Transplanting Human Organs
Prof. Susan J. Armstrong
November 2010
The first Heart Transplant
• Christiaan Barnard, a south African
surgeon, was 44 years old when in 1967
he transplanted the heart of a 25 year old
woman into the body of a dying 55 year
old man.
• The patient lived 18 days, dying from
rejection of the organ. Reactions were
mixed, the prevailing medical opinion
being that the operation had been
premature.
Types of transplants
• Living donor (lobe of the liver or a kidney)
• Directed or non-directed. Sweden in 2004.
•
instituted non-directed, compensated
donations
• Cadaver (brain-dead)
•
90% of organs come from these
individuals (6000-7000/year). (Bresnahan
2010)
Quality of life for donors and
recipients
• Cyclosporin, which blocks immune
rejection of foreign tissue, was discovered
in the early 1980s.
• Today 75% of heart transplant patients
survive for at least five years and 50-60%
survive 10 years.
• Over 60% of lung transplant patients
survive over five years.
Risk for donors
• In Iran there is a regulated market for kidneys. A
study in 2001 shows that vendors frequently feel
worthless and shameful. Akin to prostitutes.
Anxiety and depression. (Kerstein 2009)
• However some argue that organ selling may
improve the vendor’s situation. (Cherry 2000)
• In US (Omar 2010) only 0.03% mortality
Criteria of death
• For thousands of years death included
cessation of breathing and heartbeat. This
is the whole-body standard of death.
• This definition became inappropriate when
ventilators were developed that allowed
artificial respiration of brain-damaged
patients.
Criteria of brain death
• Harvard criteria (1968): Very cautious: no
behavior that indicated consciousness , flat EEG
readings 24 hours apart. No brain activity.
• Cognitive criterion: not legal in any state. Loss of
“core properties” of a person.
• Irreversibility standard. Unconsciousness is
irreversible. Persistent vegetative state over one
year
• Uniform Brain Death Act. Loss of all brain
function.
– In several religions the ethics of brain dead
organ donation continues to be controversial.
–
Conflicting Needs:
• Doing everything possible for a comatose
or dying patient
• Allowing families closure and obtaining
organs for transplantation
• A few patients can make good recovery
after being comatose for over a year.
(7/434)
Shortage of organs
• There is a growing disparity between
demand for and supply of organs. (Hippen
2009)
• In 2009 worldwide 102,000 on transplant
list. In 2008 fewer than 8000 donors and
fewer than 22,000 transplanted organs.
15% of patients die on the liver transplant
waiting list annually.
Ethic of Care
• Captures the moral situation of live kidney
donations (Kane 2008)
• Focuses on the concrete and contextual,
concentrates on relationships.
• “animism” : donor’s qualities are imagined
to live within the recipient.
Advantages of kidney transplant
• Transplantation confers a good quality and
longer life cf. to dialysis. Also cheaper.
Currently 6% of Medicare spent on .6% of
recipients.
• Dialysis: blood run through a filtering
membrane and returned to body. 3 x week
for 4-5 hours each session.
Need for organs for transplant
• Which system would more successfully
realize the goals of greater availability?
• free market, state-regulated market, or
blanket prohibition
Possible exploitation
• To exploit someone is to benefit by taking
unfair advantage of that person.
• International data: individuals who have
sold their kidneys for cash are not
financially improved 5 years later and
describe their health and overall well-being
as worse.
Black market in organs
• 41% of surveyed physicians believed they
had treated a patient who had purchased
an organ.
Should there be a market for
organs?
• Monetary compensation is prohibited in
US by National Organ Transplantation Act
but some in the professional transplant
community argue for a regulated
commercial market for living kidney
donations. (Aronsohn et al 2010)
Transplant professionals in US
• A majority opposed to
a market for kidneys
and partial livers.
• Market value of living
kidney graft: $766327,549
• Liver transplants
more risky.
• Market value of living
partial liver graft:
$18,663-69,080
• Risk: quality of life vs.
surgical risk
Main criticisms of regulated market
• It would exploit vulnerable vendors and
recipients: gray-market transactions in
developing countries.
• Two Kant-based moral constraints which
some argue would make regulated organ
market immoral:
• 1. violates human dignity and
incomparable worth
Organ market
• 2. treats others merely as a means.
• In the world as we know it the organ market
would be immoral.
• For Kant everything that lacks incomparable
worth has mere price, including human
happiness and well-being
• Living donors are otherwise healthy people who
voluntarily submit to surgery. Currently their
donation is a gift not a sale.
Alternatives to a market in organs
• Opt-out programs: citizens are presumed
to consent to donating their organs at
death but can opt out of donation if they
choose. (Spain has this system and has
the highest deceased donor rate in the
world). (Kerstein 2009)
Autonomy
• Even those transplant physicians who
support an organ market rated risk more
important than patient autonomy and
opportunity to earn money.
• Also there is human flourishing, which
would be diminished by a market.
Possible non-monetary incentives
• Guaranteed health insurance, life
insurance, payment for lost wages, etc.
Utilitarian considerations
• In the U.S. prison inmates are entitled to
organ transplants
• An inmate on Oregon’s death row
requested a kidney transplant, which
would have saved Oregon money. But
there are more than 59,000 Americans
waiting for kidneys, nearly 200 in Oregon.
Reasons for transplant for inmate
• Morally wrong to reduce an inmate’s
quality of life whether he is eventually
executed or not.
• 75% of death sentences are over-turned
on appeal.
•
(Appel 2005)
System of compensated donation
is another possibility
• A Register with compensation which will
be the same at the savings made by the
health care system from the elimination of
20 years of dialysis.$95,000 to 250,000.
Transplant tourism
• Poverty stricken persons in developing
world are organ vendors at the mercy of
brokers.
Transplant tourism
• Central Hippocratic commitment is to
nonjudgmental regard. Doesn’t matter if they are
enemy soldiers, prisoners, or have gone to
China for transplant.
• 2003 : an international study on kidney
transplant traffic. recipients paid $100,000 while
living donors had received $800. In China
kidney 1000-10,000 and liver from executed
prisoner 94000.
• for donors after care generally not available.
Liver transplants in China
• 20-30% have hepatitis B virus. Liver disease a
leading cause of death in PRC.
• China like most Asian countries has no brain
death law and so almost all come from living
donors.
• Yet 95% of liver transplants in PRC come from
deceased donors (executed prisoners).
• Survival close to that in US. 70% after 5 years.
• (Rhodes 2010)
Transplants in China or India
• U.S. patients receive substandard care.
Should they be treated in US? Yes ethics
of medicine are strict : fiduciary
responsibility: doctors are trusted agents
of their patients’ welfare and beneficence.
Presumed consent
accepted in many countries.
• Individual consent not thought to be
ethically necessary and it is good to
conserve scarce resources.
• Consent: Sweden: legally presumed but
close relatives can veto donation
Presumed consent
• To presume consent allows for the
relatives of the deceased to simply confirm
that donation can go ahead as opposed to
undertaking the decision alone.
(Cherkassky 2010)
Presumed consent
•
•
•
•
Problems:
Undermines patient autonomy
Assumes knowledge by patient
Causes distress to relative
• We could think of organ donation as a duty
the dead owe to the living