Organ and Tissue Transplants
Modern techniques of medical transplantation鈥攕urgically removing a diseased or malfunctioning kidney, heart, or other organ, and replacing it with a healthy organ from a donor鈥攈as brought new life and new hope to patients who, just a few generations ago, would have died. But the practice has also raised significant ethical questions. One such question centers on the cold reality of supply versus demand: At any moment, there are upwards of 150,000 people in the world awaiting transplants. A scarcity of donor organs usually means a long wait鈥攄uring which some patients die. A large supply of organs is available from the roughly 200,000 patients worldwide who are declared brain-dead each year, but the problem has been to secure consent from family members and loved ones to remove organs for transplant.
For many years medical ethicists have considered the question of whether ethical means can be found to increase the supply of donor organs. In the early 1980s, for example, American bioethicist Arthur Caplan of the University of Pennsylvania discussed the concept of presumed consent鈥攖he idea that, barring strenuous objection from family members, doctors could presume that a person declared brain-dead would be willing to donate organs to save others. Some Asian nations, as well as some European nations, including France, Belgium, Austria, and Spain, have such policies. The United States and Canada later enforced a concept advanced by Caplan of required request鈥攁 policy whereby hospital personnel would be legally required to seek permission from family members before harvesting organs. The adoption of this policy in the United States and Canada increased the supply of donated tissues, such as corneas and bone marrow, but failed to dramatically increase the supply of donor organs.
Current United States and Canadian law bars the sale or purchase of donor organs. The United States does permit the sale of plasma and other bodily products, such as hair and sperm. Would financial incentives provide a stimulus for more people to make organs available? Some ethicists believe so, while others find the idea of marketing organs ethically objectionable.
Other ethical issues are raised by the practice of xenotransplantation鈥攖he use of animal tissues and organs for human transplant. In 1984 the case of 鈥淏aby Fae鈥?stimulated wide ethical discussion. Doctors transplanted a baboon heart into a newborn girl to replace her own fatally flawed heart. She died shortly after. Some critics contend that xenotransplantation poses a danger to human health because of the risk of transferring deadly animal viruses to the human population. This risk causes bioethicists to question if such practices are ethical.
In recent years, one of the most promising areas related to transplantation will likely trigger ethical debate well into the future: the experimental use of tissues from aborted human fetuses. In one particularly active area of this research, scientists have experimented for more than a decade with grafting nerve cells from human fetuses into the brains of patients suffering from Parkinson disease. This disorder, caused by the mysterious death of brain cells that produce a chemical called dopamine, gradually causes patients to lose control of their muscles. In early studies some patients who received fetal cells showed improvement in their symptoms, as the transplanted cells demonstrated the capacity to produce dopamine. But the treatment also produced unpleasant side effects. This research, like all research that depends on human fetal cells, has also provoked debate. Critics question the ethics of using tissues from human fetuses for any research purposes.
Ethical uncertainty hangs over a related area of research on human embryonic stem cells. Human embryos contain stem cells that have the ability to develop into almost any type of cell. Scientists hope to direct stem cells to produce certain types of human tissue. It is possible that someday these cells might be used for transplants or for growing new tissue that can be grafted into the human body. For example, scientists hope that stem cells might one day be used to replace nerve cells destroyed by spinal injury, or heart muscle cells damaged during a heart attack. Interest in this field was heightened considerably when scientists announced in 1998 that they had learned how to grow human embryonic stem cells in the laboratory.
At present the U.S. government has banned federal funding for human-embryo research, although private biotechnology companies are exempt from this ban and have been vigorously pursuing research on embryonic cells. In 2000 the federally funded National Institutes of Health (NIH) ruled that this ban was not necessary for studies using cells derived from human embryos, since these cells are not embryos. The NIH established guidelines enabling federal funds to be used in cases where cells were derived from frozen embryos that were created for the purposes of fertility treatment but were not going to be used and were therefore slated for destruction. Other nations currently differ widely in their policies: France, for example, has forbidden human-embryo research. No laws in Canada regulate human-embryo research, although scientists or institutions receiving federal funding must follow strict guidelines governing research on human embryos. The United Kingdom has laws permitting some forms of human-embryo research, going so far as to create guidelines allowing scientists to apply cloning technology to human embryonic cells to create genetically identical cells for a potential patient.
But the ethical questions remain: Is it morally acceptable to use tissue taken from human embryos? One recent development might change the nature of this argument. Scientists discovered in 1999 that stem cells taken from adult mice, and not human embryos, also display an ability to change their function. Some stem-cell research continued with the use of adult mouse cells. In 2007 government medical authorities in the United Kingdom approved the creation of embryos that combine human and animal cells for use in medical research. British researchers claimed the hybrid embryos were vital in the fight against disease.
ETHICAL ISSUES
A number of ethical issues haunt the transplant field. With few exceptions, donated organs go to the patient who is nearest death, even though a healthier patient might benefit more by living longer after the transplant. People who need a second, third, or fourth transplant because their prior transplants failed usually gain top priority, even though they are not likely to do as well as patients who have not already had a transplant. Some critics object to giving organs to patients whose organ failure was the result of their own actions, such as cirrhosis of the liver resulting from alcohol abuse.
Money is also a major issue. Access to transplantation is impossible without access to good primary medical care and good insurance, both of which are largely unavailable to the poor. To be placed on the waiting list, patients must show they can pay for the transplant. In 2005 a kidney transplant cost about $116,000 and a liver transplant as much as $250,000 in the first year after the surgery. Many insurance companies do not cover such costs, particularly for the new procedures, such as lung, pancreas, or multiple organ transplants, which are still considered experimental.
Although organs cannot be bought and sold legally in the United States, there is evidence that a black market in organs exists in China and other countries. Persistent allegations have been made of people traveling to China and paying for organ transplants. Human rights groups have reported evidence that the bodies of executed prisoners are the source for most of the organs transplanted in China.
In the United States, where organ donation is voluntary, ethical questions arise over the nature of the consent and the use of incentives. Intensive donor solicitations in recent years have not made much of a dent in the shortages of organs. Even though many people sign organ donor cards, their families are often reluctant to grant permission at the moment of crisis. Some ethicists debate whether family members should have the right to refuse donation if the deceased signed an organ donor card. Presumed consent laws, in which everyone would be considered willing donors unless they have specifically said they were unwilling, have been tried in Europe and South America, and on a limited basis in Pennsylvania and Maryland. Some experts have suggested financial incentives, such as cash rebates, estate tax discounts, or payment for burial expenses. Others have suggested broadening the criteria used to determine death beyond the lack of all brain activity. This would permit a surgeon to use organs from anencephalic children, who are born without a brain, and from people in a persistent vegetative state.
The implantation of tissues from aborted fetuses into the brain showed promise as a treatment for both Parkinson and Huntington鈥檚 disease. Experimental results were mixed, but the treatment raised its own set of ethical questions. The foremost is the question of abortion itself. The possibility of using embryonic stem cells to create replacement organs has faced opposition for similar reasons. Some researchers believe that this issue can be surmounted by growing cells in the laboratory or by genetically engineering a patient鈥檚 own skin cells. Fetal pig cells have also been used as a treatment for Parkinson and Huntington鈥檚 disease, but that raises other ethical issues regarding the treatment of animals.
The Moral Case for Organ Donation
by Amitai Etzioni
Thursday, August 26, 1999
Amitai Etzioni is the Director of the Institute for Communitarian Policy Studies at George Washington University. He is the author of The Limits of Privacy. He can be reached at etzioni@gwu.edu.
Pennsylvania is considering paying families of organ donors $300 to help cover the donors' funeral costs. The money will be paid directly to the funeral homes, to prevent it from being used for other purposes, thus openly introducing a market in organs. Such a market has been until now considered anathema in the United States, a sentiment backed by a law banning trade in organs. Could that be changing?
In the market for organs
A May Time magazine essay by Charles Krauthammer suggested that it is acceptable that the poor will be more likely than the rich to be enticed by the Pennsylvania gambit, given that most societal harms fall more heavily on the poor. Why not a cash benefit? And, Krauthammer argues, if paying for organs would lead to a flourishing market, one that licks the great shortage in organs, breaking the taboo against such a trade is a price well worth paying.
What about an organ market?
The experience in third-world countries, such as India and Egypt, should give pause to all those who favor an outright market in organs. Poor people have their kidneys taken without being properly informed of the risk involved. Rich people can buy all the organs they need or want; those less fortunate often cannot scare up any.
At the same time, the urgent need to increase the organ supply on these shores is well established. An estimated 4,000 Americans die each year because no organs can be found for them. And the quality of life of thousands more suffers because they cannot find needed corneas and kidneys. Increased organ donations also would significantly reduce health-care expenditures. For instance, it costs less to transplant a kidney and maintain a person on the follow-up treatment needed than to keep the same person on dialysis for four years. Many stay on dialysis much longer if no kidney is found.
Is there any way to greatly increase the number of organ donors without opening a market in human parts, which many -- myself included -- find ethically highly troubling? Before chapter and verse can be spelled out, the underlying principle needs to be explicated. Social scientists have shown that we are social creatures who deeply yearn for the approval of others. These can be members of our family, friends, neighbors, and more generally, community members.
The strong power of so-called significant others is exhibited in intense, sometimes extreme, forms through peer pressure on teenagers, gang members and soldiers in combat. Members of such groups will do practically anything their group prescribes, even endanger their own lives. Much milder forms of such social pressure are evident when we donate money to a church or a civic cause, both because we believe in the merit of doing so and because we yearn for the approval of those whose opinions matter to us. (Anonymous donations are surprisingly rare.)
The case for moral suasion
Currently the voice of the community that favors organ donations has no chance to be aired or heard. People who feel like donating on their own, and remember to do so, mark their Motor Vehicle forms accordingly, but nobody is there to encourage them to do so, to appreciate it when they do, and maybe look at them with regret when they do not. Typically the issue does not come up until someone is on the death bed and -- at this most difficult time -- physicians and other health-care personnel are expected to ask the members of their family to consent to organ donation.
To give moral suasion more of a chance, two measures should be taken. First, we should provide a new form at physicians' and hospitals' waiting rooms, clinics, Red Cross stations and other places where volunteers gather. The form would state explicitly that "we the people would be most appreciative, and hold you in high regard, if you could find it in your heart to make a life-affirming donation by authorizing the use of your organs once they are no longer of service to you."
The text then would describe briefly the severe shortage of donated organs and its many dire effects. The main focus of the text, however, would be the moral virtue of donating organs. The forms would close by stating that if you decline, for religious or any other reason, no explanation is needed. All said and done, it is up to you.
Second, the names of those who made the pledge would be logged into computerized databases, accessible to physicians engaged in organ transplantation. (A new law may be needed to establish the validity of the endorsements of these forms and to prevent family members from overriding them.) If these lists also were open to the press, its reports might greatly increase the number of those who would sign up; it is the best tool to alert the community about who has -- and has not yet -- committed to make an organ donation. At the same time, at least initially, such publication might be considered too high handed.
The new forms should be promoted through public-service announcements, and by public figures -- urging people to come forward, announcing that "I myself have just made the commitment to save lives by donating my organs should I no longer need them."
The main point, though, is as elementary as it is important: Instead of waiting for each person to consider the matter, without any encouragement or recognition by their community, we should unabashedly stress that in our minds and hearts we cheer donating organs and celebrate those who pledge to do so. One need not a priori rule out a market in organs, despite all the ethical challenges it poses. But at least we should first give moral suasion a chance.
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