Chapter 8: Organ Transplants and Medical Resources Major ethical issues • As with many other bioethical issues raised in this book, the existence of those issues has resulted because of the development of new medical technologies. • In some cases, one of the ethical questions that might be raised is whether the technology should be used at all. • This has been true in the cases of genetic testing, in vitro fertilization, and human cloning, for example. With each of these technologies some have challenged the very idea of using them. Major ethical issues But this is not the case with organ transplants. The practice is widespread and widely accepted. Nonetheless, it too raises ethical concerns, three of which are emphasized in this chapter: (a) Who should receive transplanted organs and on what basis should the decision be made? (b) Under what conditions should organ donations be allowed and accepted? (c) How should organ transplants be allocated? Some facts about organ transplants • The first organs to be transplanted were kidneys beginning in the 1950s • Worldwide, more than 200,000 kidney transplants have been performed, and about 94 percent of the organs are still functioning one year later. • Over the last twenty years the list of organs that are transplanted has grown to include: corneas, bone marrow, bone and skin, livers, lungs, pancreases, intestines, and hearts. • A kidney transplant may cost about $40,000, a heart transplant about $150,000, and a liver transplant in the range from $200,000 to $300,000. Some facts about organ transplants • Kidney donors face odds of 1 in 20,000 of dying from surgical complications, but the risk of dying as a result of having only one kidney is extremely small. • People with one kidney are slightly more likely to develop high blood pressure than those with two. No long-term studies of kidney donors have been done. • The immunosuppressive drugs needed to prevent rejection of a transplanted organ cost from $10,000 to $20,000 a year, and they must be taken for the remainder of the patient’s life. • Medicare, Medicaid, and most, but not all, insurance companies pay for organ transplants and at least part of the continuing drug and treatment costs. Some facts about organ transplants • The End- Stage Renal Disease Program covers kidney transplants for everyone, yet people needing any other sort of transplant who don’t qualify for public programs and lack appropriate insurance must find some way of raising the money. • About 25,000 people a year receive transplants at the nation’s 278 transplant centers, but about 10,000 more die while waiting for organs. • At any given time, about 100,000 people are on the transplant waiting list. Some facts about organ transplants • Each year, 35,000–40,000 additional people register to get organs. For each organ transplanted, three more people sign up, and those on the waiting list die at a rate of ten a day. • According to one estimate, between 6900 and 10,700 potential organ donors are available, but for various reasons only about 37 to 57 percent of potential donors become actual donors. • At a time when the need for donors is increasing, their actual number is decreasing. The number of live donors began to decline in 2004. • Organ donations are regulated by the federal Uniform Anatomical Gift Act of 1984 which has also served as a model for state laws; virtually all states have enacted laws to promote the increase of organ donation. Some facts about organ transplants • Despite such laws, transplant centers have been reluctant to intrude on a family’s grief by asking that a deceased patient’s organs be donated. Even if a patient has signed an organ donation card, the permission of the immediate family is required, in most cases, before the organs can be removed. • The 1984, National Organ Transplantation Act made the sale of organs for transplant illegal in the United States. At least twenty other countries, including Canada, Britain, and most of Europe, have similar laws. • Sixty-nine procurement organizations, operating in federally defined geographical regions, collect organs from donors and transport them to the 278 hospitals with transplant facilities. A procurement agency may be paid about $25,000 for its services. Some facts about organ transplants • Hospitals pay for the organs they receive, but they pass on their costs. Hospitals charge, on average, $16,000 to $18,000 for a kidney or a heart and $20,000 to $22,000 for a liver. • According to one study, hospitals may mark up the cost of an organ by as much as 200 percent to cover costs that patients are unable to pay or that exceed the amount the government will reimburse. • Organs are distributed in the US through the federally funded United Network for Organ Sharing also apply (UNOS). Section 1: Who Deserves Transplant Organs? • Section 3 focuses on how the scarcity of organ transplants raises questions about their fair distribution. • This section looks at another aspect of that scarcity. Because of the life-giving function transplanted organs can potentially provide, together with their scarcity, such organs acquire extraordinary value. • The strength of this value leads to the companion idea that any organ recipient should be deserving of it. Section 1: Who Deserves Transplant Organs? • For example, should a confessed serial killer on death row be entitled to a transplant? • Or, if there is choice between a death row serial killer and a crimeless mother of three children, is the killer as deserving as the mother? • For many people the answer is an obvious “no” to both questions but decisions about who deserves a transplant are more complicated than the examples suggest, as the readings in this section make clear. Reading Wanted, Dead or Alive? Kidney Transplantation in Inmates Awaiting Execution Jacob M. Appel • Jacob Appel argues that death-row inmates should be allowed to be candidates for kidney transplants. • Although the state has determined that the inmate does not deserve to live, it would be wrong for a medical decision to lower his quality of life while he is waiting for execution. • Also, if the inmate was wrongly convicted, denying him a transplant would result in the irreversible suffering of an innocent person. Reading Wanted, Dead or Alive? Kidney Transplantation in Inmates Awaiting Execution Jacob M. Appel • Appel also argues that the life expectancy of a death-row inmate is different in kind from the “natural” one used in kidney allocation, so the inmate’s life expectancy should not be considered relevant to a transplant decision. • Finally, Appel points out, a kidney transplant costs less than dialysis, so the money saved could be used to meet other health care needs. Reading: The Prisoners’ Dilemma: Should Convicted Felons Have the Same Access to Heart Transplantation as Ordinary Citizens? Robert M. Sade • Robert Sade claims that the answer to whether an inmate should receive a heart transplant depends on who is asked. • Physicians and organ procurement and distribution agencies are obligated to consider prisoners eligible for a transplant, just because they are human beings. • For a transplant center, however, the question of payment arises; it needs to be paid by the prison system. • But for most prison systems, heart transplants are almost certainly too expensive to provide without cutting back on other needs. • Thus, in Sade’s view, prisoners should be denied transplants so that other prison expenses can be covered. Reading: Alcoholics and Liver Transplantation Carl Cohen, Martin Benjamin, and the Ethics and Social Impact Committee of the Transplant and Health Policy Center, Ann Arbor, Michigan • The authors examine the moral and medical arguments for excluding alcoholics as candidates for liver transplants and conclude that neither kind of argument justifies a categorical exclusion. • The moral argument holds that alcoholics are morally blameworthy for their condition. Thus, when resources are scarce, it is preferable to favor an equally sick non-blameworthy person over a blameworthy one. • The authors maintain that if this argument were sound, it would require physicians to examine the moral character of all patients before allocating scarce resources. But this is not feasible, and such a policy could not be administered fairly by the medical profession. Reading: Alcoholics and Liver Transplantation Carl Cohen, Martin Benjamin, and the Ethics and Social Impact Committee of the Transplant and Health Policy Center, Ann Arbor, Michigan • The medical argument holds that because of their bad habits, alcoholics have a lower success rate with transplants. • Hence, scarce organs should go to others more likely to benefit. The authors agree that the likelihood of someone’s following a treatment regimen should be considered, but they maintain that the consideration must be given case by case. • We permit transplants in cases where the prognosis is the same or worse, and the categorical exclusion of alcoholics is unfair. We cannot justify discrimination on the grounds of alleged self-abuse, “unless we are prepared to develop a detailed calculus of just deserts for health care based on good conduct.” Section 2: Acquiring Transplant Organs • While, in the future, vital human organs might be grown in a nonhuman organism or “in vitro”, at the present time all organs must be procured from other humans, either alive or recently dead. • This fact raises the question: under what circumstances is it ethically acceptable to harvest a person’s organs? • Where the donor has recently died the answer may seem simple: if the deceased or an authorized family member has consented, the harvesting is unobjectionable. • But, as discussed in the chapter on euthanasia, the definition of death has become more problematic because of advances in lifesupport technology. Section 2: Acquiring Transplant Organs • For example, suppose a patient is still breathing but is also “brain dead”. Is the patient “dead enough” to make harvesting, say, his heart morally acceptable? • In addition, where there is no question that a patient is dead, not to harvest healthy organs can be viewed as a morally objectionable waste. • Should we not, then, as suggested in the article “Conscription of Cadaveric Organs for Transplantation: Let’s at Least Talk About It”, make use of cadaveric organs even if it is contrary to the deceased, or his relatives, wishes? • In the case where the organ donor is alive, different ethical issues arise. Section 2: Acquiring Transplant Organs • Because the donor is alive and intends to remain alive, we are not considering the extraordinary case where the person is willing to see himself killed in order to make his organs available. (This would be homicide.) • This means that the kinds of organs that may be harvested are ones either that can regenerate (for example, liver lobes) or where the patient has more than one of the organ and can live with only one (most frequently, the kidneys). • It is widely accepted that a donor must consent to harvesting any of his organs; otherwise we are violating his autonomy. Section 2: Acquiring Transplant Organs • The major ethical question concerns whether the fact that a person wants to have an organ harvested is sufficient justification for granting his wish. • On the one hand, some argue that not allowing the person to do so is a violation of his autonomy (provided he has consented and understands the risks involved). The organ does, after all, belong to the person. • On the other hand, there are those who believe that, at best, the permissible circumstances should be severely circumscribed. Section 2: Acquiring Transplant Organs • The primary worry here is that, although the sale of organs is prohibited in all countries, promoting the idea that the decision to donate is primarily up to the donor encourages the view that transplant organs are simply commodities which can be bought and sold on the open market. • This can lead to the exploitation of the poor and degrades human dignity. Reading The Donor’s Right to Take a Risk Ronald Munson • Ronald Munson asks whether, given the risk to themselves, we should permit people to donate a liver lobe and whether, by operating on a donor for the benefit of a recipient, surgeons are violating the dictum “Do no harm.” • He claims that, while autonomy warrants consent, we must take measures to guarantee that consent is both informed and freely given. • So far as benefit is concerned, Munson maintains, when consent is valid, living donors can be viewed as benefiting themselves, as well as the recipients of their gift. Reading The Case for Allowing Kidney Sales Janet Radcliffe-Richards, A. S. Daar, R. D. Guttmann, R. Hoffenberg, I. Kennedy, M. Lock, R. A. Sells, N. Tilney, and the International Forum for Transplant Ethics • The authors argue that although some may feel disgust at the idea of selling kidneys, this is not a sufficient reason to deny people a necessary treatment. • The authors critically examine the objections that kidney sales would exploit the poor, benefit the rich unfairly, undermine confidence in physicians, threaten the welfare of women and children in societies that treat them as chattel, and lead to the sale of hearts and other vital organs. • The authors hold that until stronger objections are offered, the presumption should be in favor of kidney sales as a way of resolving the current shortage. Reading: Refuse to Support the Illegal Organ Trade Kishore D. Phadke and Urmila Anandh • The authors observe that, although organ sales are prohibited in all countries, society in general has shifted toward regarding transplant organs as commodities that can be bought. • In developing countries like India, laws against organ sales are not enforced and the practice has popular support. • The authors call for the medical profession to refuse to be a part of “this unscrupulous trade,” which exploits the poor, discourages altruistic giving, commercializes the body, and undercuts human dignity. Conscription of Cadaveric Organs for Transplantation: Let’s at Least Talk About It Aaron Spital and Charles A. Erin • The authors observe that the scarcity of transplant organs results in the death of many people who could be saved and that a major barrier to acquiring organs is the refusal of families of the recently dead to donate their organs. • The authors argue for the adoption of a new policy—the conscription of organs. All usable organs should be taken, without consent, and used for transplantation. • Spital and Erin address objections and defend the view that consent is not ethically required and that conscription, which can save lives, is ethically preferable to all current and proposed practices. Section 3: Allocation Principles • Transplanted organs are, today, a scarce resource. That is, there is a greater demand for the organs than there is a supply of them. • This is not peculiar to transplanted organs; it is true of many things we want and is certainly true of other medical resources such as stays in hospitals, surgical operations, MRIs, diagnostic laboratory tests, in vitro fertilization, bone-marrow transplants blood transfusions, genetic screening, respirators, etc. • Scarcity means that choices have to be made as to who will and will not receive those organs that are available. Those organs (or any scarce resource) must therefore be rationed. Section 3: Allocation Principles • There are four major ways this may be done (discussed in greater detail in the reading “The Prostitute, the Playboy, and the Poet: Rationing Schemes for Organ Transplantation” in this section). • The Market: allow organs to be sold and bought in the marketplace at a price. • The market decides who receives the organs and what the person’s qualification must be. Quite simply, the organs go to who can afford them. • A Committee: a hospital committee made up medical professionals and other stakeholders decides on who qualifies. • Either explicit criteria or committee member judgment is the basis for selection. Section 3: Allocation Principles • A Lottery: organ recipients are selected “blindly” on a random basis. • Selection of recipients depends totally on chance. • By customary practice: selection of candidates is made on the basis of understood practice among medical professionals. • Either explicit criteria or medical professional judgment is the basis for selection. • Allocation may, of course, be based on some combination of these approaches. • Framing an acceptable method of selection raises the fundamental question: Is the method fair and what criteria of fairness should be employed? The articles in this chapter explore this issue. Reading: The Prostitute, the Playboy, and the Poet: Rationing Schemes for Organ Transplantation George J. Annas • The author takes a position on transplant selection that introduces a modification of the first-come, first-served principle. • He reviews four approaches to rationing scarce medical resources— market, selection committee, lottery, and customary—and finds that each has disadvantages so serious as to make them all unacceptable. • An acceptable approach, he suggests, is one that combines efficiency, fairness, and a respect for the value of life. • Because candidates should both want a transplant and be able to derive significant benefits from one, the first phase of selection should involve a screening process that is based exclusively on medical criteria that are objective and as free as possible of judgments about social worth. Reading: The Prostitute, the Playboy, and the Poet: Rationing Schemes for Organ Transplantation George J. Annas • Since selection might still have to be made from this pool of candidates, it might be done by social-worth criteria or by lottery. • However, social-worth criteria seem arbitrary, and a lottery would be unfair to those who are in more immediate need of a transplant—ones who might die quickly without it. • After reviewing the relevant considerations, a committee operating at this stage might allow those in immediate need of a transplant to be moved to the head of a waiting list. To those not in immediate need, organs would be distributed in a first-come, first-served fashion. • Although absolute equality is not embodied in this process, the procedure is sufficiently flexible to recognize that some may have needs that are greater (more immediate) than others.