Ethics and Organ Transplantation

Objectives

• Introduction

• History

• Types of organ transplant

• Guiding principles by WHO

• Ethical issues involved

• Allocation of the resources

• Certain Guideline

• Organ Market :Controversy

• Conclusion

Transplantation

• It is the act of surgically removing an organ from one person and placing it into another person.

• Transplantation occurs because the recipient’s organ has failed or has been damaged through illness or injury.

Organ Transplant

• The transfer of a whole or partial organ from one body to another .

• Removal of an organ from:

A deceased donor

A living human person

• For the purpose of replacing the recipient’s damaged or failing organ with a working one from the donor site

Which organs can be

transplanted : • Liver

• Kidney

• Lungs

• Pancreas

• Heart

• Intestine

History of Organ Transplant

• 1954 living relating kidney transplant( Dr. Joseph Murray and Dr. David Hume Boston)

• 1962 cadaveric kidney transplant by (Dr. Joseph Murray and Dr. David Hume Boston)

• 1963 lung transplant (Dr. James Hardy Mississippi) • 1967 liver transplant( Dr. Thomas Starzl Colorado) and

heart transplant(Dr. Christiaan Barnard South Africa) • 1981 heart/lung transplant(Dr. Norman Shumway

California) • In 1983, the FDA approved cyclosporine for use in

organ transplantation, and the first lung transplant patient survived more than six years.

Types

• Autograft - A transplant of tissue from one to oneself Skin grafts, vein extraction for CABG, storing blood in advance of surgery

• Allograft - Transplanted organ or tissue from a genetically non – identical member of the same species

• Most human tissue and organ transplant

• Isograft -A subset of allografts in which organs or tissues are transplanted from a donor to a genetically identical recipient (e.g. identical twin)

• Anatomically identical to allografts, closer to autografts in terms of the recipient’s immune response

• Xenograft -Replacement of an individual’s defective organ with an organ harvested from another species - Source of organs for human use: primates (genetic similarities to humans) and pigs (large availability)

Increasing Organ Donation

• Limited Resource

• Cadaveric Organs

– Mandated Choice – voluntary donation

– Presumed Consent - a person is presumed to have consented to organ donation in the case of their accidental death.

– Incentives

– Prisoners

Informed Consent

• Diagnosis

• Nature and purpose of treatment

• Risks and benefits of treatment

• Alternatives

– Risks and benefits

• Risks and benefits of not having treatment

Increasing Organ Donation

• Living Donors

– Buying and selling of organs • Unfair pressure on economically disadvantaged

• Wealthy people have unfair access

• Donor and recipient safety

Organ allocation

• “Those who are dangerously wounded must be tended first, entirely without regard to rank or distinction. Those less severely injured must wait until the gravely wounded have been operated upon and dressed. (Hinds 1975, 6)

• Limited resource

• Distributive justice

– How to fairly divide resources

– Equal access

– Maximum benefit

Distributive Justice

• Equal Access

– Everyone should be able to access it equally

– Length of Time

– Age of recipient

• Reasons for equal access: exclude individual worth from equation

– Exclude Medical “worthiness” i.e. smoking

– Exclude Social “worthiness” i.e. prisoners

Distributive Justice

• Maximum benefit

– Maximize the number of successful transplants

– Medical need

– Probability of success

• Reasons for maximum benefit: limited resource and should avoid waste

– Second transplant

– Factor in medical outcome

Current Organ Distribution System

• Medical need

• Probability of Success

• Time on Waiting List

WHO Guiding Principle 1

• Autonomy

• Cells, tissues and organs may be removed from the bodies of deceased persons for the purpose of transplantation if:

– (a) any consent required by law is obtained, and

– (b) there is no reason to believe that the deceased person objected to such removal.

WHO Guiding Principle 2

• Beneficence

• Physicians determining that a potential donor has died should not be directly involved in cell, tissue or organ removal from the donor or subsequent transplantation procedures; nor should they be responsible for the care of any intended recipient of such cells, tissues and organs.

WHO Guiding Principle 3

• Autonomy, Non-maleficence, Justice

• In general living donors should be genetically, legally or emotionally related to their recipients.

• Informed, voluntary consent

• Professional follow up ensured and organized

• Selection criteria

• Non coercive (by force)

WHO Guiding Principle 4

• Non-maleficence

• Minors and legally incompetent people – No cells, tissues or organs should be removed from

the body of a living minor for the purpose of transplantation other than narrow exceptions allowed under national law.

– Specific measures should be in place to protect the minor and, wherever possible the minor’s assent should be obtained before donation.

WHO Guiding Principle 5, 6, and 8

• Beneficence

• Cells, tissues and organs should only be donated freely without any monetary payment or reward of monetary value.

• The prohibition on sale or purchase of cells, tissues and organs does not preclude reimbursing reasonable and verifiable expenses incurred by the donor, including loss of income, or paying the costs of recovering, processing, preserving and supplying human cells, tissues or organs for transplantation.

WHO Guiding Principle 7

• Non-maleficence

• Physicians and other health professionals should not engage in transplantation procedures, and health insurers and other payers should not cover such procedures, if the cells, tissues or organs concerned have been obtained through exploitation or coercion of, or payment to, the donor or the next of kin of a deceased donor.

WHO Guiding Principle 9

• Justice

• The allocation of organs, cells and tissues should be guided by clinical criteria and ethical norms, not financial or other considerations.

• Allocation rules, defined by appropriately constituted committees, should be equitable, externally justified, and transparent.

Ethical issues

• Is the human body a commodity?

• How should decisions be made about who receives scarce organs?

• Who should pay for transplants?

• Should one person receive several organs or several persons receive one?

• Should one person have a second transplant when the first one fails or should a different person be given a first chance at a new organ?

• Should organs be donated to those persons who have abused their bodies by drinking and smoking or only to those whose organs are damaged by disease?

• Should state or federal law makers be involved in transplantation?

Certain Guidelines

• The functional integrity of the donor as a human person should not be impaired, even though anatomical integrity may suffer.

• The risk taken by the donor as an act of charity is proportionate to the good resulting for the recipient.

• The donor’s consent is free and informed.

• The recipients for the scarce organs are selected

justly .

Organ Market :Controversy

• The vicious cycle – Needs money , has organ.

- Has money , needs organ.

Main Issues on Organ Trade It is contrary to the dignity of the human body and

depersonalizing

• Organ sale promotes coercion and exploitation of people, especially of the poor.

Insufficient screening compromises quality of organ and health of both donor and recipient

• It promotes poor quality of care as a result of poor standards of donor selection and inadequate screening for transmissible disease

All those who need such a gift should receive it, rather than only those who could pay.

• There is favor for those who have the resources to purchase these “entities” .

• Discrimination

“It makes human organs a commodity for profit and sale.”

Citations

• Informed Consent. American Medical Association< http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.shtml>

• WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation< http://www.searo.who.int/LinkFiles/BCT_WHO_guiding_principles_organ_transplantation.pdf> 26 May 2008.

"Sometimes our light goes out but is blown again

into flame by an encounter with another human

being.

Each of us owes the deepest thanks to those who

have rekindled this inner light."

– Albert Schweitzer