Chapter 8: Organ Transplants and Medical Resources

1
Chapter 8 Organ Transplants and Medical Resources
2
Major ethical issues

• As with many other bioethical issues raised in
  this book, the existence of those issues has
  resulted because of the development of new
  medical technologies.
• In some cases, one of the ethical questions that
  might be raised is whether the technology should
  be used at all.
• This has been true in the cases of genetic
  testing, in vitro fertilization, and human
  cloning, for example. With each of these
  technologies some have challenged the very idea
  of using them.

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Major ethical issues

• But this is not the case with organ transplants.
  The practice is widespread and widely accepted.
  Nonetheless, it too raises ethical concerns,
  three of which are emphasized in this chapter
• (a) Who should receive transplanted organs and on
  what basis should the decision be made?
• (b) Under what conditions should organ donations
  be allowed and accepted?
• (c) How should organ transplants be allocated?

4
Some facts about organ transplants

• The first organs to be transplanted were kidneys
  beginning in the 1950s
• Worldwide, more than 200,000 kidney transplants
  have been performed, and about 94 percent of the
  organs are still functioning one year later.
•  
• Over the last twenty years the list of organs
  that are transplanted has grown to include
  corneas, bone marrow, bone and skin, livers,
  lungs, pancreases, intestines, and hearts.
• A kidney transplant may cost about 40,000, a
  heart transplant about 150,000, and a liver
  transplant in the range from 200,000 to
  300,000.

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Some facts about organ transplants

• Kidney donors face odds of 1 in 20,000 of dying
  from surgical complications, but the risk of
  dying as a result of having only one kidney is
  extremely small.
• People with one kidney are slightly more likely
  to develop high blood pressure than those with
  two. No long-term studies of kidney donors have
  been done.
• The immunosuppressive drugs needed to prevent
  rejection of a transplanted organ cost from
  10,000 to 20,000 a year, and they must be taken
  for the remainder of the patients life.
• Medicare, Medicaid, and most, but not all,
  insurance companies pay for organ transplants and
  at least part of the continuing drug and
  treatment costs.

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Some facts about organ transplants

• The End- Stage Renal Disease Program covers
  kidney transplants for everyone, yet people
  needing any other sort of transplant who dont
  qualify for public programs and lack appropriate
  insurance must find some way of raising the
  money.
• About 25,000 people a year receive transplants at
  the nations 278 transplant centers, but about
  10,000 more die while waiting for organs.
• At any given time, about 100,000 people are on
  the transplant waiting list.

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Some facts about organ transplants

• Each year, 35,00040,000 additional people
  register to get organs. For each organ
  transplanted, three more people sign up, and
  those on the waiting list die at a rate of ten a
  day.
• According to one estimate, between 6900 and
  10,700 potential organ donors are available, but
  for various reasons only about 37 to 57 percent
  of potential donors become actual donors.
• At a time when the need for donors is increasing,
  their actual number is decreasing. The number of
  live donors began to decline in 2004.
• Organ donations are regulated by the federal
  Uniform Anatomical Gift Act of 1984 which has
  also served as a model for state laws virtually
  all states have enacted laws to promote the
  increase of organ donation.

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Some facts about organ transplants

• Despite such laws, transplant centers have been
  reluctant to intrude on a familys grief by
  asking that a deceased patients organs be
  donated. Even if a patient has signed an organ
  donation card, the permission of the immediate
  family is required, in most cases, before the
  organs can be removed.
• The 1984, National Organ Transplantation Act made
  the sale of organs for transplant illegal in the
  United States. At least twenty other countries,
  including Canada, Britain, and most of Europe,
  have similar laws.
• Sixty-nine procurement organizations, operating
  in federally defined geographical regions,
  collect organs from donors and transport them to
  the 278 hospitals with transplant facilities. A
  procurement agency may be paid about 25,000 for
  its services.

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Some facts about organ transplants

• Hospitals pay for the organs they receive, but
  they pass on their costs. Hospitals charge, on
  average, 16,000 to 18,000 for a kidney or a
  heart and 20,000 to 22,000 for a liver.
• According to one study, hospitals may mark up the
  cost of an organ by as much as 200 percent to
  cover costs that patients are unable to pay or
  that exceed the amount the government will
  reimburse.
• Organs are distributed in the US through the
  federally funded United Network for Organ Sharing
  also apply (UNOS).

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Section 1 Who Deserves Transplant Organs?

• Section 3 focuses on how the scarcity of organ
  transplants raises questions about their fair
  distribution.
• This section looks at another aspect of that
  scarcity. Because of the life-giving function
  transplanted organs can potentially provide,
  together with their scarcity, such organs acquire
  extraordinary value.
• The strength of this value leads to the companion
  idea that any organ recipient should be deserving
  of it.

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Section 1 Who Deserves Transplant Organs?

• For example, should a confessed serial killer on
  death row be entitled to a transplant?
• Or, if there is choice between a death row serial
  killer and a crimeless mother of three children,
  is the killer as deserving as the mother?
• For many people the answer is an obvious no to
  both questions but decisions about who deserves a
  transplant are more complicated than the examples
  suggest, as the readings in this section make
  clear.

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Reading Wanted, Dead or Alive? Kidney
Transplantation in Inmates Awaiting
ExecutionJacob M. Appel

• Jacob Appel argues that death-row inmates should
  be allowed to be candidates for kidney
  transplants.
• Although the state has determined that the inmate
  does not deserve to live, it would be wrong for a
  medical decision to lower his quality of life
  while he is waiting for execution.
• Also, if the inmate was wrongly convicted,
  denying him a transplant would result in the
  irreversible suffering of an innocent person.

13
Reading Wanted, Dead or Alive? Kidney
Transplantation in Inmates Awaiting
ExecutionJacob M. Appel

• Appel also argues that the life expectancy of a
  death-row inmate is different in kind from the
  natural one used in kidney allocation, so the
  inmates life expectancy should not be considered
  relevant to a transplant decision.
• Finally, Appel points out, a kidney transplant
  costs less than dialysis, so the money saved
  could be used to meet other health care needs.

14
Reading The Prisoners Dilemma Should Convicted
Felons Have the Same Access to Heart
Transplantation as Ordinary Citizens?Robert M.
Sade 

• Robert Sade claims that the answer to whether an
  inmate should receive a heart transplant depends
  on who is asked.
• Physicians and organ procurement and distribution
  agencies are obligated to consider prisoners
  eligible for a transplant, just because they are
  human beings.
• For a transplant center, however, the question of
  payment arises it needs to be paid by the prison
  system.
• But for most prison systems, heart transplants
  are almost certainly too expensive to provide
  without cutting back on other needs.
• Thus, in Sades view, prisoners should be denied
  transplants so that other prison expenses can be
  covered.

15
Reading Alcoholics and Liver TransplantationCarl
Cohen, Martin Benjamin, and the Ethics and
Social Impact Committee of the Transplant and
Health Policy Center, Ann Arbor, Michigan

• The authors examine the moral and medical
  arguments for excluding alcoholics as candidates
  for liver transplants and conclude that neither
  kind of argument justifies a categorical
  exclusion.
• The moral argument holds that alcoholics are
  morally blameworthy for their condition. Thus,
  when resources are scarce, it is preferable to
  favor an equally sick non-blameworthy person over
  a blameworthy one.
• The authors maintain that if this argument were
  sound, it would require physicians to examine the
  moral character of all patients before allocating
  scarce resources. But this is not feasible, and
  such a policy could not be administered fairly by
  the medical profession.

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Reading Alcoholics and Liver TransplantationCarl
Cohen, Martin Benjamin, and the Ethics and
Social Impact Committee of the Transplant and
Health Policy Center, Ann Arbor, Michigan

• The medical argument holds that because of their
  bad habits, alcoholics have a lower success rate
  with transplants.
• Hence, scarce organs should go to others more
  likely to benefit. The authors agree that the
  likelihood of someones following a treatment
  regimen should be considered, but they maintain
  that the consideration must be given case by
  case.
• We permit transplants in cases where the
  prognosis is the same or worse, and the
  categorical exclusion of alcoholics is unfair. We
  cannot justify discrimination on the grounds of
  alleged self-abuse, unless we are prepared to
  develop a detailed calculus of just deserts for
  health care based on good conduct.

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Section 2 Acquiring Transplant Organs

• While, in the future, vital human organs might be
  grown in a non-human organism or in vitro, at
  the present time all organs must be procured from
  other humans, either alive or recently dead.
• This fact raises the question under what
  circumstances is it ethically acceptable to
  harvest a persons organs?
• Where the donor has recently died the answer may
  seem simple if the deceased or an authorized
  family member has consented, the harvesting is
  unobjectionable.
• But, as discussed in the chapter on euthanasia,
  the definition of death has become more
  problematic because of advances in life-support
  technology.  

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Section 2 Acquiring Transplant Organs

• For example, suppose a patient is still breathing
  but is also brain dead. Is the patient dead
  enough to make harvesting, say, his heart
  morally acceptable?
• In addition, where there is no question that a
  patient is dead, not to harvest healthy organs
  can be viewed as a morally objectionable waste.
• Should we not, then, as suggested in the article
  Conscription of Cadaveric Organs for
  Transplantation Lets at Least Talk About It,
  make use of cadaveric organs even if it is
  contrary to the deceased, or his relatives,
  wishes?
• In the case where the organ donor is alive,
  different ethical issues arise.

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Section 2 Acquiring Transplant Organs

• Because the donor is alive and intends to remain
  alive, we are not considering the extraordinary
  case where the person is willing to see himself
  killed in order to make his organs available.
  (This would be homicide.)
•  
• This means that the kinds of organs that may be
  harvested are ones either that can regenerate
  (for example, liver lobes) or where the patient
  has more than one of the organ and can live with
  only one (most frequently, the kidneys).
• It is widely accepted that a donor must consent
  to harvesting any of his organs otherwise we are
  violating his autonomy.

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Section 2 Acquiring Transplant Organs

• The major ethical question concerns whether the
  fact that a person wants to have an organ
  harvested is sufficient justification for
  granting his wish.
• On the one hand, some argue that not allowing the
  person to do so is a violation of his autonomy
  (provided he has consented and understands the
  risks involved). The organ does, after all,
  belong to the person.
• On the other hand, there are those who believe
  that, at best, the permissible circumstances
  should be severely circumscribed.

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Section 2 Acquiring Transplant Organs

• The primary worry here is that, although the sale
  of organs is prohibited in all countries,
  promoting the idea that the decision to donate is
  primarily up to the donor encourages the view
  that transplant organs are simply commodities
  which can be bought and sold on the open market.
• This can lead to the exploitation of the poor and
  degrades human dignity.  

22
Reading The Donors Right to Take a RiskRonald
Munson

• Ronald Munson asks whether, given the risk to
  themselves, we should permit people to donate a
  liver lobe and whether, by operating on a donor
  for the benefit of a recipient, surgeons are
  violating the dictum Do no harm.
• He claims that, while autonomy warrants consent,
  we must take measures to guarantee that consent
  is both informed and freely given.
• So far as benefit is concerned, Munson maintains,
  when consent is valid, living donors can be
  viewed as benefiting themselves, as well as the
  recipients of their gift.

23
Reading The Case for Allowing Kidney SalesJanet
Radcliffe-Richards, A. S. Daar, R. D. Guttmann,
R. Hoffenberg, I. Kennedy, M. Lock, R. A. Sells,
N. Tilney, and the International Forum for
Transplant Ethics

• The authors argue that although some may feel
  disgust at the idea of selling kidneys, this is
  not a sufficient reason to deny people a
  necessary treatment.
•  
• The authors critically examine the objections
  that kidney sales would exploit the poor, benefit
  the rich unfairly, undermine confidence in
  physicians, threaten the welfare of women and
  children in societies that treat them as chattel,
  and lead to the sale of hearts and other vital
  organs.
•  
• The authors hold that until stronger objections
  are offered, the presumption should be in favor
  of kidney sales as a way of resolving the current
  shortage.

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Reading Refuse to Support the Illegal Organ
TradeKishore D. Phadke and Urmila Anandh

• The authors observe that, although organ sales
  are prohibited in all countries, society in
  general has shifted toward regarding transplant
  organs as commodities that can be bought.
• In developing countries like India, laws against
  organ sales are not enforced and the practice has
  popular support.
• The authors call for the medical profession to
  refuse to be a part of this unscrupulous trade,
  which exploits the poor, discourages altruistic
  giving, commercializes the body, and undercuts
  human dignity.

25
Conscription of Cadaveric Organs for
Transplantation Lets at Least Talk About
ItAaron Spital and Charles A. Erin

• The authors observe that the scarcity of
  transplant organs results in the death of many
  people who could be saved and that a major
  barrier to acquiring organs is the refusal of
  families of the recently dead to donate their
  organs.
• The authors argue for the adoption of a new
  policythe conscription of organs. All usable
  organs should be taken, without consent, and used
  for transplantation.
•  
• Spital and Erin address objections and defend the
  view that consent is not ethically required and
  that conscription, which can save lives, is
  ethically preferable to all current and proposed
  practices.

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Section 3 Allocation Principles

• Transplanted organs are, today, a scarce
  resource. That is, there is a greater demand for
  the organs than there is a supply of them.
• This is not peculiar to transplanted organs it
  is true of many things we want and is certainly
  true of other medical resources such as stays in
  hospitals, surgical operations, MRIs, diagnostic
  laboratory tests, in vitro fertilization,
  bone-marrow transplants blood transfusions,
  genetic screening, respirators, etc.
• Scarcity means that choices have to be made as to
  who will and will not receive those organs that
  are available. Those organs (or any scarce
  resource) must therefore be rationed.

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Section 3 Allocation Principles

• There are four major ways this may be done
  (discussed in greater detail in the reading The
  Prostitute, the Playboy, and the Poet Rationing
  Schemes for Organ Transplantation in this
  section).
•  
• The Market allow organs to be sold and bought in
  the marketplace at a price.
•  
• The market decides who receives the organs and
  what the persons qualification must be. Quite
  simply, the organs go to who can afford them.
• A Committee a hospital committee made up medical
  professionals and other stakeholders decides on
  who qualifies.
• Either explicit criteria or committee member
  judgment is the basis for selection.
•  

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Section 3 Allocation Principles

• A Lottery organ recipients are selected
  blindly on a random basis.
• Selection of recipients depends totally on
  chance.
• By customary practice selection of candidates is
  made on the basis of understood practice among
  medical professionals.
• Either explicit criteria or medical professional
  judgment is the basis for selection.
• Allocation may, of course, be based on some
  combination of these approaches.
• Framing an acceptable method of selection raises
  the fundamental question Is the method fair and
  what criteria of fairness should be employed? The
  articles in this chapter explore this issue.

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Reading The Prostitute, the Playboy, and the
Poet Rationing Schemes for Organ
TransplantationGeorge J. Annas

• The author takes a position on transplant
  selection that introduces a modification of the
  first-come, first-served principle.
• He reviews four approaches to rationing scarce
  medical resourcesmarket, selection committee,
  lottery, and customaryand finds that each has
  disadvantages so serious as to make them all
  unacceptable.
• An acceptable approach, he suggests, is one that
  combines efficiency, fairness, and a respect for
  the value of life.
• Because candidates should both want a transplant
  and be able to derive significant benefits from
  one, the first phase of selection should involve
  a screening process that is based exclusively on
  medical criteria that are objective and as free
  as possible of judgments about social worth.

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Reading The Prostitute, the Playboy, and the
Poet Rationing Schemes for Organ
TransplantationGeorge J. Annas

• Since selection might still have to be made from
  this pool of candidates, it might be done by
  social-worth criteria or by lottery.
• However, social-worth criteria seem arbitrary,
  and a lottery would be unfair to those who are in
  more immediate need of a transplantones who
  might die quickly without it.
• After reviewing the relevant considerations, a
  committee operating at this stage might allow
  those in immediate need of a transplant to be
  moved to the head of a waiting list. To those not
  in immediate need, organs would be distributed in
  a first-come, first-served fashion.
• Although absolute equality is not embodied in
  this process, the procedure is sufficiently
  flexible to recognize that some may have needs
  that are greater (more immediate) than others.