Organ Donation: Transplants Ethics and Issues

One of the most important advances in the medical profession is the science of transplanting human organs and tissues. This procedure not only saves lives but also returns vital functions of patients suffering from chronic crippling diseases that are difficult to treat. Oral transplantation can be used to help treat acute organ failure. For a long time, organ procurement and transplantation have been a controversial subject surrounded by intense legal criticism as well as legislative issues all around the world. Major hospitals all over the world have been affected by issues of organ donation as well the organizations that specialize in acquiring and distributing human tissue and organs. As such, the ethics and issues concerning organ transplant include the donation process, the procedure for organ procurement, the health and state of donors and also the methodology of allocation of these organs to the patients.

Ethical guidelines for organ transplantation from deceased donors

A deceased donor is a term used to refer to a person who is pronounced dead through accepted medical analysis, and there is a planned harvesting of his organs for treatment of sick people with partial or complete organ failure. Australia is one of the leading countries with the highest success in organ transplant processes. The country had a reported success of above 1,000 transplants in 2015. Not all organs of deceased people are used for transplants. People who die in hospitals especially under emergency department or intensive care unit while receiving medical care are the only ones considered for organ transplants (National Health and Medical Research Council, 2016). There is a large disparity between the demand for organs and the recipients’ eligible for transplants. A lot of people are being diagnosed with organ failure, and the shortage of donor organs results in a situation where many people who are waiting in line to receive the organs die before they receive treatment. The rate at which eligible deceased donors are available is way lower than the expected demand for their organs. Due to the organ shortage, predefined methods have been developed to ensure that the transplantation and allocation policies and decisions are transparent and robust and directed by the values and ethical principles. The current criteria for determining whether someone is eligible for a donation of organs from a deceased person provides a large list of qualified people who would benefit from the allocation, but they will not be able to receive the transplant (National Health and Medical Research Council, 2016).

According to Australia’s procurement ethics, the organs of deceased donors are allocated to patients according to a defined procedure which involves giving the organs to the most suitable people. It is considered unethical for the relatives of a dead person to give directions on who should be recipients of the donated organ or tissue. Also, the wishes of a deceased person cannot be considered when allocating the organ. However, the deceased can contribute to the way the donation will occur under three circumstances. First, there is a reason to believe that the dead person was in his right state of mind and was prepared to donate his organs after he was dead. Secondly, there is proof to support the deceased person’s claim of choosing to donate some specific organs to a close relative in need. The proof includes a directive through the advanced care system, a will written by the deceased when he was alive or an arrangement between the deceased person and the transplant team. Thirdly, the recipient chosen by the deceased donor is deemed eligible to receive the organ and accepts the organ donated to him. The quickest way an eligible recipient can receive an organ transplant is from a deceased relative (National Health and Medical Research Council, 2016).

Allocation Methods

Allocating cadaveric organs

In a situation where a patient is not eligible to receive a transplant due to the unexpected negative results, or he is not lucky to have a living donor, their transplant center places them in a waiting pool for an organ retrieved from a cadaver. The national pool is maintained by the United Network for Organ Sharing (UNOS). The distribution of the organs of to transplant patients is accomplished by the Organ Procurement Organization (OPO). The OPO takes custody of the donor organs that become available after the death of a hospitalized person. The OPO then gathers information about the donor organs and stores the information in a database. Afterward, the procurement body matches the appropriate patients who are already listed in the waiting pool with the donor organs. A computer program is used to compare the large database of the donor organs and the patient, and it then generates a ranked list of patients in need of the donor organs. The ranked list is determined by considering four main factors which include; the time the patient has been on the waiting list, the urgency of the medical care, the geographical separation between the patient and the donor organ and lastly, the type of the organ, its blood type, and size. The factor about the emergency of medical care is not taken into consideration when the transplanted organ is a lung. The transplant center of the first patient in the generated list receives the donor organ. Before the patient receives a transplant, two other factors are considered which include: the health status of the patient, whether he is healthy enough to receive the organ and his willingness and availability to receive the transplant immediately (Jonsen, 2012).

Transplant procedure

For a successful transplant, the organ needs to be transplanted immediately to avoid any complications. The transplant patient is prepared for surgery where the failing organ is surgically removed and replaced with the donor organ. After receiving the new organ, the patient starts a long journey of recovery. Sometimes, the patient’s body may reject the new organ. Rejection is a situation where the patient’s body does not accept the newly implanted organ and fights it off. Rejection is dangerous to the patient because the body puts the new organ in the same category as viruses and bacteria. Our bodies fight pathogens such as bacteria by producing antibodies which kill the pathogens. The same thing happens to the new organ, the body interprets it as a pathogen and produces antibodies to attack the new organ. Powerful immunosuppressant are used to reduce the level of antibodies so that the organ gets enough time to integrate with the body and start functioning as the previous organ.

Allocation of the available organs

The shortage of the organs needed for transplant procedures necessitates the development of a method that would result in the ethical distribution of the inadequate resource. A concept referred to as distributive justice which talks about fair distribution of resources has been considered by many. The theory states that there are different ways in which a person can be considered eligible for transplant. It further suggests that the criteria employed when a person offers his organs to a particular individual over another is broad and as long as the donor can justify the allocation in any way, the donated organ will be allocated according to the wishes of the donor. The possible criteria used by the theory include equal share; according to merit, effort, contribution, free-market exchanges, and need. Many people are in support of the equal share criteria which depends on the duration in the waiting list according to the First Come First Serve (FCFS) method and age (that is the youngest to oldest). The supporters of equal access believe that the procedure is worthy and every needy person should have equal access to the procedure. The equal access policy suggests that the distribution of the donor organs should not be based on race, the level of income, sex, geographical separation from the donated organ, social and medical worthiness biases. Social worthiness refers to a patient’s position in society and his future contributions to humanity. Therefore, prisoners and the disabled would be left out. Medical worthiness refers to the patients’ health before allocating him an organ. A person whose lifestyle contributed to the failure of the organ would not be considered. Lifelong smokers and alcohol drinkers would be affected by the criteria.

Another distributive justice criteria used is called maximum benefit. The aim of this criteria is to maximize the rate of success of organ transplants so that none of the valuable resource goes to waste. This method depends on two factors. The sickest people and the patients who are likely to live longer than the other patients are prioritized. The supporters of this criteria consider efficiency above all the other factors. They believe that donor organ should not be wasted on patients who would not benefit the most. The additional number of years a transplant patient lives after receiving an organ transplant determines the success rate of the process. The longer the life years gained, the more successful the transplant. The maximum benefit theory is opposed by three arguments. The first argument is that the criteria provide a loophole for malicious people to advance their interest due to the subjective nature of the criteria. Therefore, the distribution of the organs will be affected by lying and favoritism more than the other criteria suggested for organ allocation. The second argument suggests that it is difficult to determine whether a transplant will be successful because a successful transplant can vary. The third argument is put forward by ethicists who are in direct opposition of using age as a factor to allocate donor organs. The maximum benefit criteria suggest that younger patients should be considered before old ones, thereby devaluing the lives of older people. According to the ethicist, regardless of the age of patients, if they are not allocated donor organ, they will still lose the rest of their lives. Each single life is valuable to everyone. Organ distribution in the United States currently depends on the criteria established by each transplant center. The UNOS directs the transplant centers to use the following criteria while distributing the organs; probability of success, medical need and the time spent on the waiting list.

Organ procurement

Donated organs from cadavers are accessed to determine whether they are suitable for transplant. The collected data on transplantation practice and donation is used as a reference when assessing the organs donated based on organ and donor characteristic. The criteria used is found in TSANZ (Transplantation Society of Australia and New Zealand) Clinical guidelines for donor organs retrieved from diseased donors. The donors’ medical history is accessed to determine whether they had any chronic diseases. The cause of death- that is the final illness that caused the death of the potential donor is also determined. The risk level of transmission of hepatitis B, hepatitis C, HIV and other infectious diseases are also analyzed before procurement. The donated organ is also checked for factors that are related to the viability of the donor organ. These factors include the preservation methods used to protect the organ from damage and the donation pathway (following circulatory death). In a situation where the donated organ is from a person who died from circulatory death, clinical interventions which maintain and support organ viability before the person dies are employed (Howard & Cornell). The interventions are supported provided that they comply with the guidelines outlined in TSANZ. The associated risks and benefits of the available donor organs vary. The procured organ is analyzed according to the risk-benefit ratio. The risk-benefit ratio should be as small as possible. Fortunately, only a small number of donated organs do not meet the criteria. The risk benefit ration to a patient is categorized into a large range that spans from optimal outcomes to a minor but essential benefit (Howard & Cornell). The number of years that can be gained by the recipient is a crucial factor in a situation where the recipient would net get optimal outcomes. It is argued that the recipient is better off gaining a few more years than none at all. Transplants are risky processes that require comprehensive survey and analysis to determine the level of the risk the gains achieved. The risks include transmission of infection and malignancy or poor organ survival. It is crucial to weigh the different recipient and donor factors that affect transplants including the urgency of need, benefits that can be derived from the transplant, subsequent organ offers, gradual worsening of the health of a recipient and the duration a patient spends in the waiting pool (Howard & Cornell).

Donation process

According to the Canadian Medical Association (CMA), a coordinated, comprehensive and sustained International strategy concerning tissue and organ donation should be done by involving all the stakeholders. The need to cooperate and consult with all the relevant parties is essential for the procurement of organs and tissues in an ethical manner. The CMA promotes awareness programs by urging governments to contribute in advertising to their citizens about organ donation and transplant so that each potential donor and recipient has enough knowledge to make informed decisions. Donor registration programs are also promoted, and typical registration drives include connecting donor registration to the driver license renewal. In Canada, citizens are given an opportunity to decide whether to donate their organs by providing an ethical procedure that can be followed if one decides to donate (Canadian Medical Association, 2014). Awareness is a crucial factor in the donation drive because it enables potential donors to be aware by conducting public campaigns and media awareness. Doctors treating patients who are about to die should advise the patients on the possibility of donating their organs upon their death. The doctors then have to be compensated or given a bonus to encourage them to continue discussing tissue and organ donation with their patients. In many countries, the law enables a relative to donate their organs to their sick relatives willingly, and in this case, the patient is given priority over other patients (Simpson, 2012). The CMA does not support presumed consent which refers to the situation where there is no evidence of a donor’s explicit will to donate his organs. The policy is not recommended because of the absence of a comprehensive discussion in the society on the policies of “mandated choice and “Presumed Consent.” Informed consent and patient autonomy mat be interfered with by the two policies on choice and consent (Canadian Medical Association, 2014).

The CMA promotes the creation of a list of citizens who have considered donating organs. The national donor registry is a list of the potential donors, and it is frequently updated. For the continued success of the registry, the individual privacy of each person in the registry should be ensured. Also, the individual should be given full access to the information stored about his health, and he should be given the power to determine the disclosure of his record and control the collection process. Each person who is in the registry must be well informed and aware of all factors before making decisions and that people should be aware that the withdrawal from the registry is accepted and can easily be done (Simpson, 2012). The protocols and policies to procure tissues and organs from donors must be based on providing all the relevant information to a potential donor such as patient’s wishes on how their organs should be handled in the event of death. The wishes of the deceased donor must be given the respect they deserve because human life is valuable to everyone. Organ donation from living donors to close relatives and family members is considered ethical and thus accepted. It is unethical for a donation to be directed toward a specific class or group. Living donors should not be coerced into making decisions. Therefore, people who are not able to make informed decisions are not considered for the donation of tissues or organs, but under certain protocols, the policy is ignored (Canadian Medical Association, 2014).

Donation of an organ after cardiac death (DCD)

This donation process was restarted again due to the shortage of donor organs and the need to fulfill the wishes of individuals who would have wanted to donate their organs even when the course of death is due to cardiac death. In this scenario, the organs of the dying person are preserved before the declaration of death is done that is when the person is still medically alive. However, the retrieval of the organ before the person dies introduces ethical concerns especially if the retrieval of the organs would result in the death of the patient. Therefore, the practice does not honor the donor rule which states that “individuals must not be killed by organ retrieval.” A section of the stakeholders is in agreement that DCD can contravene the rule if the death is as a result of the irreversible loss of specific functions of the body (Simpson, 2012).

Transplant Issues

Adults who have impaired decision-making capacity

A person who is capable of acquiring information, understanding it and can intellectually make an informed decision is qualified to give consent on matters concerning his health, life, and body. The presumption that adults who are intellectually retarded or are mentally ill are in no position to make a decision concerning their lives is unfounded, wrong and unethical. A situation in which an adult is not able to make his own decisions, there should be a person who will make the decisions on his behalf, the person is either a relative or a close friend if there are no surviving relatives (Consolo & Wigmore, 2014). The person who represents the transplant patient is involved in every decision and step to be taken, and he or she is advised accordingly. The extent of the involvement is determined by the level of the incapacity of the patient, whether the disability is permanent, intermittent, partial or temporary. Even if the patient is incapable of making decisions, he should be involved in the process in whatever means possible by encouraging and providing the required information using techniques that are unique to the transplant patient (Consolo & Wigmore, 2014).

Children

It is crucial for the children who are receiving organ transplant to be informed of all the relevant information pertaining organ transplant, the risks involved, benefits and be involved in the decision-making process. Older children have increased brain development which enables them to understand the information on donation and transplant and make decisions that can be accepted by transplant agencies (Marcus, 2016).

Adolescents

Most adolescents are not mature enough to make a serious decision on the proposed transplant procedure. Despite the immaturity, adolescents should be given an opportunity to take part in decision making, be helped to understand what is being proposed and be able to give consent independently. The adolescents’ age varies, and some teenagers are more mature and aware of the situation than others, and thus the eligibility of a teenager should be subjective. Sometimes a teenager may refuse organ transplant and to cater for such response; vigorous assessment criteria should be developed to determine their ability to deny treatment which may also involve a tribunal or court to deliberate on the legalities involved. Therefore, issues of inclusion and decision making are sensitive and there is no defined way to tackle this issues due to the ethical and legal constraints that are unclear (Marcus, 2016).

Conclusion

The shortage of donor organs has created a situation where many people have been deemed eligible to receive a transplant, but due to a large number of recipients, most of them will not receive a transplant. In some cases, some recipients are lucky enough to be alive by the time they are allocated an organ, but at that time, the disease has progressed to the point where the patient will not benefit from a transplant. The ethical practice dictates that the organ has to be re-allocated to another person. Therefore, many patients’ lives are at risk and the ethical and legal issues put in place do not end up helping most of the transplant patients. Despite the challenges witnessed in the system currently employed in organ transplants, there is the need for the organ transplantation and allocation to be done by adhering to values and ethical principles. The policies and decisions on transplantation and allocation of organs should be transparent and robust. Also, the decision-making process should seek to balance the need to responsibly direct the allocation of organs and the needs of the patients who are supposed to benefit from a transplant.

References

Canadian Medical Association. (2014). Organ and Tissue Donation and Transplantation. Ottawa: Canadian Medical Association.

Consolo, H. K., & Wigmore, S. J. (2014). Ethical and legal issues associated with organ donation and transplantation. Elsevier, 32(7), 333-337. https://doi.org/10.1016/j.mpsur.2014.04.015.

Howard, R. J., & Cornell, D. L. (2016). Ethical Issues in Organ Procurement and Transplantation. Dr. Peter A. Clark (Ed.), InTech, DOI: 10.5772/64922. Available from: https://www.intechopen.com/books/bioethics-medical-ethical-and-legal-perspectives/ethical-issues-in-organ-procurement-and-transplantation.

Jonsen, A. R. (2012). The Ethics of Organ Transplantation: A Brief History. AMA Journal of Ethics, 14(3), 264-268.

Marcus, A. D. (2016). The Difficult Ethics of Organ Donations From Living Donors. The Wall Street journal, https://www.wsj.com/articles/the-difficult-ethics-of-organ-donations-from-living-donors-1466993281.

National Health and Medical Research Council. (2016). Ethical guidelines for organ transplantation from deceased donors. Canberra: Australian Government Organ and Tissue Authority.

Simpson, P. J. (2012). What are the issues in organ donation in 2012? British Journal of Anaesthesia, 108(1), 3-6. https://doi.org/10.1093/bja/aer352 .