Should organ transplants be encouraged?

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Should organ transplants be encouraged?

Echo Issue Outline 1999 / 19-20: copyright © Echo Education Services
First published in The Echo news digest and newspaper sources index.

Issue outline by J M McInerney

What they said ...
`I made a hasty decision. I do not feel I was properly informed and it is something I will always regret'
Mr Mike Wynne, who ten years ago consented to his dead nephew being an organ donor

'Most relatives see it organ donation as something positive to come out of a tragedy'
Ms Bette Martyn, a Victorrian transplant co-ordinator

In March, 1998, it was reported that for the first time there was proof that the organs of executed Chinese prisoners were being used for transplants.
In April, 1998, an Israeli surgeon announced his readiness to transplant a pig's heart into a human patient.
In May, 1998, it was announced that United States prisoners awaiting execution might soon be able to have their sentences commuted if they donated bone marrow or kidneys.
While in March of 1999 it was announced that a number of prominent medical bodies supported the use of cloned embryo tissue and possibly organs developed from embryo stem cells for use in transplants.
Over the same twelve month period there were several reports of shortages of donor organs.
These various developments have rekindled discussion of the ethics of organ transplantation and the best means of ensuring a supply of organs.

Background
Though there is currently some debate surrounding what sections of the brain need to have ceased functioning before death can be said to have occurred, the following is a simplified account of the medical considerations surrounding organ donation.
Death is generally said to occur in one of two ways, either the brain stops functioning or the heart and lungs stop.
Patients who are declared 'brain dead' in a hospital, and who are connected to ventilators that can artificially keep the heart and lungs working, can donate vital organs - heart, liver, kidneys, lungs and pancreas - for transplant.
Those who die of 'cardiac death,' meaning their hearts stop beating, can donate skin, bone, eyes or heart valves.
A person can indicate at any time that in the event of 'brain death' or 'cardiac death' they are prepared to donate their organs or tissue. This is generally shown by being placed on an organ transplant register.
It is also possible for relatives to consent, after a person has died, to have their organs or tissue harvested.
There is a large shortage, world -wide, of donor organs. Many potential transplant recipients die while on waiting lists.
Transplants involve major surgery, performed on patients who are generally severely ill. Patients do not always survive the surgery and if they do their subsequent survival period can be short.
There are a number of problems associated with transplants.
The body automatically rejects 'foreign' organisms within it. The rejection of transplanted organs often results in the patient's death.
In an attempt to prevent rejection occurring patients are given drugs to suppress their immune system. A diminished immune system leaves the patient vulnerable to illness and infection and, in the longer term, to cancer.
These immuno-suppressant drugs are taken for life.
Because of the risks involved transplants are generally only given to patients who would otherwise die.
Two recent developments have sprung up, in part as attempts to overcome organ shortages.
One is research work on using the stem cells of cloned embryos to grow tissue or organs for transplantation.
The other is genetically modifying other species so that their organs can be transplanted into human bodies.
Transplanting organs from one species to another is called xenotransplantation.

There are a huge number of Internet / Web sites dealing with organ transplantation.
A good place to start is with the Bioethics 2000 site, a public education project of the Science Museum of Virginia.
One of the bioethical questions the site looks at is organ donation/transplantation.
It supplies a general discussion of the issue, looking at organ shortages, giving a definition of `brain death' and considering some of transplantation's most contentious questions, such as whether the organs of prisoners should be used.
The relevant section of the site can be found at http://www.smv.mus.va.us/B2Kprimorgtrans.htm.
A highly informative site is Trans Web.
Trans Web is another American site with information supplied by transplant patients and their family members and friends, health care providers, organ procurement specialists, donor families, transplantation researchers, and interested members of the general public.
This is a general information site on organ transplantation. The site promotes organ donation and transplantation. It is very accessible and supplies a great deal of material, including, for example, the position of all major religions on organ transplants.
It can be found at http://www.transweb.org/index.htm
The major United States' site is that of the United Network for Organ Sharing (UNOS).
The United Network for Organ Sharing is a United States-wide umbrella organisation seeking to promote and facilitate organ donation and transplantation. It is a private, non-profit organisation.
UNOS administers the United States Organ Procurement and Transplantation Network (OPTN) and the U.S. Scientific Registry on Organ Transplantation under contracts with the U.S. Department of Health and Human Services.
The U.S. Scientific Registry is the most complete medical database in the world, tracking all solid organ transplants since October 1, 1987.
The site is of some interest to the general reader as it archives UNOS press releases promoting and giving information about organ transplants. These archives are found in the Newsroom section of the site at http://www.unos.org/frame_Default.asp?Category=Newsroom.
Also from the Newsroom section of the site you can access UNOS answers to common misconceptions or 'myths' about transplants.
The UNOS home page can be found at http://www.unos.org/frame_Default.asp
There are a number of sites containing information critical of organ transplants.
The American Black magazine, Emerge, published an article in 1999 suggesting that organs can be taken without the expressed consent of either the donor or their next of kin.
The article is titled Harvesting Organs From Silence and was written by Harriet Washington.
It claims that in 26 American states permission for transplantation can be 'presumed'. The article can be found at http://www.msbet.com/content/live/57.asp
The Christian Science Monitor published an article in January, 1998, reporting on the Presumed Organ Donor Law recently introduced into Brazil.
The report is titled, Brazil Mandates Organ 'Donation' for Transplants and is written by
Andrea McDaniels. It can be found at http://www.csmonitor.com/durable/1998/01/16/intl/intl.1.html
The report details the concern of some Brazilian citizens that their wishes regarding transplants will not be respected and that the new system is open to abuse and corruption.
The Laogia Research Foundation is a body which aims to report human rights abuses in Chinese labour camps.
In June, 1998, it issued a press release on accusations that Chinese Government officials were involved in the taking of organs from executed prisoners. It also considered the initial United States' response.
The article can be found at http://www.laogai.org/news/organs/press1.htm
Civitas, an environmental and animal rights organisation, has published a series of articles and reports questioning the ethics, safety and effectiveness of xenotransplants.
A list of these links can be found at http://www.linkny.com/~civitas/page110.html

Arguments against organ transplants
One of the primary arguments offered against organ transplants is that collection procedures and the process itself can place unreasonable demands on the relatives of donors.
According to this line of argument, respect is not always shown for the grief of the relatives of possible organ donors. It is claimed that they may be made to feel pressured to supply organs when they are either not ready or not willing to do so.
This point has been made by Mr Mike Wynne, who is vice-president of Silent Hearts, a support group for families of organ donors.
Mr Wynne gave permission ten years ago for his nephew, who had died in a car accident, to be an organ donor.
Mr Wynne now claims, `I made a hasty decision. I do not feel I was properly informed and it is something I will always regret.'
It has also been claimed that taking organs from brain dead patients who are still attached to ventilators may create confusion in relatives as to whether the person is actually dead. It may also interfere with the relatives' leave-taking, as they are not able to be with the person when the respirator is turned off.
This point has also been made by Mr Wynne, who has claimed, `I thought they turned off the ventilator, waited for the patient to stop breathing and then removed the organs.
It was a terrible shock to learn the truth.'
It has also been suggested that there are relatives who are simply not able to cope psychologically with the implications of a transplant. It has been claimed that there have, for example, been relatives of donors who have sought out organ recipients and made demands of them.
For some people, it has been suggested, the organ donation process is not a means of salvaging something positive from the death of a loved one. Instead, it has been argued, it can actually interfere with their being able to come to terms with that person's death.
Lisa Jager, donor co-ordinator at Victoria's Austin Hospital, has cited the instance of a woman who on her anniversary went to the person who had received her husband's heart and asked him to remove his shirt so that she could see her husband's heart beating.
Another concern with the organ transplant process is that it can lead to unethical or illegal actions that threaten the lives of forced donors.
According to this line of argument, the fact that organ transplantation is an accepted medical treatment and that there is a world-wide shortage of donor organs has created a black-market in human organs.
Those who maintain this point to the supposed situation in China where it has been suggested that people are being executed, sometimes for quite minor offences, so that their organs can be harvested and sold.
It has also been suggested that some of these sales have been made to Western countries.
It has further been claimed that in China government officials may be involved in the procuring of organs in this manner.
It has also been suggested that, especially in some impoverished countries, there are people who have killed others so that they can sell their organs.
There have also been concerns expressed that recent developments in some Western nations suggest that the ideal of organ donation as a free and willing gift is being undermined.
This point has been made in relation to proposals in the United States that condemned prisoners awaiting execution be able to donate a kidney or other organ and so have their sentences commuted.
There has been concern expressed that this is not appropriate in a population where there are high levels of HIV and hepatitis.
It has also been suggested that in these circumstances the individuals concerned could not be making a free choice to donate their organs. With the threat of execution before them, it has been suggested, there would be an inevitable element of coercion in any decision they made to donate an organ.
This point has been made by Dr Jeffrey Lowell, a leading St Louis transplant surgeon.
Dr Lowell has claimed, `This ... is coercion. It has to be condemned.'
Similar complaints have been made about a Victorian suggestion that a monetary incentive be made over to the estate of any person whose organs were used in a transplant.
It has been claimed that this would corrupt the donation process and might, for example, put inappropriate pressure on relatives to make a decision they would subsequently regret.
Critics of organ transplants argue that the increasing demand for organs is likely to lead to inappropriate means being employed to encourage donation. The underlying concern appears to be that human body parts could come to be seen as a commodity and that the rights of donors and their families could be compromised.
There are also concerns about the suggested use of cloned organs and tissues for transplants. Those who are concerned about this proposal tend to argue that it is unethical to create a cloned embryo which would then not be allowed to develop but which would instead be used as a source of stem cells to be developed into tissue or a particular organ for transplantation.
The underlying concern here appears to be that no human life, at any stage of its development, should be treated as a tool or a means of achieving a particular end. Critics of the proposed procedure argue that it denies the individual value of the embryo that is created to supply stem cells.
This point has been made by Right to Life spokesperson, Dr John James.
Dr James has argued, ` society ...[has to decide] if we really want to be making sacrificial copies of ourselves, whether embryonic copies or fully grown, for spare body parts.'
Finally, there are also those who are critical of proposals to transplant animal organs into human beings.
Some of these critics claim that such procedures violate animal rights.
A more general concern is that such procedures are unlikely to be effective because of the problems associated with overcoming the human body's rejection of foreign tissue.
It is also argued that such transplants could see viruses or other agents of infection cross from another species into human populations. There is concern that any such new contagents could trigger serious diseases that it would be very difficult, if not impossible, to control.
This point has been made by Dr Rinaldo Bellomo of Melbourne's Austin Research Institute.
Dr Rinaldo has claimed, `We could transmit a virus that modifies itself and unleashes an epidemic.'

Arguments in favour of organ transplants
One of the main arguments offered in support of organ transplants is that they are necessary.
According to this point of view there are large numbers of people with untreatable heart, lung, liver or kidney conditions who can only be given a possible extension of their lives via an organ transplant.
It is maintained that there are many patients suffering from either genetic or degenerative diseases that cause organ failure and ultimately death. For these people, it is claimed, an organ transplant is the one possibly effective option available.
Those who argue this position point to the growing numbers of people on waiting lists for donor organs around the world.
It has been claimed that some 55,000 people were waiting for organs to become available in the United States in 1998. In Britain some 6,450 people were on waiting lists for organ transplants at the end of 1997. In Victoria, in 1998, some 550 people were on transplant waiting lists. In Australia as a whole, in 1999, some 2,500 are waiting for organ transplants, mainly kidneys and livers.
It is also noted that corneal transplants offer the hope of improved sight to people who otherwise would not be able to see.
The next argument offered in favour of organ transplants, is that they can offer some consolation for the donor's family.
According to this line of argument, if the death of a relative can result in life or sight for another person, then the loss of that loved one may be less painful.
This point has been made by Victorian transplant co-ordinator, Bette Martyn. Ms Martyn has said that most relatives `see it [organ donation] as something positive to come out of a tragedy.'
A similar point has been made by a Victorian mother after she and her husband agreed to donate their dead daughter's organs.
The woman claimed, `... it seemed like a waste of life not to offer her organs to someone else in need.'
It has also been argued that in the vast majority of countries offering organ transplants there are regulations which ensure proper procedures are followed.
Relatives, it is argued, are not unduly pressured to offer organs for transplant and are made aware that their loved ones are in fact dead before the transplant is arranged.
Transplant co-ordinator Bette Martyn has noted that in Victoria families are offered time to think before making a decision.
Ms Martyn has claimed that the nature of brain death is also explained to them. They are told that their relative's brain has ceased functioning and that the process is irreversible. They are also told that their relative will have to be kept on a ventilator so that the organs can remain in a viable condition until they are removed for transplanting.
Others have claimed that relatives are able to change their minds and withdraw consent, even after having signed a consent form.
It has further been noted that recent developments may reduce the need for relatives to make difficult decisions about transplant donations while they are in a state of grief and shock.
People are being urged to indicate, while still in good health, whether they would be prepared to donate their organs. Many countries have established organ donor registers where people can make their wishes known. Some people also carry organ donor cards indicating their willingness to donate their organs. Such measures, advocates of organ donation claim, remove the burden of decision from relatives.
It has also been claimed that in most countries the decision to donate an organ is altruistic and voluntary so that no improper pressure can be brought to bear on those who decide.
According to this line of argument, if people were paid to donate either their own organs or those of a deceased member of their family this might exert an inappropriate leverage on those in straitened circumstances and lead them to make choices they later regret.
It has also been suggested that once financial reward is introduced then wealthy individuals in need of transplants could basically purchase an organ.
There are two objections to such a procedure. This would give an unfair advantage to the wealthy person and may lead to improper and possibly corrupt practices being used to acquire organs.
Geoff Scully, one of Melbourne's three donor transplant managers has noted, `Once you introduce the climate of money, the rich are always going to benefit at the expense of the poor.'
The fact that hospitals do not pay for the receipt of organs is seen as one way of ensuring that the transplant process is not corrupted.
In addition it has been noted that from a cost-efficiency point of view organ transplants are a desirable option for financially strained hospital systems.
Victorian organ donor transplant manager, Geoff Scully, has claimed that it costs between $35,000 and $40,000 a year to keep a patient in kidney failure on dialysis. This, he has suggested, is significantly more expensive than a transplant which costs some $20,000 in the first year and then between $8,000 and $10,000 for each subsequent year that the kidney functions properly.
Further it has been noted that transplantation procedures are being constantly improved so that recipients' chances of medium- to long-term survival are improving.
The Victorian Liver Transplant Unit, which claims the best patient survival rate in Australia, has 89 per cent of its patients alive within one year of their transplant and 84 per cent still living five years after their operation.
Supporters of organ transplants claim that current research developments offer further chances of improvement.
Recent success in cloning adult mammalian cells, together with the ability to produce fetal stem cells which may then differentiate to form different organs or tissues, are seen by many as very promising developments.
Researchers hope that they may be able to use the DNA of a potential transplant recipient and then clone from it fetal stem cells which could then be grown into the tissue or organ that needed to be replaced.
If such a procedure is perfected, supporters claim, it would mean that there would no longer be organ shortages and there would also be no problems of the recipient's body rejecting the donor organ.
There would also be no need to risk the side-effects of the immuno-suppressant drugs which are currently given to prevent the recipient's body rejecting the organ.
Finally there are those who are encouraged by developments to transplant organs from other animals, particularly pigs, into human beings.
This prospect is said to have the advantage of overcoming a shortage of donor organs. It is claimed the animals would be genetically engineered to reduce rejection problems.

Further implications
There is no question of organ transplantation being prohibited. It is an accepted medical procedure around the world, with many thousands of people awaiting transplants.
What practically is at issue is the way in which this demand for organs is going to be met.
In Australia there have been discussions about adopting a more concerted approach to boost donor levels. The rate of organ donation in Australia is low by international standards, with the lowest rate Australia-wide occurring in Victoria.
South Australia, where 23 people per million of population are organ donors, has the highest organ donor rate in the country. In this state some medical staff are responsible for alerting transplant co-ordinators to potential organ donors.
Any more concerted and aggressive harvesting programs must, however, be careful to ensure that the rights and feelings of donors and their families are respected.
Silent Heart, an Australian support group for the families of organ donors, will be hosting the world's first conference for the families of organ donors in July.
There is also discussion in a number of Australian states of means whereby the families of organ donors might be able to contact organ recipients and of the safeguards which should apply.
If means could be found to have all people indicate before death whether they are willing to be organ donors this would remove problems of consent and remove the burden of responsibility from relatives.
The current procedures adopted in some countries of assuming consent unless it has been explicitly denied appears to create ethical problems.
Against this background of concern for the rights of donors and their families and of concern to increase the number of organ donors local and international research continues into cloned tissue and body parts and the use of other species' organs.
Despite legal impediments to cloning around the world, it appears highly likely that such work will go on. Prominent medical bodies in several countries support the use of cloned embryo stem cells as a means of generating cells, tissue or organs for treatment purposes and laws which were intended to prevent cloning for reproductive purposes seem unlikely to permanently inhibit such research.
If the development of organs from cloned embryos proves successful, this is likely to put an end to attempts to develop safe organ sources from other species.
Currently, however, the demand for organs is so great, that it seems inevitable that work on overcoming the problems associated with cross-species transplants will also continue.

Sources
The Age
2/3/98 page 1 news item by Olga Craig, `Proof: China's body snatchers'
8/3/98 page 5 news item by Darren Gray, `Transplants at a record high'
14/3/98 page 1 (Saturday Extra section) analysis by Karen Kissane, `Mending a broken heart'
4/5/98 page 3 news item, `Transplant plan to get killers off death row'
7/5/98 page 24 analysis by Sarah Boseley, `The beast inside us'
9/5/98 page 5 (News Extra section) analysis by Steve Dow, `Brave new world for transplants'
30/6/98 page 5 news item by Fergus Shiel, `A decade old and still going strong'
13/7/98 page 15 analysis by Gabrielle Costa, `A stranger's gift of life'
4/10/98 page 23 analysis by Caroline Overington, `Doing the hand jive'
8/1/99 page 10, `Two set to die after girl killed for organs'
11/1/99 page 1 news item by Mary-Anne Toy, `Shortages hit organ donation'
17/1/99 page 5 news item by Mary-Anne Toy, `Victoria to act on organ donors'
12/4/99 page 6 news item by Julie Robotham, `Push to increase organ donor levels'

The Australian
19/2/98 page 3 news item by Belinda Hickman, `Transplant gives hope for liver cure'
13/4/98 page 1 news item by Lois Rogers & Andy Goldberg, `Israelis on the verge of pig-to-human heart transplant'
3/10/98 page 6 analysis by Justine Ferrari, `Ethics raised over hand transplant'
17/3/99 page 15 analysis by Stephen Lunn & Belinda Hickman, `Growth industry'

The Herald Sun
20/4/98 page 21 news item by Carolyn Alexander, `Disease fears on pig organs'
26/4/98 page 16 news item by Robyn Riley, `Decision still haunts a family'
26/4/98 page 16 news item by Robyn Riley, `A special gift from a tragedy'
26/4/98 page 17 news item by Robyn Riley, `Helping to find the positives'
28/4/98 page 9 news item by Helen Carter, `Donor organs critically low'
28/4/98 page 9 news item by Helen Carter, `No end in sight to lung wait'
8/7/98 page 13 news item by Carolyn Alexander, `Donor cash lure plan'
7/11/98 page 26 editorial, `Our surgical miracle'