Organ donation

Overview
Organ donation is the removal of the tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting. Organs and tissues are removed in procedures similar to surgery, and all incisions are closed at the conclusion of the surgery. Steps are taken to provide a traditional funeral viewing. People of all ages may be organ and tissue donors. See "organ transplant" for discussion of the mechanics and history of organ transplantation.

In numerical terms, donations from dead donors far outweigh donations by living ones. The laws of different countries allow either the potential organ donor to consent or dissent to the donation during his life time, or his relatives to consent or dissent. Due to these different legislative possibilities, the number of donations per million people varies substantially in different countries.

Organs and tissues which can be donated
Organs that can be procured include: the heart, intestines, kidneys, lungs, liver, pancreas. These are procured from a brain dead donor or a donor where the family has consent for donation after cardiac death, known as Non-heart beating donation.

The following tissues can be procured: bones, tendons, corneas, heart valves, femoral veins, great saphenous veins, small saphenous veins, pericardium, skin grafts, and the sclera (the tough, white outer coating surrounding the eye). These are only procured after someone has died.

Organs that can be donated from living donors include part of the liver or pancreas and the kidney.

Recipient protection
To protect the person receiving an organ, various health and safety tests are conducted. Because an organ transplant requires immune suppression, it is important that the organ not be infected with a disease that could harm the recipient. These tests are not perfect, but organ-related infections are relatively rare.

Precise regulations vary by country or even hospital to hospital. In most countries, organs are not accepted from a person who has an active or recent case of cancer (except a brain tumor which has not spread or certain mild kinds of skin cancer), who has ever had a blood cancer, or who has certain infectious diseases, including HIV or severe bacterial or fungal infections at the time of death. People with these conditions may be able to donate their bodies or tissues for lab research or education, but not to a living donor. Because most people die from infections, cancer, or organ failure, only 1% of people who die at a hospital will be able to donate their organs.

At least one case of a brain tumor being spread through liver transplant has been documented. However, transplant officials are reluctant to shrink the supply of organs because of this rare risk.

Some countries have proposed that HIV+ people be able to donate organs to other HIV+ people under some circumstances and has been passed into law in Illinois.

Legislation regarding organ donation
There are four different legislative approaches to the donation, if the donor has not explicitly dissented. The least restrictive approach is the dissent solution, according to which the donor has to explicitly dissent to donation during his lifetime. According to the extended dissent solution, relatives may dissent in the event the potential donor has not consented.

The different legislative approaches are the main reason that countries like Spain (27 donors per million inhabitants) or Austria (24 donors per million inhabitants) have higher donor rates than Germany (13 donors) or Greece (6 donors). In most countries with the dissent solutions, there is no waiting list for donations, or the list is short, while most countries with consent solutions have substantial organ shortages. The reason for this is that, in both situations, most people do not explicitly state their wishes. Thus, in a country requiring dissent, most people will not have dissented, while in a country requiring consent, most people will not have consented.

Under United States law, the regulation of organ donation is left to states within the limitations of the federal National Organ Transplant Act of 1968. Each state's Uniform Anatomical Gift Act seeks to streamline the process and standardize the rules among the various states, but it still requires that the donor make an affirmative statement during her or his lifetime that she or he is willing to be an organ donor. Many states have sought to encourage the donations to be made by allowing the consent to be noted on the driver's license. Still, it remains a pure consent system rather than an extended consent system or even a dissent opt-out system. Curiously, though, relatives can still dissent even in the presence of evidence of explicit consent by the potential organ donor (driver's licence, living will, registry information, etc.). As such, many organ donation campaigns in the United States encourage family communication about one's decision to donate or not to donate.

In the United Kingdom organ donation is always voluntary and no consent is presumed. There is however a national database called the Organ Donation Register where those individuals who wish to donate their organs after death can register. All NHS hospital have access to this database so that in the event of a death it can be seen if someone was a donor or not. It is also usual for hospital staff to ask relatives directly, in the event of a patient’s death if they would be willing to donate their organs or not. Some members of the public in the UK also carry Donor Cards in their wallets, which are credit card sized and state that the person wishes to be a donor in the event of their death. In patients who require kidney or bone marrow transplants and in some cases a lobe of liver it is common as in other countries for the patient’s relatives to be tested to see if they are a match. All transplants in the UK are carried out on the NHS to ensure that the whole population has access to potential donors in the event of them needing a transplant.

Bioethical issues in organ donation
Since the mid-1970s, bioethics, a relatively new area of ethics, has emerged at the forefront of modern clinical science. Many philosophical arguments against organ donation stem from this field. Generally, the arguments are rooted in either deontological or teleological ethical considerations.

Deontological issues
Pioneered by Paul Ramsey and Leon Kass, few modern bioethicists disagree on the moral status of organ donation. Certain groups, like the Roma (gypsies), oppose organ donation on religious grounds, but most of the world's religions support donation as a charitable act of great benefit to the community. Issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur. In issues relating to public health, it is possible that a compelling state interest overrules any patient right to autonomy.

From a philosophical standpoint, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definition 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.

Jewish medical ethics takes a unique approach. It accepts organ donation as a meritorious charitable act, but with two conditions: that the donor be deceased before removal of the organ and that the organ be treated respectfully (and not, for instance, merely discarded if it for some reason becomes unusable). The ethical problem stems from a lack of consensus on the definition of "deceased." According to the strictest interpretation of halachah, "deceased" means the cessation of all brain stem activity. For most organs, this point is too late for the donation to be medically useful; nevertheless, for the adherent to this view, any prior removal would be tantamount to murder. Given the nature of the market for donated organs, the second condition would limit donation to a case where there is a known and ready need for that specific organ. Alternatively, a promise can be made to ensure a proper burial for a donated organ in the event that it is not transplanted. A movement to promote organ donation from Jews to the general population in consonance with halachah has been spearheaded by the Halachic Organ Donor Society.

Further, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own. Cloning is still a controversial topic, more so when an entire person is brought into being with the express purpose of being destroyed for organ procurement. While the benefit of such a cloned organ is a zero-percent chance of transplant rejection, the ethical issues involved with creating and killing a clone may outweigh these benefits.

A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation, or the transfer of animal (usually pig) organs into human bodies, promises to eliminate many of the ethical issues while creating many of its own. While xenotransplantation promises to increase supply of organs considerably, the threat of organ transplant rejection and the risk of xenozoonosis, coupled with the general anathema to the idea decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.

Teleological issues
On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. Insofar as those that donate organs are often impoverished and those that 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 &mdash; many die while still on a waiting list.

Organ donation is fast becoming an important bioethical issue from a social perspective as well. While most first-world nations have a legal system of oversight for organ transplantation, the fact remains that demand far outstrips supply. Consequently, there has arisen a black market 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 suggest this results in a growing inequality of status between the rich and the poor. On the other hand are those who contend that the desperate should be allowed to sell their organs, and that stopping them is merely contributing to their status as impoverished. Further, those in favor of the trade hold that exploitation is morally preferable to death, and insofar 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. Conversely, surveys conducted among living donors postoperatively and in a period of five years following the procedure have shown an extreme regret in a majority of the donors who said that given the chance to repeat the procedure, they would not. Additionally, many study participants reported a decided worsening of economic condition following the procedure. These studies looked only at people who sold a kidney in countries where organ sales are already legal.

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.

Exploitation arguments generally come from two main areas:


 * Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor.


 * Financial exploitation suggests that the donor (especially in the Indian subcontinent and Africa) are not paid enough. Commonly, accounts from persons who have sold organs in both legal and black market circumstances put the prices at between $150 and $5,000, depending on the local laws, supply of ready donors and scope of the transplant operation.   In Chennai, India where one of the largest black markets for organs is known to exist, studies have placed the average sale price at little over $1,000.  Many accounts also exist of donors being postoperatively denied their promised pay.


 * The New Cannibalism is a phrase coined by anthropologist Nancy Scheper-Hughes in 1998 for an article written for The New Internationalist. Her argument was that the actual exploitation is an ethical failing, a human exploitation; a perception of the poor as organ sources which may be used to extend the lives of the wealthy.

Political issues
There are also controversial issues regarding how organs are allocated between patients. For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes.

Faith in the medical system is important to the success of organ donation. Brazil switched to an opt-out system and ultimately had to withdraw it because it further alienated patients who already distrusted the country's medical system.

Adequate funding, strong political will to see transplant outcomes improve, and the existence of specialized training, care and facilities also increase donation rates. Expansive legal definitions of death, such as Spain uses, also increase the pool of eligible donors by allowing physicians to declare a patient to be dead at an earlier stage, when the organs are still in good physical condition.

Allowing or forbidding payment for organs affects the availability of organs. Generally, where organs can not be bought or sold, quality and safety are high, but supply is not adequate to the demand. Where organs can be purchased, the supply increase somewhat, but safety declines, as families and living donors have an incentive to conceal unfavorable information.

Some political decisions have unintended consequences for donation rates. For example, motorcycle helmet laws and drunk driving laws have lowered the number of sudden deaths in vehicle accidents, and therefore lowered the number of otherwise healthy corpses which could have been organ donors.

Healthy humans have two kidneys, a redundancy that enables living donors (inter vivos) to give a kidney to someone who needs it. The most common transplants are to close relatives, but people have given kidneys to other friends. The rarest type of donation is the undirected donation whereby a donor gives a kidney to a stranger. Less than a few hundred of such kidney donations have been performed. In recent years, searching for "good Samaritan" donors via the internet has also become a way to find life saving organs.

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. Donations from corpses are anonymous, and a network for communication and transport allows fast extraction and transplant across the country. Under Spanish law, every corpse can provide organs unless the deceased person expressly rejected it. Because family members still can forbid the donation, carefully trained doctors ask the family for permission, making it very similar in practice to the United States system.

In the overwhelming majority of cases, organ donation is not possible for reasons of recipient safety, match failures, or organ condition. Even in Spain, which has the highest organ donation rate in the world, there are only 35.1 actual donors per million people, and there are hundreds of patients on the waiting list. This rate compares to 24.8 per million in Austria, where families are rarely asked to donate organs, and 22.2 per million in France, which -- like Spain -- has a presumed-consent system.

Organs for prisoners
There is also controversy surrounding whether a prison inmate should be entitled to be on the list for an organ donation. According to Dr. William Winslade, director of the Program for Legal and Ethical Issues in Correctional Health at the University of Texas Medical Branch (UTMB) prisoners should not be discriminated against as possible candidates for transplant.

Organ shortfall
A persistent issue relating to organ donation is the scarcity of organ donors relative to the number of potential recipients on organ donation waiting lists. No matter what laws and systems are in place, the demand for kidney transplants has outstripped supply in every country.

In the United States, the waiting list is quoted to be about 96,522 people long, but about a third of those patients are inactive and could not receive a donated organ. Different organs have different waiting times and success rates because demand is significantly different for different organs. Three-quarters of patients in need of an organ transplant are waiting for a kidney, and as such kidneys 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 476 days for a kidney, because demand for kidneys substantially outstrips supply. In Australia, there are 10.8 transplants per million people, about a third of the Spanish rate. The Lions Eye Institute, in Western Australia, houses the Lions Eye Bank. The Bank was established in 1986 and coordinates the collection, processing and distribution of eye tissue for transplantation. The Lions Eye Bank also maintains a waitlist of patients who require corneal graft operations. About 100 corneas are provided by the Bank for transplant each year, but there is still a waiting list for corneas.

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

Scandals
Hootan Roozrokh, MD, of California has been charged with prescribing excessive doses of morphine and sedatives to hasten the death of a man with adrenal leukodystrophy and irreversible brain damage, in order to procure his organs for transplant. The case being brought against Roozrokh is the first such case in the US.

At California's Emanuel Medical Center, neurologist Narges Pazouki, MD, said an organ-procurement organization representative pressed her to declare a patient brain-dead before the appropriate tests had been done. She refused.

In many hospitals, particularly in countries with an integrated and proactive organ network, like Spain, organ network representatives routinely screen patient records to identify potential donors in advance of their deaths. In some cases, organ-procurement representatives will request screening tests or organ-preserving drugs (such as anti-hypertension drugs) to keep potential donors' organs viable until their suitability for transplants can be determined and family consent (if needed) can be obtained. This practice increases transplant efficiency, as potential donors who are unsuitable due to infection or other causes are removed from consideration before their deaths, and decreases the avoidable loss of organs. It may also benefit families indirectly, as the families of unsuitable donors are not approached to discuss organ donation.