Transplantation Bioethics

The issue of how to increase the supply of available organs for transplant has received a great deal of consideration by health care professionals and policymakers in recent years. In an article titled “The Bioethics of Organ Transplantation”, Arthur Caplan, a Professor of Bioethics at New York University’s Langone Medical Center, examined the ethical considerations around a number of proposals under consideration. The most notable of these was the possibility of organ markets, or the sale of organs from living or deceased donors (with prior consent).

Currently illegal in the United States, providing financial incentives to those who would otherwise not donate their organs seems appealing, at first. But, according to Caplan, the ethical drawbacks, particularly the fact that poor people would be incentivized to donate organs in order to pay their bills, far outweigh the benefits of such a plan. As Caplan writes: 

“…Watching your child go hungry while you lack a job and a wealthy person waves a wad of bills in your face is not exactly a scenario that inspires confidence in the valid choices that the poor would make in a market for body parts.”

Caplan also raises the possibility of making deceased organ donation the default position for all Americans, as several European countries have done. In other words, instead of filling out a form that says you choose to donate organs upon your death, the default would be that everyone’s organs are available for transplantation unless the person has specifically opted out. In countries that have already adopted this model, such as France, Belgium, Austria and Spain, donation rates are as high as 99 percent. 

Another option that has recently become more feasible is xenotransplantation, or transplanting organs from non-human animals. Due to the very high probability of rejection, this option was heretofore considered far too risky and ethically fraught. But with the advent of genetic engineering, scientists can now breed animals that are more genetically similar to humans and less capable of inciting an immune response. (This was the case when doctors at the University of Maryland transplanted a genetically engineered pig heart into a human recipient who went on to live for two months.) Unfortunately, there are huge ethical questions around this approach as well.

Sources

“Bioethics of Organ Transplantation”. Cold Spring Harbor Perspectives in Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC3935394/ 

“Ethical Issues of Transplanting Organs from Transgenic Animals into Human Beings”. Cell Journal Yakhteh. https://pmc.ncbi.nlm.nih.gov/articles/PMC4204195/ 

Donation after circulatory determined death (DCD)is a protocol that allows doctors to retrieve organs from a person who does not meet the strict neurological criteria for brain death. In this scenario, the patient has usually suffered an injury or illness from which they will never fully recover, such as a catastrophic head injury or a massive stroke. They cannot breathe or maintain circulatory function without the aid of machines, and doctors have determined with reasonable certainty that they never will. 

If a patient’s family or surrogate decision-maker agrees to donation after circulatory determined death, the potential donor is taken to the operating room (or a location very close to the operating room) and taken off life support. If breathing and heart function don’t resume within 2 to 5 minutes, the person is declared dead and the abdominal organs are removed. Typically, hearts and lungs are not harvested from patients who have donated after cardiac death because these organs are exquisitely sensitive to oxygen deprivation and are more likely to suffer irreparable damage before the transplant can occur. However, extracorporeal membrane oxygenation (ECMO) has recently been used to successfully reperfuse hearts that were removed from a DCD donor, offering hope that these organs can one day be harvested and transplanted successfully. 

Despite its utility, donation after circulatory-determined death is ethically controversial.This ethical dilemma derives mainly from the 2 to 5 minute time limit, which is necessarily brief. (Organs deprived of oxygen for longer than 5 minutes will begin to die.) Opponents of the practice argue that there is a possibility that the patient might resume breathing on their own if surgery was delayed. And, in fact, some patients will breathe unassisted after life support is stopped, in which case the organ harvest does not occur.

Additionally, the accepted medical definition of “death” states that death must be irreversible. Thus, some ethicists believe that if breathing and circulatory function can be restored (through CPR and continued life support) the person cannot be declared dead. 

For these reasons, some hospitals and physicians refuse to participate in donation after circulatory-determined death. Nonetheless, DCD is an accepted practice in many hospitals across the United States. 

Sources

“Ethical Controversies in Organ Donation After Circulatory Death”. American Academy of Pediatrics. https://publications.aap.org/pediatrics/article/131/5/1021/31250/Ethical-Controversies-in-Organ-Donation-After?autologincheck=redirected 

Since the late 1950s, when the first successful kidney transplants from living donors were performed, organ transplantation has been a much sought-after option for millions of people who are critically ill. But because demand has always far exceeded supply, it has also created ethical dilemmas, such as the requisite rationing of available organs and the ever-present need to increase organ supply. In the late 1970s, the latter led to the expansion of the definition of death to include either irreversible cessation of all brain activity (brain death) or irreversible cessation of circulatory and respiratory functions (cardiac death). This change was codified in 1980 with the Uniform Determination of Death Act and was a factor in the development of the protocol known as Donation after Circulatory Determined Death.

Today, as organ transplantation becomes more commonplace, one of the most pressing ethical issues transplant providers face is the need to fairly and equitably distribute the limited number of organs available. According to the Organ Transplant & Procurement Network, the ethics of these decisions are based on three basic tenets: utility, justice and respect for persons, or autonomy. At the risk of oversimplifying these complex principles, below is a brief overview of what each of them means.

Utility

Utility refers to the notion that organs should be allocated where they will do the most good and the least harm. This means that “goods and harms” must be evaluated using standard measures to accurately inform public policy. The “goods” of organ transplantation include saving a life, alleviating suffering, and promoting well-being. These may be measured using algorithms that predict years of life added, graft (organ) survival, and quality-adjusted life years (how many years of good quality life the organ will provide). These “goods” are then balanced with potential harms, which include short-term morbidity (e.g., post-operative pain and disability) and long-term morbidities (e.g., side effects of immunosuppressive drugs, potential organ rejection, psychological effects). Other factors, such as the likelihood of graft survival, age, and the availability of alternative treatments may also be used in determining where an organ will go. 

Justice

The principle of justice in organ transplantation refers to the need to treat all potential recipients with the same respect and concern. This means that the allocation of organs is never based on demographics such as race, gender or socioeconomic status, nor should the “social value” of an individual (e.g., their predicted contribution to society) be a factor in where an organ goes. Further, justice in a public program means that all individuals have a moral right to access its benefits. Therefore, justice may dictate that medical need is weighted more heavily than medical benefit (utility versus justice). In other words, an organ may go to the sickest patient even if a patient who is not as sick could predictably have a better outcome. 

Respect for Persons

Based on the concept of autonomy or self-determination, respect for persons dictates that every person in the organ transplant process has the right to make decisions about their care. For example, providers should respect the decisions of surrogates who refuse to donate organs as well as the decision of a potential recipient to refuse an organ for any reason and the right of individuals to direct a donation to a specific recipient (directed donation). Because the concept of justice prevents using demographics to allocate an organ, OPTN does not allow directed donation to a specific demographic, such as a race or ethnic group. 

Sources

“Donation & Transplantation History”. Health Resources & Services Administration. https://www.organdonor.gov/learn/history

“Determination of Death Act”. Uniform Law Commission. https://www.uniformlaws.org/committees/community-home?CommunityKey=155faf5d-03c2-4027-99ba-ee4c99019d6c 

“Donation After Circulatory Death”. National Kidney Foundation. https://www.kidney.org/sites/default/files/03-60-0119_FBE_CirculatoryDeath_Bro_v5.pdf