Ethics of Organ Donation and Transplantation into the United States - Essay Example

Table of Contents Introduction Organ Donation and Transplantation Defined 2 History of Organ Donation and Transplantation 3 Organ Donation and Transplantation in the United States 5 Moral and Ethical Issues in Procurement and Distribution 5 Conclusion 8 References 10 Appendices 11 Introduction The issue of organ donation and organ transplantation has become a crucial issue in today's society. Statistics show that as of this month, there are 88,565 patients waiting for an organ donor in the United States alone (See Appendix). It is undeniable that there is a substantive shortage of organs for transplant. Such reality points to the question of procurement. What is it that we are doing to acquire the organs needed by these patients Over the years, legislators and medical professionals have been striving to come up with an organ procurement program that will, at the very least, increase the rate of organ donation the world over. The breadth of approaches and programs proposed, however, directs toward a whole new set of issues and problems that must be resolved in the midst of this shortage - the ethical uprightness of the approach with regard to the rights of the donor against the obligation to save the life of a recipient. The ethical dimension at the core of organ donation and transplantation has become a critical issue that must be considered due to the possibility of violating the rights of a donor, short of exploiting him in some cases, in the process. Organ donation and transplantation, is therefore an issue that cannot be ignored. It compels us to explore all possibilities that could be done to solve the problem of organ shortage; while at the same time, it beseeches us to give consideration to the rights of the donor and ensure that he is not exploited in the process. In addition to the issues regarding procurement, it also directs us to examine the manner that these organs are distributed. It begs us to ask the question of whether the policies surrounding distribution provides a criteria that places all candidates in an equal position of receiving organs. Thus, as this paper will argue, there is a deficiency in the policies and programs employed to increase organ donation because it neither significantly increased the rate of organ donation nor did it succeed in protecting the rights of donors. Organ Donation and Transplantation Defined Organ donation, defined as a high technology medicine that is used to intervene at the end stage of an illness, unlike other medical technologies, is considered to be an altruistic process because it requires the "gift" of organs from others to proceed (Prottas, 1995). Organs that can be donated and successfully transplanted today include the kidneys, lungs, pancreas, liver, heart, and intestines. During the early stages of organ transplantation, the criterion was that potential donors must be brain dead. Known as cadaveric organ donation, the criteria for such was defined by Harvard Medical School in 1968 as the "irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brainstem" (Sullivan, Seem, & Chabalewski, 1999). In this form of donation, organs are donated from the recently deceased. Until recently, this has been the preferred criterion for determining organ donor status. However, due the pressing organ shortage, physicians have developed new protocols in declaring death for cadaveric donations. According to Alexander Capron (2001), cardiac death has been considered as a means to qualify patients as donors. In this method, known as non-heart beating transplantation, death is pronounced through the cardiopulmonary criteria. In contrast to cadaveric donation, living organ donation seeks living organ donors to provide an organ or part of an organ to another person. Unlike cadaveric donation, this form of organ donation is more complicated because it involves, not only saving the life of the recipient, but ensuring that the life of the donor is not placed in danger as well. Studies show that in the case of liver donors, there is an estimated risk of death of 10 to 20 in every 10,000 and 3 in every 10,000 for kidney donors (Grady, 2001). This seems to violate the Hippocratic principle in medicine, which states primum non nocere - first do no harm. Furthermore, this form of donation is also limited in the sense that only certain organs can be donated. While cadaveric donation allows all recoverable organs to be used for transplant, living organ donation is limited to certain organs (liver, kidney, etc.) and to certain quantities (part of a liver or part of a kidney). A third kind of transplantation also exists - that which uses artificial organ transplants. In this form of transplantation, organs that are either harvested from animals like pigs and apes or grown genetically in a laboratory are transferred to human beings (Caplan, 1998). Like living organ donations, not all organs can be procured through this method. Moreover, aside from the limits in the type of organs that can be transplanted, this method also poses a new set of problems for the recipient. Because this method is fairly new, the possibility of transferring infectious diseases from animal species to human beings that can result from the artificial organs has yet to be eliminated. In addition, organ recipients might also find this method offensive, to say the least. This method, therefore, is far from perfection. Rigorous clinical research has yet to be accomplished to ensure its safety. Hence, it is not widely used as a popular method of organ procurement. This method, however, poses numerous benefits in solving the scarcity of available organs for transplant in the future. History of Organ Donation and Transplantation In the midst of all the developments in the technology surrounding organ transplantation, it is almost unthinkable that fifty years ago, the idea of organ transplantation was still a novelty. In 1938, the first cadaveric kidney transplant was performed in the Soviet Union. However, it was not until 1954 that Dr. Joseph Murray performed the first successful transplant in the United States; and in 1967 that doctors in South Africa successfully transplanted a human heart (Kolber, 2003). Since then, there have been numerous advances in the field both medically, and legally. Legally, the Uniform Anatomical Gift Act that was approved in 1968 spearheaded this development (Kolber, 2003). It provided the blueprint for organ donation, which was adopted, at least in one form or another by all fifty states. Some of its provisions include: (1) giving competent adults the right to donate their organs to be used upon their death "without subsequent veto by others"; (2) the method for donating organs; and (3) giving individuals immunity from civil or criminal liabilities if they acted in good faith in accordance with the provisions of the act (Kolber, 2003). Amendments to this law include the explicit mention of placing a donor's expressed request over his family's and the prohibition of commerce in bodily organs, which were both added to the legislation in 1987. In 1984, through the National Organ Transplant Act, an Organ Procurement and Transplantation Network (OPTN) was established. The goal of this organization is to "work actively to increase the supply of donated organs" and to coordinate and operate the country's organ procurement and allocation systems (Kolber, 2003). Currently, the criteria used to match donors with recipients include the following: organ compatibility, like hood that the transplant will be a success, amount of time spent in the waiting list, and the urgency of the transplant. Other criteria considered also include the proximity of the donor with the recipient. Aside from these developments, there have been numerous proposals with regard to the procurement of organs for transplant in the United States. Among these include non-communitarian approaches like conscription, presumed consent, required response, and commodification. Proposals for communitarian approaches have also been proposed such as cultural dialogues and procedural changes such as allowing non-heart beating donations. Each proposal, however, must be scrutinized both in terms of its ethical and moral dimensions. (Etzioni, 2003) Organ Donation and Transplantation in the United States In the United States, 340,770 patients have received transplants since 1988. Based on the data (Table 1) from the OPTN, the number of transplanted organs has been increasing since 1988, the bulk of which has come from cadaveric donors, which consist of 269,143 to date. This increase is still not significant enough if compared with the number of patients waiting for organ donations (Table 2). Interestingly, however, the number of cadaveric transplants after cardiac death has been increasing (Chart 1). Among these candidates, White Americans comprise half of those who are in need of organs. Black Americans, and Hispanics follow this number accordingly. (Table 3) Among all ethnic groups, kidneys have the highest demand, followed by the liver. Based on these numbers, there is no apparent difference in the demand for organs among ethnic groups such that they all are in need of kidneys the most. Consequently, as seen in Table 4, the organ with the highest demand is a kidney. Moral and Ethical Issues in Procurement and Distribution Based on these data, there are a number of ethical considerations integral to the issue of organ donation and organ transplantation. First, with regard to the issue of organ shortage, there and the different procurement proposals presented to solve such shortage, one must consider the "sanctity of the body." Based on the research, the desperation of states to alleviate the shortage of organs that could be used for transplant has lead to the development of policies that consider the provision of incentives - both financial and non-financial to the donor. This creates two ethical questions that must be addressed: (1) violation of the "intrinsic value of the human person," which degrades him into nothing more than a commodity for sale; and (2) the possible exploitation of the poor by the rich. One must take great care in implementing such policies to ensure that a market for human organs do not desecrate the sanctity of human life as more than just a commodity that could be bartered or bought with money. While there are softer versions of this approach, which makes do with non-financial incentives, it is imperative that the altruistic element of donation is not lost. Furthermore, it is also imperative that such programs do not lead to the exploitation of poorer people by the rich, or of developing countries by industrialized countries. It is undeniable that a black market for these organs already exists. In these black markets, especially in developing countries, donors are not only poorly compensated for their organs, but most are also exploited. Providing incentives for organ donation will not only lead to the further exploitation of these poorer individuals and countries, but it may also lead to the institutionalization of these black markets. Conversely, programs, which advocate commodification, will not be as immoral or unethical as it seems to be if safeguards can be instituted to ensure that the exploitation of the weak is avoided. To achieve this, however, it is imperative to ensure that the donor or the donor's family is compensated (whether financially or in kind) either by the state or by the family of the recipient itself and not by some broker for organs. It is only by ensuring that the transfer of organs be done as "un-commercially" as possible, despite the incentives, in order to avoid as much as possible treating human beings as mere commodities for sale. As Harvey (1990) argues, if commercial exploitation can be avoided in implementing organ procurement programs that involves incentives for the donor, then the moral and ethical arguments can be avoided within such schemes if non-exploitative paid organ donations take place. Second, with regard to the use of living organ donation, one must consider the Hippocratic Oath, which is at the core of medical ethics. The oath states that one should avoid inflicting harm on patients and individuals. However, it is apparent in living organ donations that the donor's life is endangered in cases like these. Statistics show that 10% of most live organ donors are likely to experience complications while 1% may die. However, as Land (1999) suggests, this fundamental tradition in Medicine falls short in the realm of organ donation and transplantation. As Land explains, there is a more complex moral reasoning behind this problem because while the donor may be placing himself in danger by donating part of his organ, this endangerment is very insignificant compared to the benefits for the recipient. Hence, he suggests, instead, a harm-benefit ration in living organ donation. One must measure the benefits that a recipient must get against the losses that a donator might give. The reasoning behind this lies in the principle of common good - where one considers the good of many before him. Third, however, one must also consider the "value of life." Christian philosophy tells us that all lives are equal despite the seeming inequality present in society. Hence, every patient in the waiting list should be given equal attention and equal chances in getting an organ transplant. However, with the current setup for the distribution of organ transplantation, it seems that even though there is no explicit rule that favors one group over the other, there is also no explicit rule that ensures equality either. Hence, the ethical questions surrounding organ transplant and donation does not only involve the procurement of organs, but it should also concern its distribution. Every life has an intrinsic value that is equal with each other. The current setup in organ distribution seems insufficient to address this reality. An example of such is the criteria, which values the patient's geographic location towards the organ. Most organs, especially kidneys, which is the most in demand in the United States, can be safely transported across geographic locations for a certain amount of time provided that it is stored properly. Hence, this criterion should only matter in cases where corruption of the organ is imminent. Furthermore, the seeming advantage of white Americans in getting organ donors over other ethnic groups should also be given attention. The data shows that white Americans receive more than half of all organ transplants in the United States without convincing data that they need the organs the most. The criteria in matching organs with recipients should therefore be reexamined in order to come up with a distribution network that ensures the equality of each patient in receiving an organ transplant. Based on these moral and ethical principles, it is apparent that the need to increase the number of available organs for transplant should be balanced with the need to respect the intrinsic value of the human person. Every person, be it the donor or the recipient, has an intrinsic value as human persons. It is therefore necessary that in determining procedures for procurement and distribution this fact is recognized to ensure that donors are not exploited or harmed and that patients are given equal treatment and chances in receiving an organ donation. Conclusion The issue of organ transplantation and donation is therefore a crucial issue that must be given consideration in today's society. On one hand, the government has the obligation to its citizens in ensuring that a sufficient supply of organs is available for patients who badly need it in order to be cured of diseases and to survive. On the other hand, the government and medical institutions must ensure that in drafting policies and programs to procure and distribute these organs donors are neither violated, exploited, or harmed, and that recipients are given equal treatment as to who should receive these organs first. The current programs being proposed in the United States today seems to be insufficient in this respect. While they have been unable to sufficiently bridge the gap between organ donations and organ transplantation, the current proposals to solve the problem either places the donor in danger of being exploited, in the case of non-communitarian approaches, or does not present a strong potential in terms of solving the organ shortage in the country, in terms of communitarian approaches. Hence, the government should invest more in researching for better ways to address the organ shortage plaguing the country today. References Childress, J. F. (2001). The failure to give: Reducing barriers to organ donation. Kennedy Institute of Ethics Journal, 11(1), 1-16. Etzioni, A. (2003). Organ donation: A communitarian approach. Kennedy Institute of Ethics Journal, 13(1), 1-18. Gutmann, T. & Land, W. (1999). Ethics in living donor organ transplantation. Division of Transplantation Surgery, Klinikum Grosshadern, Ludwig-Maximilians University. October 1999. Harvey, J. (1990). Paying organ donors. Journal of Medical Ethics, 16(3), 117-119. Kolber, A. J. (2003). A matter of priority: Transplanting Organs Preferentially to Registered Donors. Rutgers Law Review, 55, Spring 2003, 671-739. McCarrick, P. M. & Darragh, M. (2003). Incentives for providing organs. Kennedy Institute of Ethics Journal, 13(1), 53-64. Ngahooroo, J. & Gillett, G. (2004). Over my dead body: The ethics of organ donation in New Zealand. The New Zealand Medical Journal, 117(1201), 1051-56. Prottas, J. (1995). Organ and Tissue Procurement: Medical and Organizational Aspects. In Encyclopedia of Bioethics (Reich WT, ed). New York: Simon & Schuster; 1852-6. Ross, L. F. (2002). All donations should not be treated equally: A response to Jeffrey Kahn's commentary. Journal of Law, Medicine and Ethics, 30(3), 448-451. Sheely, E. (2003). Estimating the number of potential organ donors in the United States. New England Journal of Medicine, 349(7), 667-674. Sullivan, J., Seem, D. L., & Chabalewski, F. (1999). Determining brain death. Critical Care Nurse, 19, 37-46. United States. Department of Health and Human Services. Organ Procurement and Transplantation Network. (2004). OPTN/SRTR Annual Report. Source: OPTN Databank, May 2005. Table 1. Number of Organ Transplants (All Organs) To Date (since 1988) 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 All Donor Types 340,770 4,375 27,035 25,464 24,905 24,212 23,239 22,012 21,513 20,302 19,749 19,389 18,297 Deceased Donor 269,143 3,342 20,044 18,653 18,288 17,631 17,329 17,004 16,969 16,260 15,980 15,917 15,209 Living Donor 71,627 1,033 6,991 6,811 6,617 6,581 5,910 5,008 4,544 4,042 3,769 3,472 3,088 Source: OPTN Databank, May 2005. Table 2. Number of Waitlisted Candidates for Transplant (All Organs) To Date (since 1988) 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 All Donor Types 164,416 2,263 14,155 13,283 12,819 12,686 11,913 10,861 10,361 9,537 9,206 8,854 8,203 Deceased Donor 92,573 1,232 7,150 6,457 6,190 6,080 5,985 5,824 5,793 5,478 5,416 5,362 5,099 Living Donor 71,843 1,031 7,005 6,826 6,629 6,606 5,928 5,037 4,568 4,059 3,790 3,492 3,104 Source: OPTN Databank, May 2005. Table 3. Candidates in Need of Organs (By Ethnicity) All Organs Kidney Liver Pancreas Kidney / Pancreas Heart Lung Heart / Lung Intestine All Ethnicities 88,165 61,960 17,381 1,706 2,463 3,148 3,659 166 202 White 44,172 24,638 12,553 1,424 1,700 2,272 3,025 121 130 Black 24,011 21,687 1,225 149 450 516 375 21 33 Hispanic 13,530 10,285 2,667 101 242 257 180 16 32 Unknown 10 6 3 0 0 1 0 0 0 Asian 4,824 3,940 775 18 39 57 49 5 4 American Indian/Alaska Native 814 716 74 8 15 7 9 1 0 Pacific Islander 601 541 32 2 13 16 10 1 1 Multiracial 654 532 79 6 8 23 13 1 2 Source: OPTN Databank, May 2005. Table 4. Transplants by Ethnicity To Date 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 All Ethnicities 340,770 4,375 27,035 25,464 24,905 24,212 23,239 22,012 21,513 20,302 19,749 19,389 White 232,904 2,774 17,009 16,390 16,344 16,078 15,664 14,956 14,657 14,043 13,730 13,433 Black 57,955 835 4,857 4,619 4,368 4,265 3,951 3,779 3,638 3,458 3,360 3,172 Hispanic 33,640 528 3,257 3,019 2,872 2,664 2,483 2,179 2,168 1,877 1,785 1,949 Unknown 796 16 346 45 31 17 19 29 24 19 11 10 Asian 10,365 154 1,072 925 869 817 755 687 669 613 545 498 American Indian/ Alaska Native 2,442 29 216 191 165 164 171 184 151 123 155 147 Pacific Islander 1,034 16 91 103 92 90 89 74 81 80 62 46 Multiracial 1,634 23 187 172 164 117 107 124 125 89 101 134 Source: OPTN Databank, May 2005. Waiting list candidates as of (May 2005) All 88,565 Kidney 62,051 Pancreas 1,698 Kidney/Pancreas 2,443 Liver 17,349 Intestine 203 Heart 3,127 Lung 3,608 Heart/Lung 168 All candidates will be less than the sum due to candidates waiting for multiple organs Source: OPTN Databank, May 2005. Read More