The Institute of Medicine Report: Sensible and Consequential

Abstract

Dr. Dick Howard has recently written that we have a societal obligation to provide organs for transplantation after we die and that ‘good deeds are not voluntary; they are required’ (1). Further, he states that: ‘the transplant community urges individuals while they are alive and the families of appropriate brain-dead persons and others … to bestow the “gift of life” or to “donate life” to someone in need’ and ‘we place high value on the lives of others, even if we do not know them (such as people on the transplant waiting list). The transplant community should begin to frame the discussion in these terms’. Dr. Howard's moral view captures the goodness of organ donation (its altruism) and brings a call to social responsibility. This was a welcome commentary on behalf of the transplant community and in keeping with the nobility of the field: to value the dignity of human life and the dignity of the patients that we care for (donors and recipients). For Dr. Howard to have this commendable perspective on moral duty and then shortly thereafter, bring a perspective on the Institute of Medicine (IOM) report is seemingly conflicted with the ideals he has previously espoused and counter to the IOM report (2, 3). Those arguments for moral duty and social responsibility are at the core of the IOM recommendations not to support financial incentives for deceased donors or permit the buying and selling of organs from live vendors. Further, not all would agree with Dr. Howard's conclusion that the IOM ‘report adds little that is new’. What is ‘new’ is that this IOM document brings a current and independent thinking that would be influential if a Congressional hearing was to be convened for a revision of NOTA; yet the release of the IOM report makes the consideration of a NOTA revision all the more unlikely. To assert that ‘nowhere does the report state emphatically that financial or other incentives are ethically wrong’ is disputed by many pages of the IOM report. At least these 2 sentences provide an unambiguous ethical rebuttal. Every society draws lines separating things treated as commodities from things that should not be treated as things ‘for sale’ (3). ‘Despite the growing market for body parts and products, there remains a strong societal taboo not only against buying solid organs from living people but also against buying and selling dead bodies or certain parts of dead bodies, including solid organs’ (3). The IOM's reasons for rejecting a market in organs from deceased individuals also apply to a market involving organs from living people (3). ‘These reasons hold even though a few analysts argue that it would be cost effective to pay individuals as much as $90 000 to provide a kidney for transplantation and even propose changes in the laws to permit such a payment in a regulated market. These proposals have yet to gain traction in the United States because they are incompatible with the fundamental values and norms that govern transplantation and because international markets in organs from living individuals appear to involve the exploitation of relatively impoverished people…’ Dr. Howard suggests that ‘much of the report is disappointing in that the IOM seems to have lost sight of the real goal of their effort: increasing the number of organ donors.’ On the contrary, what did the IOM clearly recommend? It recommended a way to increase the number of organ donors by the following: ‘We believe that at this time the best approaches are to pursue ways to increase donations based on circulatory determination of death …’ The IOM recommended that federal agencies work with states and cities that have extensive trauma centers and emergency response systems to develop demonstration projects that can determine the feasibility of increasing rates of donation after circulatory determination of death. There is a component of Dr. Howard's commentary that would derive a consensus and it is by this statement: ‘it would be valuable if everyone could think of donation as part of end-of-life considerations’. To this recommendation, the transplant community should be supportive especially for donation after cardiac death—as proposed by the IOM.