ORGAN TRANSPLANTATION

AND DONATION

Medical Ethics III

College of Medicine
DEFINITION OF TERMS
• Organ donation
• The giving of tissue/organ/body by a person to another
person or to an institution

• Donor
• The giver who maybe a cadaver, or a living person . A
donor who exchanges the organ for money is a vendor

• Recipient
• The receiver who may receive directly from the donor
or from an institution. A recipient who pays for the
organ is a buyer
• Organ transplant
• A surgical operation where a failing or
damaged organ in the human body is
removed and replaced with a new one.

• Graft
• The process of removing tissue from one part
of a person’s body (or another person’s body)
and surgically reimplanting it to replace or
compensate for damaged tissue
• Organ sale
• The trading of an organ in exchange of money or
similar material. The person or institution who
arranges for the trade between buyer and vendor is
the middleman. Organ trafficking is trading for profit

• Gratuity
• Action/of remuneration received by the donor that
constitutes an act of gratitude for the organ given

• Xenotransplantation
• The transfer of animal organs to human beings.
• Attending physician
• The doctor caring for the patient

• Transplant team
• The healthcare providers performing the
actual transfer of the tissue/organ

• Transplant Committee
• The group created to ensure that the
donation process follows professional and
ethical standards
ETHICAL ISSUES
 I. The Organ Shortage
• The primary ethical dilemmas surrounding
organ transplantation arise from the
shortage of available organs

• Not everyone who needs an organ

transplant gets one and in fact, the scales
tip quite heavily in the opposite direction.
Extent of the organ shortage:

 “On average, 106 people are added to the

nation's organ transplant waiting list each day
1 every 14 minutes.
 “On average, 68 people receive transplants
every day from either a living or deceased donor.
 “On average, 17 patients die every day while
awaiting an organ  1 every 85 minutes.
In 2002, 6,187 individuals died on the U.S. organ
transplant waiting list because the organ they needed
was not donated in time.
• The number of donated organs has stayed
fairly constant over the last few years while
the number of people needing organs
continues to increase.
• Increasing number of new medical technological
advances
• Aging population
• Effectiveness of seat belt campaigns and air bag use.
Distribution of available organs
• The concept of distributive justice – how to
fairly divide resources – arises around organ
transplantation because there are not enough
organs available for everyone who needs one.

• Distributive justice theory states that there is not

one “right” way to distribute organs, but rather
many ways a person could justify giving an organ
to one particular individual over someone else
• This list of possible Distributive justice criteria
comes from the University of Washington School
of Medicine website:
1. To each person an equal share
2. To each person according to need
3. To each person according to effort
4. To each person according to contribution
5. To each person according to merit
6. To each person according to free-market
exchanges
• One distributive justice criteria is equal access.

• Organs allocated according to equal access

criteria are distributed to patients based on
objective factors aimed to limit bias and unfair
distribution.

• Equal access criteria include:

• Length of time waiting (i.e. first come, first served)
• Age (i.e. youngest to oldest)
• Supporters of Equal Access Distribution
say…….

• Everyone should have equal access to

organs because everyone could
potentially benefit from the system.
• To encourage equality in organ
transplantation, the equal access theory
encourages a distribution process for
transplantable organs that is free of biases
based on:
• Race
• Sex
• Income level, and
• Geographic distance from the organ.
• Some who believe in equal access distribution
would also like to have an organ distribution
process free of medical or social worthiness
biases.
• Medical “worthiness” biases could exclude patients from
reaching the top of the transplant waiting list if lifestyle
choices like smoking and alcohol use damaged their
organs.
• Social “worthiness” biases would factor in a patient’s place
in society or potential societal contribution before giving
them an organ, affecting, among others, prisoners being
punished for offenses against society.
• The primary reasons for wanting to prevent
individual worth from factoring into organ
distribution include:
a) The argument that individual worth does not determine
medical need;
b) The dilemma involved in deciding who will make
decisions of who is worthy or not worthy to receive an
organ, and;
c) The slippery slope of determining an individual’s worth
and whether or not it is fair to label someone worthy of a
medical procedure
• On the other hand, some ethicists argue that
individual worth is important to consider during
organ distribution. They argue that distribution is
biased against worthy individuals when individual
worthiness factors are not included

• Kluge’s argument states that people who engage in poor

lifestyle choices are behaving irresponsibly and could
have prevented their illness and are, in essence,
increasing the need for organs and depriving people who,
“have no control over their need,” of necessary treatment
(Canadian Medical Association Journal, 1990)
• A second type of distributive justice criteria is
maximum benefit.

• The goal for maximum benefit criteria is to

maximize the number of successful transplants.
• Ex:
• Medical need (i.e. the sickest people are given the first
opportunity for a transplantable organ)
• Probable success of a transplant (i.e. giving organs to
the person who will be most likely to live the longest)
• Supporters of maximum benefit distribution
say …

• Organs should be distributed so that the

greatest benefit is derived from every available
organ
• People who support the maximum benefit
philosophy believe organ transplants are medically
valuable procedures and wish to avoid the wasting
of organs because they are very scarce

• To avoid waste, they support ranking transplant

candidates by taking into account how sick the
patient is and how likely it is that the patient
will live after he or she receives a transplant.
• Successful transplants are measured by
the number of life years gained.
• Life years are the number of years that a
person will live with a successful organ
transplant that they would not have lived
otherwise.
3 Primary arguments oppose using the maximum benefit distribution criteria

• First, predicting medical success is difficult

because a successful outcome can vary.
• Is success the number of years a patient lives after a
transplant?
• Or is success the number of years a transplanted organ
functions?
• Is success the level of rehabilitation and quality of life
the patient experiences afterward?
• These questions pose challenges to those
attempting to allocate organs using medical
success prediction criteria
• The second argument against maximum benefit
distribution is that distributing organs in this way
could leave the door open for bias, lying,
favoritism and other unfair practices more so than
other forms of distribution due to the subjective
nature of these criteria

• Third, some ethicists argue against using age and

maximizing life years as criteria for distributing
organs because it devalues the remaining life of
an older person awaiting a transplant.
Current organ distribution policy
• Criteria for distributing organs:
1) medical need;
2) probability of success, and;
3) time on the waiting list

• Ethical conflicts arise both when specifying what

the criteria mean, and when weighing the criteria
in cases of conflict
II: DONOR ORGANS
Cadaveric organ donation
• Currently, once a person dies, his or her organs
may be donated if the person consented to do so
before they passed away
• A person is considered dead once either the heart
stops beating or brain function ceases (called
brain death).
• The deceased person may be kept on life support
once they have died until the organs can be taken,
in order to preserve the organs until they are
removed.
• If the deceased person’s organ donation wishes
are unknown, the hospital, physician, or organ
procurement organization will approach a family
member to obtain consent to remove the organs
• The family members with the authority to do so is
generally determined by this hierarchy:
• Spouse. If no spouse, then…
• Adult child. If no adult children, then…
• Parent. If no parents, then…
• Adult sibling. If no siblings, then…
• Legal guardian
5 strategies to increase cadaveric organ
donations:
1. Education
- Increasing the number of people who consent to be
an organ donor before they die and educating families
2. Mandated choice
- When a person dies, the hospital must comply with
their written wishes regardless of what their family
may want.
3. Presumed consent
- Organs are taken after they die, unless a person
specifically requests to not donate while still living.
4. Incentives
• Frequently debated incentive strategies are:
• Give assistance to families of a donor with
funeral costs
• Donate to a charity in the deceased person’s
name if organs are donated
• Offer recognition and gratitude incentives like
a plaque or memorial
• Provide financial or payment incentives
5. Prisoners
• Organs taken from prisoners who are put to
death
• Some could argue that organ retrieval from
executed prisoners is morally justifiable only if a
“presumed consent” donation practice was in
place
• Many, if not most, bioethicists consider taking
organs from condemned prisoners a morally
objectionable practice.
Living organ donation
• Drawbacks to becoming an organ donor:
• Health consequences: Pain, discomfort,
infection, bleeding and potential future health
complications are all possible
• Psychological consequences: Family pressure,
guilt or resentment
• Pressure: Family members may feel pressured
to donate when they have a sick family member
or loved ones
• No donor advocate: While the patients have
advocates, like the transplant surgeon or
medical team (who are there to advise the
patient and work in favor of his or her best
interests) donors do not have such an advocate
and can be faced with an overwhelming and
complicated process with no one to turn to for
guidance or advice
BUYING AND SELLING ORGANS
• Paying people to donate their kidneys is one of
the most contentious ethical issues being
debated at the moment.
• The most common arguments against this
practice include:
• Donor safety
• Unfair appeal of financial incentives to the economically
disadvantaged
• Turning the body into a money-making tool
• Wealthy people would be able to access more readily
• The current United States policy does not allow
for the sale of human organs. The National Organ
Transplant Act of 1984 banned such a practice.

• In 2002, an article that examined the effects of

offering payment for kidneys in India was
published in the Journal of the American Medical
Association.
• The findings uncovered some interesting
data:

• 96% of people sold their kidneys to pay off debt

• 74% of people who sold their kidneys still had
debt 6 years later
• 86% of people reported a deterioration in their
health status after donation
• 79% would not recommend to others that they
sell their kidneys
79
Alternative organ sources
• Animal Organs
• One cautionary argument in opposition to the use of
animal organs concerns the possibility of transferring
animal bacteria and viruses to humans.

• Artificial organs
• The ethical issues involved in artificial organs often
revert to questions about the cost and effectiveness of
artificial organs.
• Stem cells
• The ethical objections concerning stem cells have
focused primarily on their source.
• While stem cells can be found in the adult human
body, the seemingly most potent stem cells come
from the first few cells of a human embryo.
• When the stem cells are removed, the embryo is
destroyed  morally objectionable and would like
to put a stop to research and medical procedures
that destroy human embryos in the process.
• Aborted fetus
• Debates address whether it is morally appropriate to
use organs from a fetus aborted late in a pregnancy for
transplantation that could save the life of another infant.
• Many people believe that this practice would condone
late-term abortions, which some individuals and groups
find morally objectionable.
• Another objection comes from people who fear that
encouraging the use of aborted fetal organs would
encourage “organ farming,” or the practice of
conceiving a child with the intention of aborting it for its
organs.
THE PHYSICIAN
• Has the positive obligation to provide the best
possible care to the patient: either donor or
recipient
SOCIETY
• The obligation of the society
• To provide for the common good and
necessitates that it make organs and
transplantation available
• To be just in the allocation of resources
• Policy against uncontrolled trading in an open market
which would allow exploitation or those with more to
jump to the cue
• Ethical standards must be ensured to avoid
“transplant tourism”
 KIDNEY SALES
• Until there are enough organs for all who need
them and for as long as some are willing to pay
while others are willing top sell, kidneys will be
sold, regardless of it being illegal or prohibited
Issues
• What is the motive of the vendor selling a kidney?
• Related and directed  from ties of love and
connectedness
• Non-related donors with no material exchange 
altruistic act
• Sales  altruism? Sustain basic needs? Educational
needs of children?
• Need of a poor man may be related to responsibility,
charity or altruism
Issues

 What harm can selling kidneys do?

 Excluding sold organs may reduce the number of
available organs
 Allowing a poor man to sell his organs maybe to his best
interest by opening a chance to improve his life
 A poor vendor may conceal high risk exposure/
behaviors to be acceptable
 Selling human organs may change the way vendor and
buyer view themselves as possessors of property rather
than stewards
 Associating the transplant ream to money making may
undermine the confidence of the public in the medical
profession
Issues
• What be the right price for a kidney?
• A reasonable price based on the average donors
expenses and the economic capacity of the recipient
and not on the outcome of the transplant or the market,
not so low as to exploit the vendor, not so high as to
coerce the vendor or exploit the recipient, with a ceiling
price can be determine
CONCLUSION
• Organ donation and transplantation is a good with
one man helping his fellowmen.

• It should always be done in the context of

sharing, compassion and love
POLICY STATEMENT
These guidelines promote the principles and
values underlying AO 2008-004
• The Department of Health AO 2008-0004
Revised National Policy on Living Non-Related
Organ Donors and Transplantation and Its
Implementing Structures set “the general
guidelines and ethical principles whereby the act
of donation and the conduct of transplantation
using NON-RELATED donors shall be managed
and regulated”.
1. Common Good and Solidarity
• Organ donation and transplantation is a way of caring for
the other
• It is a manifestation of generosity and love
• It should be done first and foremost , to save and improve
the quality of life of another
• Both donor and recipient should benefit from the process
2. Non-maleficence
 A living non-related donor (LNRD) shall be considered
only after neither a deceased donor nor a living related
donor is available 3 months after the potential recipient
is enrolled in the registry
 The removal of the organ, its transplantation and all
related procedures shall be done only in hospitals
accredited by the Bureau of Health Facilities and
Services, DOH and by the PhilHealth
 Both the donor and recipient shall receive appropriate
health care, before, during and after the transplantation
 There shall be no conflict of interest
 There shall be no exploitation of donor or recipient
3. Respect for Person
 Organ sale is not allowed
 Free and Informed Consent shall be obtained from the
donor and if married, from the spouse and the recipient.
 No deception in the information given, no coercion in obtaining of
consent, and volunteerism on the part of the donor and recipient
 Special efforts shall be exerted to protect the vulnerable
and those with diminished autonomy
 A substitute decision maker cannot authorize the
donation of an organ from another living person, but can
authorize the donation of an organ from a deceased
person
4. Justice and Equity
 Non-directed donated organs shall be allocated equitably
among patients with priority based on the objective
criteria for medical need and probability of success as
specified by the Donation Allocation Guidelines
 “First come, first served” basis
 A donor shall be reimbursed for the expenses related to
the donation and transplantation (medical, loss of
income, inconvenience), but not for the organ itself
 Benefits and burdens must be equally distributed
 A gratuity should be given to the donor
 There shall be transparency in the whole process
5. Beneficence
• There shall be a review of these guidelines every
year as more information and experience become
available
• Revisions shall be proposed as needed
Case Discussion
• An elderly indian female around 50’s was found slumped
over a bench at a bus station in Pasay and paramedics
were called.
She was found to have cardiac rhythm abnormalities and
was immediately transferred to Pasay General hospital
emergency department (ED). In the ED, she was found to
have profound neurologic deficits and two large areas of
ischemic stroke, with associated brain edema on CT scan.
She was subsequently intubated, placed on a ventilator,
and immediately transferred from the local hospital to the
area’s tertiary medical center intensive care unit (ICU) for
further management. Attempts were made to identify the
patient with police assistance, without success.
• In the tertiary care hospital, a repeat scan of the brain
noted extension of the stroke with poor prognostic
indicators, including additional areas of damage and
worsening brain edema causing a high potential for
brainstem herniation. The patient remained unidentified
in the ICU and area police were called who performed
fingerprint analysis and entered her picture into facial
recognition software. No return identification was made
despite aggressive measures. The patient was noted to
decline clinically with loss of further neurologic
responses. A bioethics consultation was called for
consideration of de-escalation of aggressive measures
in the setting of a very poor prognosis.
• The patient subsequently began to decline rapidly and
she was declared brain dead by radiographic and clinical
criteria in accordance with hospital policy. Also in
accordance with hospital policy, the patient’s death was
reported to the organ donation organization associated
with the institution. The organ donation organization
personnel informed the ICU staff that an unidentified
person who is declared brain dead was directed toward
organ donation. Further, the hospital administrator was
informed that she was obliged to sign the consent
providing there was no evidence that the patient would not
want organ harvesting.
Question:
1. What is society’s view of organ donation, and what
decision can the rational, competent adult be expected to
make with regards to the practice?
2. What does the law says about this?
3. What ethical dilemma applied to the Hospital
administration?