Organ donation

This is a background article See

Organ donation is the removal of specific tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting or grafting them into other persons. Organs and tissues are removed in procedures similar to surgery, and all incisions are closed at the conclusion of the surgery. People of all ages may be organ and tissue donors. See the entry "organ transplant" for discussion of the mechanics and history of organ transplantation.

In numerical terms, donations from dead donors far outweigh donations by living ones. The laws of different countries allow either the potential organ donor to consent or dissent to the donation during his life time, or his relatives to consent or dissent. Due to these different legislative possibilities, the number of donations per million people varies substantially in different countries.

Organs and tissues which can be donated
Organs that can be donated include: the heart, intestines, kidneys, lungs, liver, pancreas. The following tissues can be grafted: bones, corneas, femoral veins, great saphenous veins, heart valves, skin grafts, small saphenous veins, tendon. Organs that can be donated from living donors include the lung, partial liver and the kidney.

Legislation regarding organ donation
There are basically four different legislative approaches to the regulation of organ donation. The most restrictive is the "consent solution", according to which the donor has to explicitly consent to a donation during their lifetime. The "extended consent solution" includes the possibility of near relatives consenting to the donation, if the donor has not explicitly dissented. The least restrictive approach is the "dissent solution", according to which the donor has to explicitly dissent to donation during his lifetime. According to the "extended dissent solution", relatives may dissent in the event the potential donor has not consented.

The different legislative approaches are the main reason that countries like Spain (27 donors per million inhabitants) or Austria (24 donors per million inhabitants) have higher "donor rates" than Germany (13 donors) or Greece (6 donors). In most countries with the dissent solutions, there is no "waiting list" for donations, or the list is short, while most countries with consent solutions have substantial "organ shortfalls".

Under United States law, the regulation of organ donation is left to states within the limitations of the federal National Organ Transplant Act of 1968. Each state's Uniform Anatomical Gift Act seeks to streamline the process and standardize the rules among the various states, but it still requires that the donor make an affirmative statement during her or his lifetime that she or he is willing to be an organ donor. Many states have sought to encourage the donations to be made by allowing the consent to be noted on the driver's license. Still, it remains a pure consent system rather than an extended consent system or even a dissent opt-out system. Curiously, though, relatives can still dissent even in the presence of evidence of explicit consent by the potential organ donor (driver's liscence, living will, registry information, etc.). As such, many organ donation campaigns in the United States encourage family communication about one's decision to donate or not to donate.

Bioethical issues in organ donation
Since the mid-1970s, bioethics, a relatively new area of ethics, has emerged at the forefront of modern clinical science. Many philosophical arguments against organ donation stem from this field. Generally, the arguments are rooted in either deontological or teleological ethical considerations.

Deontological issues
Pioneered by Paul Ramsey and Leon Kass, few modern bioethicists disagree on the moral status of organ donation. Certain groups, like the Roma ("gypsies"), oppose organ donation on religious grounds, but most of the world's religions support donation as a charitable act of great benefit to the community. Issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur. In issues relating to public health, it is possible that a compelling state interest overrules any patient right to autonomy.

From a philosophical standpoint, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definition of life, death, human, and body is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for harvesting is an ongoing problem in clinical bioethics.

Further, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own. Cloning is still a controversial topic, more so when the clone is created with the express purpose of being destroyed for harvesting. While the benefit of such a cloned organ is a zero-percent chance of transplant rejection, the ethical issues involved with creating and killing a clone may outweigh these benefits.

A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation, or the transfer of animal (usually pig) organs into human bodies, promises to eliminate many of the ethical issues while creating many of its own. While xenotransplantation promises to increase supply of organs considerably, the threat of organ transplant rejection coupled with the general anathema to the somewhat alien idea decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.

Teleological issues
On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. In so far as those that donate organs are often impoverished and those that can afford black market organs are typically well-off, it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time &mdash; many die while still on a waiting list.

Organ donation is fast becoming an important bioethical issue from a social perspective as well. While most first-world nations have a legal system of oversight for organ transplantation, the fact remains that demand far outstrips supply. Consequently, there has arisen a black market often referred to as the transplant trade outside of the United States.

The issues are weighty and controversial. On the one hand are those who contend that those who can afford to buy organs are "exploiting" those who are desperate enough to sell their organs. Many suggest this results in a growing inequality of status between the rich and the poor. On the other hand are those who contend that the desperate should be allowed to sell their organs, and that stopping them is merely contributing to their status as impoverished. Further, those in favor of the trade hold that "exploitation" is morally preferable to "death," and insofar as the choice lies between abstract notions of "justice" on the one hand and a dying person desperately in need of an organ on the other hand, the organ trade should be legalized.

Legalization of the organ trade carries with it its own sense of "justice" as well. Continuing black-market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade would lead to increased supply, lowering prices so that the poor might be able to afford such organs as well.

Exploitation arguments generally come from two main areas:


 * Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor.


 * Financial exploitation suggests that the donor (especially in the Indian subcontinent and Africa) are not paid "enough." This argument generally relies upon the assumption that there exists some financial amount that does indeed constitute "enough," but that the donors in question are not receiving this amount of money in return. Some evidence suggests that in an operation for a kidney the transplantee pays $125,000 USD. Of this, $20,000 is received by the donor, $40,000 is paid to a private hospital, $10,000 goes on flights and accommodation. This leaves the broker with a profit of $55,000. Some would suggest the donors are not receiving enough and hence are exploited. Other evidence describes brokers as only receiving $10,000. The high prices and profits may be partly attributed to the black-market status of the transaction.

If, however, neither of the above arguments are valid, the act generally cannot be condemned on a utilitarian basis. Still, the issue remains controversial.

Political issues
There are also controversial issues regarding how organs are allocated between patients. For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes.

Healthy humans have two kidneys, a redundancy that enables living donors (inter vivos) to give a kidney to someone who needs it. The most common transplants are to close relatives, but people have given kidneys to other friends. The rarest type of donation is the undirected donation whereby a donor gives a kidney to a stranger. Less than a few hundred of such kidney donations have been performed. In recent years, searching for "good Samaritan" donors via the internet has also become a way to find life saving organs.

The Spanish transplant system is one of the most successful in the world, but it still can't meet the demand, as 10% of those needing a transplant die while still on the transplant list. Donations from corpses are anonymous, and a network for communication and transport allows fast extraction and transplant across the country. Under Spanish law, every corpse can provide organs unless the deceased person expressly rejected it. Nonetheless, doctors ask the family for permission, making it very similar in practice to the United States system.

Organ shortfall
A persistent issue relating to organ donation is the scarcity of organ donors relative to the number of potential recipients on organ donation waiting lists. In the United States, the waiting list is quoted to be about 94,000 people long. It is not uncommon for those on the waiting list to die before receiving a suitable organ.

Approaches to addressing this shortfall include:
 * donor registries and "primary consent" laws, to remove the burden of the donation decision from the legal next-of-kin
 * monetary incentives for signing up to be a donor
 * an opt-out system ("dissent solution"), in which a potential donor or its relatives must take specific action to be excluded from organ donation, rather than specific action to be included
 * social incentive programs, wherein members sign a legal agreement to direct their organs first to other members who are on the transplant waiting list

Reasons for not consenting to be a donor
A 1999 report on donor intention compiled by the Australian Bureau of Statistics (as reported in CHOICE magazine) gave a list of reasons Australians provided for not becoming a donor. The list includes concern about being too old or too young; concern that an illness might cause a problem; concern about disfigurement of the body, causing problems for a funeral; concern about religious views; concern about organ recipient and anonymity; concern that the donor's family will have to bear costs; concern that the prospective donor might not receive the best possible medical care because of the donation agreement; and concern that the prospective donor might not be dead.

Responses were given regarding each of the above listed items, explaining that age, illness, and (usually) religion should not prevent someone from being a donor. The article goes on to assure that there is no cost to the family for procedures and treatments related to the donation after death is certified, and that anonymity would be preserved for both donor and recipient. The article further stated that "[h]ospital staff [in Australia], particularly in intensive care, are dedicated to saving [lives and have] nothing to do with donation agencies or transplant teams until brain death is confirmed", and it clarified that organ donation does not involve disfigurement of the human body.