1. Ethical Issues Regarding the Donor
3. Ethical Issues Regarding Allocation of Limited Resources
Some Cases and Questions For Discussion
Although the idea of organ transplantation is an old one, successful transplantation did not occur until the Twentieth Century. When different blood types and their respective compatibility or incompatibility, as well as a method of preserving blood, were discovered, blood transfusions became an accepted medical procedure. They were widely used during the First World War. Dr. Emmerich Ullmann experimented on dogs with kidney transplants in the early 1900's. He found that the transplanted organ functioned longer, the closer the donor and recipient were genetically related. Human skin grafts were attempted in the late 1920's. It was found that they could be performed without the problem of rejection between identical twins. In the early 1940's Dr. Peter Medawar and his team experimented with rabbits. They began to understand the immune system which exists in higher animals and human beings. Antigens, on the surface of cells, enable higher organisms to recognize a foreign body. They stimulate the production of antibodies which are important in fighting infection. This, however, also causes the phenomenon of rejection in organ transplantations.
The more similar the tissues' antigens, of donor and recipient, the less likely they are to recognize each other as alien bodies. Tissue typing and matching is based on this. Rejection remains one of the main causes of failure in organ transplantation because it is difficult to find completely matching tissues. New drugs (e.g. cyclosporine) greatly ease the rejection problem. Recipients, except in the case of a transplant between identical twins, need to take such drugs for the rest of their lives. In the case of a successful kidney transplant, however, the costs related to the transplant and the required drugs are cheaper than the alternative of renal dialysis. The quality of life of the recipient is also better.
Today the transplantation of many organs between well-matched human beings is quite successful, with the majority of recipients living five or more years. Kidney, cornea, bone marrow and skin transplants today, for example, are considered routine for certain conditions. Heart and lung or heart-lung transplants, liver and pancreas (or pancreatic islets) transplants are also becoming more common. According to Dr. Robert White, even a human head transplant (perhaps better referred to as a body transplant) may be possible. The recipient in this case though would resemble a quadriplegic because it would be impossible to connect the 100 to 200 million severed nerve endings.(Varga, 211-19)
Experiments continue to be done to try to improve the technology and possibilities regarding transplantation. For example, research is being done regarding human cell cultures, transplants from human fetuses, including brain tissue, and from animals to human beings. The latter includes attempts to genetically design animals with organs that are less likely to be rejected by human beings. Some animal products (e.g. insulin and pig heart valves) are already used regularly. Research also continues to be done to improve artificial organs and other artificial aids to human functioning.
Since many people can benefit greatly in terms of length and quality of life from organ and tissue transplants, the demand usually exceeds the supply. The costs related to some organ transplants are very high as well. Therefore, many questions are raised today regarding how best to procure more organs, how to fairly distribute limited resources, and whether all transplants should be covered by public funds.
The ethical and legal issues related to organ and tissue procurement and transplantation are often discussed in light of such principles as autonomy, benevolence, non-maleficence, free and informed consent, respecting the dignity, integrity and equality of human beings, fairness, and the common good. The Judeo-Christian perspective affirms the great dignity of each human person created in the image of God (cf. Gen 1:26-31). The various aspects, parts and functions of a human person participate in this dignity. We are also social beings who have a responsibility as co-creators and stewards of God's creation. "In the donation and transplantation of human organs, respect is to be given to the rights of the donor, the recipient and the common good of society."(CHAC, 44)
1. Ethical Issues Regarding the Donor
a) From the Deceased
In general it is seen as praiseworthy to will one's body or parts of one's body for the benefit of others after one's death. In 1956 Pope Pius XII summed up the Catholic view on this:
A person may will to dispose of his [or her] body and to destine it to ends that are useful, morally irreproachable and even noble, among them the desire to aid the sick and suffering. One may make a decision of this nature with respect to his own body with full realization of the reverence which is due it....this decision should not be condemned but positively justified.(quoted from Ashley and O'Rourke 1989, 305)
More recently (1985) the Pontifical Academy of Sciences stated:
Taking into consideration the important advances made in surgical techniques and in the means to increase tolerance to transplants, this group holds that transplants deserve the support of the medical profession, of the law, and of people in general. The donation of organs should, in all circumstances, respect the last will of the donor, or the consent of the family present.(MacNeil)
Such a donation can greatly benefit others and cannot harm the donor who is dead. Not to offer such a donation can be a sign of indifference to the welfare of others. To donate, however, is not considered obligatory. Transplantation is against some people's consciences for religious or other reasons.(cf. LRCC, 140-2) Consideration for the sensibilities of the survivors may also make some people hesitate to sign over their bodies.
In any case proper respect should always be shown human cadavers. Although they are by no means on par with a living human body/person, they once bore the presence of a living person. The probably dying potential donor should be provided the usual care that should be given to any critically ill or dying person. Because of a potential conflict of interest, it is widely agreed that the transplant team should be different from the team providing care for the potential donor, who is not to be "deprived of life or of the essential integrity of their bodily functions.... No organs may be removed until the donor's death has been authenticated by a competent authority other than the recipient's physician or the transplant team."(CHAC, 44 and 46) Various parts of the human body can often be kept in good condition for transplant purposes after the death, irreversible cessation of all brain functions, of the donor.(Jonsen, 235-7)
The Catholic Health Association of Canada (CHAC) considers transplantations of brain cells (presuming irreversible cessation of all brain functions of the donor) in order to restore functions lost through disease as permissible "as long as the unique personal identity and abilities of the recipient are not compromised in any way."(45)
The German Bishops' Conference and the Council of the German Evangelical Church consider the transplant of "reproductive glands" as unethical, "since it intervenes in the genetic individuality of the human being."(374) This does not seem to exclude transplanting all sexual body parts, but the gonads. Any child that resulted following an ovary or testicle transplant would have the dead donor and not the living recipient as its biological mother or father. This would violate the rights of the child (see SCDF 1987, 23-26).
The case of the body of a pregnant woman in Germany, who had been declared brain dead, being kept alive with the hopes of the child coming to term was recently given some media attention. Some criticized this as not giving proper respect to the woman. Can not this effort, however, be seen as similar in some ways to organ donation and, therefore, as commendable? The woman had at least implicitly offered her body for the child's sake before her fatal accident. Her family also requested this.(Associated Press) Cases such as this also raise the question of "ordinary" and "extraordinary" means of saving life (see below under 1.b).
The use and possible use of cadavers and "neomorts" (brain-dead individuals maintained on life support) for a variety of purposes (transplants, research, training medical students), perhaps even a considerable time after the person's death, has provoked ethical and legal debate. Various concerns include respect for the dead and their wishes, respecting the family's wishes, benefitting others and the common good. In light of this, anyone considering donating their organs and/or body after their death, highly commendable in itself, may wish to specify certain limits.(cf. LRCC, 113-17; Gaylin; and CHAC, 43 and 46)
b) From Living Persons (Adults, Mentally Disabled, Minors)
Transplants between living persons raise the question whether it can ever be ethical to mutilate one living person to benefit another. Concerning this many distinguish between parts of the body that can regenerate (e.g. blood and bone marrow) and parts that do not regenerate. Regarding the latter some are paired (e.g. kidneys, corneas and lungs), whereas others are not (e.g. heart). Before transplants of organs such as kidneys were performed, many Catholic theologians considered this unethical between living persons. They thought it violated the Principle of Totality which allowed the sacrifice of one part or function of the body to preserve the person's own health or life (i.e. a part could be sacrificed for the sake of the whole body), but did not allow one person to be related to another as a means to an end. When such transplants began in the early 1950's ethicists gave the problem closer study.
Gerald Kelly (1956) argued that such donations which have as their purpose helping others could be justified by the Principle of Fraternal Love or Charity provided there was only limited harm to the donor. Some ethicists argued this did not violate the Principle of Totality provided that functional integrity of the body was not destroyed, even though there is some loss to anatomical (physical) integrity. Donating one of one's kidneys could be justified for proportionate reasons, since one can function with one healthy kidney. ("Living kidney donors constituted some 15% of the donor pool in Canada in 1989."[LRCC, 20]) Donating one of one's functioning eyes, however, can not be justified, since one's ability to see (functional integrity) would be seriously impaired.
Basic to medical ethics is the Principle of Free and Informed Consent. To be properly informed the potential living donor should be given the best available knowledge regarding risks to him/herself, the likelihood of success/failure of the transplant and of any alternatives. In some cases there is much pressure to donate (e.g. from family members if one is a good match). The courts have rightly refused to compel such donations. Motivated by charity, which includes a properly ordered love for others and oneself, one could decide not to offer an organ.(Ashley and O'Rourke 1989, 305-8; CHAC, 31 and 34)
The distinction of ordinary and extraordinary means is also applicable to transplants. The Catholic Church teaches that one is obliged to use ordinary means to preserve life, but not extraordinary means, that is, means that are very burdensome (very painful, expensive, inconvenient, risky, or even very psychologically burdensome) or do not offer reasonable hope of benefit, or are disproportionate (cf. SCDF 1980, section IV; Ashley and O'Rourke 1986, Ch. 11.5; and CHAC, 52-4). Some forms of organ and tissue transplant from a living donor, especially those involving invasive surgery, involve considerable burden to the donor. If means are available that do not involve such burdens, such as a matching organ from a deceased donor, these are certainly to be preferred.
The above principles would allow in some cases such procedures as "transplanting part of the liver from a living adult donor into a child recipient, whereafter the adult donor's liver regenerates within a month and the child's new partial liver develops as the child grows"(LRCC, 15), or donating one's heart if one were to simultaneously receive a heart and lung transplant (Garrett et al., 200).
A competent adult can give free and informed consent to be or not to be a living donor, but an incompetent person cannot. Can a guardian ethically consent for a legally incompetent person, such as a severely mentally disabled adult or a minor, to be a living donor? Concerning this issue some distinguish, for example, between a young child and a mature minor's ability to comprehend the implications of donating. Regarding medical decisions an incompetent person's guardian is to act for their benefit or best interests, and, as far as possible, their wishes, if known and reasonable. Some think children and the mentally disabled should never be living donors. They are simply being used with a violation of their bodily integrity, risks to their health and life, and no benefit to themselves. An argument against their being a living donor of an organ such as a kidney, is that an alternative such as renal dialysis is often available until a suitable deceased donor can be found. Others argue that in some cases the psychological benefit to the donor (e.g. a child's sibling lives) could outweigh the risks (e.g. of donating bone marrow).(LRCC, 48-50) The Catholic Health Association of Canada (CHAC) says that, "Organ or tissue donation by minors may be permitted in certain rare situations."(44)
Can it be ethical to have another child for transplant purposes (e.g. for a bone marrow transplant)? Conceiving and having a child for this motive alone would involve treating him/her as a mere means to another's benefit. This would violate the great dignity of a person, created in God's image, who should be loved for his/her own sake.(cf. CHAC, 45; Garrett et al., 200)
Concerning the whole issue of living donors, the German Bishops' Conference and the Council of the German Evangelical Church say:
...No one is obliged to donate tissue or an organ; therefore no one can be forced to do so. The decision to donate one's organs while still alive can only be made by the individual concerned personally. Not even parents are allowed to decide on an organ donation by their child; they are allowed to give their consent only for a donation of tissue (e.g., donation of bone-marrow). The doctor in this case has a special responsibility because no one can control whether a donation is truly voluntary.
When a living person donates an organ as a result of a personal decision, then the organ's transplant is to be carried out with due attention, and post-operative medical care of the donors as well as the recipients must be provided. Further, consideration must be given so that no problems develop in the relationship between the donor and the recipients (dependence, excessive gratitude, guilt feeling).(375)
c) From Anencephalic Infants
Anencephalic infants are born with a major portion of the brain absent. If born alive they die within a few days, although in rare cases some survive for weeks or months. They can suck and cry and some argue that their degrees of consciousness or unconsciousness may vary. According to the widely accepted criteria of death as irreversible cessation of all brain functions, they are living human beings/persons. To increase the likelihood of procuring viable organs from them, some would like to redefine death in terms of partial brain death so that they could be considered dead (although still breathing spontaneously...), or for them to be exempt from the total brain death criteria, or to consider them non-persons. Many others, however, argue that partial brain death criteria are invalid in light of our present knowledge and/or such an arbitrary move would endanger other classes of living human beings and lead many more people to refuse to sign organ donor cards. Although extraordinary means of prolonging the life of anencephalic infants do not need to be used, they should be given the normal care of dying persons.(cf. CHAC, 45-6; LRCC, 95-106; Garrett et al., 202; Ashley and O'Rourke 1986, Ch. 11.2, and 1989, 311-12)
d) From Human Fetuses
Is it ethical to transplant brain or other tissues from human fetuses to benefit others (e.g. those suffering from Parkinson's Disease)? If the fetus has died of natural causes, the ethical issues would be similar to other transplants from the deceased. When the fetus has died or will die as a result of procured abortion, however, other ethical issues arise. The Catholic Church considers direct abortion (the intentional killing of an innocent human being) to be gravely immoral. Some argue that to use tissues from a fetus killed by abortion could be done without approving direct abortion (cf. using tissues or organs from a murder victim). Such use, however, could "justify" abortion (i.e. to benefit others) for many women who otherwise are unsure about having an abortion. A good end though does not justify an evil means (see Rm 3:8). The timing of the abortion may be influenced as well. The widespread usage of electively aborted fetuses would establish an "institutional and economic bond between abortion centers and biomedical science..."(Post, 14; cf. CHAC, 15, re unethical cooperation)
Some argue that transplanting fetal brain tissue would require the fetus to be still alive, that is, the tissue would not be good for transplant purposes after the fetus has experienced total brain death.(cf. Duncan, 16-22) Some say that other means of treating such diseases as Parkinson's can and should be developed.(cf. Dailey)
Another issue involves consent. Anyone involved in procured abortion would not qualify as the fetus' guardian since they hardly have his/her best interests at heart. The Catholic Health Association of Canada (CHAC) concludes that, "Transplantations using organs and tissues from deliberately aborted fetuses are ethically objectionable." (45; cf. SCDF 1987, 16-18)
2. Ethical Issues Regarding the Recipient
...nobody [i.e. no potential recipient] has a claim on organs or tissue of any person, living or dead. The sick should thus accept the tissue and organs freely offered by others as a gift.(German Bishops..., 373)
This position is widely accepted.
Another moral issue involving the recipient is free and informed consent. A competent person who could possibly benefit from receiving a transplant should be adequately informed regarding the expected benefits, risks, burdens and costs of the transplant and aftercare, and of other possible alternatives. So should the guardian(s) of an incompetent person. A legally incompetent person who can understand some things that are relevant to their condition, a proposed transplant, and decisions that they are capable of making, should be informed of these in an appropriate way. Guardians should respect the wishes, if known and reasonable, of incompetent persons in their care. No unfair influence should be put on someone to be a transplant recipient. Potential recipients and their families can be tempted to pressure, blackmail or bribe a potential living donor to donate or a health care professional to give them a privileged position on the waiting list. Such practices are unethical because they fail to properly respect the freedom of the donor or they violate other potential recipients' rights regarding access (cf. Garrett et al., 206-7) Recipients should also avoid any unethical cooperation in any abuses (e.g. the organs or tissues have been procured immorally/illegally) that are sometimes associated with transplantation.(cf. CHAC, 15 and 31; Ashley and O'Rourke 1986, 88 and 90-1; and 4.a below)
A potential transplant recipient and/or their guardian(s) could also consider their decision in light of ordinary and extraordinary means of preserving life (see above, under 1.b). The competent adult Jehovah Witness who refuses a life-saving blood transfusion, for example, because this is against a tenet of their religion, can be understood to be refusing means that would be "very burdensome" for them. Courts, however, sometimes override the decision of natural guardians including parents when this is judged clearly against the best interests of incompetent persons including a child (e.g. to allow a life-saving blood transfusion to the child of Jehovah Witness parents). This issue is more difficult when the child begins to develop his/her own value system, but is still considered legally incompetent.(see n. 3 below under "Some Cases...")
Proper safety measures should be followed to protect transplant recipients from receiving AIDS and hepatitis viruses, etc.(cf. LRCC, 161; and Garrett et al., 200)
3. Ethical Issues Regarding Allocation of Limited Resources
a) Criteria for Selection
Requests or the demand for human organs and tissues usually exceed what is available or the supply. Significant practical and ethical questions regarding efficiency and fairness arise as to how best to distribute these limited resources. On what basis should this person rather than that person be chosen to receive a given organ? Who should choose? These decisions are serious as they can involve who will live and who will die. In section 4 below we will consider some ways of addressing this problem by attempting to increase the supply of human organs and tissues. In sections 3.b and c we will consider some alternative methods of attempting to meet some of the needs in this area. In this section, however, we will consider some criteria for selecting which potential transplant recipient will receive a given human organ or tissue.
A widely used and approved criterion of selection is to give priority to those who have great need and who are expected to benefit greatly. For example, it does not make sense to give a limited number of available organs to those who will not benefit or who are expected to only live marginally longer but suffer much with the transplants, when others would benefit greatly. While this criterion is widely accepted as fair, there is much discussion about how to define and assess "benefit". Many argue that both expected length of survival and the possibilities regarding rehabilitation should be considered.
In spite of the success of transplants, care must be taken not only that they extend life biologically, but that they also offer the patient a real chance for a healthy life. The new organs should add new years to life, and help to provide a new and better life.
....as a last resort a choice sometimes has to be made between a transplant immediately available but with a very small chance of survival, and a long term transplant offering a greater possibility of healing.(German Bishops..., 374-5)
With regard to who will likely benefit more from receiving a transplant, medical criteria such as blood and tissue typing (i.e. who is less likely to reject the transplant), and the absence of other life-threatening diseases, are used. Other factors such as the potential recipient's will to live, motivation and ability to follow post-operative directions (e.g. taking immunosuppressants), his or her family support, and the skill of the transplant team can also be relevant to the success of a transplant.(Garrett et al., 213-216)
Potential recipients (i.e. those likely to benefit from a transplant) are registered on a "first come, first serve" basis. This, or random methods of selection (e.g. a lottery) where there is equal chance, is fair provided that the need and benefit are approximately the same among potential recipients.(cf. Varga, 226; and Ashley and O'Rourke 1986, 112, and 1989, 308)
Some argue in favor of using criteria such as social worth, and merit or demerit, to select or prioritize potential recipients. Concerning "social worth", for example, is it fair to give priority to a mother of young children over a single person, or to a successful doctor over someone who is at present unemployed? Concerning merit should a retired person who contributed a lot to the community be given priority over a young person who has not yet proven him or herself? Regarding demerit, for example, should someone who previously abused alcohol, smoked heavily or ate unhealthily be denied a liver, lung or heart transplant?(cf. Altman; Moss and Siegler) Many, however, criticize these and other criteria such as ability to pay, race, religion, gender, and age, as involving unfair discrimination. They are said to violate the equal dignity of all human beings. Criteria such as "social worth" are also seen by some to be too difficult and subjective to apply efficiently and reasonably.(cf. CHAC, 30 and 45; Appleton International Conference, 6-7; Varga, 226; Garrett et al., 216; Childress) Childress argues as well that the criteria for selecting recipients should be open and subject to public scrutiny.
b) Using Animals
The shortage of various human parts for transplant purposes has in part motivated research in animal to human transplants. The use of some animal parts such as insulin extracted from animal pancreases, catgut as absorbable sutures, and pig heart valves, are already "accepted" medical treatments. Attempts, however, to transplant a baboon's heart to a human infant (Baby Fae) or a pig liver to a dying woman, for example, have aroused considerable controversy.(see LRCC, 18-19; n. 4 below under "Some Cases..."; and Siegel) Some argue that the present state of transplants between species does not justify such experiments which so far do not offer hope of therapeutic benefit to the human recipients. Defenders of such experiments argue that they can be justified if no other alternatives are available and for the knowledge gained. Some have questioned whether such transplants involve irresponsible meddling with nature. Various animal rights groups have protested the sacrifice of animals involved in this and other research, which uses them as "mere means" to human welfare. Concerning organ transplants from animals to human beings research is being done with various immunosuppressive agents with the hope of finding a combination to overcome the rejection problem.(Johnston) Attempts are also being made to genetically engineer and breed new strains of some animals such as pigs so that their organs can be transplanted into humans with less risk of rejection. If successful, the scientists involved hope that this will overcome the large shortage of human donor organs.(Reuter; Hanson)
Widely accepted directives for human experimentation call for both adequate preliminary animal experimentation to minimize the risks to human subjects and that the welfare of animals used in research be respected.(e.g. Helsinki Declaration of 1975, p. 1771) Pope John Paul II in an address to a Congress of the Pontifical Academy of Sciences said, "...animals are at the service of man and can hence be the object of experimentation. Nevertheless, they must be treated as creatures of God which are destined to serve man's good, but not to be abused by him...."(p. 5) The Catholic Health Association of Canada (CHAC) stipulates that animals involved in research are to be properly respected and such research "is to be allowed only when other methods involving non-living subjects are no longer helpful. When use of such subjects is justified, pain relief must be used or suffering reduced to a minimum."(60)
With respect to tissue transplants between individuals of different species, Pope Pius XII on May 14, 1956, spoke of the transplant of a cornea, for example, as moral, if possible and warranted. He, however, considered the transplant of the sexual glands of an animal to a human being as immoral. Thomas O'Donnell interprets the condemnation of the latter as aimed at transplants that would "envision an act of attempted generation."(104-7)
The Sacred Congregation for the Doctrine of the Faith excludes, among other things, attempts of fertilization between human and animal gametes and to gestate human embryos in the uteruses of animals as contrary to human dignity. It considers genetic interventions that are therapeutic, for proportionate reasons, however, as licit.(SCDF 1987, 15-20; cf. CHAC, 60)
The Catholic Health Association of Canada (CHAC) considers transplants from living animals to humans as
...permissible as long as these can fulfill an essentially beneficial human function in the recipient. The human dignity of the recipient is not to be compromised in any way and due respect is to be paid to the non-human donor in the whole transplant procedure.(46)
c) Artificial Substitutes for Tissues and Organs
The shortage of various human parts for transplant purposes has also in part motivated research in the development of artificial and synthetic substitutes for tissues and organs. There are a number of substances that the human body does not reject. A number of artificial replacement technologies including false teeth, artificial limbs and joints, hearing aids, synthetic lenses, pacemakers, mechanical and synthetic heart valves, genetically engineered insulin and growth hormone, and renal dialysis, are already routinely used in treatment. Other technologies such as the implantable artificial heart are still experimental or are used temporarily with the hope of keeping the person alive until a suitable human donor organ is found.
Artificial replacement technologies are generally very costly to develop. If they prove to be successful and are mass produced, their long-term costs can be significantly reduced. A number of routinely used replacement technologies such as long-term renal dialysis, however, remain expensive. Some ethical questions concerning such costs will be considered in section 3.d below.
Another issue is that the recipient of some artificial parts may need to make certain psychological adjustments. Consider, for example, the implantable artificial heart (also a heart transplant from another animal species) in light of the "popular belief that the heart is the center of human emotions, the organ of love."(Varga, 239. Cf. ibid, 238-41; LRCC, 20-22; and Thomas and Waluchow, Case 7:3.)
The Catholic Health Association of Canada (CHAC) states that artificial substitutes for tissues and organs are permissible provided they "can fulfill an essentially beneficial human function in the recipient" and the "human dignity of the recipient" is not compromised in any way.(46)
d) High Costs, Universality and Justice
The development and use of technology related to organ and tissue transplants or artificial substitutes is expensive. For example, estimates of the costs of transplant procedures, without complications, "range from $20,000-$30,000 for a kidney, $60,000-$80,000 for a heart, and $120,000-$150,000 for a liver."(Goddard) With complications the costs can be much higher. Such costs are beyond the means of many people, if they are not covered by public funds, medical insurance or charity. The demand for transplants has also increased because they have become quite effective. For example, the one-year survival rate for all transplants is at least 70-80%; and the five-year survival rate for heart and liver transplants is 70% and 70-80% respectively.(Goddard)
Today the issue of whether transplants and other expensive medical technologies are cost-effective and whether public funds should cover the costs of all such procedures for everyone who could benefit from them is being discussed a lot. It should be noted, however, that the average cost per life year gained from a transplant (e.g. kidney) can be significantly lower than alternative treatments (e.g. hemodialysis). In addition, the recipient of a successful transplant often contributes much more to the economy through work, spending and paying taxes, than if they would have died or remained ill.(Goddard)
Other questions include: Could the large sums of money (or some of it) that is spent on developing and using transplant technology and artificial substitutes be better used to improve the health and quality of life of more people if spent in other ways (e.g. providing better access to primary health care, improving education and preventative health programs, improving the environment by further reducing pollutants, etc.)? What percent of health care dollars should be allotted to transplant programs and related research? Broader questions include: What per cent of public funds should be spent on the good of health as compared to other goods? Should government spending and public health services be limited or reduced, or should taxes be increased to provide for more people's needs and/or wants? To what extent should transplant services and organs be supplied to people of other countries? There are no easy answers to such questions of distributive justice which, among other things, can affect who lives and who dies. One can also ask how it affects us as moral agents if we do not help or save all those we can?(cf. Ashley and O'Rourke 1989, 308-10; Engelhardt; Garrett et al., 216-19; and Thomas and Waluchow, 132-4)
Parliament through the Canada Health Act (1985) has committed Canada to providing "reasonable access" to "medically necessary" hospital and health services on a uniform basis. Reasonable access, however, does not mean absolute access. The term "medically necessary" is also open to interpretation.(LRCC, 124-5)
The position of the Catholic Health Association of Canada (CHAC) is: "Basic health care needs are to be considered in the allocation of resources for transplantations, especially when it is a question of novel procedures involving scarce organs and expensive, limited medical facilities."(45) With respect to allocating resources in general it calls for solidarity with sick persons, careful stewardship of God's gifts and "active participation in the formulation of policy for the equitable distribution of health care funds in society as a whole", among other things.(22-24)
4. Ethical Issues Regarding Procurement of Organs and Tissues
a) Buying and Selling Human Organs and Tissues
Some argue in favor of allowing human organs and tissues to be bought and sold to increase the supply and to respect people's autonomy. Others argue against such saying that to treat the human body and its parts as commodities violates human dignity.(cf. LRCC, 56-62; and May, 165-7) Human tissues and organs are in fact being sold in some places. For example, a French pharmaceutical firm buys placentas from 110 Canadian hospitals to manufacture vaccines and other blood products (Aikenhead), and some living poor people in countries such as India sell one of their kidneys for $700 or so. In Bombay, for example, there have also been some cases of kidnapping where victims regain consciousness to find that one of their kidneys was removed while they were drugged.(Wallace; cf. Rinehart)
Concerning this whole issue some distinguish between human waste products such as placentas, body parts that regenerate such as blood, and nonregenerative human organs such as kidneys. Many distinguish profit making from covering the donor's expenses. Paying for organs can constitute unjust moral pressure on the donor. It could invalidate any free consent or a contract. Some also fear that the buying and selling of organs and tissues, if it became widespread, would undermine the altruism (giving motivated by love) and social bonding now associated with transplants. It could also lead to organs going to the highest bidder. Equity would be violated with ability to pay rather than medical need determining the distribution of organs. Some others, however, argue that this could be controlled by regulating sales, and that totally forbidding the buying and selling of human tissues and organs would drive the market underground. Because of the controversy and ethical problems surrounding the buying and selling of human body parts, some say that other alternatives should be pursued to increase the supply.(cf. LRCC, 78-86; and Garrett et al., 203-4)
A World Health Organization resolution in 1989 that was eventually supported by more than 151 nations in part, "Calls Upon Member States to take appropriate measures to prevent the purchase and sale of human organs for transplantation..."(LRCC, 162-3 and 202-3) With respect to blood transfusions, Pope Pius XII said, "It is commendable for the donor to refuse recompense: it is not necessarily a fault to accept it."(LRCC, 58) Concerning the Christian vision which sees human life and the body as "a gift of the Creator, which persons cannot dispose of as they please", the German Bishops' Conference and the Council of the German Evangelical Church say, "This does not exclude compensation for the expenses incurred by the donation of tissue and organs, but it does forbid deriving profit from it."(375; cf. Chilean Bishops' Permanent Commission, 374). The Catholic Health Association of Canada (CHAC) holds that the buying and selling of human organs, tissues and blood "contradicts the principle of charity which is part of the necessary justification for such transplantations."(46)
b) Media Publicity
Sometimes an organ or tissue is procured for a person by publicizing their need through the media. This could bypass the regular transplant channels and their selecting recipients for an available organ on the basis of greatest need and greatest likelihood of benefit, and first come first serve (see 3.a above). On the other hand, media pleas frequently bring in more volunteers than those required for the case being publicized. Media publicity also increases public awareness of the need for transplants and so in the long run should increase the supply of donated tissues and organs. Garrett et al. argue that at this stage of medical history media publicity for a particular case should be tolerated, but in time it should be eliminated as much as possible.(212)
c) Types of Consent (Voluntary or Expressed, Family,
Presumed, Required Request, Routine Inquiry)
Voluntary or expressed consent involves a person making known their free offer to donate one or more of their organs and/or bodily tissue, after they have died or while alive.(cf. 1.a and b above) Concerning cadaver donation, a person can express their wishes by some form of advanced directives, such as by filling out the Universal Donor Card attached to their driver's license. Free and informed consent is required when the transplant is from a living donor. Previously expressed voluntary consent regarding a deceased donor is the ideal because it involves an act of love and responsible stewardship over one's body. It also communicates to others, including one's family and health care professionals, one's wishes. In the absence of clearly expressed voluntary consent, the family or person lawfully responsible for the body of the deceased may be approached regarding donation. Proper respect involves due consideration of the wishes of the deceased and their loved ones.
Many potential organs and tissues for transplantation (e.g. of brain-dead accident victims) are lost because the person did not previously express voluntary consent and their families were not approached about donating. Because of this and the shortage of organs and tissues for transplantation, some have proposed other models of consent including presumed, required request and routine inquiry, to hopefully increase the supply. Although only a minority of deceased potential donors have signed donor cards, surveys show that most people favor organ donation. Some argue that it is ethical to presume consent on their behalf, unless the person while alive gave clear indications to the contrary, since a transplant does not harm the donor after death and it can benefit others. France, Belgium and some other countries have various forms of presumed consent legislation in place. People can opt out by registering their intention not to be a donor. Questions concerning this approach include: Should minors and the mentally disabled be included? To what extent should health care professionals check to see if the person has expressed a wish not to donate? Can not this be a form of exploiting human ignorance and weakness (cf. people ignorant that they can opt out or too lackadaisical to do so)?
Required request requires hospitals to develop protocols to ensure that families of potential donors are actually asked to donate. Routine inquiry requires hospitals to develop protocols to ensure that families of undeclared potential donors have the opportunity to donate - people tend to react more positively when offered a choice. Some have criticized these approaches as not allowing professional discretion. Many health professionals are reluctant to approach families who have just lost a loved one about transplantation. This is considered a major barrier to increasing the supply of organs and tissues. Most families though do not object to being approached. Required request or routine inquiry has been widely endorsed in the United States as a preferred public policy option when compared to a free or regulated market of organ and tissue sales or a presumed consent approach. It is seen as more respectful of altruism, familial sentiments and religious interests. It can also help the bereavement process by making something positive come out of the death. Some significant increases in organ and tissue donation have been recorded where this policy is in place. A few jurisdictions also allow presumed consent following required inquiry if the family did not object.
The Law Reform Commission of Canada recommends maintaining and strengthening the present express consent model in Canada with hospitals implementing routine-inquiry protocols. These, however, are to recognize professional discretion not to ask in cases where this would clearly be inappropriate.(LRCC, 39-46, 145-39, and 176-82; cf. Varga, 221-2; Garrett et al., 210-11; Ashley and O'Rourke 1989, 310; and May, 167-8)
d) Fears, Confusion and the Need for Education
There is a need for education of the general public and many health care professionals concerning the whole area of organ and tissue transplants. Many people are not well informed of the needs, the shortage of organs and tissues, and the great potential benefit of many people for transplants. Many have unfounded fears or reservations or are confused about some of the issues of being a donor. In a recent United States survey, "the two most common reasons given for not permitting organ donation were (1) they might do something to me before I am really dead; (2) doctors might hasten my death."(LRCC, note 226) This shows ignorance of standard policy and procedure concerning transplants. These include strict criteria for determining total brain death and the separation of the ill or dying patient's health care team and the transplant team.
Although surveys show that most people think transplantation is a good thing, only a minority sign an organ donor card. Why? First of all, many are not fully aware of the advantages of this type of voluntary expressed consent.(see section 4.c above) Some people may be unwilling to think about their own mortality, an inevitable fact, or be superstitious. For example, they may mistakenly think that signing a donor card will increase their chance of a fatal accident. Some may have concerns about the mutilation of their body. Organs and tissues, however, are carefully removed and incisions are closed, so that it will not be apparent to anyone viewing the body that organs or tissues have been donated.(HOPE, 3) Also,
Some people wonder what will happen to their bodies if at death they donate an organ. The truth is that every earthly body decays. Therefore, the alternative is between an organ decomposing or serving to keep an other human being alive. We Christians believe, as St Paul tells us, that our corruptible body will be transformed into a spiritual body for the glory of God (cf. 1 Cor 15:35-53)(Chilean Bishops' Permanent Conference, 375)
Some people may also not realize that they can specify limits on an organ donor form regarding the use of their body (e.g. which organs they may or may not wish to donate). People should be encouraged to consider organ and tissue donation as a "legacy of love", as an incarnate form of "CHARITY AFTER DEATH."(Wolak, 18)
Health care professionals also need to be educated about the meaning of organ and tissue donation.(CHAC, 43) Some have unfounded reservations about approaching individuals or families to consider organ and tissue donation. It is important that some members of the health care team be trained in approaching potential donors and their families in a sensitive way. They need to be able to provide the necessary personal and social support regarding the grieving process.(cf. Batten) Some health care professionals also need to learn that properly respecting the dead human body is a requirement of our humanness. Along these lines some medical schools offer services of remembrance and gratitude before and after dissecting human cadavers.(Lynch, 1018) Care needs to be taken, too, regarding the language one uses about the dead. For example, "harvesting the dead" connotes "taking" and is repugnant, whereas "donation" connotes "giving" and is dignified.(cf. Belk) In order to increase the potential for transplants, some health care professionals have a special responsibility with regard to raising the general level of consciousness of the needs. This should be done in a way that always properly respects patients' rights of confidentiality and that does not detract from communicating other pressing health care issues. "The public is entitled to be accurately informed about the medical progress and implications of transplantation."(CHAC, 47; cf. German Bishops..., 376)
A number of the many ethical issues concerning organ and tissue transplants have been treated in this paper. These issues concern the donor, the recipient, the allocation of limited resources, and the means of procuring organs and tissues. Although there have been some abuses in this field, and there are some areas of controversy, I would like to conclude with a positive note.
Organ donation, carried out under proper conditions, is a beautiful and modern expression of Christian charity: it gives dignity to the person who in death becomes a life-support for another; it shows noble concern for the respect of the life of others; and it implies a sense of communion with humanity. The Gospel proclaims that there is no greater love than to give one's life for another (cf. Jn 15:13). Jesus welcomes the good done to another as though it were done to himself (cf. Matt 25).(Chilean Bishops' Permanent Commission, 375)
Some Cases and Questions For Discussion
1. Don and Dan are identical twins. After Don suffers kidney failure, Dan is requested by his brother's wife to donate one of his healthy kidneys to Don. Does Dan have any obligation to surrender one of his healthy kidneys to his brother? Under what condition would you defend Dan's decision not to surrender his kidney.(From Ashley and O'Rourke 1986, 172)
2. Is it ethical for a living person with two good eyes to donate an eye to enable a blind person to see?
3. Sally was 15 years old and had been a practising Jehovah Witness for several years. She lived with her sister Jane, who was 18 years old and an atheist, and mother, who had been a Jehovah Witness but who renounced this following a legal separation with her husband. Sally had only seen her father, who was a devout Jehovah Witness, a few times since the separation. Sally was involved in a bad car accident and before lapsing into a coma was heard to say repeatedly, "I don't want to die. Please help me." The doctor said Sally would die without surgery which required a blood transfusion. The surgery had a 90% success rate, with a 5% chance of paraplegia and another 5% chance of death. Sally's mother insisted that the operation with a blood transfusion take place to save her life. Her father strongly objected that this would violate a sacred principle of Sally, an avowed Jehovah Witness. Jane pointed out that Sally was a minor and questioned whether her commitment to the blood transfusion principle could have been fully informed and voluntary. Her parents were her legal guardians. The doctor went before a judge to seek a resolution. If you were the judge, what would be your decision?(condensed from Thomas and Waluchow, 150-4)
4. Baby Fae was born with a severe heart defect which would cause her death within a few weeks. Her parents were poor and in a country without universal medical insurance. Loma Linda Hospital offered to cover the costs of transplanting a heart from a baboon. The parents signed an elaborate consent form which was never released. The doctors did not consider the possibility of a human donor, thinking the hopes of finding one were almost nonexistent. It seems that they also did not seriously consider a new form of corrective surgery for this type of heart defect with a 40 percent survival rate after several years. Baby Fae was reported in serious but stable condition for two weeks following the operation, but died a week later, apparently of complications related to rejecting the baboon heart. Did the doctors act in an ethical manner? Under what conditions, if any, would a transplant of this nature be acceptable?(cf. Ashley and O'Rourke 1986, 117; and Thomas and Waluchow, 119-24)
5. Should public funds cover the related costs of transplants for all people who can benefit from them? Should taxes be increased to fund more publicity of the need and so increase the supply of organs and tissues for transplants, and to pay for more transplants, so that more people can live longer and healthier?
6. Mrs. Simpatico, a nurse, had cared for Joseph, who was 30 years old, a few weeks before he died. The hospital has a policy requiring nurses to ask the families of all dead patients for organ donations. Both she and the family are very upset about the death. She believes Joseph's young wife and three children need comfort and not decisions at this moment, so she does not ask for the organ donation, even though the hospital has a long waiting list. When the nursing supervisor discovers this omission, she reprimands Mrs. Simpatico and warns her: "One more incident like that and you will be fired." Is the hospital's policy good? Was it right for Mrs. Simpatico to make an exception in this case?(adapted from Garrett et al., 221)
7. Two men on the same service are awaiting a cornea transplant because of chemical burns on their eyes. One is an alcoholic street person with other serious health problems. The other is a prominent lawyer with a wife and three children. A donor's eye becomes available, and by coincidence both men's cornea match the donor's. The physician decides on the basis of "first come, first served" and transplants the cornea to the alcoholic. Is it ethical to do this when the alcoholic has more serious health problems? Is there a relevance to the patients' social positions?(adapted from Garrett et al., 221)
8. Anissa is 17 years old when it is discovered she has leukemia. Her primary hope for survival rests on a bone marrow transplant, but there are no likely donors for her unusual genetic characteristics. Her parents decide to have another child in the hope that the infant will provide a tissue match (a 25% chance). Is it ethically right to conceive a child for the purpose of generating tissue for transplantation? If the infant is a tissue match, is it right for the parents to decide for the infant?(adapted from Garrett et al., 222)
9. In your opinion why do comparatively few people sign the Universal Donor Card on their driver's license?(adapted from Ashley and O'Rourke 1986, 210)
10. After Ben, a 10 year old boy, is declared brain dead in Alberta Children's Hospital, Dr. Mitchell asks Ben's parents if they have considered organ donation. They consent because they think it is a good way to deal with their grief and what Ben would have wanted. As a result a few other children are living normal lives: Kirsten of Edmonton received Ben's heart; Stuart of Airdrie and Amy of Calgary each received one of Ben's kidneys; Johnny of Pittsburgh received Ben's liver; and Steven of Lethbridge received Ben's cornea. (This case is presented in the video, "Have You Considered Organ Donation?"[1991, 11 minutes], the Human Organ Procurement and Exchange Program [HOPE], University of Alberta Hospitals.)
Aikenhead, Sherri (1993). "Sale of Human Placentas to French Pharmaceutical Firm Questioned" and "Hospitals Should Inform Mothers if Placentas Traded - Commissioner," The Edmonton Journal, 3 Mar. 1993, A14, and 4 Mar. 1993, A11, respectively.
Altman, Lawrence K., M.D.(1990). "Should Alcoholics get new Livers?", The Edmonton Journal, 15 Apr. 1990, E6.
Appleton International Conference (1992), "Developing Guidelines to Forgo Life-prolonging Medical Treatment," The Bioethics Bulletin, University of Alberta, Edmonton, Jan. 1993, 2-7.
Ashley, Benedict M., OP; and Kevin D. O'Rourke, OP (1986). Ethics of Health Care. St. Louis: Catholic Health Association of the United States.
__________ (1989). Health Care Ethics, Third Edition. St. Louis: Catholic Health Association of the United States.
Associated Press, "Brain-dead woman suffers miscarriage," The Edmonton Journal, 17 Nov. 1992.
Batten, Helen Levine (1990). "The Social Construction of Altruism in Organ Donation," Ch. 8 in Organ Donation and Transplantation: Psychological and Behavioral Factors, ed. by James Shanteau and Richard Jackson Harris. Washington, DC: American Psychological Association.
Belk, Russell W. (1990). "Me and Thee Versus Mine and Thine: How Perceptions of the Body Influence Organ Donation and Transplantation," Ch. 12 in Organ Donation and Transplantation: Psychological and Behavioral Factors, ed. by James Shanteau and Richard Jackson Harris. Washington, DC: American Psychological Association.
Cefalo, Robert C.; and H. Tristam Engelhardt, Jr. (1993). "The Use of Fetal and Anencephalic Tissue for Transplantation," Eike-Henner Kluge, ed., Readings in Biomedical Ethics: A Canadian Focus. Scarborough: Prentice Hall Canada Inc., 367-78.
CFRN Television (1987). "A Second Chance" (Video, 50 minutes). Available from HOPE, University of Alberta Hospitals, Edmonton.
[CHAC] Catholic Health Association of Canada (1991). Health Care Ethics Guide. Ottawa. References are by page number.
Childress, James (1978). "Rationing of Medical Treatment," Encyclopedia of Bioethics. New York: The Free Press, 1414-19.
Chilean Bishops' Permanent Commission (1991). "On Organ Transplants," Catholic International, 15-30 April 1991, 374-5.
Dailey, Thomas G. (1993). "Fetal Tissue Transplants: Some Ethical Questions." Edmonton: St. Joseph's College Catholic Bioethics Centre, Jan. 1993.
Duncan, Glenn E. (1992). "Grim Harvest," The Catholic World Report, Aug. 1992, 16-22.
Engelhardt, H. Tristram (1987). "Allocating Scarce Medical Resources and the Availability of Organ Transplantation: Some Moral Presuppositions," Thomas A. Shannon, ed. Bioethics, Third Edition. Mahwah: Paulist Press, 565-79.
Garrett, Thomas M.; Harold W. Baillie; and Rosellen M. Garrett (1993). Health Care Ethics: Principles and Problems. Englewood Cliffs: Prentice Hall, Ch. 9.
Gaylin, Willard, M.D. (1987). "Harvesting the Dead," in Bioethics, Third Edition, ed. by Thomas A. Shannon. Mahwah: Paulist Press, 553-63.
German Bishops' Conference and the Council of the German Evangelical Church (1988). "Christians and the Ethics of Organ Transplants," Catholic International, 15-30 April 1991, 373-6.
Goddard, Hans (1992). "No Easy Way to Figure Costs of Transplants," The Medical Post, 7 July 1992, 43.
Hanson, Mark J. (1992). "A Pig in a Poke," Hastings Center Report, Nov.-Dec. 1992, 2.
Helsinki Declaration of 1975, Encyclopedia of Bioethics, Vol. 1V. New York: The Free Press, 1978, pp. 1771-3.
[HOPE] Human Organ Procurement and Exchange Program (1993). Organ & Tissue Donation (pamphlet). Edmonton: University of Alberta Hospitals.
John Paul II, Pope (1982). "Biological Experiments Should Contribute to the Well-Being of Mankind," L'Osservatore Romano, English weekly ed., 8 Nov. 1982, pp. 4-5.
Johnston, Cameron (1993). "Transplanting Animal Organs Into Humans Could Soon Become a Reality in Canada," The Medical Post, 5 Jan. 1993.
Jonsen, Albert R. (1989). "Ethical Issues in Organ Transplantation," Ch. 9 in Medical Ethics, ed. by Robert M. Veatch. Boston: Jones and Bartlett Publishers, 229-52.
[LRCC] Law Reform Commission of Canada (1992). Procurement and Transfer of Human Tissues and Organs, Working Paper 66. Ottawa: Canada Communication Group - Publishing.
Lynch, A. (1990). "Respect for the Dead Human Body: A Question of Body, Mind, Spirit, Psyche," Transplantation Proceedings, Vol. 22, No. 3 (June), 1990, pp. 1016-18.
MacNeil, Archbishop Joseph N. (1986), excerpt in "Your Religion and Organ Donation" (pamphlet). Edmonton: Lions Eye Bank.
May, William E. (1977). Human Existence, Medicine and Ethics. Chicago: Franciscan Herald Press, Ch. 7.
Moss, Alvin H.; and Mark Siegler (1993). "Should Alcoholics Compete Equally for Liver Transplantation?", Eike-Henner Kluge, ed., Readings in Biomedical Ethics: A Canadian Focus. Scarborough: Prentice Hall Canada Inc., 85-94.
O'Donnell, Thomas J., S.J. (1976). Medicine and Christian Morality. New York: Alba House.
Post, Stephen G. (1991). "Fetal Tissue Transplant: The Right to Question Progress," America, 12 Jan. 1991, 14-16.
Reuter (1993). "Pigs Born with Human Genes," The Edmonton Journal, 12 Mar. 1993.
Rinehart, Dianne (1993). "Sold for Organs, Risk to Kids Grows," The Edmonton Journal, 22 Jun. 1993, B14.
[SCDF] Sacred Congregation for the Doctrine of the Faith (1980). Declaration on Euthanasia. Battleford, Sask.: Marian Press.
__________ (1987). Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation. Boston: St. Paul Editions.
Siegel, Lee (1992). "Use of Pig Liver Defended," The Press Democrat, 14 Oct. 1992, B4.
Thomas, John E.; and Wilfrid J. Waluchow (1990). Well and Good: Case Studies in Biomedical Ethics, Revised Edition. Peterborough: Broadview Press.
Varga, Andrew C. (1984). The Main Issues in Bioethics, Revised Edition. Ramsey: Paulist Press, Chs. 11 and 12.
Wallace, Charles P. (1992). "Trafficking on Kidney Street: The Rich get Healthier from Trade in Human Organs," Science and Medicine, 13 Sept. 1992.
Wolak, Richard, OMI (1990). "Donate Your Organs: Charity After Death: Everyone Should Plan to be an Organ Donor," Our Family, July/August 1990, 15-18.
Ashley, Benedict M., OP; and Kevin D. O'Rourke, OP (1989), Health Care Ethics. St. Louis: Catholic Health Association of the United States, especially re ethical methodologies, norms of Christian decision in bioethics, and organ transplantation.
Catholic Health Association of Canada (1991). Health Care Ethics Guide. Ottawa, especially pp. 42-47.
Human Organ Procurement and Exchange Program [HOPE] (1991). "Have You Considered Organ Donation" (Video, 11 minutes). Edmonton: University of Alberta Hospitals. HOPE also has available other relevant videos and up-to-date educational literature.
Law Reform Commission of Canada (1992). Procurement and Transfer of Human Tissues and Organs, Working Paper 66. Ottawa: Canada Communication Group - Publishing.
Thomas, John E.; and Wilfrid J. Waluchow (1990). Well and Good: Case Studies in Biomedical Ethics, Revised Edition. Peterborough: Broadview Press, Cases 7:1, 7:3, 8:4, 9:1, 10:1, 10:2, and 12:6.