MODULE 9 AC
ETHICAL CONSIDERATIONS
ON ORGAN TRANSPLANTATION
 As of 3:20 p.m. on July 25, 2003, there were 82,344 Americans on waiting lists
for donor organs.
 Between January and April of 2003, only 8,350 transplants had occurred.
 These organs came from only 4,302 donors.
 U.S. consent rates from families is a low as 46%.
 It is estimated that between 17 and 31 Americans die every day waiting for
transplants.
This scarcity of available donor organs suggests many ethical dilemmas. For the most
part, they fall into two categories:
1. Are there ethical means that can be employed to limit those who are allowed to
receive donor organs?
2. Are there ethical means that can be adopted to ease the restrictions on the
harvesting of organs?
1.
Suggested plans for limiting those who are allowed to receive donor organs

The Blame Game - Ethical Dilemma: Is it ethical to deny a group of patients
donor organs because of their own behavior?
There are certain medical conditions that eliminate persons from competition for
scarce donor organs. These are objective standards that do not take into consideration
a particular patient’s personal “worthiness” to receive an organ. But there are those
who suggest that patients who fall ill because of their own behavior ought not be
allowed to receive a donor organ. This concern is generally voiced out of concern that
a “guilty” patient will receive a scarce organ at the expense of an “innocent” patient
who fell ill through no fault of his or her own. While this may sound reasonable (if
not charitable), its practical application would be problematic.
For example, some argue that those suffering from end-stage alcoholic liver disease
should not be eligible to receive donor livers. Today, however, most programs require
a period of sobriety before one can be placed on the waiting list. So, if even these
“recovering alcoholics” were denied donor organs, how could we justify giving such
organs to people who may be ill because they once dined too often at McDonalds and
KFC; used illegal drugs; had unsafe sex; or smoked? How could we even ascertain
these facts? As an aside, the argument that alcoholics might start drinking again—
and will thus “waste” the new livers—does not hold up to scientific scrutiny. Survival
and retransplantation rates are the same for drinkers as for those who abstain.1
Further, could we be sure that overeating, unsafe sex, and drug abuse would not begin
anew?
Another problem: Alcoholism is now understood to have some genetic element, and
scientists have discovered a “risk-taking” gene as well. If a recovering alcoholic is
vying with a daredevil for a particular donor liver, can a credible ethical argument be
made that the alcoholic is somehow more responsible for needing the new liver than
the cliff-diving daredevil? Or is the alcoholic more “guilty” than a person who
destroyed her liver sniffing glue? And what of the person who was simply too
careless to read the bottle of Tylenol, and washed the acetaminophen down with
scotch?
The standard practice today is to avoid impossible value judgments and to grant
places on the waiting lists on the basis of medical criteria alone. For alcoholics,
obtaining a place may require a period of sobriety, just as weight loss, diet, and
similar health habits may first need to be addressed by others.
Other considerations on limiting recipients include asking whether priority should
favor the sickest patients or those with the best chance of survival; time on the
waiting list or need.

Reciprocity – Ethical dilemma: Is it ethical to distribute donor organs on a
quid pro quo basis?
Some suggest that only persons who voluntarily sign up to be organ donors while
healthy could receive a donor organ if the need arose. Signing up could not be done
retroactively. This approach would require considerable ongoing education of the
population. It is problematic in that young people often fail to acknowledge that they
may someday fall ill or be injured, and many might thus fail to sign up to be donors.
2. Suggested plans for easing the restrictions on harvesting organs– Ethical
Dilemma:

Ethical Dilemmas: What degree of consent must be sought before harvesting
dead donor organs? How do we best address the need for freely given
consent from living donors?
Rather than eliminating potential recipients from waiting lists, perhaps the critical
shortage of transplantable organs is better addressed by easing the restrictions on
See, for example, Paul Cotton, “Alcohol’s Threat to Liver Transplant Recipients May be Overstated,
Suggests Retrospective Study,” Journal of the American Medical Association 27 (23) (June 15, 1994):
1815-17.
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obtaining those organs from both dead and living donors. Suggestions for doing so
include some that are ethical and some that are problematic at best.
Dead Donors: At present, the final permission to take organs from a person who has
died comes from that person’s survivors. Even if the person has indicated that he or
she wants to be a donor, organ procurement organizations (OPOs), hospitals, and
physicians are virtually always unwilling to harvest organs if survivors object. It is
generally felt that out of respect for those who are mourning, for the good of
hospital/community relations, and to avoid scandalous stories that might impede
organ donations, it is better to pass than to harvest the organs when family members
object.
Increases in organs for transplantation have been achieved through both organ sharing
(in which a liver might be split, with two patients each receiving one lobe), or through
a procedure known as “domino transplantation.” An example of a domino transplant
occurred recently when surgeons transplanted the intestines of a dead donor into a
young. Her functioning liver was removed because, "By putting the entire package
from the donor in, we have to make much less connection, and the concern about size
discrepancy is not a significant issue," her surgeon explained. He then transplanted
her liver into another patient.
Other ideas for maximizing dead donor organ donation include:
 Widespread activist education about the realities of organ donation - The
involvement of schools and churches is encouraged. (Many people erroneously
believe that their religion does not allow organ removal.)
 Universal donation – this approach would allow OPOs to harvest organs from
every eligible dead person unless given specific instructions to the contrary from
the individual or his or her family.
 Compulsory removal - based on the power of the state to prevent wasting of
valuable assets by the deceased, organs would be taken without seeking the
permission of survivors, and regardless of any objection.
 Mandated Choice – everyone would be asked, upon turning 18, whether or not he
or she wanted to be an organ donor. Family members could not overrule this
decision after the person’s death.
 Payment for organs – suggestions range from covering the funeral coasts of the
donor to substantial set payments or free-market private purchase arrangements.
 Executed persons – suggestions range from allowing prisoners who are going to
be executed to donate organs, to simply taking organs from all medically eligible
executed prisoners.
 Taking organs from patients in a persistent vegetative state, who would then
continue living as before (using a “greater need” argument), or after the decision
to end life support has been made.
Living Donors: Great scientific inroads have been made over the last decade in this
regard. Living donors are able to donate “spare organs,” such as one kidney, or one lobe
of a liver. At present, this must be a “not-for-profit” act of generosity, usually among
family members, but occasionally from an altruistic non-related donor. Ethical problems
do exist, and must be dealt with with great discretion. For example, a circumstance can
arise in which a family may know that one member is a possible match and a potential
organ donor, capable of saving the life of another family member. The potential donor
may feel great pressure to do so, even if he or she does not want to. This issue is
generally handled through a private interview with medical staff. If it is clear that he or
she does not want to donate, family will be told that the complete set of test results shows
that the person would not, after all, be a match, and thus cannot donate. Other ethical
questions surround parental permission for a minor to be a donor. Does a parent have a
right to remove a healthy organ from a healthy child, even to save the life of another?
Other ideas for maximizing living donor organ donation include:


Payment for organs – This would allow individuals to sell the above mentioned
“spare organs” to the highest bidder. Some even support permitting U.S. patients
to purchase organs from Third World donors.
Prisoner donation – Some suggest allowing parole for prisoners who donate
organs
Other Possibilities:
 Rebuilt organs – see http://organtx.org/ethics/marginal_donors.htmm
 Genetically built organs
 Cloned organs
 Xenotransplantation – see, http://akak.essortment.com/whatisxenotr_rgsy.htm