What Are the Ethical Issues Involved in Organ Transplantation?

Since the late 1950s, when the first successful kidney transplants from living donors were performed, organ transplantation has been a much sought-after option for millions of people who are critically ill. But because demand has always far exceeded supply, it has also created ethical dilemmas, such as the requisite rationing of available organs and the ever-present need to increase organ supply. In the late 1970s, the latter led to the expansion of the definition of death to include either irreversible cessation of all brain activity (brain death) or irreversible cessation of circulatory and respiratory functions (cardiac death). This change was codified in 1980 with the Uniform Determination of Death Act and was a factor in the development of the protocol known as Donation after Circulatory Determined Death.

Today, as organ transplantation becomes more commonplace, one of the most pressing ethical issues transplant providers face is the need to fairly and equitably distribute the limited number of organs available. According to the Organ Transplant & Procurement Network, the ethics of these decisions are based on three basic tenets: utility, justice and respect for persons, or autonomy. At the risk of oversimplifying these complex principles, below is a brief overview of what each of them means.

Utility

Utility refers to the notion that organs should be allocated where they will do the most good and the least harm. This means that “goods and harms” must be evaluated using standard measures to accurately inform public policy. The “goods” of organ transplantation include saving a life, alleviating suffering, and promoting well-being. These may be measured using algorithms that predict years of life added, graft (organ) survival, and quality-adjusted life years (how many years of good quality life the organ will provide). These “goods” are then balanced with potential harms, which include short-term morbidity (e.g., post-operative pain and disability) and long-term morbidities (e.g., side effects of immunosuppressive drugs, potential organ rejection, psychological effects). Other factors, such as the likelihood of graft survival, age, and the availability of alternative treatments may also be used in determining where an organ will go. 

Justice

The principle of justice in organ transplantation refers to the need to treat all potential recipients with the same respect and concern. This means that the allocation of organs is never based on demographics such as race, gender or socioeconomic status, nor should the “social value” of an individual (e.g., their predicted contribution to society) be a factor in where an organ goes. Further, justice in a public program means that all individuals have a moral right to access its benefits. Therefore, justice may dictate that medical need is weighted more heavily than medical benefit (utility versus justice). In other words, an organ may go to the sickest patient even if a patient who is not as sick could predictably have a better outcome. 

Respect for Persons

Based on the concept of autonomy or self-determination, respect for persons dictates that every person in the organ transplant process has the right to make decisions about their care. For example, providers should respect the decisions of surrogates who refuse to donate organs as well as the decision of a potential recipient to refuse an organ for any reason and the right of individuals to direct a donation to a specific recipient (directed donation). Because the concept of justice prevents using demographics to allocate an organ, OPTN does not allow directed donation to a specific demographic, such as a race or ethnic group. 

Sources

“Donation & Transplantation History”. Health Resources & Services Administration. https://www.organdonor.gov/learn/history

“Determination of Death Act”. Uniform Law Commission. https://www.uniformlaws.org/committees/community-home?CommunityKey=155faf5d-03c2-4027-99ba-ee4c99019d6c 

“Donation After Circulatory Death”. National Kidney Foundation. https://www.kidney.org/sites/default/files/03-60-0119_FBE_CirculatoryDeath_Bro_v5.pdf