about okay well let's do something what out there that can be replaced, there is nothing that will replace. At least now we are talking, when I was a fellow we were talking about doing a senior transplantation using animals organs for humans. Well I was told at that time that was around the corner and that was 20 years ago. So it's not materialized at all and I strongly believe that it will not really be materialized in the next 10 years. So the next one is going to be scaffolding which is using stem cells and growing organs and then putting them in an already pre-framed collagen, let's say, structure that will allow them the cells to grow and perform the action and function of the organs we are trying to replace. And that is also around the corner. Only that the corner is probably 5 or 10 years away. So for the next 10 years we are stuck with this issue and everything I think about when I think about ethics in transplantation is how we can do it in a way that it's good for everybody. And the reality is that the only source that we have that we can use is living donors. You can go around this as much as you want is living donors. The alternative would be to say that we stop placing patients on the list. And that would cause a little bit of ethical dilemma too because once you open the door to the 70 year old to get the kidney transplant or liver transplant or a heart transplant, I think Dick Cheney was close to his 70 when he got his heart transplant, it's hard to start saying, okay, let's put barriers. Let's say that certain people get the transplant, certain people get not the transplant, so the supply and demand will equal. You can do that. And even if you start to do that, then you have a problem of how ethically justifies something like that. So the bottom line, all this introduction is based on the fact that living donors seems to be the only options we have. And then for my point of view, how can we somewhat make sure that we understand that given the premise, how can we can work with the living donors and make them the source that they could be. And in my opinion, this has been an evolution in my thinking is that in the beginning I thought that living donors should be a second choice to disease donors. And the more I work in this field and the more I understand in reality should be the opposite. That the living donors should be the first choice. And disease donors should be the second choice. And although this seems very radical, the bottom line is we are the only profession in medicine that routinely offer a lesser quality treatment when another one is available. Because there is no disease organ that can be comparable in function and duration to a living organ donor. So this is a very intriguing point if you think a little bit about that. And then we are also the only profession, the only section of medicine that tells a patient that you have a problem, this is the treatment, get in line. It's very strange for a society that is used to have everything right away, well done in a perfect fashion and possibly at the top of the line. So this is the conundrum, this is the problem we live on. So having said that, this is what we have. I thought how can we make a living donor more, let me use this better and palatable to the professionals and the people who think that living donor is now a good choice, it shouldn't be the first choice. And it takes a lot of work around that. But I thought why, for example, there are other things we do in medicine that are fairly accepted by everybody. And nobody has really any problem with it. And then when we start touching upon living donors, any sort of medical concern comes about. And that is always a very interesting question for me. So I thought about cosmetic surgery because cosmetic surgery is performed everywhere. When I trained in the University of Chicago, we didn't do cosmetic surgery. Now cosmetic surgery is part of the activity, regular activity, daily activity of the department of university hospital like University of Chicago. It's not only the small plastic surgeon out there that does cosmetic surgery. So it's accepted by everybody. And yet this is an example, in my opinion, and it could be also the one of the sort of matter where somebody doesn't need the treatment but gets the treatment. Unless we believe that by becoming a cosmetic surgery patient, you live longer or something happens to you. Anyway, the difference that I saw is that while in cosmetic surgery is absolute autonomy, and I think very few could probably argue with this point, we are extremely paternalistic, me included, in approaching the living donation process and the living donors. So what is the problem with it? The problem is exactly going back to what I tried to say before. The problem is that by approaching the living donation with this premise, in a certain way, we use it in terms as a deterrent and we decrease the potential number of patients, the donors, not patients, the human beings that would like to step forward and become living donors. So the problem may be, while are you sure that we are being paternalistic when we approach the living donation? Well, I live with this every day and I think we are. I don't think there is probably any article on living donation, I saw probably a couple of them, one of them we were reading remark, that doesn't think that the donor is a vulnerable person. It's just in the mind of everybody. It's a diffuse feeling that we have to think about as a vulnerable person, to the point that the donor has to have an advocate. There is no other specialty medicine where you go to the doctor with an advocate, but we do that for living donation. And then we know that the donor must be protected from coercion and coercion is always the big word. As soon as you talk about living donation, the first reaction is coercion. And I can tell you that in the Western world, there are different connotation of coercion, but it's not as present, as daily seen, as you may think. And then there is also this approach that we have to protect the donor from his own desires and from his own action. And it's our job as physicians to do that, which is probably the epitome of paternalism. And then we scrutinize them. We scrutinize them in a way that's extremely personal. We go into their financial planning, the very heavy insurance plan, and their behaviors. And then we get in trouble of ourselves because we have to disclose eventually that the donor, for example, has practices that may harm the recipient. So this is another ethical problem that we get ourselves into. So how are they similar? Cosmetic surgery and living donation. Neither patient really needs the surgery. There is no curative intent, as far as we know, at least for the person involved himself in the surgery. But both of them may have a great deal of fulfillment. I think that whoever has worked with living donation knows that the donor usually is an incredible fulfillment by being a donor. Both of these surgeries have potential dangerous consequences, even lifelong or the life itself. And there may be an inner pressure in both for different reasons, of course. The living donor because of family issues, maybe, or the cosmetic surgery patient because she feels that she has to do something in order to be better accepted by society. How are they different then? If that's the premise, they have all these similarities. How are these two procedures different? The attitude is completely different. The attitude is that the living donor consider a vulnerable and the cosmetic surgery patient is not. Because otherwise, we would have another circus of physicians and donor advocate also, or cosmetic surgery advocates also for this part of the of the patient population. The premium nonocular concept is always evoked when we think about living donation. There are plenty of articles out there where in the introduction, premium nursery comes up as like we're doing something which we should be ashamed. And then the donor is, as I said, assign donor advocate, which serves to protect eventually the donor. There is a very, very lengthy social screening and behavioral screening. And I never understood where this is done to protect the donor or at the end of the day to protect the recipient because the two things sometimes kind of mingle. And then the motivation. This is something that I feel strongly about. We always question the motivation of the living donor always. And if by any chance the motivation of the living donor is not what we either by society or by because we are physician accept, then very often this donor is, this guy doesn't have it. This guy is going to get in trouble. This guy has some secondary intent. And then we of course, deny donation because that happens. Those are very good reason for denying donation. And then we offer them a cool enough period, which is like to say, are you really sure you want to do that? But I don't think we offer any cool enough period to anybody who wants to have cosmetic surgery, for example. In conclusion, I think we should have a little bit thought about this, that it should be a greater respect for the donor. I would advocate for a more balanced approach between the risks and the benefit, not denying the risk, but also not putting them in front and telling what the benefit of being a donor here. I would like to create a cultural donation, like we in a certain way we create a cultural beauty with cosmetic surgery. So instead of now ever have you ever heard about a national campaign, advocating living donation, never happened? Why not? When this should be really a good option for many, many patients. At the end, I believe everybody will benefit. Thank you for your attention.