Citation: Abouna, George M. (2003). Medical principal and practice. Ethical Issue in Organ Transplantation, 12(1), 54-74. DOI: 10.1159/000068158
What Strikes Me Most:
Organ transplant is the medical practice where a healthy body organ is taken from a donor and planted in recipient whose own organ has failed. This new frontier in medical surgery started in 1954, and by the year 2002, some 750,000 transplants had been carried out in 1800 hospitals worldwide. Meanwhile the waiting list had grown to over 80,000 patients in the US alone and most patients died while still in the waiting list. Organ transplants give better expectancy and quality of life than medicines and therapy, for example a kidney recipient has between 20% and 30% longer life expectancy than a dialysis patient. So severe is the shortage of organs that many questionable practices take place, raising the issue of ethical practices in organ transplants. Some of the issues include presumption of consent upon death; anonymity; who should be given priority in transplant; compensation for donors; sources of organs; possible effects on donor, recipient, and their respective families; alternative forms of transplants, among other ethical issues. The author presents detailed scenarios of practice, explores unethical practices, and outlines some solutions to the unethical practices. The author is a transplant surgeon, and therefore naturally advocates for organ donation.
Transplants improve the quality and expectancy of life. A recipient can lead a normal life for over 30 years with donated organs. There is an acute shortage of organ donations and a long waiting list of recipients (p. 54). Most organs have to be harvested within hours of death, and can only be stored for a limited period of time. Many countries have organ transplant policies and advocacy groups. The practice of organ transplant is generally acceptable to different societies, religions, cultures and so on, but some practices raise ethical issues.
The author mentions Spain, Kuwait and Singapore, as having a policy of “presumed consent” to donate organs upon death, which allows hospitals to harvest organs from cadavers without first seeking permission from relatives. In China, organs from convicted persons are routinely harvested after hanging, without consent (p.57). Ethicists see these two as unethical body snatching and organ theft practices.
Anonymity shelters both recipient and donor from the burden of debt, guilt and gratitude, as well as discourages sale of organs. Some donors choose whom to donate an organ to; perhaps a family member or a friend. This sounds unethical because the recipient will have jumped the waiting queue and may not be the neediest recipient. But on the flipside, it reduces the demand for anonymous donors (p.60).
A child donor is not competent to consent to and understand the consequences of donating an organ, they donate an organ through coercion.
The criteria used for allocation of cadaver organs in US include geographical proximity of the recipient to the donor, blood group match, and the patient’s “Points Score” that include recipient’s waiting period, age, immunological tolerance, and medical urgency (p.57). Some medical practitioners deliberately raise a patient’s Points Score to place them ahead on the recipient list. In some countries, sera positive, and cancer patients will be denied organs on account that they will die of those other diseases anyway. Cirrhosis patients are obliged to abstain from alcohol for at least six months. Generally, young patients are given priority because they have a higher tolerance for donated organs and they get the most benefit from such donation. Organ donation in Europe and US to non-citizens is restricted because of shortage of organs (p. 58).
Some medics and recipients use questionable criteria to get priority on transplant. For example they may use financial influence, undue lobbying, deviation from acceptable protocols and agreements, fail to declare conflict of interest, social merit, publicity stunt, and base merit on recipient’s moral lifestyle (p. 61).
Medical personnel and organ traders or brokers who are involved in transplants benefit financially from the practice, recipients benefit from better health, albeit at a high cost, but donors receive nothing in return for their contribution. Organ trade degrades human dignity, promotes coercion to donate, and exploits the poor to serve the wealthy (p. 57). Some states allow limited compensation in form of funeral expenses and accommodation, with a ceiling of 300 dollars (p.59). Advocates recommend legalizing organ trade, better incentives like a 3000 dollar compensation to the donor or family, a lifetime tax exemption, foreign donors be given citizenship status and lifetime medical insurance, as incentives to donate organs (p.64).
Donors may be living or dead persons. They may be minors or adults or even fetuses. Living organs are more resilient than those of cadavers. But the donor may have to contend with health consequences like morbidity, infection of wounds, excessive bleeding, anxiety, and psychological problems like the feeling that one is dismembered of some body part. 20% to 30% of liver donors suffer from morbidity and 4 in 10,000 donor fatalities. Families also suffer from anxiety about their decisions and the health of the donor and recipient. A rejected organ cannot be returned to the donor, leading to a double loss. Besides, a recipient may not feel comfortable about having a dead person’s organ (p. 65)
Ideally, a child should donate to a child, and an adult to an adult. Most donors are adults with too large organs for young recipients.
Acute shortage of human organs has resulted in new and unusual frontiers in organ transplant. For example animal organs have been tried on human, but the results have been dismal, with recipients surviving a few days or a few weeks. Animal organs would greatly reduce demand for human donors. Animal rights’ groups are opposed to this form of “cruelty to animals” (p.66). The use of primates is particularly discouraged for fear of genetic mutation, decimation of endangered species, and ease of animal-to-human retroviral transmission. The other frontier is stem cell, cloning and tissue grafting technologies that mostly use discarded human embryos and fetuses. Of concern is the practice of using live embryos and aborted fetuses. A 1992 executive order restricted fetus use to only spontaneous abortions. Both abortion and tissue harvest must therefore be consented separately and independently of each other. Anonymity between the donor and the recipient should be observed (p.64-65).
The Source Reconsidered:
Having read this article, I found it quite interesting, as it opened my eyes to many more ethical issues in organ transplant. I agree organ transplant is necessary, organ shortage is acute, and not all aspects of the practice are ethical.
In the matter of acceptability, I feel that the vast majority of living donors are coerced into becoming donors, and they are ill-informed about the consequences of donating organs.
I thought over the ethical issue of “presumed consent” and wondered how I would feel if I was called on telephone to collect my relative’s body only to find it “incomplete”, that some doctor had skinned it or dismembered it. This is not right or dignified to the affected families. Certainly it is wrong to force convicts to donate their organs, unless they are themselves organ thieves.
It is quite in order for a donor to select a recipient for their organ. Organ donation is an inheritance and an act of love, just like bequeathing one’s wealth, and therefore one should be free to choose whom to give. Families and friends would be more forthcoming to their kin in need of an organ, than would a total stranger.
It is not right to expect a minor to donate their organ, even to their twin sibling, however noble it may sound. If a minor may not consent to sex, or consume alcohol and cigarettes, it is even more important they are not involved in organ donation.
Having a laid down policy and criteria for prioritizing organ recipients is good. However, I would also deduct point from patients whose problem is related to inappropriate lifestyles. An alcohol addict should not be given a liver in preference to a teetotaler, because the addicts problem is partly self-inflicted. Certain calibers of citizen should be given priority in organ transplants, for example doctors and professors, because their skills are way too useful to the general populace. Inducing aliens to donate organs as a way of gaining citizenship is unethical, akin to buying organs. Seekers of citizenship to another country are often desperate people and giving them such an option is coercion.
To me, it is alright to lobby to receive an organ, as long as it is lobbying friends’ and family members’ organs. As for anonymous donation, it is better to stick to the laid down criteria.
Currently, donors are the only “non-beneficiaries” of organ transplant. I would advocate for adequate financial and medical support for any donor who need it. They make a big sacrifice to donate their organs, and they face many challenges thereafter. I do not think many people would simply choose to sell their organs for financial gain. I see no problem in a recipient supporting their benefactors financially, if they are able to do so. I do not think lifetime incentives on tax, insurance, and so on, are ethical as they may lead to sedentary behavior of donors. One major problem with financial compensation is what to do if the donated organ fails or is rejected?
All members of the public should be sensitized on the necessity and value of organ donation, especially after they are dead, the same way that blood donation is publicized. This would reduce ethical misgivings, like organs are sold to the highest bidder, donors become morbid, and so on.
I do agree with the author that animal organs should be used for transplant if that is possible. The risk of cross-species mutation and disease is far outweighed by the improved quality of life and the ready supply of animal donors. It is decent to slaughter animals for their meat; therefore it is even more decent to slaughter them for their life-saving organs.
I am skeptical about stem cell, grafting and cloning technologies mainly because they are open to abuse. Given the high rate of induced abortion in US and other countries, the abortion would be turned into an illegal organ trade. Genetic defects can occur in extreme medical technologies.
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