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ORGAN AND TISSUE TRANSPLANTS
III. ETHICAL AND LEGAL ISSUES
Arthur L. Caplan
No modern medical technology raises more ethical, legal, and policy questions than
transplantation. Since World War II, most nations capable of performing transplants have obtained
organs and tissues from both living persons and the dead, on the basis of voluntary consent
motivated by altruism. In the case of the deceased, consent is obtained either through a written
advance directive, often a "donor card," or on the basis of proxy consent by next of kin. The values
of voluntarism and altruism have come in for much critical scrutiny and debate in recent years as
the supply of organs and tissues has not kept up with the capacity to perform these operations.
The scarcity of organs and tissues available for transplantation has forced those in the field
to articulate policies and criteria for allocating what are often life-saving resources. Disputes about
equity in the distribution of organs and tissues have elicited a great deal of discussion about the
relevance of such factors as age, mental and physical disabilities, ability to pay, psychosocial
variables, and patient compliance in organ and tissue allocation. Transplants are often very
expensive. Issues of fairness in terms of covering the exorbitant costs of transplants by third-party
payers continue to dominate debates about access to and coverage for transplants. Questions of
fairness also arise with respect to which centers and teams can and should perform various types of
transplants, and whether too many fiscal and human resources are being devoted to the creation of a
greater capacity to perform transplants, given both the scarcity of organs and the need to provide
other forms of health-care services. Questions about the proper moral foundation for obtaining
organs and tissues and how best to allocate the limited supply have swirled about the field of organ
transplantation since the first successful transplants were performed.
The early years: The 1950s and 1960s
The modern age of organ transplantation began in 1954 with the successful transplantation
of a kidney from a young boy to his identical twin brother at the Peter Bent Brigham Hospital in
Boston, Massachusetts. The early surgical pioneers and their patients faced tremendous technical
challenges. Organs could be taken only from living donors, since it was not known whether cadaver
organs would function. Even if cadaver organs did function, it was unclear how to remove, store,
and handle them. There were no effective drugs available to prevent or to treat the rejection of a
transplanted organ from a nonidentical biological source. Knowledge about the biology of the
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human immune system was spotty. Identical twins or closely related siblings were the only feasible
donor-recipient pairs since their bodily organs possessed the same or very similar genetic
information. In the middle and late 1950s, the only organs transplanted were kidneys. Surgeons
believed this was the only organ that could be removed from a human being without compromising
the health of the donor (Murray, 1992).
Because of the dubious efficacy of transplantation during this period, moral concerns
focused more on the rights and interests of prospective donors than on those of prospective
recipients. A person with chronic renal failure with no other hope of survival would, doctors
assumed, accept the risks and uncertainties associated with kidney transplantation. Physicians were
deeply concerned, as were many religious leaders, that those doing transplants make every effort to
minimize the risk of serious harm to donors (Wolstenholme and O'Connor, 1966). Some worried
that removing a kidney from a healthy person solely to benefit another came uncomfortably close to
violating the principle of nonmaleficence, or "do no harm," which permeates and continues to
dominate the ethic of Western medicine.
The moral means that emerged for not violating the principle of nonmaleficence by risking
the health of one person to aid another were informed consent and altruism. Those doing transplants
felt they were not harming prospective donors if they were certain that the risk of doing harm was
very low and fully disclosed and if the decision to make a kidney available was freely and
voluntarily chosen. Voluntary altruism became the central tenet of transplantation ethics. This ethos
did not emerge because giving was seen as morally preferable to either allowing organs to be sold
or granting the state or doctors the right simply to take organs when someone was in need. Rather,
physicians and theologians felt that the act of removing a kidney did not violate the strict
prohibition against doing harm when procurement took place with the informed and altruistic
concurrence of the donor.
The desire to respect the principle of nonmaleficence in the earliest days of transplantation
was reinforced by Jewish and Christian religious traditions, which saw a person's relationship to his
or her body as the stewardship of a gift from God. The key moral challenge raised by living
donation, especially within the Catholic and Jewish traditions, was whether removing a kidney to
give to another constituted immoral self-mutilation of the body (Wolstenholme and O'Connor,
1966). It was not until the 1960s that a consensus emerged among religious authorities in North
America and Europe that if the act of organ donation were freely and voluntarily entered into from
the motive of love and the desire to help another human being (beneficence), then donation was
morally licit.
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The most problematic moral cases during this period concerned prospective donors who
were young children or mentally incompetent persons. The pool of possible kidney donors was so
small that those in need of transplants had no alternative but to turn to family members, some of
whom were clearly not competent to make voluntary, altruistic choices.
When approached about the prospect of using minor or incompetent donors, U.S. courts
followed two principles. Some judges argued that it was in the best interest of a child or cognitively
impaired person to be permitted to try to save the life of a relative. Thus, they approved donation on
behalf of such persons on the grounds that it was in their interest. Other U.S. courts insisted that
guardians or surrogate decision makers, frequently parents, be appointed to exercise surrogate
informed consent for the minor or incompetent prospective donor (Scott, 1981). In the United
States, a number of donations by children and incompetent adults did occur with the proxy consent
of parents. In most nations in Europe, however, children under the age of eighteen and mentally
incompetent persons were ruled out as possible donors on the grounds that they could not freely
consent, thereby undermining the moral basis for violating the nonmaleficence principle.
From experiment to therapy: The 1970s and 1980s
A number of technological innovations revolutionized the world of organ transplantation in
the late 1960s and early 1970s. The widespread dissemination of ventilators and other life-support
machines raised the possibility of utilizing cadavers as sources of organs. This newly emerging
technology could prevent immediate damage to vital organs even though the patient had died.
The ability to artificially support organ function even though a person had died called into
question the medical profession's criteria for pronouncing death. There were no agreed-upon legal
or clinical criteria for determining death in a person whose vital organ functions were being
maintained by machines. Heated debates broke out among physicians and others concerning the
need to redefine or expand the definition of death to include those whose brains had irreversibly
ceased to function, even though their hearts and lungs continued to do so. These debates culminated
in the addition of brain death to the long-accepted definition of cardiopulmonary death in U.S. state
laws and in the laws of other nations such as Great Britain, Australia, France, and Canada (Scott,
1981).
The ability to preserve the organs of cadavers opened the door to the possibility of using
cadaver organs for transplantation. This possibility became a reality when breakthroughs were made
in the fields of immunology and pharmacology. Scientists began to unlock the mysteries of the
immune system. They discovered key chemicals in each cell—antigens—that triggered the body's
natural defenses against foreign tissue. The more closely related two people are, the more likely it is
that they have the same antigens in their cells. Testing for antigens in a given organ made it possible
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to match those who were not immediate biological relatives but who, by chance, happened to have
similar antigen types. Breakthroughs in the development of immunosuppressive drugs allowed
transplant teams to use organs from donors who were not precise biological matches by suppressing
the rejection phenomena in recipients. With the development of successful techniques for
preserving, handling, and shipping organs outside the body using cryopreservation and various
preservative solutions, the world of transplantation underwent a revolution.
By the early 1980s, it was commonplace to use cadavers as sources of organs. Not only
kidneys, but hearts, livers, lungs, and combinations of these organs were being transplanted
successfully. Organs from cadaver sources were routinely shipped hundreds of miles to recipients
who bore no biological relationship to donors. The rates of success in transplants using cadaver
organs started to approximate those associated with living donors. This rapid evolution in the field
of transplantation raised a host of new ethical problems and challenges about using cadavers as the
primary source of organs.
The shift to cadaver sources
The earlier emphasis on voluntary choice and altruism as the moral basis for permitting
living donors to assume risks in the face of uncertain benefits carried over to cadaver donation in
the 1970s and 1980s. Public concern about the importance of altruistic, voluntary choice was
reinforced when it was revealed that, during the late 1960s, some physicians had surreptitiously
removed pituitary glands from cadavers in order to obtain growth hormone to help children born
with congenital dwarfism (Caplan, 1984).
In the United States, both the public and the Congress expressed outrage over the removal of
tissues from cadavers without prior consent from either the deceased via wills or from their
families. This reaction indicated that the desire to guarantee individuals the right to control their
own bodies was thought to extend to the disposition of their remains after death. The great value
placed on personal autonomy in the United States led to professional and public discussions about
the need to design a system of advance directives that would allow each individual to control the
disposition of his or her bodily remains (Scott, 1981; Meyers, 1990). The Uniform Anatomical Gift
Act, which created the donor-card system, emerged from the moral concern about individual choice.
In the late 1960s, various model statutes were advanced proposing a brain-death standard
(Scott, 1981). By 1975, some form of brain-death legislation had been adopted in more than thirty
states (Meyers, 1990). These states recognized the total and irreversible cessation of all brain
function as a criterion of death that could be used along with the older definition of death, that is,
the irreversible cessation of cardiopulmonary function.
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The ability to use cadavers as sources of transplantable organs led to heated debate about
whether public policy with respect to organ and tissue procurement should be changed. Some
analysts argued that the impressive success of transplantation justified abandoning the prerequisite
of informed consent in favor of laws based on the presumption of consent, thereby permitting the
routine salvaging of cadaver organs (Sanders and Dukeminier, 1968). Others argued that the time
had come to allow financial rewards to those willing to make organs and tissues available after their
deaths (Scott, 1981).
Critics of presumed consent and routine salvaging argued that it was unfair to imperil the
rights of those who opposed cadaveric organ and tissue donation for religious reasons (Ramsey,
1970). Those holding minority points of view about cadaver donation would feel powerful social
pressure to abandon their religious beliefs. Others who opposed any change in the moral foundation
of procurement were concerned that public policies that allowed either the routine removal of
organs and tissues from cadavers or permitted financial incentives would corrode social attitudes
toward the dignity of the body and the sanctity and worth of the individual. The moral argument
that ultimately prevailed was that public policy should be based on voluntary choice and altruism,
because these values were consistent with the need to respect individual autonomy. Public policies
based on these values might permit an adequate supply of organs and tissues to be obtained from
cadaver sources if adequate educational efforts were made to inform the public about the
importance of cadaver-organ donation (Caplan, 1984).
State and federal laws pertaining to cadaver donation. The ethical concern that the donation
of organs and tissues be voluntary and altruistic was reflected in the earliest U.S. legislation dealing
with cadaver donation. In 1968, the National Conference of Commissioners on Uniform State Laws
adopted the Uniform Anatomical Gift Act (UAGA). By 1972, versions of this law had been passed
in all fifty states. These laws recognized a signed card as completely sufficient for donation as long
as family members did not object. Health-care professionals who made a good-faith effort to locate
next of kin prior to relying on a donor card to remove organs and tissues were immunized against
legal action (Meyers, 1990). In order to ensure that decisions to donate were altruistic, laws
explicitly prohibiting the sale of organs and most tissues were subsequently enacted in some states;
and in 1984, federal legislation, the National Organ Transplant Act, became law.
If a deceased person did not complete a donor card, the UAGA permits donation based on
the consent of relatives or guardians. In such circumstances, immediate family members have the
right to veto donation. The law clearly recognizes family members' legitimate interest in the fate of
bodily remains but does not assign the family a property interest in the body (Caplan, 1984).
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In the 1980s, as the demand for cadaver organs increased and waiting lists began to grow,
another legislative reform was introduced—"required request." Legislation was enacted requiring
that a request be made to family members for organ donation at the time of death. This legislation
was based on the ethical argument that mandating requests would not be coercive to families but
would afford them the opportunity to choose to donate. Oregon and New York enacted the first
required-request laws in 1985. By 1992, forty-seven states and the District of Columbia had enacted
some form of required-request legislation governing cadaver sources (Caplan, 1992). In 1986, the
U.S. Congress enacted legislation requiring hospitals to institute required-request policies. Shortly
thereafter, the Joint Commission on Accreditation of Health-Care Organizations ordered that
request policies be in place as a condition of hospital accreditation.
The only exception to the requirement of voluntary consent in U.S. public policy concerns
the disposition of bodies in the custody of the state. Ten states and a small number of municipalities
have enacted legislation granting authority to medical examiners and coroners to procure organs
and tissues from unclaimed bodies undergoing autopsy. The states of Louisiana, Texas, Florida, and
Ohio and the cities of San Francisco and Denver are among the localities that permit procurement
from bodies under the control of medical examiners or coroners when no family members can be
found and there is no reason to assume any prior objection to procurement. In 1992, Texas enacted
a modification of the UAGA whereby family members are not allowed to object to donation when
the deceased has signed a donor card.
The problem of scarcity
Scarcity in the supply of organs emerged in the 1990s as the single most frustrating problem
for those involved in transplantation. At the end of 1987, the United Network for Organ Sharing
(UNOS), the semiprivate entity created to help distribute organs among the nation's transplantation
centers, reported that 13,396 people were waiting to receive kidneys, hearts, livers, or lungs. In
1989, there were 19,173 names on the waiting list. One year later, there were 22,008 names on the
list, an increase of more than 60 percent over three years. Despite the fact that more and more
transplants are performed each year, the list has continued to grow. Similar gaps between supply
and demand exist in every other nation where transplants are done.
A key factor in the expansion of waiting lists is that, as surgical skill has improved, the
criteria have relaxed for considering people with end-stage organ disease as potential transplant
recipients. Age limits that prevailed in the 1970s—no one older than fifty-five for heart and liver
transplants, for example—have since been extended to include persons in their late sixties and early
seventies. Diabetes is no longer an absolute contraindication for kidney transplantation. Persons
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suffering liver failure resulting from alcohol abuse have had successful transplantations (Caplan,
1992).
As the pool of potential recipients has grown, so have the numbers of those who die while
on waiting lists. Between one-third and one-half of all Americans on waiting lists for hearts, livers,
lungs, and multiple-organ combinations die before transplantable organs are found. The shortage of
organs for newborns and very young children is especially acute. UNOS reports that 25 percent of
those waiting for liver transplants are children less than ten years old and that in 1993, more than
400 infants born with congenital defects of the heart died because there were no donor hearts
available for them.
The demand for organs is likely to continue to increase at a rapid rate. Success rates
associated with all forms of transplantation have improved. The shift in the demographics of the
United States, Europe, and Japan toward an older population means that more individuals will need
transplants. Continuing improvements in immunosuppressive drugs, combined with a better
understanding of the genetics of the immune system that the Human Genome Project is providing,
mean that success rates will continue to improve for various types of transplants, making an even
larger segment of those suffering from organ failure potential candidates for transplants.
Since the early 1960s, the number of medical centers and hospitals capable of performing
transplants has steadily increased. This increasing capacity to do transplants, and the high costs
involved, have also increased the pressure to find more organs and tissues.
Other factors promise further increases in the demand for transplants. These include
improvements in techniques for "bridging"—temporarily keeping those in acute organ failure
alive—such as the use of Left Ventricular Assist Devices (LVADs), bioartificial livers, or
xenografts of pig or primate organs; the ability to maintain patients with end-stage organ failure
using new technology, such as the insulin pump and extracorporeal membrane oxygenation; and the
modification of the immune systems of donor and recipient through genetic engineering.
Moral choices in the face of scarcity. In many countries, national policies for allocating
organs emerged
after a series of complaints and media accounts concerning the inequitable
distribution of organs at individual transplant centers. For example, in the early 1980s the media in
the United States, Italy, and the United Kingdom carried many reports about wealthy foreigners
who paid high sums of money for priority placement on transplant center waiting lists. That wealthy
noncitizens could move to the top of waiting lists seemed to many to be unfair and immoral. The
U.S. government threatened to take over the allocation of cadaver organs unless the transplant
community established a publicly accountable national network to distribute organs to those in
need. This resulted in the development of UNOS during the late 1980s.
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UNOS resolved the question of access by declaring that no more than 10 percent of any
center's transplant population could be foreigners. But other problems quickly boiled to the surface
as UNOS and other agencies, such as U.K. Transplant and Eurotransplant, which handles organ
distribution in Germany and the Benelux nations, began to grapple with how best to allocate an
increasingly scarce supply of organs.
Traditionally, transplant programs around the world had given great weight in their
allocation policies to such factors as tissue type, the physical size of donor and recipient, blood
type, medical urgency, and how much time the recipient had spent on the waiting list. But doubts
began to surface in some circles about the fairness of biological criteria (Kjellstrand, 1988). The use
of the closest match of tissue types may increase the success of a transplant, but it puts minorities at
a disadvantage. Asian-Americans, Pacific Island peoples, and aboriginal peoples living in the
United States or other nations with large caucasian populations are less likely than whites to find
close matches in a pool of cadaver donors that is largely white. Decisions about the importance of
biology in allocating organs involve trade-offs between the desire to maximize the outcome of a
transplant and the desire to ensure that each person in need has a fair chance of receiving a
transplant.
Organs obtained from cadaver donors are distributed among transplant centers according to
criteria that include blood type, geographic location where organs are obtained, tissue-matching,
patient waiting time, and medical urgency (Caplan, 1992). Most transplant centers follow a policy
of "share one, keep one" where locally obtained cadaver kidneys are concerned. With few
exceptions, organs go to those who have been waiting the longest at centers near where the donor is.
Consortiums in other nations use similar criteria to share organs.
Some critics maintain that giving top priority to the sickest patients on a national waiting list
skews the allocation of valuable organs to those who are least likely to survive (Ubel et al., 1993).
Those who need a second, third, or even fourth transplant because their initial transplant failed gain
top priority for the next available kidney, heart, or liver even though the odds of a successful
retransplant are lower than they are for first-time transplants. Similarly, assigning top priority to
those who have received an artificial organ or a xenograft as a temporary bridge has elicited much
criticism as an unfair and inefficient use of scarce cadaver organs (Annas, 1993).
Macroallocation and morality. Despite the fact that there are national criteria for allocating
organs to ensure fair access to those who need transplants, there are still reasons for concern about
the overall fairness of the current system. Primary among these is the role played by money in
determining not who gets a transplant at a particular hospital, but who is referred for consideration
and gains admission to a transplant center.
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Transplantation is an expensive procedure. In 1992, a kidney transplant cost around
$35,000; a heart transplant, between $60,000 and $100,000; and a liver transplant, anywhere
between $150,000 and $250,000 (Caplan, 1992). These figures presume a procedure that goes
relatively well, without complications requiring longer hospital stays or further surgery. They do
not include costs such as travel, time lost from the job, or day care, which can be enormously
burdensome to transplant candidates and their families since these costs are not covered by medical
insurance.
In order to be considered for a transplant, a person must be able to meet these costs. He or
she must also have access to a physician who is capable of recognizing that the medical problem is
amenable to a transplant. In the United States and many other nations, insurance to cover primary
medical care and to pay the costs of a transplant is pivotal in determining who gains access to
transplant centers for evaluation and, if appropriate, placement on a waiting list.
Many insurance programs do not cover the costs of certain kinds of transplants. This is
especially true for newer, more innovative forms of transplantation such as lung, pancreas, or
intestinal transplants; xenografts; or multiple-organ transplants. Whether or not government
insurance programs, such as Medicaid, will cover the costs of transplants depends on where an
individual lives and whether or not he or she has been disabled for a significant period of time.
Access to transplantation is very much a function of access to good primary medical care and the
right kind of insurance coverage (Caplan, 1992).
Some people would argue that the ability to pay is a fair basis for allocating an expensive
service such as organ transplants, and that societies do not have an obligation to provide access to
every possible form of medical care, especially when organ failure is the result of voluntary
behavior such as smoking and drug or alcohol abuse (Moss and Siegler, 1991). Others maintain
that, while money might be an unfair method for determining who has access to transplant services,
equity requires limiting rather than increasing access. If there are large numbers of persons in a
particular society who do not have access to basic health-care services, then allowing a tiny number
access to expensive forms of treatment such as transplantation seems inherently unfair (Fox and
Swazey, 1992).
There is no consensus about how to evaluate the overall equity of a health-care system or the
provision of particular services such as transplantation. However, most theories of justice hold that
if the provision of a particular service using public money places an undue burden on the services
that are available to others, then those who have access to such a service ought to pay the costs
involved out of their own resources. Few would want to defend publicly funded provision of
procedures that lack efficacy, or are capable of providing only marginal benefits, when other
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procedures are known to be far more efficacious and beneficial. The debate about the equity of
transplantation services available in a given society, or how much a society ought to spend on these
services relative to other types of medical or public-health interventions, requires attention not only
in terms of justice, but also in terms of the efficacy and benefit associated with particular kinds of
treatments.
International responses to the problem of scarcity. Most nations in the Western world
maintain a strong commitment to voluntarism and altruism as the basis of obtaining organs from
both cadaver and living sources. But the lack of organs for transplant has led some nations to pursue
public policies such as routine salvage or presumed consent, which rest upon different values.
France, using the argument that the needs of society outweigh the rights of the individual to control
bodily remains after death, enacted a presumed-consent law in 1976. For many decades, Austria has
had what amounts to a routine salvage policy, in which the state assigns dominion over bodies to
physicians to use them for important social purposes. In 1988, Singapore instituted a donation
policy based upon reciprocal altruism: Those willing to serve as donors receive priority for
transplants.
A small increase in kidney donation followed the enactment of the presumed-consent law in
France. Most of the increase, however, was used to decrease the number of kidney transplants
involving living donors (Kokkedee, 1992). Other nations such as Austria and Belgium, which have
placed societal needs ahead of individual autonomy and voluntarism, have not, according to
Eurotransplant officials, seen any improvement as of 1994 in the supply of organs.
A few nations, including India, Turkey, Haiti, the former Soviet Union, the Philippines, and
Brazil, permit—or have at least tolerated—the offering of financial incentives to living donors or to
the families of cadaver donors. These practices have provoked heated debate about the morality of
markets in body parts, both within and outside the countries in which they occur. No nation appears
to allow financial rewards with respect to cadaver donation; however, reports of payment for
cadaver kidneys obtained from prisoners have emerged from China and Hong Kong. The moral
justification for allowing financial incentives is rooted in the claim that individuals should be free to
sell bodily organs if they wish to do so, as long as they do so without pressure or coercion
(Blumstein and Sloan, 1989; Peters, 1991). Counterarguments hinge on the view that the body
ought not be made an object of commerce; that more potential donors will be repelled by monetary
rewards than will be attracted by them; and that the quality of organs obtained through policies that
permit financial compensation will be lower, since those who are paid will have a motive to conceal
their health status (Caplan et al., 1993).
The ongoing ethics challenge of scarcity
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Regardless of the public policy adopted, the number of potential cadaver organ sources is
very small (Novello, 1992). One possible strategy for increasing the number of organs and tissues
available is to encourage more educational efforts to persuade individuals and families to donate
organs. Despite public-opinion polls showing widespread support for organ donation, family refusal
is a real barrier to procurement. It is not clear whether this is a failure of voluntarism, or the failure
of health-care professionals to explain carefully and thoughtfully the reasons for organ donation.
Without adequate empirical information, it is impossible to determine whether the appropriate
public-policy response is more educational training for health-care professionals; more public
education; changes in the timing, setting, or identity of those making requests; or abandoning the
moral framework of altruistic voluntarism altogether.
Revisions in the UAGA suggest that hospitals ask all patients about their organ-donor status
upon admission. Some states, such as New Jersey, have enacted this requirement into law. The
Patient Self-Determination Act of 1990 mandates that all prospective patients be apprised of the
importance of having a living will; many of the standard forms used with this document contain a
provision regarding organ donation.
Another strategy to alleviate the problem of scarcity is to broaden the criteria of age and
health status used to determine both living- and cadaver-donor eligibility. However, broadening the
definition of who can be a donor raises important moral and legal questions. Most living donors
have a biological relationship with those in need of a transplant. Some programs have begun to
explore the option of recruiting strangers to serve as living donors for those in need. The moral
justification for such a strategy is that it is the individual who can best weigh the risk associated
with donating a kidney or part of another organ against the benefits to be gained. Reliance on
individual autonomy is the rationale for expanding the pool of persons who are considered potential
organ donors (Spital and Spital, 1985).
Another way to increase the supply of organs is to permit the elective use of mechanical
ventilation solely to permit organ donation in persons who otherwise would die without life support.
In persons dying from cerebrovascular accidents, where life support has not been used, families
could be asked for their consent to the use of mechanical ventilation in order to make organ
donation possible (Arnold and Youngner, 1993). A similar strategy for expanding the cadaverdonor pool involves obtaining organs from persons who die in emergency rooms or hospitals by
preserving them using special fluids as soon as death has been pronounced (Novello, 1992).
It may also be possible to make more efficient use of the cadaver-donor pool than is
currently the case. For example, if allocation rules on waiting lists were to place less emphasis on
severity of illness and waiting time and more on likely prognosis, the same number of cadaver
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organs might be able to save more lives. If more selective criteria were used in determining
eligibility for transplants, including discouraging or prohibiting retransplantation, overall
posttransplant survival might be increased (Fox and Swazey, 1992).
There has been some discussion of broadening the definition or the criteria used to
determine death. For example, some commentators have suggested permitting the use of different
criteria for determining brain death in anencephalic infants to facilitate their use as organ donors.
Others suggest that the concept of donor be expanded to include persons in permanent vegetative
states or those for whom brain death cannot be determined but whose hearts have stopped (Arnold
and Youngner, 1993).
Another strategy to increase the size of the pool of organs available for transplant is to turn
to animal sources. There are obvious ethical, psychosocial, and public-policy issues involved in
pursuing this alternative. Many people believe that it would be immoral to kill animals, particularly
primates, for the sole purpose of harvesting their organs. Others note that the use of animals is
currently so experimental that the informed-consent procedures of recipients must be especially
rigorous and peer review exceedingly conscientious before any potential recipients can be recruited
(Caplan, 1992). The ethics of using animals as routine sources of organs must be carefully
examined, since breakthroughs in genetic engineering and immunology are likely to facilitate crossspecies transplants.
Scarcity will characterize the field of transplantation for the rest of the twentieth century.
The key moral questions are whether the framework of values that has dominated U.S. attitudes
toward the procurement of human organs and tissues is consistent with expanding the pool of
cadaver and living donors; whether the pressing need for organs justifies abandoning these values;
and whether the symbolic and social cost of shifts in these values would come at an ethical price
that is too high to pay (Fox and Swazey, 1992).
Bibliography
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University Press.
Arnold, Robert M., and Youngner, Stuart J. 1993. "Non-Heart-Beating Donors." Kennedy Institute
of Ethics Journal 3, no. 2:1-12.
Blumstein, James F., and Sloan, Frank A., eds. 1989. Organ Transplantation Policy: Issues and
Prospects. Durham, N.C.: Duke University Press.
Caplan, Arthur L. 1984. "Organ Procurement: It's Not in the Cards." Hastings Center Report 14, no.
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———. 1992. If I Were a Rich Man Could I Buy a Pancreas? and Other Essays on the Ethics of
Health Care. Bloomington: Indiana University Press.
Pontifícia Universidade Católica do Rio Grande do Sul
Programa de Pós-Graduação em Medicina e Odontologia
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Texto incluído em
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