Organ transplantation

Organ transplantation
Intervention

Saints Cosmas and Damian miraculously transplant the (black) leg of a Moor onto the (white) body of Justinian. Ditzingen, 16th century

ICD-10-PCS

0?Y

MeSH

D016377

Organ transplantation an organ from one body to another or from a donor site on the patient's own body, for the purpose of replacing the recipient's damaged or absent organ. The emerging field of regenerative medicine is allowing scientists and engineers to create organs to be regrown from the patient's own cells (stem cells, or cells extracted from the failing organs). Organs and/or tissues that are transplanted within the same person's body are called autografts.

Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source. Organs that can be transplanted are the heart, kidneys, liver, lungs, pancreas, intestine, and thymus. Tissues include bones, tendons (both referred to as musculoskeletal grafts), cornea, skin, heart valves, and veins. Worldwide, the kidneys are the most commonly transplanted organs, followed closely by the liver and then the heart. The cornea and musculoskeletal grafts are the most commonly transplanted tissues; these outnumber organ transplants by more than tenfold. Organ donors may be living, or brain dead. Tissue may be recovered from donors who are cardiac dead up to 24 hours past the cessation of heartbeat. Unlike organs, most tissues (with the exception of corneas) can be preserved and stored for up to five years, meaning they can be "banked". Transplantation raises a number of [[issues, including the definition of death, when and how consent should be given for an organ to be transplanted and payment for organs for transplantation.[1][2] Other ethical issues include transplantation tourism and more broadly the socio-economic context in which organ harvesting or transplantation may occur. A particular problem is organ trafficking.[3] Some organs, such as the brain, cannot yet be transplanted in humans. In the United States of America, tissue transplants are regulated by the U.S. Food and Drug Administration (FDA) which sets strict regulations on the safety of the transplants, primarily aimed at the prevention of the spread of communicable disease. Regulations include criteria for donor screening and testing as well as strict regulations on the processing and distribution of tissue grafts. Organ transplants are not regulated by the FDA.[citation needed] Transplantation medicine is one of the most challenging and complex areas of modern medicine. Some of the key areas for medical management are the problems of transplant rejection, during which the body has an immune response to the transplanted organ, possibly leading to transplant failure and the need to immediately remove the organ from the recipient. When possible, transplant rejection can be reduced through serotyping to determine the most appropriate donorrecipient match and through the use of immunosuppressant drugs.[4]

Contents
[hide]

1 History o 1.1 Timeline of successful transplants 2 Types of transplant o 2.1 Autograft o 2.2 Allograft and allotransplantation 2.2.1 Isograft o 2.3 Xenograft and xenotransplantation o 2.4 Split transplants o 2.5 Domino transplants 3 Major organs and tissues transplanted

3.1 Thoracic organs 3.2 Abdominal organs 3.3 Tissues, cells, fluids 4 Types of donor o 4.1 Living donor o 4.2 Deceased donor 5 Allocation of donated organs 6 Reasons for donation and ethical issues o 6.1 Living related donors 6.1.1 Paired exchange o 6.2 Good Samaritan o 6.3 Compensated donation o 6.4 Forced donation 7 Organ transplantation in different countries o 7.1 Demographics o 7.2 Comparative costs o 7.3 Safety o 7.4 Organ transplant laws o 7.5 Ethical concerns o 7.6 Artificial organ transplantation 8 References 9 Sources and bibliography 10 Further reading 11 External links

o o o

[edit] History
Successful human allotransplants have a relatively long history of operative skills that were present long before the necessities for post-operative survival were discovered. Rejection and the side effects of preventing rejection (especially infection and nephropathy) were, are, and may always be the key problem. Several apocryphal accounts of transplants exist well prior to the scientific understanding and advancements that would be necessary for them to have actually occurred. The Chinese physician Pien Chi'ao reportedly exchanged hearts between a man of strong spirit but weak will with one of a man of weak spirit but strong will in an attempt to achieve balance in each man. Roman Catholic accounts report the 3rd-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian. Most accounts have the saints performing the transplant in the 4th century, decades after their deaths; some accounts have them only instructing living surgeons who performed the procedure. The more likely accounts of early transplants deal with skin transplantation. The first reasonable account is of the Indian surgeon Sushruta in the 2nd century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty. Success or failure of these procedures is not well documented. Centuries later, the Italian surgeon Gasparo Tagliacozzi performed successful

skin autografts; he also failed consistently with allografts, offering the first suggestion of rejection centuries before that mechanism could possibly be understood. He attributed it to the "force and power of individuality" in his 1596 work De Curtorum Chirurgia per Insitionem.

Alexis Carrel The first successful corneal allograft transplant was performed in 1837 in a gazelle model; the first successful human corneal transplant, a keratoplastic operation, was performed by Eduard Zirm at Olomouc Eye Clinic, now Czech Republic, in 1905. Thyroid gland tissue was transplanted in 1882 by Theodor Kocher.[5] Pioneering work in the surgical technique of transplantation was made in the early 1900s by the French surgeon Alexis Carrel, with Charles Guthrie, with the transplantation of arteries or veins. Their skilful anastomosis operations, the new suturing techniques, laid the groundwork for later transplant surgery and won Carrel the 1912 Nobel Prize in Physiology or Medicine. From 1902 Carrel performed transplant experiments on dogs. Surgically successful in moving kidneys, hearts and spleens, he was one of the first to identify the problem of rejection, which remained insurmountable for decades. Major steps in skin transplantation occurred during the First World War, notably in the work of Harold Gillies at Aldershot. Among his advances was the tubed pedicle graft, maintaining a flesh connection from the donor site until the graft established its own blood flow. Gillies' assistant, Archibald McIndoe, carried on the work into the Second World War as reconstructive surgery. In 1962 the first successful replantation surgery was performed re-attaching a severed limb and restoring (limited) function and feeling. The first attempted human deceased-donor transplant was performed by the Ukrainian surgeon Yu Yu Voronoy in the 1930s; rejection resulted in failure. Joseph Murray and J. Hartwell Harrison performed the first successful transplant, a kidney transplant between identical twins, in 1954, successful because no immunosuppression was necessary in genetically identical twins. In the late 1940s Peter Medawar, working for the National Institute for Medical Research, improved the understanding of rejection. Identifying the immune reactions in 1951 Medawar suggested that immunosuppressive drugs could be used. Cortisone had been recently discovered and the more effective azathioprine was identified in 1959, but it was not until the discovery of cyclosporine in 1970 that transplant surgery found a sufficiently powerful immunosuppressive.

Dr. Murray's success with the kidney led to attempts with other organs. There was a successful deceased-donor lung transplant into a lung cancer sufferer in June 1963 by James Hardy in Jackson, Mississippi. The patient survived for eighteen days before dying of kidney failure. Thomas Starzl of Denver attempted a liver transplant in the same year but was not successful until 1967. The heart was a major prize for transplant surgeons. But over and above rejection issues, the heart deteriorates within minutes of death, so any operation would have to be performed at great speed. The development of the heart-lung machine was also needed. Lung pioneer James Hardy attempted a human heart transplant in 1964, but when a premature failure of the recipient's heart caught Hardy with no human donor, he used a chimpanzee heart, which failed very quickly. The first success was achieved on December 3, 1967, by Christiaan Barnard in Cape Town, South Africa. Louis Washkansky, the recipient, survived for eighteen days amid what many[who?] saw as a distasteful publicity circus. The media interest prompted a spate of heart transplants. Over a hundred were performed in 196869, but almost all the patients died within sixty days. Barnard's second patient, Philip Blaiberg, lived for 19 months. It was the advent of cyclosporine that altered transplants from research surgery to life-saving treatment. In 1968 surgical pioneer Denton Cooley performed seventeen transplants, including the first heart-lung transplant. Fourteen of his patients were dead within six months. By 1984 two-thirds of all heart transplant patients survived for five years or more. With organ transplants becoming commonplace, limited only by donors, surgeons moved on to riskier fields, including multiple-organ transplants on humans and whole-body transplant research on animals. On March 9, 1981, the first successful heart-lung transplant took place at Stanford University Hospital. The head surgeon, Bruce Reitz, credited the patient's recovery to cyclosporine-A. As the rising success rate of transplants and modern immunosuppression make transplants more common, the need for more organs has become critical. Transplants from living donors, especially relatives, have become increasingly common. Additionally, there is substantive research into xenotransplantation, or transgenic organs; although these forms of transplant are not yet being used in humans, clinical trials involving the use of specific cell types have been conducted with promising results, such as using porcine islets of Langerhans to treat type 1 diabetes. However, there are still many problems that would need to be solved before they would be feasible options in patients requiring transplants. Recently, researchers have been looking into means of reducing the general burden of immunosuppression. Common approaches include avoidance of steroids, reduced exposure to calcineurin inhibitors, and other means of weaning drugs based on patient outcome and function. While short-term outcomes appear promising, long-term outcomes are still unknown, and in general, reduced immunosuppression increases the risk of rejection and decreases the risk of infection. Many other new drugs are under development for transplantation.[6]

The emerging field of regenerative medicine promises to solve the problem of organ transplant rejection by regrowing organs in the lab, using the patients' own cells (stem cells or healthy cells extracted from the donor site.)

[edit] Timeline of successful transplants

1905: First successful cornea transplant by Eduard Zirm [Czech Republic] 1954: First successful kidney transplant by J. Hartwell Harrison and Joseph Murray (Boston, U.S.A.) 1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota, U.S.A.) 1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.) 1967: First successful heart transplant by Christian Barnard (Cape Town, South Africa) 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.) 1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada) 1984: First successful double organ transplant by Thomas Starzl and Henry T. Bahnson (Pittsburgh, U.S.A.) 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto, Canada) 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis Kavoussi (Baltimore, U.S.A.) 1997: First successful allogeneic vascularized transplantation of a fresh and perfused human knee joint by Gunther O. Hofmann 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, U.S.A.) 1998: First successful hand transplant by Dr. Jean-Michel Dubernard (Lyon, France) 1999: First successful Tissue Engineered Bladder transplanted by Anthony Atala (Boston Children's Hospital, U.S.A.) 2005: First successful ovarian transplant by Dr P N Mhatre (wadia hospital Mumbai, India) 2005: First successful partial face transplant (France) 2006: First jaw transplant to combine donor jaw with bone marrow from the patient, by Eric M. Genden Mount Sinai Hospital, New York 2008: First successful complete full double arm transplant by Edgar Biemer, Christoph Hhnke and Manfred Stangl (Technical University of Munich, Germany) 2008: First baby born from transplanted ovary by James Randerson 2008: First transplant of a Vertebrate trachea|human windpipe using a patients own stem cells, by Paolo Macchiarini (Barcelona, Spain) 2008: First successful transplantation of near total area (80%) of face, (including palate, nose, cheeks, and eyelid) by Maria Siemionow (Cleveland, USA) 2010: First full facial transplant, by Dr Joan Pere Barret and team (Hospital Universitari Vall d'Hebron on July 26, 2010 in Barcelona, Spain.) 2011: First double leg transplant, by Dr Cavadas and team (Valencia's Hospital La Fe, Spain)

[edit] Types of transplant

[edit] Autograft
Main article: Autotransplantation Transplant of tissue to the same person. Sometimes this is done with surplus tissue, or tissue that can regenerate, or tissues more desperately needed elsewhere (examples include skin grafts, vein extraction for CABG, etc.) Sometimes an autograft is done to remove the tissue and then treat it or the person, before returning it (examples include stem cell autograft and storing blood in advance of surgery). In a rotationplasty a distal joint is used to replace a more proximal one, typically a foot and ankle joint is used to replace a knee joint. The patient's foot is severed and reversed, the knee removed, and the tibia joined with the femur.

[edit] Allograft and allotransplantation

Main article: Allotransplantation An allograft is a transplant of an organ or tissue between two genetically non-identical members of the same species. Most human tissue and organ transplants are allografts. Due to the genetic difference between the organ and the recipient, the recipient's immune system will identify the organ as foreign and attempt to destroy it, causing transplant rejection. The Risk of transplant rejection can be estimated by measuring the Panel reactive antibody level. [edit] Isograft A subset of allografts in which organs or tissues are transplanted from a donor to a genetically identical recipient (such as an identical twin). Isografts are differentiated from other types of transplants because while they are anatomically identical to allografts, they do not trigger an immune response.

[edit] Xenograft and xenotransplantation

Main article: Xenotransplantation A transplant of organs or tissue from one species to another. An example is porcine heart valve transplant, which is quite common and successful. Another example is attempted piscine-primate (fish to non-human primate) transplant of islet (i.e. pancreatic or insular tissue) tissue. The latter research study was intended to pave the way for potential human use, if successful. However, xenotransplantion is often an extremely dangerous type of transplant because of the increased risk of non-compatibility, rejection, and disease carried in the tissue.

[edit] Split transplants

Sometimes a deceased-donor organ, usually a liver, may be divided between two recipients, especially an adult and a child. This is not usually a preferred option because the transplantation of a whole organ is more successful.

[edit] Domino transplants

In patients with cystic fibrosis, where both lungs need to be replaced, it is a technically easier operation with a higher rate of success to replace both the heart and lungs of the recipient with those of the donor. As the recipient's original heart is usually healthy, it can then be transplanted into a second recipient in need of a heart transplant.[7] Another example of this situation occurs with a special form of liver transplant in which the recipient suffers from familial amyloidotic polyneuropathy, a disease where the liver slowly produces a protein that damages other organs. The recipient's liver can then be transplanted into an older patient for whom the effects of the disease will not necessarily contribute significantly to mortality.[8] This term also refers to a series of living donor transplants in which one donor donates to the highest recipient on the waiting list and the transplant center utilizes that donation to facilitate multiple transplants. These other transplants are otherwise impossible due to blood type or antibody barriers to transplantation. The "Good Samaritan" kidney is transplanted into one of the other recipients, whose donor in turn donates his or her kidney to an unrelated recipient. Depending on the patients on the waiting list, this has sometimes been repeated for up to six pairs, with the final donor donating to the patient at the top of the list. This method allows all organ recipients to get a transplant even if their living donor is not a match to them. This further benefits patients below any of these recipients on waiting lists, as they move closer to the top of the list for a deceased-donor organ. Johns Hopkins Medical Center in Baltimore and Northwestern University's Northwestern Memorial Hospital have received significant attention for pioneering transplants of this kind. [9][10] In February 2012 the last link in a record sixty-person domino chain of thirty kidney transplants was completed.[11][12]

[edit] Major organs and tissues transplanted

Main article: Transplantable organs and tissues

[edit] Thoracic organs

Heart (Deceased-donor only) Lung (Deceased-donor and living-related lung transplantation) Heart/Lung (Deceased-donor and Domino transplant)

[edit] Abdominal organs

Kidney (Deceased-donor and Living-Donor) Liver (Deceased-donor and Living-Donor) Pancreas (Deceased-donor only) Intestine (Deceased-donor and Living-Donor) Stomach (Deceased-donor only) Testis[13]

[edit] Tissues, cells, fluids

Hand (Deceased-donor only), see the first recipient Clint Hallam Cornea (Deceased-donor only) see the ophthalmologist Eduard Zirm Skin including Face replant (autograft) and Face transplant (extremely rare) Islets of Langerhans (Pancreas Islet Cells) (Deceased-donor and Living-Donor) Bone marrow/Adult stem cell (Living-Donor and Autograft) Blood transfusion/Blood Parts Transfusion (Living-Donor and Autograft) Blood vessels (Autograft and Deceased-Donor) Heart valve (Deceased-Donor, Living-Donor and Xenograft[Porcine/bovine]) Bone (Deceased-Donor and Living-Donor)

[edit] Types of donor

Organ donors may be living, or brain dead. Brain dead means the donor must have received an injury (either traumatic or pathological) to the part of the brain that controls heartbeat and breathing. Breathing is maintained via artificial sources, which, in turn, maintains heartbeat. Once brain death has been declared the person can be considered for organ donation. Criteria for brain death vary. Because less than 3% of all deaths in the U.S. are the result of brain death, the overwhelming majority of deaths are ineligible for organ donation, resulting in severe shortages. Tissue may be recovered from donors who are cardiac dead. That is, their breathing and heartbeat has ceased. They are referred to as cadaveric donors. In general, tissues may be recovered from donors up to 24 hours past the cessation of heartbeat. In contrast to organs, most tissues (with the exception of corneas) can be preserved and stored for up to five years, meaning they can be "banked." Also, more than 60 grafts may be obtained from a single tissue donor. Because of these three factorsthe ability to recover from a non-heart beating donor, the ability to bank tissue, and the number of grafts available from each donortissue transplants are much more common than organ transplants. The American Association of Tissue Banks estimates that more than one million tissue transplants take place in the United States each year.

[edit] Living donor

In "living donors", the donor remains alive and donates a renewable tissue, cell, or fluid (e.g. blood, skin), or donates an organ or part of an organ in which the remaining organ can regenerate or take on the workload of the rest of the organ (primarily single kidney donation, partial donation of liver, small bowel). Regenerative medicine may one day allow for laboratory-grown organs, using patient's own cells via stem cells, or healthy cells extracted from the failing organs.

[edit] Deceased donor

Deceased (formerly cadaveric) are donors who have been declared brain-dead and whose organs are kept viable by ventilators or other mechanical mechanisms until they can be excised for transplantation. Apart from brain-stem dead donors, who have formed the majority of deceased donors for the last twenty years, there is increasing use of Donation after Cardiac Death Donors (formerly non-heart beating donors) to increase the potential pool of donors as demand for

transplants continues to grow.[citation needed] These organs have inferior outcomes to organs from a brain-dead donor; however given the scarcity of suitable organs and the number of people who die waiting, any potentially suitable organ must be considered.[citation needed]

[edit] Allocation of donated organs

The overwhelming majority of deceased-donor organs in the United States are allocated by federal contract to the Organ Procurement and Transplantation Network (OPTN), held since it was created by the Organ Transplant Act of 1984 by the United Network for Organ Sharing or UNOS. (UNOS does not handle donor cornea tissue; corneal donor tissue is usually handled by various eye banks.) Individual regional organ procurement organizations (OPOs), all members of the OPTN, are responsible for the identification of suitable donors and collection of the donated organs. UNOS then allocates organs based on the method considered most fair by the scientific leadership in the field. For kidneys, for instance, that is by waiting time; for livers, it is by MELD (Model of End-Stage Liver Disease), an empirical score based on lab values indicative of the sickness of the patient from liver disease. Experiencing somewhat increased popularity, but still very rare, is directed or targeted donation, in which the family of a deceased donor (often honoring the wishes of the deceased) requests an organ be given to a specific person. If medically suitable, the allocation system is subverted, and the organ is given to that person. In the United States, there are various lengths of waiting due to the different availabilities of organs in different UNOS regions. In other countries such as the UK, only medical factors and the position on the waiting list can affect who receives the organ. If this is not the desired person, it is noted that this puts them higher on the list. One of the more publicized cases of this type was the 1994 Chester and Patti Szuber transplant. This was the first time that a parent had received a heart donated by one of their own children. Although the decision to accept the heart from their recently killed child was not an easy decision, the Szuber family agreed that giving Pattis heart to her father would have been something that she would have wanted.[14][15] Access to organ transplantation is one reason for the growth of medical tourism.

[edit] Reasons for donation and ethical issues

[edit] Living related donors
Living related donors donate to family members or friends in whom they have an emotional investment. The risk of surgery is offset by the psychological benefit of not losing someone related to them, or not seeing them suffer the ill effects of waiting on a list. [edit] Paired exchange

Diagram of an exchange between otherwise incompatible pairs A "paired-exchange" is a technique of matching willing living donors to compatible recipients using serotyping. For example a spouse may be willing to donate a kidney to their partner but cannot since there is not a biological match. The willing spouse's kidney is donated to a matching recipient who also has an incompatible but willing spouse. The second donor must match the first recipient to complete the pair exchange. Typically the surgeries are scheduled simultaneously in case one of the donors decides to back out and the couples are kept anonymous from each other until after the transplant. Paired exchange programs were popularized in the New England Journal of Medicine article "Ethics of a paired-kidney-exchange program" in 1997 by L.F. Ross.[16] It was also proposed by Felix T. Rapport [4] in 1986 as part of his initial proposals for live-donor transplants "The case for a living emotionally related international kidney donor exchange registry" in Transplant Proceedings.[17] A paired exchange is the simplest case of a much larger exchange registry program where willing donors are matched with any number of compatible recipients [5]. Transplant exchange programs have been suggested as early as 1970: "A cooperative kidney typing and exchange program.".[18] The first pair exchange transplant in the U.S. was in 2001 at Johns Hopkins Hospital[6]. The first complex multihospital kidney exchange involving 12 patients was performed in February 2009 by The Johns Hopkins Hospital, Barnes-Jewish Hospital in St. Louis and Integris Baptist Medical Center in Oklahoma City.[19] Another 12-patient multihospital kidney exchange was performed four weeks later by Saint Barnabas Medical Center in Livingston, New Jersey, Newark Beth Israel Medical Center and New York-Presbyterian Hospital.[20] Surgical teams led by Johns Hopkins continue to pioneer in this field by having more complex chain of exchange such as eight-way multihospital kidney exchange.[21] In December 2009, a 13 organ 13 recipient matched kidney exchange took place, coordinated through Georgetown University Hospital and Washington Hospital Center, Washington DC.[22] Paired-donor exchange, led by work in the New England Program for Kidney Exchange as well as at Johns Hopkins University and the Ohio OPOs may more efficiently allocate organs and lead to more transplants.

[edit] Good Samaritan

Good Samaritan or "altruistic" donation is giving a donation to someone not well-known to the donor. Some people choose to do this out of a need to donate. Some donate to the next person on the list; others use some method of choosing a recipient based on criteria important to them. Web sites are being developed that facilitate such donation. It has been featured in recent television journalism that over half of the members of the Jesus Christians, an Australian religious group, have donated kidneys in such a fashion.[23]

[edit] Compensated donation

See also: Organ theft, Organ sale, and Organ trade In compensated donation, donors get money or other compensation in exchange for their organs. This practice is common in some parts of the world, whether legal or not, and is one of the many factors driving medical tourism.[24] An article by Gary Becker and Julio Elias on "Introducing Incentives in the market for Live and Cadaveric Organ Donations"[25] said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000). In the United States, The National Organ Transplant Act of 1984 made organ sales illegal. In the United Kingdom, the Human Organ Transplants Act 1989 first made organ sales illegal, and has been superseded by the Human Tissue Act 2004. In 2007, two major European conferences recommended against the sale of organs.[26] Recent development of web sites and personal advertisements for organs among listed candidates has raised the stakes when it comes to the selling of organs, and have also sparked significant ethical debates over directed donation, "good-Samaritan" donation, and the current U.S. organ allocation policy. Bioethicist Jacob M. Appel has argued that organ solicitation on billboards and the internet may actually increase the overall supply of organs.[27] Two books, Kidney for Sale By Owner by Mark Cherry (Georgetown University Press, 2005); and Stakes and Kidneys: Why markets in human body parts are morally imperative by James Stacey Taylor: (Ashgate Press, 2005); advocate using markets to increase the supply of organs available for transplantation. In a 2004 journal article Economist Alex Tabarrok argues that allowing organ sales, and elimination of organ donor lists will increase supply, lower costs and diminish social anxiety towards organ markets.[28] Iran has had a legal market for kidneys since 1988,[29] and the market price is of the order of US$1,200 for the recipient.[30] The Economist[7] and the Ayn Rand Institute[8] approve and advocate a legal market elsewhere. They argued that if 0.06% of Americans between 19 and 65 were to sell one kidney, the national waiting list would disappear (which, the Economist wrote,

happened in Iran). The Economist argued that donating kidneys is no more risky than surrogate motherhood, which can be done legally for pay in most countries. In Pakistan, 40 percent to 50 percent of the residents of some villages have only one kidney because they have sold the other for a transplant into a wealthy person, probably from another country, said Dr. Farhat Moazam of Pakistan, at a World Health Organization conference. Pakistani donors are offered $2,500 for a kidney but receive only about half of that because middlemen take so much.[31] In Chennai, southern India, poor fishermen and their families sold kidneys after their livelihoods were destroyed by the Indian Ocean tsunami on December 26, 2004. About 100 people, mostly women, sold their kidneys for 40,00060,000 rupees ($900 $1,350).[32] Thilakavathy Agatheesh, 30, who sold a kidney in May 2005 for 40,000 rupees said, "I used to earn some money selling fish but now the post-surgery stomach cramps prevent me from going to work." Most kidney sellers say that selling their kidney was a mistake.[33] In Cyprus in 2010 police closed a fertility clinic under charges of trafficking in human eggs. The Petra Clinic, as it was known locally, imported women from Ukraine and Russia for egg harvesting and sold the genetic material to foreign fertility tourists.[34] This sort of reproductive trafficking violates laws in the European Union. In 2010 the Pulitzer Center on Crisis Reporting and the magazine Fast Company explored illicit fertility networks in Spain, the United States and Israel.[35][36]

[edit] Forced donation

See also: Organ transplants in the People's Republic of China This section contains weasel words: vague phrasing that often accompanies biased or unverifiable information. Such statements should be clarified or removed. (March
2011)

There have been various accusations that certain authorities are harvesting organs from those the authorities deem undesirable, such as prison populations. The World Medical Association stated that individuals in detention are not in the position to give free consent to donate their organs [37][dead link] . Illegal dissection of corpses is a form of body-snatching and may have taken place to obtain allografts. [9] According to the Chinese Deputy Minister of Health, Huang Jiefu,[38][dead link] approximately 95% of all organs used for transplantation are from executed prisoners. The lack of public organ donation program in China is used as a justification for this practice. However reports in Chinese media raised concerns if executed criminals are the only source for organs used in transplants. In October 2007, bowing to international pressure, the Chinese Medical Association agreed on a moratorium of commercial organ harvesting from condemned prisoners, but did not specify a deadline. China agreed to restrict transplantations from donors to their immediate relatives.[39][40] People in other parts of the world are responding to this availability of organs, and a number of individuals (including US and Japanese citizens) have elected to travel to China or India as

medical tourists to receive organ transplants which may have been sourced in what might be considered elsewhere to be unethical ways (see later). [10] [11] [12].

[edit] Organ transplantation in different countries

[edit] Demographics
Despite efforts of international transplantation societies, it is not possible to access an accurate source on the number, rates and outcomes of all forms of transplantation globally; the best that we can achieve is estimations. This is not a sound basis for the future and thus one of the crucial strategies for the Global Alliance in Transplantation is to foster the collection and analysis of global data. Transplantation of organs in different continents/regions year/ 2000 Kidney Liver Heart

(pmp*) (pmp) (pmp) USA Europe Africa Asia 52 27 11 3 19 10 3.5 0.3 1.6 8 4 1 0.03 0.5

Latin America 13

All numbers per million population

Source: [13][dead link],[14][dead link] According to the Council of Europe, Spain through the Spanish Transplant Organization led by Dr Rafael Matesanz shows the highest worldwide rate of 35.1[41][42] donors per million population in 2005 and 33.8[43] in 2006. In 2011, was 35.3 http://www.agenciasinc.es/Noticias/Espana-alcanza-un-record-historico-de-trasplantes-en-2011 In addition to the citizens waiting for organ transplants in the US and other developed nations, there are long waiting lists in the rest of the world. More than 2 million people need organ transplants in China, 50,000 waiting in Latin America (90% of which are waiting for kidneys), as well as thousands more in the less documented continent of Africa. Donor bases vary in developing nations. Traditionally, Muslims believe body desecration in life or death to be forbidden, and thus many reject organ transplant.[44] However most Muslim authorities nowadays accept the practice if another life will be saved.[45]

In Latin America the donor rate is 40100 per million per year, similar to that of developed countries. However, in Uruguay, Cuba, and Chile, 90% of organ transplants came from cadaveric donors. Cadaveric donors represent 35% of donors in Saudi Arabia. There is continuous effort to increase the utilization of cadaveric donors in Asia, however the popularity of living, single kidney donors in India yields India a cadaveric donor prevalence of less than 1 pmp. Organ transplantation in China has taken place since the 1960s, and China has one of the largest transplant programmes in the world, peaking at over 13,000 transplants a year by 2004.[46] Organ donation, however, is against Chinese tradition and culture,[47][48] and involuntary organ donation is illegal under Chinese law.[49] China's transplant programme attracted the attention of international news media in the 1990s due to ethical concerns about the organs and tissue removed from the corpses of executed criminals being commercially traded for transplants.[50][51][52] With regard to organ transplantation in Israel, there is a severe organ shortage due to religious objections by some rabbis who oppose all organ donations and others who advocate that a rabbi participate in all decision making regarding a particular donor. One third of all heart transplants performed on Israelis are done in the Peoples' Republic of China; others are done in Europe. Dr. Jacob Lavee, head of the heart-transplant unit, Sheba Medical Center, Tel Aviv, believes that "transplant tourism" is unethical and Israeli insurers should not pay for it. The organization HODS (Halachic Organ Donor Society) is working to increase knowledge and participation in organ donation among Jews throughout the world.[53] Transplantation rates also differ based on race, sex, and income. A study done with patients beginning long term dialysis showed that the sociodemographic barriers to renal transplantation present themselves even before patients are on the transplant list.[54] For example, different groups express definite interest and complete pretransplant workup at different rates. Previous efforts to create fair transplantation policies had focused on patients currently on the transplantation waiting list.

[edit] Comparative costs

One of the driving forces for illegal organ trafficking and for transplantation tourism is the price differences for organs and transplant surgeries in different areas of the world. According to the New England Journal of Medicine, a human kidney can be purchased in Manila for $1000 $2000, but in urban Latin America a kidney may cost more than $10,000. Kidneys in South Africa have sold for as high as $20,000. Price disparities based on donor race are a driving force of attractive organ sales in South Africa, as well as in other parts of the world. In China, a kidney transplant operation runs for around $70,000, liver for $160,000, and heart for $120,000 [15][dead link]. Although these prices are still unattainable to the poor, compared to the fees of the United States, where a kidney transplant may demand $100,000, a liver $250,000, and a heart $860,000, Chinese prices have made China a major provider of organs and transplantation surgeries to other countries. In India, a kidney transplant operation runs for around as low as $5000.

[edit] Safety
Compensation for donors also increases the risk of introducing diseased organs to recipients because these donors often yield from poorer populations unable to receive health care regularly and organ dealers may evade disease screening processes. The majority of such deals include one major payment and no follow up care for the donor. Some cases argue that there is a possibility of 1:18 to acquire HIV from such transplants.[citation needed] In November 2007, the CDC reported the first-ever case of HIV and Hepatitis C being simultaneously transferred through an organ transplant. The donor was a 38-year-old male, considered "high-risk" by donation organizations, and his organs transmitted HIV and Hepatitis C to four organ recipients, none of whom had been told he was "high-risk." Experts say that the reason the diseases did not show up on screening tests is probably because they were contracted within three weeks before the donor's death, so antibodies would not have existed in high enough numbers to detect. The crisis has caused many to call for more sensitive screening tests, which could pick up antibodies sooner. Currently, the screens cannot pick up on the small number of antibodies produced in HIV infections within the last 90 days or Hepatitis C infections within the last 1821 days before a donation is made. NAT (nucleic acid testing) is now being done by many organ procurement organizations and is able to detect antibodies for HIV and Hepatitis C within seven to ten days of exposure to the virus.

[edit] Organ transplant laws

Both developing and developed countries have forged various policies to try to increase the safety and availability of organ transplants to their citizens. Brazil, France, Italy, Poland and Spain have ruled all adults potential donors with the opting out policy, unless they attain cards specifying not to be. However, whilst potential recipients in developing countries may mirror their more developed counterparts in desperation, potential donors in developing countries do not. The Indian government has had difficulty tracking the flourishing organ black market in their country and have yet to officially condemn it. Other countries victimized by illegal organ trade have implemented legislative reactions. Moldova has made international adoption illegal in fear of organ traffickers. China has made selling of organs illegal as of July 2006 and claims that all prisoner organ donors have filed consent. However, doctors in other countries, such as the United Kingdom, have accused China of abusing its high capital punishment rate. Despite these efforts, illegal organ trafficking continues to thrive and can be attributed to corruption in healthcare systems, which has been traced as high up as the doctors themselves in China, Ukraine, and India, and the blind eye economically strained governments and health care programs must sometimes turn to organ trafficking. Some organs are also shipped to Uganda and the Netherlands. This was a main product in the triangular trade in 1934. Starting on May 1, 2007, doctors involved in commercial trade of organs will face fines and suspensions in China. Only a few certified hospitals will be allowed to perform organ transplants in order to curb illegal transplants. Harvesting organs without donor's consent was also deemed a crime.[55]

On June 27, 2008, Indonesian, Sulaiman Damanik, 26, pleaded guilty in Singapore court for sale of his kidney to CK Tang's executive chair, Mr Tang Wee Sung, 55, for 150 million rupiah (S$ 22,200). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of "poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks." Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient's adopted son, and was paid 186 million rupiah (20,200 US). Upon sentence, both would suffer each, 12 months in jail or 10,000 Singapore dollars (7,600 US) fine.[56][57] In an article appearing in the Econ Journal Watch, April 2004.[28] Economist Alex Tabarrok examined the impact of direct consent laws on transplant organ availability. Tabarrok found that social pressures resisting the use of transplant organs decreased over time as the opportunity of individual decisions increased. Tabarrok concluded his study suggesting that gradual elimination of organ donation restrictions and move to a free market in organ sales will increase supply of organs and encourage broader social acceptance of organ donation as a practice.

[edit] Ethical concerns

The existence and distribution of organ transplantation procedures in developing countries, while almost always beneficial to those receiving them, raise many ethical concerns. Both the source and method of obtaining the organ to transplant are major ethical issues to consider, as well as the notion of distributive justice. The World Health Organization argues that transplantations promote health, but the notion of transplantation tourism has the potential to violate human rights or exploit the poor, to have unintended health consequences, and to provide unequal access to services, all of which ultimately may cause harm. Regardless of the gift of life, in the context of developing countries, this might be coercive. The practice of coercion could be considered exploitative of the poor population, violating basic human rights according to Articles 3 and 4 of the Universal Declaration of Human Rights. There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights. Even within developed countries there is concern that enthusiasm for increasing the supply of organs may trample on respect for the right to life. The question is made even more complicated by the fact that the "irreversibility" criterion for legal death cannot be adequately defined and can easily change with changing technology.[58]

[edit] Artificial organ transplantation

Surgeons in Sweden performed the first implantation of a synthetic trachea in July 2011, for a 36-year-old patient who was suffering from cancer. Stem cells taken from the patient's hip were treated with growth factors and incubated on a plastic replica of his natural trachea.[59]

Home About Us Meetings Reports Transcripts Background Materials Former Bioethics Commissions

This topic was discussed at the Council's January 2003 meeting. This background paper was prepared by staff solely to aid discussion, and does not represent the official views of the Council or of the United States Government.

Staff Background Paper

Organ Transplantation: Ethical Dilemmas and Policy Choices

Since the first human kidney was transplanted in 1954, the nation has engaged in searching public discussions about the ethics of organ transplantation: about the human significance of removing organs from both living and cadaveric donors; about the criteria for determining when death occurs and thus when the decedent's organs might be taken; about whose wishes should ultimately decide whether organs are used or not used; and about the ethics of different organ procurement and allocation laws. The current organ policy is shaped largely by two important laws: The first is the Uniform Anatomical Gift Act of 1968, adopted in all fifty states, which granted individuals the right to decide before death whether they wished to donate their organs; the second is the Organ Transplantation Act of 1984, which aimed to encourage organ donation by establishing an organized organ matching and procurement network, while outlawing the buying and selling of human organs or the direct compensation of organ donors and their families. Taken together, these laws sought to reap the medical benefits of organ transplantation and to encourage individuals to become organ donors, while preserving certain ethical limits against treating the body as property and the newly dead as simply natural resources. It also sought to ensure, as much as possible given other inequities in the health-care system, that organs are allocated in an equitable way. Whether this policy has been a great success or terrible failure both medically and ethically is a complex question. Many lives have been saved that would not have been otherwise, and yet waiting lists for organs continue to increase. Many individuals have given of themselves (literally) to save the life of another, and yet the unequivocal protection of those who are not-yet-dead (but would be useful if they were) has been called into question. The human body (dead or alive) has not been reduced to mere property, and yet the desperation of watching thousands of individuals die every year while waiting for organs has prompted a renewed debate about whether monetary incentives should be used in an effort to increase organ supply. In the 107th Congress (2001 2002), a number of bills aimed at promoting organ donation and increasing organ supply were proposed. Some bills would have provided formal recognition of donors with commemorative medals. Other bills

offered tax credits to individuals who donate organs (or credits to their surviving families) or reimbursement of the costs incurred by living donors.2 In addition, numerous books and articles have been written claiming that the current organ procurement system has been a failure, resulting in "prolonged suffering, declining health, and rising death rates,"3 and that the time has come to explore a marketbased system to solve the organ supply problem. A new group called LifeSharers is attempting to develop a private network of organ giving and receiving, so that members have first priority on the organs of other members. And while the medical community generally supports the guiding principle of the current policy that organ donation should be an act of giving, without monetary incentives of any kind the American Society of Transplant Surgeons has endorsed the idea of a pilot program that would partially reimburse surviving families for the funeral expenses of individuals who allow their organs to be taken after death.

I. The Human Context for Considering Organ Transplantation

Before considering the moral arguments for and against different organ procurement policies, one must first consider the human context and human meaning of organ transplantation itself. This context is first of all the dignity and integrity of the human body. A frequent line of argument in the organ transplantation debate is that organs are "no use" to individuals after they have died. No doubt this is in a certain sense true. And yet, it suggests that an individual's body has meaning only because it is "useful"; that the body is a tool individuals have rather than what individuals are. We are tempted, as Gilbert Meilaender has written, "to suppose that the 'real' person transcends the body." But in fact, our humanity and identity are inseparable from our bodies including the human dilemmas that arise when our bodies fail us, the humor we experience when bodies sometimes have a mind of their own, the grace or excellence that we embody when we (our bodies) perform in ways only we (they) can, and the dignity of fundamental human-bodily activities such as the loving embrace and procreation. Of course, modern medicine and medical progress depend on gaining some mastery of the body, including the routine study of the dead so that we might gain knowledge to help the living, and experimentation on living individual's bodies in the hope of curing dreaded diseases. Medicine often involves "violating" the body in order to "save" it for example, amputating a limb or opening the chest to operate on the heart. In the case of organ transplantation, this "violation" is done to one person, living or dead, in order to save another with possibilities both for great charity and great coercion that this intervention entails. This brings us to the second context for understanding organ transplantation: the obligations and limits of medicine. No one can deny the great good that has come from organ transplantation in both lives saved and suffering ameliorated, as well as the great suffering that cannot be ameliorated because of the organ shortage. And yet, if saving the most possible lives while inflicting the least harm on the living

were the only significant human obligation, then our policy on organ transplantation (not to mention human experimentation) would be very different. Society could simply take all available organs, and treat dead bodies as a public resource. But we do not do this, and for good reason. The obligation to heal as fundamental as it is to the good life and good society exists in concert (and sometimes in conflict) with other human values: the principle of autonomy, the duty of families to mourn the deceased, the responsibility of doctors to do no harm even when very great good might come from it. Beyond this, there are many further questions to consider: Whose wishes should finally prevail in determining whether organs are taken the dead person himself while he or she was living or the family that must mourn the deceased after death? Does autonomy mean having the right to dispose of one's body (or enter into contracts for one's body) in any way an individual sees fit? Do fears about turning the body into property justify policies such as no payment for organs that potentially limit the supply of a life-saving "resource" and limit the right of individuals to make decisions about their bodies before and after death? Are there legitimate moral reasons not to be an organ donor or not to allow the organs of a deceased loved one to be taken? Do siblings or parents, while alive, have a moral obligation to donate organs to siblings or children who would otherwise die? Has the possibility of organ transplantation created new kinds of pressures or new forms of suffering such as waiting in misery on organ waiting lists, and perhaps facing a death that comes to seem "unnecessary"?

II. Organ Transplantation and Public Policy

With these difficult questions in mind, we now turn to consider a number of different systems for governing the procurement of cadaveric organs. We begin with three caveats: First, it is impossible to separate the ethical-political debate over cadaveric organs from the debate over living organ donation: both many of the principles involved (such as the meaning of treating the body as property) and the practical dilemmas (such as the problem of rationing an insufficient supply of organs or deciding whether or not to donate) overlap. Second, it is not easy in practice though possible in principle to separate the debate over organ procurement (how we get organs) from the debate over organ allocation (how we distribute them): for one thing, people's moral assessment of how organs are allocated might affect their judgment about whether to become organ donors, and proposals to compensate individuals for providing organs potentially entail their right to sell their organs to the highest bidder. Third, many proposed policies especially organ compensation and organ markets are untested hypotheses; this means that their claims can neither be written off in advance nor accepted at face value. One of the most important questions in this debate is why some people or some families decide not to donate their organs, and thus whether or not payment would change this behavior. William F. May has described the different principles that might govern an organ

procurement system as "giving-and-receiving" (the current system of altruistic organ donation), "taking-and-getting" (a system of routine retrieval of all organs without the explicit consent of the deceased or the surviving family), and "sellingand-buying" (a system of organ markets). One might add two others to this list: "honoring-and-shaming" (a system of public medals and community pressure) and "compensating-and-providing" (a system of public payment or tax credits for organ "donors"). We must, as we judge these different policies, think about the meaning of organ transplantation in its fullness: that is, about organ donation as a "gift of life," organ retrieval as a violation of the human body, organ transplantation as a "noble form of cannibalism," and the organ shortage as a tragedy for those individuals and families that wait for organs and often die waiting. To think about public policy in this area means balancing these different realities and facing soberly the moral costs and benefits of different policies. We begin by considering three policies what we might call ideal types in reverse that nearly all American would rightfully find unacceptable for different reasons; understanding why these policies are unacceptable can perhaps guide us as we seek to discern the most responsible and prudent policy. The first is a policy of organ conscription or mandatory organ retrieval. Under such a policy, all cadaver organs would be retrieved regardless of the wishes of the deceased individual or the surviving family; dead bodies would be treated simply as a public resource in the service of the common goal of saving human life. The second is a policy of unrestricted autonomy, which would allow individuals, dead or alive, to enter into any contracts they wish for the buying-and-selling of their organs. The guiding principle of such a policy is that individuals "own" their bodies as a "possession," and that only individuals can weigh the risks versus benefits, the pains versus pleasures, entailed in deciding whether to keep, sell, or be buried with one's organs. Such a policy would include, on its own principles, the right to sell vital organs while alive (so-called "lethal transplants"), since an individual might rationally decide that the satisfaction of providing money for his family outweighs his desire to continue living. (And his family might agree!) The third policy is state-mandated protection of the inviolability of all bodies, dead or alive. Such a policy would outlaw all organ retrieval, on the principle that the body ought not to be turned into a thing, even for a noble purpose such as saving life, and that the activity of mourning must not be interfered with by removing the deceased individual's organs. Each of these policies, by trying to preserve or pursue an absolute but isolated human good-saving the most life, granting the largest possible measure of individual autonomy, protecting the integrity of bodily life-ends up compromising or sacrificing other vital human goods. By seeing the error of these policies, we are perhaps awakened to the challenge of making a policy (or preserving the existing policy) that is both more moderate and more sober.

III. Five Organ Procurement Policies and Proposals: A Comparison

This section considers the moral and prudential arguments for and against five different organ procurement policies. 1.Organ Donation ("Giving and Receiving"): Under the current system, individuals can decide before death whether they wish to donate their organs after they die. As a legal matter, this positive decision to be an organ donor gives the surviving family no say; in practice, however, the surviving kin are typically asked permission, and in cases when families of organ donors do not wish for the decedent's organs to be taken, those family wishes are typically respected. In cases where individuals have made no declaration positively or negatively about whether they wished their organs to be removed, the decision is left to the surviving family entirely. The guiding principles of this system, as described above, are the following: to encourage organ donation; to respect, as much as possible, both the prior wishes of the individual who has died and the wishes of the surviving family; to prevent the commodification of the body or perverse incentives for self-mutilation; to ensure that the system of organ allocation is as equitable as possible; and to enshrine in society the principle of "gifting." 4 The greatest shortcoming of this system is that it does not result, at least at present, in a sufficient number of cadaveric organs for all who would benefit from them. Whether any system (or any ethically defensible system) could entirely solve the organ "shortage" is an open question. But there are reasons to believe that new monetary incentives or more aggressive organ retrieval would increase the organ supply. 2. Public Recognition and Community Pressure ("Honoring and Shaming"): One proposal for increasing the organ supply is to publicly honor with medals or ceremonies, not compensation those individuals (or their surviving families) who donate their organs. This proposal rests on the belief that donation to save life is a (prima facie) civic duty, not just a philanthropic option. Often combined with this proposed policy of honoring organ donors is a proposal for civic "shaming" of those who are not organ donors with slogans like "Friends don't let their friends waste the gift of life" or the creation of public registries so that community members can exhort their fellow non-donating citizens.5 The likelihood that such a program would increase organ supply is of course uncertain. The only objection one can imagine to public recognition of organ donors is that recognition might become (at least partly) the reason for donating, and thus the donation might become less an "other-regarding" gift and more a "selfregarding" act. The idea of civic "shaming" of non-organ donors raises more questions: for example, whether individuals or families might have morally legitimate or morally admirable reasons (such as religious belief) for not donating

their organs. It forces us to reflect on the difference between "asking" for organs and "expecting" them, and the difference between "charity" and "obligation." 3.Public Compensation ("Paying and Providing"): In recent years, there have been a number of different proposals for compensating individuals or their surviving families for allowing their organs to be used (notice: it becomes less accurate, perhaps inaccurate, to call it "donation" once payment is involved). The primary goal of these proposals is to increase organ supply by motivating more individuals and families (with cash payment or other "valuable consideration") to allow their organs to be retrieved. In addition, such a policy could offer public recognition and honor to those who benefit society by allowing their organs to be retrieved. These proposals take different forms: some offer full or partial reimbursement of funeral expenses; some offer tax credits or rebates; some offer direct cash payment. Defenders of such compensation proposals often seek to distinguish them from organ markets: the compensation would be public, not private, and thus would represent the appreciation of the entire community rather than a private contract between parties; a compensation system would set firm limits on what could be compensated for example, allowing reimbursement for funerals of the deceased but not payment for living donors who wish to sell one of their organs; and a compensation system for procurement would be kept separate from the system of organ allocation so as not to endanger the equity of organ allocation, whereas the right to sell one's organs in the open market might also mean giving special advantages to wealthy prospective recipients. It is impossible to know in advance what effect such a policy would have on increasing organ supply; this depends both on the reasons why many individuals and families do not currently allow their organs to be retrieved and on the size of the compensation, if in fact individuals or families have a price above which the "costs" of giving up their organs are outweighed by the monetary benefits. The greatest objection to such a policy is that it opens the door to a greatly increased commodification of the body; that it puts different prices on different body parts; that it risks creating new tensions and new 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," and thus undermines the civic purpose of teaching "charity." 4.Organ Markets ("Selling and Buying"): There have been a number of proposals in recent years for organ markets, which would allow individuals before death or surviving family members after death to sell their own or their loved one's organs in private contracts. The primary goal of this system is to increase organ supply while respecting and expanding autonomy over one's body or the bodies of one's loved ones. Such market proposals take many different forms. These include "Futures Markets," where individuals agree before death to sell their organs and receive cash payment or lowered health-insurance

rates while still living; and "Spot Markets," where families decide after death to sell their loved one's organs for cash payment or some other valuable consideration. Some proposals would have a market system for procurement only thus allowing private selling but restricting private buying; other proposals would have both private buying and selling. Advocates for such policies argue that organ markets would be more efficient than public compensation, by allowing the price for different body parts to shift with shifting supply and demand. They also argue that it is unfair for everyone in the transplantation business to be making money except for the person who provides the precious organs. As with public compensation, it is impossible to know in advance what effect any of these organ market policies, if enacted, would have on increasing the organ supply. Many of the same objections that are made to a public compensation system (see above) are made against organ markets with the added argument that markets entail the full-scale (not partial) transformation of the body into property; and that organ markets promise to make organ allocation more unequal, since the benefits of a market system ultimately will require the freedom to buy at any price as well as freedom to sell at any price. Moreover, a market system risks creating conflicts between insurance companies, who "own" the rights to the organs of the deceased individuals who sold them, and the surviving family. 5.Routine Retrieval ("Taking and Getting"): A final policy option is so-called "routine retrieval" or "presumed consent," in which it becomes standard policy to retrieve all usable organs after death, unless individuals or surviving families expressly request that such organs not be retrieved. The primary aim of such a policy is to increase organ supply, while at the same time eliminating the difficult task of requesting organs from family members moments after a loved one has died and the need for a public campaign encouraging people to become organ donors. There are different versions of this policy-ranging from those that make non-retrieval of organs relatively easy to those that make it relatively difficult. A version of this policy has been attempted in many European countries with mixed results. 6 While such a system seems likely to increase the supply of organs, it does so at a cost: staking a claim to the deceased and his or her body without individual or family consent. At the same time, it would change the character of organ procurement from "giving" to "taking," and thus undermine the civic purpose of teaching charity or the opportunity for individuals to be charitable. It would greatly expand the power of the state, forcing families to claim "possession" of the deceased body only so that they might proceed with rites of "surrender and separation." 7

IV. Conclusion

The debate over organ transplantation touches on many of the deepest issues in bioethics: the obligation of healing the sick and its limits; the blessing and the burden of medical progress; the dignity and integrity of bodily life; the dangers of turning the body, dead or alive, into just another commodity; the importance of individual consent and the limits of human autonomy; and the difficult ethical and prudential judgments required when making public policy in areas that are both morally complex and deeply important. It is no exaggeration to say that our attitudes about organ transplantation say much about the kind of society that we are, both for better and for worse. In the end, we are forced to accept the "tragic" nature of each of the above policy proposals to accept that some goods are inevitably given up in order to preserve other goods that are deemed to be more important. And yet, by setting moral limits and outlawing "cash for flesh," we may be decreasing organ supply and thus accepting the suffering and death of those we might have saved, at least temporarily. By setting aside those moral limits by treating the body as property in the hope of increasing organ supply, we risk devaluing the very human life (and human bodies) that we seek to save. It is of course possible that current opposition to organ markets or public compensation will someday seem as quaint and misguided as opposition to organ transplantation itself. No doubt the taboos of the past such as respect for dead bodies have stood in the way of much that is good about modern life and modern medicine. But it is also possible that the sweeping aside of some old taboos has lessened us, dehumanized us, and corrupted us. It is this risk of corruption and dehumanization that we must not fail to recognize, even as we seek to ameliorate suffering and cure disease by every ethical means possible. The specific question before us is this: What is the most ethically responsible and prudent public policy for procuring cadaver organs? Should the current law be changed, modified, or preserved?

ENDNOTES
1. 2. 3. This paper draw heavily on an essay by staff consultant Eric Cohen, to be published in the Spring 2003 issue of The Public Interest. For a helpful account of recent proposals, see "Ethical Incentives-Not Payment-for Organ Donation" in the N. Engl. J. Med, Vol. 346, No. 25, June 20, 2002. This quote is taken from The U.S. Organ Procurement System: A Prescription for Reform (AEI Press, 2002) by David L. Kaserman and A. H. Barnett, an important new book making the case for organ markets. And yet, we must wonder whether patients with heart or kidney failure are really worse off today than they were before organ transplantation was possible or widespread? The authors' own tables document the fact that the number of organ transplantations performed each year is increasing, not declining. It is true that our progress has created a new form of suffering: waiting for organs, suffering months or even years on dialysis, waiting in pain for others to die. But it is wrong to declare that the "organ shortage" is the "cause of death" for those who die waiting for organs, and that bigger organ waiting lists mean that the quality of our health-care is deteriorating. Our medical system and medical advances seem to have lowered death rates, not increased them. Social welfare measured simply as the number of patients saved with organ failure is improving, not declining. And the cause of death for those who die waiting for organs is not the shortage

4.

5. 6. 7.

itself but the same diseases and frailties of human life that existed before organ transplantation was even possible. This is not to deny the genuine human cost of the organ shortage or the terrible suffering (and courage) of those who wait for organs. It is simply to point out the ways in which a social problem seen as a "crisis" from one perspective looks like "gradual improvement" from another. Paul Ramsey, in his classic work Patient as Person (1970), described this "gifting" principle as follows: "A society will be a better human community in which giving and receiving is the rule, not taking for the sake of good to come. The civilizing task of mankind is the fostering, the achievement, or the shoring up of consensual community in general, and not only in regard to the advancement of medical science and the availability of cadaver organs in efforts to save the lives of others.. The positive consent called for by Gift Acts, answering the need for gifts by encouraging real givers, meets the measure of authentic community among men. The routine taking of organs would deprive individuals of the exercise of the virtue of generosity. If, as is said, the young rarely think about their own deaths or about giving their organs upon death, then they should be constrained and enabled to do so by the institutions and practices and laws we enact. To become partners in proved therapies, or joint adventurers in proving therapies, could be among the most civilized and civilizing things young people can do. The moral sequels that might flow from education and action in line with the proposed Gift Acts may be of far more importance than prolonging lives routinely. The moral history of mankind is of more importance than its medical advancement, unless the latter can be joined with the former in a community of affirmative assent." See, for example, "Organ Donation: A Communitarian Approach," by Amitai Etzioni. See Kaserman and Barnett, op. cit., p. 46-47. For an elaboration of this point, see William F. May, "Attitudes Toward the Newly Dead," The Hastings Center Studies, Vol. 1, No. 1, 1973.

Home Site Map Disclaimers Privacy Notice Accessibility NBAC HHS