| Abstract|| |
Ethical controversies in transplantation medicine are frequent and are not only discussed in the medical societies, but also by the pubic at large. Recently, the shortage of donor organs has led to a discussion of the commonly accepted ethical principles applied in transplantation medicine. In this paper, we highlight some of the thoughts expressed in the literature and discuss them in the context of transplantation.
Keywords: Transplantation, Organ donation, Ethics, Brain death, Non-heart-beating organ donors, Financial incentives.
|How to cite this article:|
Fitzgerald A, Mayrhofer-Reinhartshuber D, Suske M, Fitzgerald RD. Recent Thoughts about the Ethics of Renal Transplantation. Saudi J Kidney Dis Transpl 2005;16:540-6
|How to cite this URL:|
Fitzgerald A, Mayrhofer-Reinhartshuber D, Suske M, Fitzgerald RD. Recent Thoughts about the Ethics of Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2019 Nov 17];16:540-6. Available from: http://www.sjkdt.org/text.asp?2005/16/4/540/32845
| Introduction|| |
Ethical aspects in medicine find increasing interest in the medical literature, attract widespread public interest and are regularly covered in the lay press. Since its early days, organ transplantation has inflicted controversies within medical societies and the public. However, consensus was reached concerning donation and allocation of organs that resulted in a successful and quick expansion of transplantation practices. The success especially of renal transplantation was so great, that it developed into rather an easy and save procedure, saving patients from hemodialysis or death, when dialysis facilities are not sufficiently available. Worldwide more and more patients are listed for renal transplantation, unmatched by supply for the increasing demand. According to the data published on the Eurotransplant homepage for the year 2001 804 Austrian patients and 11184 patients in Germany were waiting for organs.  According to the United Network for Organ Sharing (UNOS)  80812 patients (stand of 2002-12-17) are on the waiting list for organs in the USA.
The long waiting periods resulting from the organ shortage constitute a considerable risk for the patients to die before they receive a lifesaving organ. According to UNOS 5000 patients died in the year 2000 in the USA while on the waiting list for organ transplantation. Thus, in the quest to increase the number of transplantable organs, the ethical consensus is challenged. This article attempts to give an overview on the different opinions expressed and to discuss some of the arguments.
| Should we Discuss Ethical Principles?|| |
Ethical principles are set as general rules to allow judgement in special aspects and questions. They should be based on the truth of the most basic rules of ethics, which are not altered over time or by circumstances. Thus, concern is sometimes expressed that when these rules were agreed upon, it does not seem understandable that they should be discussed or altered, when circumstances change. In the special case described above, the change in circumstances would be the increasing demand for donor organs. When we have concerns about the use of organs, is it right to question the rules set and to say that they are not right anymore, just because we want to have more organs? Would that not equal a situation where we have made consensus on traffic lights and question them the first moment we have to wait at the red lights?
Of course, a change in demand cannot be the basis for a revision of an ethical consensus. But it is legitimate to review any principles in the light of new aspects, which could alter the consensus. If the basis of a consensus has changed, or new arguments are introduced, decisions have to be reconsidered.
Thus, we want to discuss arguments if they qualify sufficiently for a change of the consensus which is the basis of ethical decisions in transplant medicine.
Changes have been proposed on different levels of the organ donation process: (i) is a donor really dead? (ii) The consent of the family to organ retrieval of a deceased, (iii) the related living organ donation, and (iv) unrelated living organ donation.
| Is the Donor Really Dead?|| |
At the moment there are two sources for organs - from the living donors or the deceased ones. Taking organs from cadavers is accepted by many people as a justifiable practice within certain ethical boundaries. Controversies result from an inability to define exactly where those boundaries are.  Definitions and procedures throughout the world show considerable differences as well as the acceptance of brain death and the permission to retrieve organs from such donors.
The handling of non-heart beating donors remains a point of conflict, where lack of time eliminates the procedures necessary for the declaration of brain-death in heart beating donors. Are these donors really dead?  Is there a prohibitive conflict of interest of professionals and institutions , or is there even a danger of euthanasia?  Is unethical and illegal practice preventable?  While non-heart-beating organ donation was widely used before the introduction of the brain death criteria, this source for organs remained almost unused until the demand for transplantable organs led to the re-emergence of this method with the introduction of the Pittsburgh Protocol.  An observation period of 5 min for verifying the absence of circulation and respiration was proposed to be sufficient to allow organ retrieval. Immediately a discussion arose on how sure a person would be dead or how much time would have to pass, to be sure, that resuscitation would not restore body functions. , Also, as potential non-heart beating organ donation often follows a decision to withdraw medical support, a potential conflict of interests must be considered.
This debate and the need for specific standard criteria led to a position paper of the Ethics Committee of the American College of Critical Care Medicine of the Society of Critical Care Medicine in 2001.  In short the authors conclude, that
- organ procurement from non-heartbeating donors is ethical
- consent is requested
- death must be certified
- pediatric donation is possible, even in the light of the special situation, that the guardian has to choose for them.
While these recommendations are a landmark in the process of forming an acceptable consensus, the discussion is surely not at an end. Presumably, an internationally valid consensus will have to include more the situation in other cultures and nations.
Consent of the Family
A controversial topic in organ transplantations is the question whether relatives of the deceased organ donors should receive a financial incentive for their consent to organ removal. However, in most countries it is illegal to acquire, receive, or transfer any human organ for use in human transplantation. The implementation of such suggestions cannot be carried out without a change of the established laws, which is already discussed in some countries. In Great Britain a change of the current laws concerning financial compensation of living relative organ donation is in preparation. 
In the discussion in favor or against financial incentives for the consent to organ donation many arguments were published.
Models about the form of such financial incentives are multiple.  The direct payment of a lump sum to the decedents or estate as advocated by Peters  or Lysaght and Mason  is the most straightforward form of payment. The amount discussed varies up to 20,000 $  based on the price for fertilized eggs. Critics oppose this suggestion because the payment of a lump sum could easily give the impression of selling the body of the deceased relative.
Another similar suggestion is a tax benefit for the relatives of the deceased organ donor. , Although a direct payment or a tax benefit might provide the greatest likelihood of increasing donation , they are regarded as the ethically least acceptable. 
Another suggestion to a financial incentive, regarded by some to be more ethical, is the reimbursement of funeral expenses in the amount of 300$. , This system, already implemented in Taiwan  is devised to avoid the impression of selling the body but rather express appreciation for the donation. The reimbursement for the funeral expense would not subvert the altruistic donation system but rather improve and support it. In a pilot project in the US state of Pennsylvania the effects of the reimbursement on the consent rate are currently investigated. 
A form of financial incentive regarded to be very ethical constitutes a contribution to a charitable organization determined by the family or the deceased. However, it is questioned whether such a form of a financial incentive would increase the rate of consent for donation. 
Another suggestion to the form of financial incentives is the implementation of a future market system,  where an individual agrees in advance to donate his organs after death with a payment to be made to his beneficiaries or his estate only when the donation has taken place. The advantage of this proposal is that the donors can opt-in to the donation process. The family is neither confronted with the decision for donation nor with the ethical problem for receiving money for consent.
Supporters of financial incentives for organ donation are convinced that by the existing donor shortage the established altruistic donation model is not adequate to meet the current needs. , Lysaght and Mason  compared the current situation with leaving fire-fighting in a major metropolis to the same volunteer fire department that served the city well during its early years. They discuss, that the lack of organ donors can only be compensated by financial incentives. Supporters also argue that the demands of other medical resources like blood plasma, sperm as well as for corpses for teaching purposes in medical schools can only be satisfied by payment. 
Another argument of the supporters of financial incentives is that the families of deceased donors are the only ones involved not directly benefiting from the transplantation process. All other persons concerned like physicians, surgeons, nurses, coordinators etc. are paid, the recipients receive an organ and only the family of the donor is not compensated. , According to Peters  this is one of the main reasons why many families refuse to consent to organ removal and it would be appropriate that the relatives of the deceased donors should also benefit from the transplantations process.
Opponents of financial incentives base their objections primarily on the argument that the established altruistic system has not failed as much as it has not been fully promoted.  The number of organ donors could also be increased by additional information and advertisements to raise the knowledge and the public opinion towards the organ transplantation process. As it was shown that attitudes in medical personnel are inhomogeneous 21 another possibility to increase the number of organ donors is to increase the qualification of the requestor and to sensitize all medical staff involved in the transplantation. , Opponents have also suggested that donation rates could decrease under a system of financial incentives due to a backlash and losses from the current donor pool based on pure altruistic giving. 
Protas  calculated that if 50% of the families now refusing to give consent to the organ removal would donate the organs in return for financial compensation and 30% of the present donors would refuse to do so under a system of financial incentives the supply of the organ remains about the same.
For Protas  one of the main problems in the discussion about financial incentives for deceased organ donation is the economic reasoning. It is stated that increasing the price will increase the supply of a commodity and that no shortage can persist in a market where truly free pricing prevails.  First the validity of this reasoning depends on its basic assumption - that human bodies are commodities and that families of potential organ donors will treat the bodies of the deceased relatives as commodities. If they refuse to consider the bodies of the next-of-kin as tradable commodities, then the economics of supply and demand are irrelevant to this question.
Payment for blood donation also posed the problem that donors who have an economic need for compensation were not truthful of their medical history. Therefore the blood of paid donors had a higher rate of post-transfusion infection.  The same problem could occur in organ donation if donors or the relatives of a donor are motivated with financial incentives.
It is argued that another risk of the implementation of financial incentives would be that a moral barrier would be broken and it would be difficult to contain abuses by regulations and laws.  If the current prohibition against the sale of organs would be repealed, there would be little legal or ethical justification for preventing persons from bypassing the regulated system and using other means to obtain or sell an organ at a better price. 
A free market of organ brokerage would discriminate the poor in the population because they would not be able to afford organ transplantation on the one hand and on the other hand they would become the donors for the more wealthy due to their financial demands. 
Summarizing all these arguments it is obvious that most arguments of the supporters and the opponents are assumptions and fears and not empirical findings. However, little attention has hitherto been paid to the psychological aspects of the introduction of financial incentives for consent to organ donation, e.g. on the family, the society, or the staff involved. Applying the theory of cognitive dissonance of Festinger,  Mayrhofer and others have investigated the effects of a financial incentive on consent rates and concluded that reduction of consents would be possible. ,
Living Related Donors
While living related donation is commonly assumed to be ethically correct, this was questioned in a recent publication by Al-Khader and co-workers.  Overlooking a period of 24 years of doing live related transplantation they report on many examples of pressure exerted on the donor be it financial, psychological, familial, social or tribal. The pressure put to bear might often be subtle and indirect. The donor in question may be pressured by body language of the other relatives or by putting the situation in such a way that a specific relative will have to come forward to donate. The authors summarize 'that (i) a gift of a kidney should be entirely altruistic. If it is not and if the above argument holds, then one might as well buy the kidney - which is abhorred by all International Transplant Societies. (ii) Moreover, a kidney given under these circumstances goes against the longheld view that no medical intervention should take place to an adult, conscious and mentally normal patient without his unprejudiced consent. This should apply even more so as we are dealing not with a patient but with a perfectly normal person. (iii) Perhaps more importantly, a kidney given under these circumstances leads to a drastic psychological adverse upheaval in the donor and a sense of long lasting guilt among the family members including the recipient.
Thus, while little attention is paid to the ethical and psychological background of the 'accepted' living related donor situation, this situation should require more attention
Living Unrelated Donors
Traditionally, most donors have strong relationship with the recipient (related donors). However, in situations of donor-recipient incompatibility, systems of paired exchange and list-paired exchange have been proposed. In the paired exchange system, two recipients who do not have compatible donors can be matched where the donor of one recipient donates to the other and vice versa. 
Altruistic donors are donors who do not necessarily know the recipient. The donation is a pure act of altruism, with no expectation of a material reward of any sort. There are few examples in the literature on this kind of donation. 
For this reasons in June of 2000 representatives of the transplant community evaluated the current practices in organ transplantation  and reached a consensus, recommending certain guidelines for the ethical practice of living organ donation. They established standards of consent, medical suitability for the evaluation of the donor patient, encompassing issues including competency, willingness to donate, freedom from coercion, and full disclosure regarding the risks and benefits of both donor and recipient surgeries. However, Biller-Andorno describes in the findings from empirical data how difficult it is to find the balance between possibility and pressure and that it is not very easy to evaluate especially if there is a combination of the medical doctors authority and the advice. 
Trade with organs is happening and was reported in many regions of the world.  A panel from the American Society of Transplant Surgeons unanimously opposed to the exchange of money for cadaver donor organs because either a direct payment or tax incentive would violate the ideal standard of altruism and unacceptably commercialize the value of human life by commodifying donated organs.  This is further aggravated by the lack of improvement of the life of the donor by the financial compensation and a possible decline in health.  However, a majority of the members of the panel mentioned above, favored contributions for funeral expenses or donations to charitable organizations as a possible recompensation for the donation. 
In general the benefits to both - donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ. At least this can be fulfilled if donors are not called upon to donate in clinically hopeless situations.
When several alternatives are discussed, mostly all of them have some truth, but seldom one owns all the truth. Many contemporary moral discussions are "interminable" -i.e. they are endless arguments pitting conflicting positions held by different parties each of whom believes his or her position are undisputedly correct.
On the other hand various ethical reflections influence and enrich each other. Thinking about principles helps acting in a more professional way, considering aspects of care improves the quality of communication and narrative ethics and casuistry.
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Robert D Fitzgerald
Ludwig Boltzmann Institute for the Economics of Medicine in Anesthesia and Intensive Care, Wolkersbergenstrabe 1, A-1130, Vienna