BIOETHICS AND ORGAN

TRANSPLANTATION
 CONTENT:

 1. The concept and types of human tissue and

organ transplantation.
 2. Legal and bioethical features in organ
transplantation.
 3. The moral status of the donor in organ
transplantation.
 MEDICAL ISSUES

What is organ transplantation?

 An organ is a mass of specialized cells and tissues that work together to
perform a function in the body. The heart is an example of an organ. It is
made up of tissues and cells that all work together to perform the function
of pumping blood through the human body.
 Any part of the body that performs a specialized function is an organ.
Therefore eyes are organs because their specialized function is to see, skin
is an organ because its function is to protect and regulate the body, and the
liver is an organ that functions to remove waste from the blood.
 An organ transplant is a surgical operation where a failing or damaged
organ in the human body is removed and replaced with a new one.
WHAT ARE ORGANS WHICH CAN BE TRANSPLANTED?

Solid transplantable organs: Other organs:

 Heart  Eyes,
 Lungs  Ear & nose
 Skin
 Liver  Bladder
 Pancreas  Nerves
 Brain and spinal cord
 Intestines  Skeleton
 Kidneys  Gall bladder
 Stomach
 Mouth & tongue
 Muscles
 1. The first source for organs removes them from recently deceased
people.
These organs are called cadaveric organs. A person becomes a
cadaveric organ donor by indicating that they would like to be an organ
donor when they die. This decision can be expressed either on a driver’s
license or in a health care directive.
 In some states, when a person dies and he/she has not indicated organ
donation preferences, the family is asked if they would be willing to
donate their relatives’ organs. Some states’ hospitals have policies
requiring family consent for organ removal, regardless of whether organ
donation wishes are written down.
 Therefore, many organ donation advocacy organizations encourage
people to discuss their organ donation preferences with their families to
assure that their wishes are known and followed.
 2. The second source for donor organs is a living person

 Living donors are often related to the patient, but that is not always the
case.
 Spouses and close friends frequently donate organs to ailing loved ones.
 Some people who wish to donate their organs may decide to donate to a
stranger.
 A few not-for-profit organizations maintain lists of willing living donors.
 For example, the National Marrow Donor Program (USA, Minneapolis,
Minnesota) maintains a list of people willing to donate bone marrow to a
stranger and there are a variety of non-related living kidney donor
organizations that maintain regional lists of willing donors.
 LIVING ORGAN DONATION

 Living people who wish to donate their organs can donate in two ways:
1. Donate one-half of a paired organ set.
Example: Kidney
2. Donate a portion of an organ that will still be able to function without it.
Example: A portion of the liver.
A lobe of the lung.

Individuals who wish to donate one of their organs to a stranger may also
initiate a nondirected donation (NDD). Nondirected donors approach
either a transplant center or a nationally sponsored organ procurement
organization and offer one of their organs for transplant to anyone who may
need it.
 Distributing cadaveric organs

 If a person does not have a readily available living donor or is

ineligible for a living donation because their predicted outcome is
questionable, they are placed into a waiting pool for an organ from
a cadaver by their transplant center.
 The United Network for Organ Sharing (UNOS) maintains the list
for the national waiting list, because it is a non-profit, scientific
and educational organization that administers the only Organ
Procurement and Transplantation Network (OPTN) in the United
States, established by the U.S.
 Distributing cadaveric organs

 When donor organs become available after a person dies an organ

procurement organization (OPO) takes the organs into custody.
 The OPO then matches the donor organs with the appropriate
transplant patients by gathering information about the donor
organs and entering it into a computer program.
 The program takes this information and compares it to information
about the patients in the waiting pool.
 The computer then generates a ranked list of transplant patients
who can receive the donor organs.
 Information that factors into this ranked list include:

 Organ type, blood type and organ size.

 Distance from the donor organ to the patient. ·
 Level of medical urgency (not considered for lung transplant candidates).·
 Time on the waiting list.
After the generation of the ranked list, the donated organ is offered to the
first patient’s transplant center. However, the first person on the ranked list
may not receive the organ. Additional factors to be evaluated before the organ
procurement organization selects the appropriate candidate are: ·
 Is the patient available and willing to be transplanted immediately? ·
 Is the patient healthy enough to be transplanted?
 Types of organ transplantation:

 A graft is similar to a transplant. It is the process of removing tissue from one part of a
person’s body (or another person’s body) and surgically are implanting it to replace or
compensate for damaged tissue. Grafting is different from transplantation because it does
not remove and replace an entire organ, but rather only a portion.
 Autograft - A transplant of tissue from one to oneself Skin grafts, vein extraction
for CABG, storing blood in advance of surgery.
 Allograft - Transplanted organ or tissue from a genetically non-identical member of
the same species.
 Isograft - A subset of allografts in which organs or tissues are transplanted from a
donor to a genetically identical recipient (e.g. identical twin).
 Anatomically identical to allografts, closer to autografts in terms of the recipient’s
immune response.
 Xenograft - Replacement of an individual’s defective organ with an organ
harvested from another species. Source of organs for human use: primates (genetic
similarities to humans) and pigs (large availability).
 XENOTRANSPLANTATION
In 1986, the first xenotransplanted organ transplant was performed.
This intriguing field of study becomes more attractive to some researchers as
the number of people needing organ transplants continues to grow. ·
 Invention and use of the first artificial organs. The first artificial heart
transplant in the 1980s was closely followed by the news media and the
American public. ·
 Splitting organs into pieces (either from living donors or cadaveric
donors). The first split liver transplant in 1996 allowed one cadaveric liver to
be used among multiple transplant patients. ·
 Stem cell research. Stem cell research is examining adult and human
embryo cells in an attempt to discover how organs are developed and what
stimulates their growth.
 TIMELINE OF MEDICAL ADVANCES IN ORGAN
TRANSPLANTATION
 1954
The first successful kidney transplant. A kidney is taken from one identical brother and transplanted in
another, where it worked for 8 years.
 1962
The first successful cadaveric transplant used a deceased donor kidney. The kidney worked for almost
2 years.
 1966
First successful liver transplant. The liver worked for over one year.
 1967
First successful heart transplant. The heart worked for 2 1/2 weeks.
 1981
First successful heart-lung transplant. The organs worked for 5 years.
 1982
 First artificial heart transplant.
 MEDICAL ADVANCES

 1983
Cyclosporine, an immunosuppressant drug, was approved by the FDA (Food and
Drug Administration).
 1986
A baboon heart was transplanted into Baby Faye and worked for 20 days.
 1989
The first successful living-related liver transplant.
 1996
The first “split liver” transplant was performed where one cadaveric liver was split
into several pieces to transplant into more than one person.
 2000
First culture of human embryonic stem cells.
 2001
Number of living organ donations passed cadaveric donations.
 BIOETHICAL ISSUES
•17 people die each day waiting for an organ transplant.
•Every donor can save 8 lives and enhance over 75 more.
•39,000 transplants were performed in 2019.
•Every 9 minutes another person is added
to the transplant waiting list.
•Organ transplantation has greatly reduced
in the COVID-19 pandemic.
 THE ORGAN SHORTAGE

 The primary ethical dilemmas surrounding organ

transplantation arise from the shortage of available organs.
Not everyone who needs an organ transplant gets one and in
fact, the scales tip quite heavily in the opposite direction.
 The United Network for Organ Sharing (UNOS) maintains a
comprehensive, up to-date website that gives the status of
people awaiting organ transplants.
 According to their website (updated daily at www.unos.org)
over 83,000 people are currently awaiting transplants in the
United States.
 The number of donated organs has stayed fairly constant over the
last few years while the number of people needing organs
continues to increase. Many explanations are offered to explain the
length of the list – such as the number of new medical
technological advances and the aging population.
 One possible explanation as to why the number of donated organs
from cadavers remains static concerns the increasing effectiveness
of seat belt campaigns and air bag use. In the past, a large source of
healthy cadaveric organs came from victims of car crashes. With
static or declining numbers of car crash fatalities, there are also
declining sources of healthy human organs for transplant.
 THE ETHICS OF TRANSPLANTATION
 The ethics of transplantation derives from a tension between two poles:
 1) bodily integrity and
 2) human solidarity.
 As persons we are embodied. Our bodies are unique, individual
instruments by which we live, in reflection, expression, action, reception,
relation.
 Bodily integrity, therefore, must be protected: we count it a wrong to
kill, to harm, to abuse, to mutilate the human body; even to denigrate or
disvalue it.
That wrong can also be, in terms of law a crime, in terms of religion a sin.
 DISTRIBUTION OF AVAILABLE ORGANS

 The concept of distributive justice – how to fairly divide

resources – arises around organ transplantation because
there are not enough organs available for everyone who
needs one.
 Distributive justice theory states that there is not one “right”
way to distribute organs, but rather many ways a person
could justify giving an organ to one particular individual
over someone else.
 DISTRIBUTIVE JUSTICE CRITERIA

 1. To each person an equal share.

 2. To each person according to need.
 3. To each person according to effort.
 4. To each person according to contribution.
 5. To each person according to merit.
 6. To each person according to free-market exchanges.

University of Washington School of Medicine

 1. EQUAL ACCESS

 One distributive justice criteria is equal access.

 Organs allocated according to equal access criteria are distributed to
patients based on objective factors aimed to limit bias and unfair
distribution.
 Equal access criteria include:
 Length of time waiting (i.e. first come, first served);
 Age (i.e. youngest to oldest).
 EQUAL ACCESS

 Equal access supporters believe that organ transplantation is a

valuable medical procedure and worth offering to those who need it.

 They also argue that because the procedure is worthy, everyone

should be able to access it equally.

 To encourage equality in organ transplantation, the equal

access theory encourages a distribution process for
transplantable organs that is free of biases based on race,
sex, income level and geographic distance from the organ.
 Some who believe in equal access distribution would also like
to have an organ distribution process free of medical or social
worthiness biases.
 Medical “worthiness” biases could exclude patients from
reaching the top of the transplant waiting list if lifestyle
choices like smoking and alcohol use damaged their organs.
 Social “worthiness” biases would factor in a patient’s place in
society or potential societal contribution before giving them
an organ. This would affect, among others, prisoners being
punished for offenses against society.
The primary reasons for wanting to prevent individual worth from
factoring into organ distribution include:

a) the argument that individual worth does not determine medical

need;
b) the dilemma involved in deciding who will make decisions of
who is worthy or not worthy to receive an organ, and;
c) the slippery slope of determining an individual’s worth and
whether or not it is fair to label someone worthy of a medical
procedure.
 EQUAL ACCESS

 On the other hand, some ethicists argue that individual worth is important to
consider during organ distribution. They argue that distribution is biased
against worthy individuals when individual worthiness factors are not
included.
 One example of this argument comes from a 1990s article in the Canadian
Medical Association Journal by E. Kluge.
 Kluge argues that equal access distribution of organs is not fair and just if it
includes people whose lifestyle choices, namely tobacco and alcohol use,
ruined their organs. Kluge’s argument states that people who engage in poor
lifestyle choices are behaving irresponsibly and could have prevented their
illness and are, in essence, increasing the need for organs and depriving
people who, “have no control over their need,” of necessary treatment.
 2. MAXIMUM BENEFIT

 A second type of distributive justice criteria is maximum

benefit. The goal for maximum benefit criteria is to
maximize the number of successful transplants.
 Examples of maximum benefit criteria include:
Medical need (i.e. the sickest people are given the first
opportunity for a transplantable organ)
Probable success of a transplant (i.e. giving organs to
the person who will be most likely to live the longest).
 MAXIMUM BENEFIT

 People who support the maximum benefit philosophy

believe organ transplants are medically valuable procedures
and wish to avoid the wasting of organs because they are
very scarce.
 To avoid waste, they support ranking transplant candidates
by taking into account how sick the patient is and how likely
it is that the patient will live after he or she receives a
transplant.
 Successful transplants are measured
by the number of life years gained.

 Life years are the number of years that a person will live with
a successful organ transplant that they would not have lived
otherwise.
 This philosophy allows organ procurement organizations to
take into account several things when distributing organs
that the equal access philosophy does not – like giving a
second organ transplant to someone who’s already had one
or factoring in the probability of a successful medical
outcome.
 THE ETHICAL PROBLEMS OF ORGAN
TRANSPLANTATION
 Organ transplantation required a complex interaction of
surgery, anesthesia, neurology, legal medicine, religious, and
state authorities that was negotiated in scientific
communities, political circles, and the media.
 The ethical problems of organ transplantation result from
the fact that it is a highly risky and, at the same time, highly
beneficial procedure involving questions of personhood,
bodily integrity attitudes towards the dead, and the social
and symbolic value of human body parts.
 POST-MORTEM DONORS

 In most Western industrialized countries the major

source for transplanted organs are dead or brain-dead
persons, while in countries like Japan or Iran living
organ donation prevails.
 Post-mortal organs can be harvested from brain-dead
or non-heart-beating donors.
Three primary arguments oppose using the maximum
benefit distribution criteria:

1. First, predicting medical success is difficult because a

successful outcome can vary.
 Is success the number of years a patient lives after a transplant?
 Or is success the number of years a transplanted organ functions?
 Is success the level of rehabilitation and quality of life the patient
experiences afterward?
 These questions pose challenges to those attempting to allocate
organs using medical success prediction criteria.
 Primary arguments oppose using the maximum benefit
distribution criteria:

2. The second argument against maximum benefit distribution is

that distributing organs in this way could leave the door open
for bias, lying, favoritism and other unfair practices more so
than other forms of distribution due to the subjective nature
of these criteria.
 Primary arguments oppose using the maximum benefit
distribution criteria:

3. Third, some ethicists argue against using age and

maximizing life years as criteria for distributing organs
because it devalues the remaining life of an older
person awaiting a transplant.
 Regardless of how old someone is, if that person does not
receive a transplant they will still be losing “the rest of his
or her life,” which is valuable to everyone.
 Current organ distribution policy

 The current organ distribution method in the United States relies on each
transplant center to determine which criteria they will use to fairly allocate
organs. UNOS (United Network for Organ Sharing) encourages transplant
centers to consider the following criteria for distributing organs:
1) medical need;
2) probability of success, and;
3) time on the waiting list.
According to a 2001 article by James Childress, most experts agree
that these three criteria are relevant. Childress states that ethical
conflicts arise both when specifying what the criteria mean, and when
weighing the criteria in cases of conflict.
Not everyone believes in the need to increase the number of organ
transplants.

 There are some who believe that organ transplantation inappropriately

encourages the medicalization of society. In fact, one on-line website suggests
that organ transplants are merely one way in which United States citizens
attempt to transcend death.
 A second point of view that questions increasing the practice of organ
transplantation relies on the assumption that resources for health care are
scarce and organ transplants are costly. The questions this raise include –
what is the social worth of organ transplants and are they diverting money
from other necessary medical care?
 Finally, a recent article suggested that not enough research has been
conducted on poor transplant outcomes. The authors suggest that
unsuccessful transplant patients continue to receive aggressive, curative
treatment when they should be receiving more caring and holistic treatment.
 ORGAN SHORTAGE: ETHICAL QUESTIONS
 Transplantable organs are scarce. Knowing that there are more people who need organs than there are
organs available, how would you answer the following questions? Are your answers based on a belief
of equal access or maximum benefit distribution?
1. Should someone who has received one organ transplant be given a second transplant? Or should people
who have not had a transplant be given priority over those who have already had one?
2. Should people whose lifestyle choices (smoking, drinking, drug use, obesity, etc.) damaged their organ
be given a chance at an organ transplant?
3. Should suicidal individuals be given an organ transplant? What if they attempted suicide in the past but
are not currently contemplating suicide?
4. Should people who have young children be given an organ transplant over a single person? Over an
elderly person? Should age and whether or not a person has children even matter?
5. Should people who can’t afford expensive anti-rejection drugs be passed over for a transplant? Should
people who don’t have insurance and can’t pay for a transplant be allowed to go on the national waiting
list?
6. Should condemned prisoners receive organ transplants? What if they are serving a life sentence without
parole?
 DONOR ORGANS

 One way to avoid the ethical problems associated with the shortage of
transplantable organs is to increase the number of donor organs. However,
fears abound that policies to maximize organ donations could go too far –
leading to organ farming or premature declarations of death in order to
harvest organs.
 Many, if not most, people agree that taking organs from any source is a
justifiable practice within certain ethical boundaries. Controversies result
from an inability to define exactly where those boundaries lie. Everyone may
have their own unique ideas about the boundaries they would like to see
concerning the following three sources of transplantable organs: cadaveric
donors, living donors and alternative organ sources.
 CADAVERIC ORGAN DONATION

 Currently, once a person dies, his or her organs may be donated if the
person consented to do so before they passed away. A person’s consent
to donate their organs is made while still living and appears on a
driver’s license or in an advance directive. After consenting to donate
organs, nothing happens with that information until the person dies. A
person is considered dead once either the heart stops beating or brain
function ceases (called brain death). After death, the organs are taken
from the deceased person’s body. If possible, the deceased person may
be kept on life support once they have died until the organs can be
taken, in order to preserve the organs until they are removed.
 BRAIN DEATH

If the deceased person’s organ donation wishes are unknown, the hospital,
physician, or organ procurement organization will approach a family member to
obtain consent to remove the organs. The family members with the authority to do
so is generally determined by this hierarchy: ·
 Spouse. If no spouse, then… ·
 Adult child. If no adult children, then… ·
 Parent. If no parents, then… ·
 Adult sibling. If no siblings, then… ·
 Legal guardian.
One cadaveric donor can provide organs for several different people. Which organs
and tissues can be recovered may depend on the cause of death or damage to an
organ, but typically several organs can be recovered from a single cadaver. In
2020, more than 22,000 organs were recovered from 6,182 cadaveric donors.
 Personal autonomy “opt-in” / “opt-out”

 Is explicit or implicit informed consent required?

 Does death annul a person’s right to determine what will happen with her/his
body?
 Some countries have adopted a so called “opt-in” solution. In this case, explicit
informed consent by the deceased person before death is required (by carrying an
organ donor card, a written statement, a notice in the driver license etc.).
 Other countries foster a combination of individual consent and proxy consent. This
means that family members can ensure the deceased person’s will is observed.
 In contrast, the “opt-out” solution is based on the idea that everyone counts as
potential organ donor and dissenters have to explicitly state their will (e.g., by
registering in a data bank, or by personal communication).
 Personal autonomy “opt-in” / “opt-out”

 In both the opt-in and opt-out systems, individuals have the

freedom of choice.
 Yet, in the first case the patient’s autonomy is understood as
something to be actively enacted that cannot be substituted, whereas
the second and third options put more weight on relieving the donor
from the responsibility to decide and on the interests of organ
recipients.
 A fourth, albeit rare, position states that dead bodies are no longer
subject to personal rights and, thus, implies a right of society to
dispose of organs.
 Five strategies to increase cadaveric organ donations

 Since one cadaveric donor can provide multiple organs, this is a

natural place to look to increase the number of available organs.
 Efforts to increase the number of cadaveric donors have met with
much debate and controversy.
 There are five primary strategies currently under consideration
for the future:
1. education;
2. mandated choice;
3. presumed consent;
4. Incentives;
5. Prisoners.
 1. Strategy to increase cadaveric organs: EDUCATION

 Education is the first strategy suggested by many to increase

cadaveric organ donation.
 Some educational efforts focus on increasing the number of people
who consent to be an organ donor before they die.
 Other educational efforts focus on educating families when they are
considering giving consent for their deceased loved one’s organs.
 Social responsibility and the idea of “the gift of life” are popularized
by UNOS (United Network for Organ Sharing) and other
organizations that seek to promote the idea of cadaveric organ
donation.
 2. Strategy to increase cadaveric organs: MANDATED CHOICE

 A second potential strategy to increase organs from cadaveric

donors is mandated choice.
 Under this strategy, every American would have to indicate
their wishes regarding organ transplantation, perhaps on
income tax forms or drivers licenses.
 When a person dies, the hospital must comply with their
written wishes regardless of what their family may want.
 The positive aspect of this strategy is that it strongly enforces
the concept of individual autonomy of the organ donor.
 MANDATED CHOICE

 A mandated choice policy would require an enormous level

of trust in the medical system.
 People must be able to trust their health care providers to
care for them no matter what their organ donation wishes.
 A 2019 survey of 600 family members who had experience
donating organs from a deceased loved one, found about
25% of respondents would be concerned that a doctor
wouldn’t do as much to save their loved one’s life if they
knew they were willing to donate their organs.
3. Strategy to increase cadaveric organs: PRESUMED CONSENT

 Presumed consent is a third strategy aimed to increase cadaveric organ

donation. This method of procuring organs is in fact the policy of many
European nations. In countries with presumed consent, their citizens’
organs are taken after they die, unless a person specifically requests to
not donate while still living.
 Advocates of a presumed consent approach might say that it is every
person’s civic duty to donate their organs once they no longer need them
(i.e. after death) to those who do. People against presumed consent
would argue that to implement this policy, the general public would have
to be educated and well informed about organ donation, which would be
difficult to adequately achieve.
 PRESUMED CONSENT

 Doubters of the presumed consent approach might also

argue that requiring people to opt out of donating their
organs requires them to take action and this might unfairly
burden some people.
 There are worries that people who frequently choose not to
donate organs for religious and cultural reasons (minority
cultural groups and immigrants, primarily) might find it the
most challenging to opt out of donating due to language
barriers, transportation difficulties or for other reasons.
 4. Strategy to increase cadaveric organs: INCENTIVES

 The fourth strategy under consideration to increase cadaveric organ

donation is the use of incentives. Incentives take many forms. Some
of the most frequently debated incentive strategies are:
1. Give assistance to families of a donor with funeral costs.
2. Donate to a charity in the deceased person’s name if organs are
donated.
3. Offer recognition and gratitude incentives like a plaque or
memorial.
4. Provide financial or payment incentives.
 One of the most highly debated incentives would give donating
families assistance with burial or funeral costs for their loved one.

 With funerals costs in the thousands, this could be an attractive incentive for many
families. The majority of members of the American Society of Transplant Surgeons
support funeral reimbursement or charitable organization donation as a strategy to
increase donation.
 Many people favor charitable donation or recognizing donors as an incentive for
organ donation.
 Some argue that providing recognition of a donor is not really an incentive at all, but
merely an appropriate response to a very generous donation.
 Another twist on this group of incentives is offering recognition or charitable
donation to people while they are living to encourage them to donate.
 Proponents say that since the person will be dead and unable to receive the
recognition, that this would not be a coercive action.
Some ethicists believe that many of the incentives above, while not
attached directly to cash money, are still coercive and unfair.

 They believe that some people will be swayed to donate, in

spite of their better judgment, if an incentive is attractive
enough. They further argue that a gesture may seem small and
a mere token to one person, but others might interpret it quite
differently.
 A final anti-incentives argument offered by some ethicists
discourages the practice of incentivizing organ donation. They
believe that society should instead re-culture its thinking to
embrace a communitarian spirit of giving and altruism where
people actively want to donate their organs.
 5. Strategy to increase cadaveric organs: PRISONERS

 The final strategy under consideration to increase the number of

available cadaveric organs is to use organs taken from prisoners who are
put to death. One argument in favor of taking organs from prisoners who
are put to death, is that it is the execution that is ethically unsound and
not the organ removal.
 Indeed, in light of the severe organ shortage, some ethicists could make
the argument that to not use the organs for transplantation is wasteful.
 John Robertson, in a 1999 article, put forth the argument that
obtaining organs from condemned prisoners is allowable if the prisoner
or their next of kin consents to donation, as long as organ donation is not
the means by which the prisoner is killed because that violates the
principle that a cadaveric donor be dead prior to donation.
 PRISONERS

 Finally, some could argue that organ retrieval from executed prisoners
is morally justifiable only if a “presumed consent” donation practice
was in place.

 Many, if not most, bioethicists consider taking organs from condemned

prisoners a morally objectionable practice.
 Colorful language used by some ethicists includes the following words
to describe the practice: “immoral,” “repugnance,” and “revulsion.
 LIVING ORGAN DONATION

A person with organ damage or organ failure may look for a living
donor to donate an organ, allowing the patient to bypass the national
waiting pool to receive a cadaveric organ. According to UNOS (the
United Network for Organ Sharing), there are a number of benefits to
living donation, both for the donor and the patient: ·
 The donation can be pre-arranged, allowing the patient to begin taking
anti rejection drugs in advance, thereby increasing the chances of
success ·
 There are often better matches between donors and recipients with
living donation, because many donors are genetically related to the
recipient.
 Psychological benefits for both the donors and recipients.
Not everyone encourages the practice of living donation for all
people.
Drawbacks to becoming a living donor may include: ·
 Health consequences: Pain, discomfort, infection, bleeding and
potential future health complications are all possible.
 Psychological consequences: Family pressure, guilt or resentment.
 Pressure: Family members may feel pressured to donate when they
have a sick family member or loved one.
 No donor advocate: While the patients have advocates, like the
transplant surgeon or medical team (who are there to advise the patient
and work in favor of his or her best interests) donors do not have such an
advocate and can be faced with an overwhelming and complicated
process with no one to turn to for guidance or advice.
 THE LIVING DONATION

 A few medical and ethical professionals argue that living donation is

inappropriate under any circumstances and should not only be
discouraged but abandoned all together because of the risk and dangers
associated with donating organs.
 Other critics seek to discourage living donation because they think
extending life through costly and physically taxing medical procedures is
not the purpose of health and healthcare.
 Although there are some who object to the practice of living donation,
this potential source of organs is currently a major focus as a way to
reduce the shortage of organs. Increasing the number of living donors
could occur through a variety of strategies from education and civic duty
promotion to the sale and purchase of organs.
 THE LIVING DONATION

 There are a few non-financial incentives available as options to

increase living donation, such as medical leave or special
insurance for living donors. The idea of nonfinancial
incentives may be rising in popularity as a way to entice
people to donate their organs.
 In January of 2004, Wisconsin, USA, became the first state to
offer a living donation incentive to its citizens. The new law
allows living donors in Wisconsin to receive an income tax
deduction to recoup donation expenses like travel costs and
lost wages.
 ENCOURAGING LIVING DONATION

 Financial incentives aimed at encouraging living donation have received

much attention from bioethicists lately. Most experts argue that buying
and selling human organs is an immoral and disrespectful practice.
 The moral objection raised most often argues that selling organs will
appeal to the socio economically disadvantaged (people who are poor,
uneducated, live in a depressed area, etc.) and these groups will be
unfairly pressured to sell their organs by the promise of money. This
pressure could also cause people to overlook the possible drawbacks in
favor of cash incentives. On the other hand, wealthy people would have
unfair access to organs due to their financial situations.
 Arguments that favor the buying and selling of human organs are
scarce, but a few do exist.
 Robert M. Veatch (1939-2020), professor of Medical Ethics, in his book,
Transplant Ethics, argues that the United States has the money and resources
to eliminate socioeconomic disparities, and if this were done, people could
then sell their organs, because it is poverty that requires people to act out in
desperation for money and not with an objective and informed mind.
 Another argument that does not object to the purchase of organs suggests that
payments aren’t necessarily a bad idea if they work to increase the number of
donated organs. The position contends that donating an organ is a relatively
small burden compared to the enormous benefit reaped by recipients.
 Finally, John B. Dossetor (1925-2020), Canadian physician and bioethicist,
argues that buying and selling organs is not morally objectionable, but that the
system as it exists is inadequate to provide appropriate safeguards. This
critique extends not only to the medical system, but also to legal and religious
safeguarding organizations as well.
 ALTERNATIVE ORGAN SOURCES

With the state of discrepancy between organ donors and people

waiting for an organ transplant, researchers and advocates have begun
to consider non-traditional donation.
Some potential non-traditional sources of organs are:
 ANIMAL ORGANS;
 ARTIFICIAL ORGANS;
 STEM CELLS;
 ABORTED FETUSES.
 ANIMAL ORGANS

 Animals are a potential source of donated organs.

 Experiments with baboon hearts and pig liver transplants have received
extensive media attention in the past.
 One cautionary argument in opposition to the use of animal organs concerns
the possibility of transferring animal bacteria and viruses to humans.
 For the first time, a pig's kidney was transplanted to a human patient without
triggering an immediate rejection by the host's immune system, which is a
huge medical breakthrough and could eventually help alleviate organ
shortages. (The article: US surgeons successfully test pig kidney transplant in
human patient. October 20, 2021).
 A US man has become the world's first person to get a heart transplant from a
genetically modified pig and has died after 2 months. (The article: Doctors
transplant a genetically modified pig heart into a human for the 1st time
 https://www.npr.org/2022/01/10/1071906223/doctors-transplant-genetically-
modified-pig-heart ).
 ARTIFICIAL ORGANS

 Artificial organs are yet another potential option.

 The ethical issues involved in artificial organs often revert to
questions about the cost and effectiveness of artificial
organs.
 People who receive artificial organ transplants might require
further transplanting if there is a problem with the device.
 STEM CELLS

 Stem cells are cells that can specialize into the many different cells
found in the human body.
 Researchers have great hopes that stem cells can one day be used to
grow entire organs, or at least groups of specialized cells.
 The ethical objections concerning stem cells have focused primarily on
their source. While stem cells can be found in the adult human body,
the seemingly most potent stem cells come from the first few cells of a
human embryo. When the stem cells are removed, the embryo is
destroyed. Some people find this practice morally objectionable and
would like to put a stop to research and medical procedures that destroy
human embryos in the process.
 ABORTED FETUSES

 Aborted fetuses are a proposed source of organs.

 Debates address whether it is morally appropriate to use organs from a
fetus aborted late in a pregnancy for transplantation that could save the
life of another infant.
 Many people believe that this practice would condone late-term
abortions, which some individuals and groups find morally
objectionable.
 Another objection comes from people who fear that encouraging the use
of aborted fetal organs would encourage „organ farming”, or the practice
of conceiving a child with the intention of aborting it for its organs.
 CULTURAL OR RELIGIOUS APPROACH

 Objection to post-mortem donations can, for example,

be based on cultural or religious assumptions on how to
appropriately handle the human corpse.
 Some religious authorities of monotheistic religions like
Christianity and Islam have accepted brain death as
criterion for the death of a human being and have, thus,
endorsed organ transplantation.
 Yet, others deny the right to call a still breathing person
dead.
 Cultural or religious approach

 Cultural conceptions of death, like in Japan, can contravene scientific

convictions. In Japan, death is not considered to occur at an exact
instant but is a continuum that requires several days.
 Thus, the body must remain whole. A dead person with an incomplete
body before burial or cremation is associated with misfortune.
 The reason for refusing donation is fear of injuring the dead person's
"itai" (remains) by his or her own will (Schrier 1997).
 Therefore, every case needs an assessment of the donor’s and recipient’s
cultural and religious attitudes towards brain death and organ donation.
 OPPONENTS vs. PROPONENTS

 A few medical and ethical

 Although there are some who object to
professionals argue that living
the practice of living donation, this
donation is inappropriate under any
potential source of organs is currently a
circumstances and should not only be
major focus as a way to reduce the
discouraged but abandoned all
shortage of organs.
together because of the risk and
dangers associated with donating  Increasing the number of living donors
organs. could occur through a variety of
strategies from education and civic
 Other critics seek to discourage living
duty promotion to the sale and
donation because they think extending
purchase of organs.
life through costly and physically
taxing medical procedures is not the
purpose of health and healthcare.
 LEGAL AND SOCIAL ISSUES

 CURRENT LAWS
Organ donation laws at the state and federal levels exist
for two primary purposes.
1. The first purpose of organ donation laws is to help ensure a
safe and fair organ donation collection and distribution
practice.
2. The second type of organ donation laws have been enacted
to widen the pool of potential donors in an effort to
increase the number of organs available for transplant.
 Study case
 A 42-year-old man is currently being assessed for a heart transplant. He has a history of
amphetamine use and repeatedly claims to have stopped using amphetamines over 12
months ago. However, laboratory tests confirm recent amphetamine use. Apart from his
heart condition he has no other medical conditions. His heart condition is now rapidly
deteriorating and an urgent decision needs to be made.
 Active substance abuse excludes people from being considered as eligible for heart
transplantation.
 While he is in urgent need of a transplant, his current amphetamine use (confirmed by
blood testing) means that he is more likely to have a poorer outcome following transplant
and he is less likely to be able to adhere to the necessary ongoing treatment and health
advice after transplantation.
 Given his confirmed amphetamine use, this man is not currently eligible for a transplant
despite the urgency of his need.
 Case: Organ transplantation – mentally incompetent
recipients
 Mrs. R.S. is a patient who has been detained in a psychiatric hospital on account of a
severe depression which amounts to a mental illness. She also has failing kidneys and
will die imminently in the absence of a transplant. Not surprisingly perhaps, Mrs. R.S.
won’t give her consent to the transplantation and she has also expressed the view that
transplants are morally unacceptable. If a person has a severe depression, the decision
he or she makes about life-saving treatment may not be a true decision but one that
results from the illness. It could be that Mrs. R.S. has not weighed factors that she
would consider if mentally well, and so the balancing act that would normally be
followed by a person weighing the risks and potential benefits of a transplant has been
infected by the depressive illness.

 The doctor is unsure whether the decision to accept or reject a transplant

belongs to Mrs. R.S. and whether Mrs. R.S. is entitled to consider that the risks
of the process do not outweigh the potential benefits.
 Please discuss the alternatives and justify your answer!
How would you approach the ethical questions?

 Mrs. R.S. should be given a life-saving transplant because there is a

duty of care arising from the need to treat the depressive illness – if
the refusal to accept the transplant is a symptom or consequence of
the depressive illness, then the transplant may be seen as directly
linked with the treatment for the mental illness given the
importance of the issues involved (death if there is no transplant
despite the intrusive nature of the operation).
 As it is most important that there is a solid decision making
procedure that allows the patient’s viewpoint to be represented, a
court will be involved to make a final decision.
 The refusal of Mrs. R.S. is accepted because, even if the patient may not
approach the matter by carrying out a cost-benefit analysis, she holds the
view that transplants are wrong on moral grounds. If it is the patient’s lot to
die, that is something the doctor should accept. The fact that the patient is
mentally ill at the time he or she has to make the decision does not alter the
starting point, namely the presumption that the person can make his or her
own decision and that this decision should be accepted.

Teaching Ethics in Organ Transplantation and Tissue Donation. UNESCO Chair in Bioethics.
pdf Kris Gledhill, New Zealand
http://www.unesco-chair-bioethics.org/?mbt_book=teaching-ethics-in-organ-
transplantation-and-tissue-donation-cases-and-movies