The dilemma of cadaver organ donation

Abstract

UDOUBTEDLY, significant progress has been made in the field of organ transplantation. Still, ever since the emergence of cadaver organ donation as the definitive treatment for end-stage organ disease, we have been plagued by problems with the transplantable organ supply. In the early stages of clinical application this was not of great concern, but the number of kidney, liver, heart, lung, and other solid organ transplantations increased sharply. This increase was mostly due to the introduction of new immunosuppressive drugs such as cyclosporine A. Such advancements further boosted the success of cadaver-donor organ transplantations, and thus stimulated the need for cadaveric donors. As this demand began to grow, the insidious, snowballing problem of organ shortage became the most significant limiting factor in transplantation practice. The supply of living-donor organs is limited by delicate ethical and immunological concerns. This has also spurred more rigorous and effective promotion of cadaver-organ donation because cadaveric transplantations do not involve as many sensitive concerns. However, the issue is still complex. Attitudes towards removing organs from a loved one’s body are driven mostly by culture, tradition, religion and law. Although some commonalities exist in human nature and behavior across different people, there remain many important distinctions between countries, ethnic groups, and even individuals within a given society. Differences in the various facets of society worldwide dictate the impossibility of universal remedies for the organ shortage dilemma. In this study, we reviewed basic elements of cadaver-organ donation: the attitude of the public and of the grieving family, religious and cultural impacts, the role of mass media, attitudes of health care professionals, legislative and judicial issues, and ethical matters. We also looked at potential tools for increasing cadaver-organ donation, such as education of the public and of health care personnel and organizational considerations. Although less than 3% of brain deaths occur in situations in where organ donation is likely, studies indicate that the large number of potential donors could actually provide transplantable organs and tissues for the majority of recipients on waiting lists. This indicates that there are still weak points in the management of the entire donation process and that careful assessment of these factors could eventually boost cadaver donation. Although we seem to know a lot about relevant strategies, we must ask how good are these schemes, and how effectively are they implemented. Efforts to develop and increase cadaver-organ donation in the Middle East and mid-Asia, while requiring time and patience, will eventually reduce the need for living-organ donation, a procedure that has its own set of risks and limitations. Next to immunologic barriers, legal and ethical issues are the major concerns in living-donor organ transplantation. The problem of underground organ trading is already increasing and certainly represents the largest threat to the acceptance and success of living-donor transplantation. Unfortunately, there are signs that this has spread all over the world: now there are even web pages on the internet that offer black market organs. Living-donor transplantation is presently limited to kidney and more recently partial liver, with partial pancreas operations performed in very rare cases. There are many advantages to, and better graft survival rates with, living-donor grafts, but a cadaver can potentially supply almost all the transplantable organs and tissues, some of which cannot be obtained from living donors under any circumstance. In the majority of Middle Eastern and mid-Asian countries, living-donor kidney transplantations outnumber cadaver-donor procedures. The circumstances are opposite in most western countries where cadaver-organ shortage is comparably less. This difference from the West indicates that further efforts are needed, and that new strategies must be developed and implemented to enhance cadaver-organ donation in the Middle East and mid-Asia. Despite variations between countries with regard to social and cultural characteristics, there is a list of common factors that impact cadaver-organ donation around the globe: (1) public and family attitudes; (2) health care professionals; (3) institutional factors; and (4) legal issues.