Bioethics of Organ Transplantation

Abstract

As the ability to transplant organs and tissues has grown, the demand for these procedures has increased as well – to the point where it far exceeds the available supply. There are also financial obstacles to access to transplant waiting lists in USA and other nations. There are severe limits on the availability of transplant services in many underdeveloped nations. Transplant physicians are well aware of this gap in supply and demand. They cope with the shortage by denying access to transplant centres to candidates on the grounds that some potential recipients are too old or medically ‘unsuitable’. This ‘scientific’ judgement often is based upon psychosocial factors. There is an active blackmarket in organ transplants internationally since many nations have no effective cadaver procurement system and some transplant centres are willing to guarantee an organ for the right price to noncitizens who can pay. Ultimately solutions to shortage in organs will involve better artificial organs, genetically engineered organs, regenerative techniques involving stem cells or the use of organs from genetically modified animals.

Key Concepts:

  • Although the demand for organs now exceeds the supply in every nation, the size of waiting lists would quickly expand were there to suddenly be an equally large expansion in the number of organs available for transplantation. Many older patients are not considered eligible for transplants but would be if more organs were available.

  • The waiting lists for cadaver organs have grown so long that a quiet form of triage takes place every day based on age, citizenship, ability to pay, potential for compliance and criminal record.

  • The reasons why the policy of encouraged voluntarism has not produced as many organs and tissues for transplant as might be expected are many. Large numbers of people still do not carry a donor card or other written directive specifying the disposition of their bodies when they die. Rates of donation among the poor are low. Some fear they will not receive adequate treatment if they say they are potential donors.

  • Donation is closer to being an obligation than it is to an extraordinary act of extraorindary moral beneficence or courage.

  • Transplant tourism remains an ethical challenge. For example, travel to China by foreigners to secure organ transplants has grown over the past decade. ‘Transplant tourists’ are attracted by a competitive price and a guarantee of a transplant. With no cadaver organ procurement system in place, the only way to guarantee the transplant of a liver or heart during the short time a transplant tourist is in China is to find matches among those in prison and execute anyone who is a suitable match.

  • Some transplant programs say they exclude some categories of patients from transplants because they have a history of drug abuse, a criminal convinction or because they have a mental illness or disability thereby giving strong reason for doubt about overall equity in the allocation of scarce organs.

  • In deciding what is fair in rationing organs the goal is to save lives and to get the most years of life from each organ. If so, then giving organs to the sickest persons who need them or the oldest is not necessarily the best way to allocate these life‐saving resources.

Keywords: encouraged voluntarism; organ procurement; presumed consent; payment for organs; distribution of organs; equity; eligibility; justice; efficacy

References

Alexander GC and Sehgal AR (1998) Barriers to cadaveric renal transplantation among blacks, women, and the poor. Journal of the American Medical Association 280(13): 1148–1152.

Caplan AL (2008) Organ transplantation. In: Crowley M (ed.) From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book, pp. 72–75. Garrison, NY: Hastings Center

Caplan AL (2011) The use of prisoners as sources of organs – an ethically dubious practice. American Journal of Bioethics 11(10): 1–5.

Childress JF and Liverman CT (2006) Organ Donation. Washington: IOM Press.

DeVita M and Caplan AL (2007) Caring for organs or for patients? Ethical concerns about the Uniform Anatomical Gift Act. Annals of Internal Medicine 147: 876–879.

Halpern SD, Shaked A, Hasz RD and Caplan AL (2008) Informing solid organ transplant candidates of donor risk factors. New England Journal of Medicine 358: 2832–2837.

Hippen BJ, Thistlethwaite JR and Ross LF (2011) Risk, prognosis, and unintended consequences in kidney allocation. New England Journal of Medicine 364(14): 1285–1287.

Richards CT, Crawley LM and Magnus D (2009) Use of neurodevelopmental delay in pediatric solid organ transplant listing decisions: inconsistencies in standards across major pediatric transplant centers. Pediatric Transplantation 13(7): 843–850.

Reese P, Abt PL, Bloom RD, Karlawish J and Caplan A (2010) Should we use age to ration health care? The case of kidney transplantation. Journal of the American Geriatrics Society 58(10): 1–7.

Reese P and Caplan AL (2011) Better off living – the ethics of the new UNOS proposal for allocating kidneys for transplantation. Clinical Journal of the American Society of Nephrology 6,9: 2310–2312.

Further Reading

Caplan AL and Coehlo DH (1998) The Ethics of Organ Transplants. New York: Prometheus.

Caplan AL and Prior F (2009) Trafficking in organs, tissues and cells and trafficking in human beings for the purpose of the removal of organs. Joint Council of Europe/United Nations Study.

Jensen SJ (ed.) (2011) The Ethics of Organ Transplantation. Washington, DC: CUA Press.

Miller FG and Truog R (2012) Death Dying and Organ Transplantation. Oxford, UK: Oxford University Press.

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How to Cite close
Caplan, Art(Apr 2012) Bioethics of Organ Transplantation. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0003481.pub2]