BODY PARTS NEEDED Part three of Four

Organ transplants can save lives and help improve the quality of life for someone who is seriously ill. The earliest transplant to be carried out was of a cornea, and which took place in 1905 in what is now the Czech Republic. In 1954 the USA carried out the first kidney transplant, and 6 years later, in Scotland, the first living donor kidney transplant took place. Transplants are still major operations but they have become routine over the last four decades. 

The first ever liver transplant in the UK was carried out in 1963 and since that time more than fifteen thousand liver transplants have been performed in Britain. Heart and liver transplant programs are among the major organ transplants performed in the UK. In the first five years of the 21 century, Britain carried out over 4000 liver transplants and in the twelve-month period running from April 2007 to the end of March 2008, UK surgeons transplanted a total of 3235 organs from 1665 donors. (donors gave more than one organ for a successful transplant) 

Currently, there are no accurate figures for the number of transplants performed worldwide. Only general trends and information is available from estimates. These show, for example, that the USA performs twice the number of kidney transplants than are carried out in the whole of Europe each year.

SHORTAGE

The shortage of organ donors is a universal problem and strict rules are in place, though not always respected or enforced,  encouraged by the World Health Organization, to prevent poor and underprivileged people being forced into becoming living donors. This practice is becoming more common but needs to be tightly controlled. In most countries there is a shortage of suitable organs for transplantation. Countries often have formal systems in place to manage the process of determining who is an organ donor and in what order organ recipients receive available organs. 

In the United States, about 108,000 people are on the waiting list. Wait times and success rates for organs differ significantly between organs due to demand and procedure difficulty. Three-quarters of patients in need of an organ transplant are waiting for a kidney, and therefore have much longer waiting times. At the Oregon Health and Science University, for example, the median patient who ultimately received an organ waited only three weeks for a heart and three months for a pancreas or liver — but 15 months for a kidney, because demand for kidneys substantially outstrips supply.

Approaches to addressing this shortfall include: donor registries and "primary consent" laws, to remove the burden of the donation decision from the legal next-of-kin monetary incentives for signing up to be a donor an opt-out system ("dissent solution"), in which a potential donor or his/her relatives must take specific action to be excluded from organ donation, rather than specific action to be included social incentive programs, wherein members sign a legal agreement to direct their organs first to other members who are on the transplant waiting list In hospitals, organ network representatives routinely screen patient records to identify potential donors.

ETHICAL ISSUES

Issues include the definition of death, when and how consent should be given for an organ to be transplanted and payment for organs for transplantation. Other ethical issues include transplantation tourism and more broadly the socio-economic context in which organ harvesting or transplantation may occur. A particular problem is organ trafficking.

Transplantation Tourism

Because of the ongoing organ donor shortage, transplant tourism is occurring at an increasing rate both in the USA and abroad. Transplant tourism is an increasing reality facing the USA transplant centers. Most professional societies do not condone it yet cannot abrogate a physician's right to care for such patients. Ethical principles mandate transplant physicians provide adequate care for returning transplant tourists. Transplant tourism exists because of the disparity between the need for organ donors and their availability and will increase. 

Opt-in vs. opt-out 

There are two main systems for voluntary systems "opt in" (anyone who has not given consent is not a donor) and "opt out" (anyone who has not refused is a donor); legislative approaches started in the 1990s.

United States 

It remains a pure consent system rather than an extended consent system or even a dissent opt-out system. 

Europe 

The EU does not regulate organ donation uniformly; the decision is left to member states. According to a 2010 New York Times article, a total of 24 European countries have some form of presumed consent (opt-out) system. In 2008, the EU parliament overwhelmingly voted for an initiative to introduce an EU organ donor card in order to foster organ donation in Europe. In the United Kingdom organ donation is voluntary and no consent is presumed. The UK has recently discussed whether to switch to an opt-out system in light of the success in other countries and a severe British organ donor shortfall.

The Spanish System

The Spanish transplant system is one of the most successful in the world, but it still can't meet the demand, as 10% of those needing a transplant die while still on the transplant list. Under Spanish law, every corpse can provide organs unless the deceased person expressly rejected it. And because family members can still forbid the donation, carefully trained doctors ask the family for permission, making it very similar in practice to the United States. A network for communication and transport allows fast extraction and transplant across the country.

Deontological issues 

Most of the world's religions support donation as a charitable act of great benefit to the community. Nonetheless, issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur. 

From a philosophical standpoint, the primary issues surrounding the morality of organ donation are semantical; the definitions of life, death, human, and body is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for procurement is an ongoing problem in clinical bioethics. 

Teleological issues 

On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. In so far as those who donate organs are often impoverished and those who can afford black market organs are typically well-off, it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time — many die while still on a waiting list. 

Organ donation is fast becoming an important bioethical issue as well from a social perspective: the fact remains that demand far outstrips supply. Consequently, there has arisen a black market trend often referred to as transplant tourism. The issues are weighty and controversial. On the one hand are those who contend that those who can afford to buy organs are exploiting those who are desperate enough to sell their organs. Many of those in favor of the trade hold that exploitation is morally preferable to death, and in so far as the choice lies between abstract notions of justice on the one hand and a dying person whose life could be saved on the other hand, the organ trade should be legalized. Legalization of the organ trade carries with it its own sense of justice as well. Continuing black-market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade could lead to increased supply, lowering prices so that persons outside the wealthiest segments could afford such organs as well. 

Prison inmates 

In the United States, prisoners are not discriminated against as organ recipients and are equally eligible for organ transplants along with the general population.

Because donor organs are in short supply, there are more people waiting for a transplant than available organs. When a prisoner receives an organ, there is a high probability that someone else will die waiting for the next available organ. A response to this ethical dilemma states that felons who have a history of violent crime, who have violated others’ basic rights, have lost the right to receive an organ transplant.

Many argue that a quid pro quo arrangement be introduced: donate an organ in exchange for a reduced sentence.

Religious Viewpoints 

All major religions accept organ donation in at least some form on either utilitarian grounds (i.e., because of its life-saving capabilities) or deontological grounds (e.g., the right of an individual believer to make his or her own decision). Most religions, among them the Roman Catholic Church, support organ donation on the grounds that it constitutes an act of charity and provides a means of saving a life, although certain bodies, such as the popes', are not to be used.

Some religions impose certain restrictions on the types of organs that may be donated and/or on the means by which organs may be harvested and/or transplanted. For example, Jehovah's Witnesses require that organs be drained of any blood due to their interpretation of the Hebrew Bible/Christian Old Testament as prohibiting blood transfusion, and Muslims require that the donor have provided written consent in advance. Orthodox Judaism considers organ donation obligatory if it will save a life, as long as the donor is considered dead as defined by Jewish law.

There appears to be three basic issues in the euthanasia debate as it pertain to religious arguments: 

Value – What value has a human life? 

Fear – What are the main fears which euthanasia is intended to relieve? 

Autonomy – What right do we have over our own life? 

Value 

It is the belief of many contemporary non-Christians that there is no inherent absolute or intrinsic value to human life. 

On the other hand there are non-Christian scholars who still recognize and support an intrinsic importance and value to human life; a view of human ‘value’ based upon ‘best interests’, drawing a distinction between: 

Experiential interests – what causes pleasure or pain. 

Critical interests – what gives life meaning. In many respects this kind of viewpoint is an attempt to create a secular understanding of human value.

Alternatively, the Christian worldview understands and proffers the fact that we have intrinsic value because God has created us in his own image. Human beings are godlike beings, possessing a range of faculties (rational, moral and social) that distinguishes us all other creatures.

Succinctly, from a Christian point of view liberalizing the law would be hugely problematic for at least three reasons: 

First, human life bears God’s image and it is not for us to terminate. 

Second, according to the Christian worldview we are part of community joined to each other. We are not autonomous. The decisions we make impact other people. 

Finally, if the law was changed there would be a great risk that people would feel pressured into accessing assisted suicide or euthanasia. At present if you are a burden on your family and the state and have a sensitive conscience you don’t need to feel guilty about being a burden in the sense that there is nothing you can do about it. If assisted suicide or euthanasia became available, though, then there would be a mechanism sanctified with legal approval that one could suppor.


Sven Ljungholm
Former Officer, USA, Sweden,Russia, Ukraine