Ethics of cadaveric organ procurement and allocation (II)

Abstract

THE FIRST TOPIC discussed by the panelists was collaboration between ethicists and medical professionals to elaborate a system of ethical assessment related to all transplantation activities. The necessity of such a system was agreed to be undisputable. Mutual consultation requires a common language, fully understandable by both parties. One of the panelists, an ethicist with a good medical background, reported the reactions of students who listened to his lecture on ethical aspects of new achievements of medicine. Medical students regarded the medical issues as evident, but could not follow the ethical comments by the lecturer. Philosophy students fully understood the ethical comments, but could not follow the lecturer’s discussion of the medical problems. The disputants agreed that bioethicists as well as medical professionals must increase their knowledge of the others’ discipline and professional language. Teaching of ethics must play an important role in medical education. Issues related to paid organ donation and organ commerce were the next topic. Generally, all panelists considered all forms of organ sale to be unacceptable. The ethicists pointed out that the dead human body has a unique character; it is no longer a human being, but it was occupied by the whole of someone’s life. The body itself (as well as its particular organs) is not anyone’s property, neither the living “owner’s” nor the deceased person’s family. Therefore, from a purely ethical point of view, it cannot become an object of any commercial transaction. A living healthy person may donate an organ as an act of love toward a sick peron. The family of a deceased person accepting the decision of transplanting his or her organs, gives evidence of their generosity and compassion for those whose lives can be saved by transplantation. Although a poor man desperately selling his organ to save his hungry children’s life is not to be blamed for such a decision, replacement of humanitarian motives of donation by commercial ones cannot be accepted. Surgeons, speaking from their practical experience, presented the opinion that increasing organ procurement by means of financial motivation to the deceased persons’ families or offering remuneration to living donors is wrong. Instead of improving the situation, it might spoil the transplantation enterprise. Development of paid organ donation might, as it happened with blood donation, slow down instead of accelerating advances in the program. The adverse influence of organ harvesting on the physical and psychological condition of “organ vendors” should not be ignored. One panelist reported the results of questioning the kidney vendors in Iran; the vast majority of kidney vendors deeply regretted their decision to sell organs. They had significantly lower scores on quality of life compared with the controls. Medical ethics does not justify a donation (with its associated health risk) to the donors without a clear donor-recipient emotional relationship. It is disputable as to whether incentives or reimbursements for families of cadaveric donors (as recently proposed in the United States) are a form of commercialization or rather an act of justice in the case of people who have not only lost their loved one, but also experienced certain financial losses. It seems that some forms of financial support may be considered acceptable as long as there is no concealed corruption. The same applies to some reimbursements offered by society to the living related donors. Some panelists pointed out that, irrespective of our beliefs and ethical judgements, paid organ donation is a reality; in some countries it is legal, and in the others it is functioning as a black market with all the negative aspects. We have to face this fact without trying to ignore it in our thinking and policy-making. The next topic was the relation of the presumed consent principle for cadaveric organ donation to human autonomy. This principle, instituted by law, respects the free will of every member of the society to refuse to be an organ donor after death. From the ethical point of view it is questionable whether the lack of refusal does really mean consent. The trigger point in this discussion was the following questions: are all people adequately informed about the possibilities of expressing their refusal and are they aware of the consequences of not expressing it? Should the answer be “yes,” than there would be no moral objections. We know that it is not the case; the information is far from sufficient. The practical task for transplantation centers and institutions is to intensify information and education in this matter, as