Organ Shortage Creates Opportunities for Heroism, Raises Ethical Questions

Organ Shortage Creates Opportunities
for Heroism, Raises Ethical Questions

By Mary R. Anderlik
Health Law & Policy Institute

Controversy surrounds efforts to increase the supply of organs by offering "donors" money. See Market Making Inroads in Organ Transplantation, Assisted Reproduction. Oddly enough, altruism also makes ethicists uncomfortable. An article in the August 10, 2000 issue of the New England Journal of Medicine describes some of the ethical issues raised in the drafting and implementation of a policy for "nondirected donation," the acceptance of kidneys offered to strangers by living donors.

Initially, it is a challenge to identify what is troubling about nondirected donation. Other gifts involving substantial sacrifice or risk are greeted with nearly universal acclamation: the gift to a charity that depletes financial reserves, the journey to Africa to treat patients with HIV/AIDS, or the plunge into turbulent waters to rescue a drowning child. Possible objections or cautions include:

The offer cannot be a genuine one; it must reflect some psychological problem such as low self esteem or a pathological desire for attention. As an absolute rejection of the possibility of altruism, few will buy this argument. However, an offer may be a cry for help, and a policy should provide for psychological evaluation of potential donors.

In making the offer to take on risk to benefit a stranger, the donor does not display sufficient respect for his or her own claims to life and health. Put another way, there may be a duty to value one’s own life equally with those of others. (If so, an impulsive rescue attempt could indeed be affirmed more unequivocally than a considered decision to offer a kidney.) An early episode of the TV show "Ally McBeal" presented the extreme case of a man who wished to donate his heart to a friend, ending his own life in the process. The degree of risk may be key.

It may be ethical to accept organs from properly motivated individuals who initiate contact with a transplant center, but down the road these kinds of policies could lead to coercion. This is the classic "slippery slope" argument. The potential for abuse would seem to justify safeguards but not an absolute prohibition on the practice of nondirected donation by living donors.

In evaluating any particular policy, a number of factors may be significant: the balance of risks and benefits in relation to the specific transplant procedure; the institution of safeguards such as an informed consent process that conveys information concerning known risks and areas of uncertainty; and the availability of alternative means of increasing the supply of a particular organ, or the extent to which the acceptance of organs from living donors may reduce incentives to pursue alternatives.

Kidney donation has been associated with donor morbidity ranges of 1-1.3% and mortality ranges of 0-.03% in studies with a mean follow-up period of 15 years. Major liver resection has a morbidity rate of about 10% and has resulted in death for at least 2 donors out of 1000. Given the associated risks, live donation of organs to strangers is unlikely to become a popular activity. It is extremely unlikely that implementation of policies for nondirected donation will diminish efforts to increase the supply of cadaveric organs or impede research into the generation of organs from stem cells or xenotransplantation. The significance of nondirected donation by living donors is largely symbolic—but symbols may be very potent. We can hope that the heroism of these donors will inspire others to take the much less risky step of signing a card authorizing organ removal after their deaths.

08/31/00