Also in Slate, Farhad Manjoo explains why Steve Jobs won't return to Apple even if his health improves. Annie Lowrey says shareholders deserve more disclosure from Jobs about his health.
What's wrong with Steve Jobs? Apple won't say. On Monday, the company said he was taking a medical leave —his third since 2004—but refused to disclose why. Yesterday Apple touted its market prospects in a conference call but again said nothing about its CEO's health. You can argue that Jobs' medical privacy is more important than the interests of Apple's investors. But there's another reason why he should tell us what's going on, and it's bigger than money. It's life and death.
Two years ago, Jobs gamed the transplant allocation system to get a liver that could have saved somebody else. At the time, skeptics doubted that he should have received the organ, since he'd been treated for pancreatic cancer—in fact, he may have sought the liver because of the cancer—and the likelihood of the cancer's recurrence made him a bad bet for putting the liver to best use. If his health is now failing because of the cancer, that suspicion may be vindicated.
Jobs lives in Northern California, but he got his liver in Tennessee. Why? Different parts of the country have different waiting lists, and the wait in Northern California was three times longer than the wait in Tennessee. In fact, the median wait in the Tennessee area where Jobs snagged his liver was around 15 percent of the national average. Jobs confirmed last year that this is why he went to Tennessee: "My doctors here advised me to enroll in a transplant program in Memphis, Tennessee, where the supply/demand ratio of livers is more favorable than it is in California here."* Legally, you're allowed to get on multiple waiting lists around the country. That's how you game the system.
So why doesn't everybody do this? Because they can't. First you have to show up for an extensive in-person evaluation. Then you have to be available for a transplant in the area within hours of an organ becoming available. And while one jurisdiction might accept you as a charity case, if you want to play the field you'll have to prove you can pay for the transplant yourself. You also get priority points for being able to guarantee follow-up medical care, since this assures transplant allocators that the organ will be well cared for. Ordinary people can't compete with billionaires at meeting these tests. They can't go to multiple states for evaluations. They don't have private jets. Their insurance doesn't cover multiple evaluations and may not cover much of the half-million dollar transplant, much less the follow-up care.
If Jobs was on multiple lists, he wasn't just multiplying his chances and shortening his projected wait. He was increasing the odds that one of the transplant centers where he was listed would give him a liver despite his cancer history. That's another way to game the system: criteria shopping. "Patients who are smart or who have savvy primary care doctors know that different transplant centers follow different rules in deciding who to admit," Arthur Caplan, an expert in the transplant allocation process, observed two years ago. "Some would view a liver transplant for a person with cancer as a 'waste' of an organ. Some might take a chance on a patient with cancer." Caplan called this a likely factor in the targeting of Tennessee: Jobs had to find a transplant center that would "take him despite his cancer." And, being a CEO, he succeeded.
Jobs never explained the reason for his transplant. But it's hard to believe it was unconnected to his cancer. One expert notes that the kind of cancer Jobs had in 2004 commonly spreads to another organ—the probability of metastasis is 75 percent—and that organ is usually the liver. Jobs' pre-transplant health problems—weight loss and hormone imbalance—also match the symptom list for a recurrence of his cancer. And doctors sometimes try a liver transplant when the cancer has migrated there.
It's a dubious strategy. Half the time, the cancer comes back. The patient, impaired by immunosuppressive drugs because of the transplant, is often more vulnerable to the cancer. At the time, the Wall Street Journal cited a surgeon's warning that attempting a liver transplant in such a scenario was "controversial because livers are scarce and the surgery's efficacy as a cure hasn't been proved." And Caplan pointed out that
there were roughly 16,000 people on the national liver waiting list when Jobs got a liver. He was one of 1,581 people who got livers in the United States in the first quarter of . Almost none of those people had any form of cancer. In fact, if Jobs' tumor has spread from his pancreas into his liver as is likely, some transplant surgeons say that they would not recommend a liver transplant because there is no data that shows a transplant will stop or even slow the spread of the cancer. This raises the question: Is this the best use of a liver?
Caplan posed that question a year and a half ago. Now Jobs is taking yet another unexplained medical leave. Given his symptoms, in the absence of further information, the most likely reason is recurrence or complications of his cancer. If that's the case, then Jobs, having gamed the system to obtain a liver that could have saved somebody else, might soon take that liver to his grave. And he's had it less than two years.
To his great credit, Jobs has used his influence to help others in his situation. As Nicholas Carlson reported in Business Insider, Jobs pressed last year for a new law in California that requires applicants for a driver's license to be asked whether they'd like to be organ donors. *
But now comes the new report of Jobs' illness, and with it, the unresolved question of whether he should have gotten that liver. We don't know what's ailing him, because he won't say. "My family and I would deeply appreciate respect for our privacy," he pleads.
I hear you, Steve. We're all pulling for you. It's your life and your family. But that liver wasn't yours. Somebody died to make it available. And other people who aren't billionaires may have died on waiting lists so you could have it. What was your cancer situation when you got the transplant? Has the cancer returned? You owe us some answers.
Correction, Jan. 19, 2011: I originally wrote that Jobs "never explained why" he went to Tennessee. But after the article was posted, I found Nicholas Carlson's Business Insider story, which quoted Jobs' comments on this subject at a press conference last year. In these remarks, Jobs confirmed that he went to Tennessee for an easier waiting list. More important, Jobs attended the press conference to promote the California organ-donor legislation, and Carlson detailed Jobs' role in lobbying for the bill. I've added a paragraph to note this contribution by Jobs. It doesn't erase the questions of inequity and judgment in Jobs' transplant, but it does attest to his character. (Return to the corrected sentence.)
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