Doctors, Ethicists to Grapple With Organ Donation

Doctors, Ethicists to Grapple With Organ Donation

Posted on: Thursday, 3 April 2008, 21:00 CDT

CHICAGO -- The most vexing challenges in organ transplantation used to center on what medicine couldn't do.

But scientific advances have made transplants possible that were unimaginable even a few years ago, ushering in an era where social and ethical considerations take center stage.

On this new frontier, Americans increasingly turn to the Internet to solicit organs from people they don't know. Some travel to China, India and other parts of the developing world to buy organs taken from executed prisoners or people so impoverished they sell their body parts. Others pay a fee to a commercial enterprise in the U.S., matchingdonors.com, that pairs them with strangers willing to give an organ.

At a national transplant ethics conference opening here Friday, doctors, psychologists, ethicists and others will grapple with the ever more complex decision-making that surrounds distribution of scarce organs to the tens of thousands of Americans desperate for a life-sustaining transplant.

The decisions impact both sides of the transplant equation _ patients and donors.

Among the many thorny questions: Is it fair to exclude people with developmental disabilities or dementia from transplant waiting lists? Should younger people get preference? Is it ethical for children to be living donors?

Two roiling debates involve whether to compensate living donors for their organs and whether to permit patients to solicit donors through the Internet, billboards, newspaper ads and other public venues such as TV talk shows.

"It's all about who gets what, and who gets to make the decision," said Linda Wright, a bioethicist at University Health Network and the Joint Center on Bioethics at the University of Toronto.

Those who think organs are a public resource believe the government or some other agency should regulate them, including organs from living donors. Organs from cadavers are currently distributed by United Network for Organ Sharing, a private group that contracts with the federal government.

Others believe the organ _ usually a kidney _ belongs to the person born with it, and living donors should be able to decide who will receive it and whether to accept compensation. Debate rages over who should control organs from "good Samaritan" or altruistic living donors because they are not giving to a friend, relative or someone they know.

Last year, more than 6,300 transplants were performed with organs from living people, including about 100 organs from people who offered to donate to anyone in need. More than 1,200 transplants involved organs from living people who directed that the organ go to a specific individual not related to them.

More than 28,000 transplants overall were performed in the U.S. last year.

Dan Brock, professor of medical ethics at Harvard Medical School, said people should be able to decide what to do with their own organs.

"The usual view is that I own my body, including the organs," said Brock, who has offered tongue-in-cheek to sell his kidney for $2 million to colleagues at several transplant conferences. "If I haven't chosen to donate to the transplant system, it's a private resource; it's mine. That means I'm entitled to give it to who I want."

Others see it differently.

Dr. Douglas Hanto, a professor of surgery also at Harvard Medical School, said he supports anonymous donation in which organs are given to biologically compatible people on the waiting list. Solicitation, he said, could result in exploitation of vulnerable people, including those who are poor, mentally impaired or psychologically unstable.

Solicitation also can divert organs to people who are unsuitable candidates for transplant, especially those who are trying to circumvent the allocation system, he said.

"Biologically unrelated donors who are interested in being donors, and want to do it fairly, should go to their local transplant center so that the organ will go to the next person on the waiting list," Hanto said.

It is illegal to buy and sell human organs in the U.S., but concern has been growing that some donors in the U.S. are paid under the table.

Economists and others have floated the idea of legally compensating donors, financially and in other ways, such as offering lifetime health insurance or a tax benefit.

University of Minnesota transplant surgeon Dr. Arthur Matas advocates a compensation program, regulated by the government, that would pay the donor a fixed price of $95,000. Under his proposal, the government or health insurers would pay.

"Transplantation is far less expensive than keeping people on dialysis, and the government already pays for dialysis," he said. "My argument is that you could figure out the administrative and other costs and keep it cost-neutral to the medical system."

Matas contrasted his plan with the way paid donation plays out today in the Philippines, Pakistan and India, where donors and recipients meet each other, usually through a broker, and negotiate a price without oversight. Such transactions are illegal in those countries.

On the other side of the transplant equation, hard decisions are being made about who should get the limited numbers of organs available.

Transplantation is not an entitlement, said Katrina Bramstedt, a clinical ethicist at California-Pacific Medical Center in San Francisco.

"There's not enough organs to go around, and they need to go into people who doctors feel have a capacity to benefit," she said. "It's a tough decision, but we have to look at all the various factors that affect outcomes."

Many centers exclude patients from the waiting list if they smoke, drink, use drugs illegally or have a history of psychological problems. Patients, including children, without a strong support system also can be rejected.

Bramstedt said while many people question the fairness of using those criteria to decide whether a person gets a transplant, scientific evidence suggests such factors affect medical outcomes.

Smoking, for example, increases the chance of a malignancy because the immune system is suppressed, Bramstedt said. People who get liver transplants have a high rate of head and neck cancers if they continue to smoke.

Participants at the 2 {-day conference, organized by the American Society of Transplant Surgeons, the Academy of Psychosomatic Medicine, the Chicago Transplant Ethics Consortium and Northwestern University's Feinberg School of Medicine, plan to develop non-binding consensus positions on selecting transplant recipients as well as solicitation and compensation of living donors.

Source: Chicago Tribune

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