Death is often an unpleasant thought, even though it is a simple fact of life. For some it is a welcome event that can alleviate pain and suffering and can sometimes save the life of another. A simple decision to become an organ donor can save lives and improve the quality of life of recipients. Receiving a needed organ facilitates a restoration of physiological functioning and often means the difference between life and death. Many people have misconceptions regarding organ donation and simply do not understand the facts. Some do not realize the vast numbers on waiting lists and how simply becoming a donor could save the life of another. Others may be apprehensive about making a decision about their bodies after death. In this paper we explain the origins and history of organ donation, the process by which organs are donated, the ethical implications behind organ donation and discuss many of the proposed solutions to solve the organ shortage issue.
HISTORY OF ORGAN DONATION
The origins of organ donation arose with several experimental transplants. The first successful transplant was a bone transplant in 1878, which used a bone from a cadaver. (14) Experimentally, bone marrow transplants began by giving patients bone marrow orally after meals to cure leukemia. This had no effect, but later when they used intravenous injections to treat aplastic anemia, there was some effect (14). One development that largely aided organ donation was the discovery of blood groups in the early 20th century. The first recorded kidney transplant was in 1909 and was a rabbit kidney inserted into a child suffering from kidney failure. The child died after two weeks (8). The first human to human kidney transplantation was in 1936 and failed. The first successful kidney transplant wasn’t until 1954 and was between two identical twins. Soon after, heart transplants began, but originally consisted only of valves and arteries (8). The emergence of bioethics came about in the 1960’s and became at the core of transplantation issues. It wasn’t until 1967 that the first successful heart transplant took place. With this new development, the donor card was established as a legal document the next year (8). In 1984, National Organ Transplant Act was passed; this established the Organ Procurement and Transplant Network. This fundamentally guaranteed fairness in distribution of donated organs (5). Three years later a new drug to suppress the immune system was developed. It was not approved until 1994.
Technology for organ donation has come along way. Science has even been able to transplant a full hand. Many articles suggest that the future of transplantation is stem cells. That is in using stem cells to grow tissue and organs. Many researchers are also studying how to use genetically modified animals for transplantable organs. So why is it so important to develop other ways to receive organs? Why then are we still researching this area? The largest difficulty with Organ Donation is the immense shortage. As of November third of this year, there are 100,372 people on the waiting list for organ donation, in the United States (13). Approximately one person is added to that list every 11 minutes (9). It is also estimated that on average, between 16 and 17 people die per day due to lack of an organ transplant (1). Some studies indicate that rate may be higher. The rough facts are that they don’t need to. It is estimated that 10,000 to 14,000 people who die each year qualify for organ donation, but less than half of them become donors (1). In 2001, 2,025 kidney patients, 1,347 liver patients, 458 heart patients and 361 lung patients died waiting for organ transplants due to the shortage of organ transplantation (1). These numbers include young people; nearly 10 percent waiting for liver transplants are under 18 years of age (1).
PROCESS OF ORGAN DONATION
There are many steps to take during the organ donation process. The procurement process differs for the type of organ being donated, and whether or not the donor is living. For a deceased donor, the organs and tissues that are in good condition are removed in a surgical procedure and all incisions are closed so an open casket funeral can take place. After the organs have been removed, the patient is taken off artificial support. Organs must be used between 6 and 72 hours after removal from the donor’s body (depending on the organ), tissues such as corneas, skin, heart valves, bone, tendons, ligaments, and cartilage can be preserved and stored in tissue banks for later use.
Some organs and tissues can be donated while the donor is alive. Living individuals can donate one of their two kidneys and the remaining kidney provides the necessary function needed to remove waste from the body. Single kidney donation is the most frequent living donor procedure. A living donor can donate one of two lobes of their liver. This is possible because liver cells in the remaining lobe regenerate until the liver is almost its original size. Living donors can also donate a lung or part of a lung, part of the pancreas, or part of the intestines. Although these organs do not regenerate, both the donated portion of the organ and the portion remaining with the donor are fully functioning. Surprisingly, it is also possible for a living person to donate a heart, but only if he or she is receiving a replacement heart.
Tissues donated by living donors are blood, marrow, blood stem cells, and umbilical cord blood. A healthy body can easily replace some tissues such as blood or bone marrow. Blood is made up of white and red blood cells, platelets, and the serum that carries blood cells throughout the circulatory system. Bone marrow contains stem cells. In addition, stem cells found in circulating blood in adults and from the umbilical cord of a newborn also can be donated. Both blood and bone marrow can even be donated more than once since they are regenerated and replaced by the body after donation.
Each potential living donor is evaluated to determine his or her suitability to donate. The evaluation includes both the possible psychological response and physical response to the donation process. This is done to ensure that no adverse outcome, either physically, psychologically, or emotionally, will occur before, during, or following the donation. Generally, living donors should be physically fit, in good health, between the ages of 18 and 60, and not currently have or have had diabetes, cancer, high blood pressure, kidney disease, or heart disease.
After death, a person can choose to donate their whole body to a medical school or other scientific research facility. People who wish to donate their entire body to medical science should contact the medical school or willed body program of their choice and make arrangements to do so before they die. Medical schools need bodies to teach medical students about anatomy, and research facilities need them to study disease processes so they can devise cures. Since the bodies used for these purposes generally must be complete with all their organs and tissues, organ donation is not an option. Some programs, however, make exceptions. A person making this decision can inform their family that organ donation is the first choice, but if it is found that the organs are not medically suitable for organ donation, the family can carry out the wishes for whole body donation.
To begin the transplantation process, those in need of organs are placed on a registry list. All patients accepted onto a transplant hospital’s waiting list are registered with the United Network of Organ Sharing (UNOS) Organ Center, where a centralized computer network links all organ procurement organizations (OPOs) and transplant centers. Staffed 24 hours a day throughout the year, the Organ Center assists with the matching, transporting, and sharing of organs throughout the U.S.
When donor organs are identified, the procuring organization typically accesses the UNOS organ matching system, enters information about the donor organs, and runs the match program. For each organ that becomes available, the program generates a list of potential recipients ranked according to objective criteria (i.e. blood type, tissue type, size of the organ, medical urgency of the patient, time on the waiting list, and distance between donor and recipient). Ethnicity, gender, religion, and financial status are not part of the computer matching system. The procurement coordinator contacts the transplant surgeon caring for the top-ranked patient to offer the organ. If the organ is turned down, the next listed individual’s transplant center is contacted, and so on, until the organ is placed.
Once the organ is accepted for a potential recipient, transportation arrangements are made for the surgical teams to come to the donor hospital and surgery is scheduled. For heart, lung, or liver transplantation, the recipient of the organ is identified prior to the organ recovery and called into the hospital where the transplant will occur to prepare for the surgery. The recovered organs are stored in a cold organ preservation solution and transported from the donor to the recipient hospital. For heart and lung recipients, it is best to transplant the organ within six hours of organ recovery. Livers can be preserved up to 24 hours after recovery. For kidneys and typically the pancreas, laboratory tests designed to measure the compatibility between the donor organ and recipient are performed. A surgeon will not accept the organ if these tests show that the patient’s immune system will reject the organ.
The role of the organ procurement organization (OPO) is very important in the matching process. OPOs become involved when a patient is identified as brain dead and is therefore a potential donor. The OPO coordinates the logistics between the organ donor’s family, the donor organs, the transplant center, and the transplant candidate. OPOs provide organ recovery services to hospitals located within designated geographical area of the U.S. OPOs are non-profit organizations and are members of the OPTN. Each has its own board of directors and a medical director on staff who is usually a transplant surgeon or physician. OPOs employ highly trained professionals called procurement coordinators who carry out the organization’s mission. From the moment of consent for donation to the release of the donor’s body to the morgue, all costs associated with the organ donation process are billed directly to the OPO.
Organ donation and transplantation carry with them some unique ethical implications. According to Veatch, “it is clear that choosing an ethical principle [to guide decisions in organ donation and transplantation] determines some very practical matters, including who lives and who dies” (15). There are many elements of organ donation and transplantation that create ethical dilemmas. The difficult resolution of these questions is largely attributed to the discrepancy between the number of potential recipients and the scarcity of available organs. Issues related to organ donation create a number of unique and intriguing challenges that are not easily resolved.
Along with the allocation of organs, there are myriad ethical considerations when dealing with organ donation, procurement and transplantation. Some of these other considerations include variations in, and the standardization of, the definition of death, ethical differences between living and deceased donors, transplant tourism, the buying and selling of organs and xenotransplantation (cross-species transplantations). Each of these presents unique circumstances that need to be considered and addressed. This issue touches every level of society regardless of socioeconomic status or any other dividing factor. Everything from the black market of human organs to animal rights creeps into ethical decisions of this type. There is no easy way to make these choices, especially those that often mean the difference between life and death. Numerous ethical models are used to support and detest certain practices regarding organ allocation. The most pervasive ethical theories that guide decision making are social utility and justice.
Social utility is a principle based on the maximization of social utility. It holds that those who will receive the most social benefit should receive the organ. Social utility favors the best HLA (Human Leukocyte Antigen) match. The consideration of the likelihood of success based on donor-recipient compatibility is of utmost importance in this view. Also, this is generally the preferred guiding principle of medical professionals. Because of the availability of immunosuppressive drugs, the difference between poor matches and good matches is marginal at best (15). Because of the negligible difference between good and poor HLA matches, many people assert that justice should be the guiding ethical principle in allocating organs.
The view that everyone should be treated equally, regardless of the odds for a successful transplant, is called justice. It is often favored because skewed donor demographics can reduce a person’s chance of receiving organs based on a good HLA match or other genetic differences (race, gender etc.). Those in favor of justice advocate equal access based on criteria such as blood type and time on the recipient waiting list. Proponents of the justice approach are often non-physician decision makers who try to focus on fairness instead of medical or social benefit. How can seemingly conflicting ethical principles be considered and applied? What is the best course of action?
Ethics committees for organizations such as UNOS try to combine ethical principles when making organ allocation decisions. In his book, The Basics of Bioethics, Veatch asserts that ethics committees “endorsed a policy of giving half the weight in the allocation to considerations of medical utility and half the weight to considerations of justice” in order to appease both parties (15). Finding an effective and universal method for making ethical decisions that will please everyone is unlikely because of the discrepancy between general policy and individual cases. Unfortunately, not everyone will be treated fairly all the time or agree with policies in which only generalizations can be made because of personal biases and experiences. Therefore, committees such as the UNOS Ethics Committee do not review individual cases, but focus on general policy instead. Ethics committees must do the best they can to be fair and provide social utility simultaneously.
SOLUTIONS FOR THE SHORTAGE
Despite the advances in medicine and technology, the demand for organs drastically outnumbers the number of organ donors. According to The United Network for Organ Sharing (UNOS) the chronic shortage of organ donors is the most critical issue facing the field of organ transplantation.
The current approach to acquiring organs for transplantation relies on the voluntarism of live donors and the altruism of deceased donor families. Increased educational expenditures have frequently been used as a way of motivating people to become donors. The Organ Procurement Organizations (OPOs) have launched substantial promotional campaigns. The campaigns have been designed to both educate the general public about the desperate need for donated organs and educate physicians and critical care hospital staff regarding the identification of potential deceased donors. Over the years, a substantial sum has been spent on these types of educational activities. Recent evidence, however, suggests that further spending on these programs is unlikely to increase supply by a significant amount.3 As a result, there are many new proposed solutions to solve the organ shortage problem.
One of the most controversial proposals is to provide individuals with some type of incentive to become a donor. It is currently illegal to compensate donors or their families for organ transplantation. The National Organ Transplant Act (NOTA) of 1984 states: “It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation. “ Due to the increasing shortage of organs many groups, including The American Medical Association, The American Society of Transplant Surgeons, and The United Network for Organ Sharing, have come out in favor of testing financial compensation. Financial incentives can be divided into forward looking approaches and on the spot approaches.
Forward approaches involve offering some type of incentive for people to become part of an organ donor registry so that if they die under circumstances where they can donate, their organ will be recovered. An advantage of this type of approach is that the donor is in control, taking the burden off the family to have to make a decision in that most difficult situation.
On the spot incentives would be offered only to the families of people who are suitable deceased donor candidates. The American Society of Transplant Surgeons has said that it would be ethically acceptable to offer to make a charitable contribution on behalf of the deceased donor to cover the funeral expenses.2 This kind of payment could be given as a way of saying thanks for the sacrifice the family has made, and would be similar to the death benefit offered to families of servicemen who die in the line of duty.
It is impossible to know in advance what effect such polices would have on increasing organ supply. One of the greatest objections to financial incentive plans is that they risk creating tensions and divisions between surviving family members at the bedside about whether or not to take the money; and that it changes the character of organ procurement from “giving” to “selling.” 4 Critics also argue that payments for organ donation could lead to a black market for human organs.
Reciprocity plans are another approach to motivate people to donate their organs. One such proposal is a “no- give, no- take” policy. Under this system, in order to receive an organ you must have previously signed your organ donor card. A variant of this plan could be implemented within the current point system. Organs are currently allocated according to a point system which is based on factors such as quality of life, match between donor and recipient, or the amount of time a recipient has been on the waiting list. Under this type of plan, those who have previously signed their organ donor card would receive extra points that would move them higher up on the list.
Another proposal is to reverse the current system in which doctors must obtain a patient’s (or his or her family’s) consent in order to remove organs after death. Under this policy, known as “presumed consent”, all patients would be presumed to want to become organ donors unless explicitly stated otherwise. This approach is followed in different forms in several European countries and has had varying levels of success. While it has resulted in significant increases in organ donation rates in Austria, Belgium, France and Spain, other countries that have presumed consent laws such as Switzerland, Greece, and Italy have organ donation rates that are lower than those of many voluntary consent” countries. This type of proposal has consistently been met with opposition on the grounds that it violates an individual’s right to make medical decisions for them self. Critics of presumed consent also warn that there may be a public backlash against organ donation as a result. They state that individuals may be more likely to donate if they feel free to exercise a choice rather than being compelled to do so by the law.
Less extreme approaches to presumed consent are “mandated choice” or “required response” policies. Rather than waiting for people to volunteer for organ donation, hospitals or government organizations could require individuals to state their preference about organ donation when they get their driver’s licenses or file tax returns. Their wishes would be considered legally binding unless they had a documented change of mind before actually dying. In 1991, Texas enacted a law requiring citizens to make a “yes” or “no” choice about organ donation when they renewed their driver’s license. The law had to be repealed in 1997 because the implementation of the mandatory choice resulted in a refusal rate of 80%. This high rate of refusal was attributed to the lack of public education about organ donation.(16)
Researchers are also working on developing artificial organs. As of February 2002, five people have received fully self –contained artificial hearts. The artificial heart has rarely been used because it is still highly experimental and because recipients must be willing to have their own heart removed. Although there are many technical hurdles to overcome in the field of artificial organs, researchers are hopeful. Various laboratories in the United States and around the world are developing artificial hearts, lungs, livers, and pancreases.
Perhaps the simplest approach to significantly reducing the demand for organ transplantation would be the sustained, committed, long-term emphasis on disease and injury prevention. Preventing disease before it begins would shrink the number of people on transplant waiting lists and reduce the demand for human organs. However, there is reason to doubt that these measures would have a significant impact. Preventive medicine cannot ultimately stop the natural aging of the body, which leads to organ failure. Also, many Americans will not follow the strict regimen of diet and exercise necessary to get and stay healthy, and even for those who change their ways, the disease processes set in motion by years and decades of poor health habits are often not readily reversible. In light of these constraints, we can expect only so much from preventive medicine.
Most people do not consider what happens to their bodies after death, so they do not often think about organ donation. They do not consider that after their own death they can save others from reaching the same fate prematurely. A simple decision about giving away organs no longer needed for a lifeless body can save lives, restore lost body function, and improve the quality of life.
1. “25 Facts About Organ Donation and Transplantation.” United States House of Representatives. February 2002. Congressional Kidney Caucus. 4 November 2008. http://www.house.gov/mcdermott/kidneycaucus/index.html.
2. Arnold, R. et al. 2002. Financial Incentives for Cadaver Organ Donation: An Ethical Reappraisal. Transplantation 73 (8):1361-67.
3. Beard, T. Randolph, John D. Jackson, and David L. Kaserman. “The Failure of U.S. Organ Procurement Policy.” Regulation Winter 2008: 22-30.
4. Crowe, Sam. “Increasing the Supply of Human Organs: Three Policy Proposals” http://www.bioethics.gov/background/increasing_supply_of_human_organs.html
5. “Donation and Transplantation.” The Organ Procurement and Transplantation Network. 3 November 2008 http://www.optn.org/about/.
6. Etzion, Amitai . “Organ Donation: A Communitarian Approach.” The Communitarian Network. 1 November 2008. http://www.gwu.edu/~ccps/Organ_Donation.pdf.
7. Guy, Bonnie S and Aldridge, Alicia. “Marketing Organ Donation Around the Globe,” Marketing Health Services [Winter 2001]: 31).
8. “History of Organ Transplantation.” New York Organ Donor Network. 12 November 2008 http://www.donatelifeny.org/transplant/organ_history.html.
9. Howards, Lawrence A.. “Ethics of organ donation.” Milwaukee Journal Sentinel. 20 June 1999. 7 November 2008 http://www2.jsonline.com/alive/column/jun99/howards62099.asp.
10. Sundwall, David N. “Utahns committeed to organ donation .” Deseret news 17 January 2008 12 November 2008 http://www.deseretnews.com/article/1,5143,695244690,00.html.
11. Torr, James D. “Introduction.” At Issue: Organ Transplants. Ed. James D. Torr. San Diego: Greenhaven Press, 2002. August 2004. 4 November 2008. http://www.enotes.com/organ-transplants-article/38952
12. Truog, Robert. “The Ethics of Organ Donation by Living Donors.” The New England Journal of Medicine. 2005 Aug 4;353(5):444-6.
13. “Types of Donation.” Department of Health and Human Services. 15 November 2008
14. “Understanding Donation.” Donate Life America. 12 November 2008 http://www.donatelife.net/UnderstandingDonation/Statistics.php.
15. Veatch, Robert M. The Basics of Bioethics, Second Edition. Upper Saddle River, NJ: Pearson Education, Inc., 2003, 2000.
16. Verheijde, Joseph L., Rady, Mohamed Y., and McGregor, Joan. “Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation.” PubMed Central 22 May 2007. 7 November 2008. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17519030#B64.