CBHD: Human Dignity and the Organ Supply: Do Proposed = Solutions to the Current Crisis Measure Up? by Gregory W. = Rutecki

From: Subject: CBHD: Human Dignity and the Organ Supply: Do Proposed Solutions to the Current Crisis Measure Up? by Gregory W. Rutecki Date: Fri, 14 Feb 2003 20:14:38 -0600 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0007_01C2D465.B322C160"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1106 This is a multi-part message in MIME format. ------=_NextPart_000_0007_01C2D465.B322C160 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cbhd.org/resources/aps/rutecki_03-02-11.htm CBHD: Human Dignity and the Organ Supply: Do Proposed = Solutions to the Current Crisis Measure Up? by Gregory W. = Rutecki

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Human = Dignity and=20 the Organ Supply
Do = Proposed=20 Solutions to the Current Crisis Measure = Up?
Gregory W.=20 Rutecki

		Printer- Friendly=20 Version

Gregory = W.=20 Rutecki, M.D. is=20 fellow of The Center for Bioethics and Human = Dignity,=20 The E. Stephen Kurtides Chair of Medical = Education and=20 Residency Program Director at Evanston = Northwestern=20 Healthcare and an Associate Professor of = Medicine at the=20 Feinberg School of Medicine at Northwestern=20 University
Post Date: February 11,=20 2003

Organ transplantation has developed its very = own=20 prime directive: the generation of a greater supply of = transplantable organs. The reason for this may be the = only=20 simple part of an increasingly complex equation = because the=20 laudable goal, an adequate supply of organs retrieved = in=20 timely fashion and transplanted into critically ill = patients,=20 has remained far from reality.

The United Network for Organ Sharing (UNOS) is a = non-profit=20 organization established by Congress in 1984 that = seeks to=20 encourage organ donation and distribute available = organs=20 equitably. Currently, an average of seventeen = people=20 die each day following a futile wait for organs on the = UNOS=20 waiting list. There are just not enough organs to go = around.=20 In 2001, 6400 people in need of a transplant died = before an=20 organ became available. In the case of single organs = such as=20 livers, there is at least a ten-percent mortality rate = among=20 those awaiting a transplant=97an estimate that is most = certainly=20 too low.¹ Unfortunately, end-stage liver = disease=20 does not permit the luxury of time. During the 1990s,=20 approximately 13,000 people were added to the waiting = list for=20 livers, while only 1549 livers were donated. = Statistics for=20 other organ waiting lists are equally grim. It is = clear that=20 the supply side presents the "rub" for organ = transplantation.=20 The proposed answers to the question of how to obtain = more=20 viable organs, appropriately called "scarce = non-renewable=20 resources," include several innovations that deserve=20 significant reflection.²

Redefining donor eligibility has been one response = to the=20 organ supply crisis. Since the "gold standard" for = single=20 organ donation has been "brain dead" donors, this = time-honored=20 definition of death has been regarded as an impediment = to=20 obtaining an adequate supply of transplantable organs. = In=20 order to qualify for brain death, a person must have = lost all=20 brain function irreversibly while retaining heart, = lung,=20 and liver viability. Such a prospective = donor=20 usually presents after trauma, such as gunshot wound = or=20 vehicular accident. The recent movie Blood Work=20 portrays the limited availability of such donors. = If=20 precious time is lost at the scene, a prospective = donor=92s=20 organs may no longer be viable by the time he arrives = at the=20 hospital. As a result, new definitions of death have = been=20 posited. So-called asystolic donors (formerly = termed=20 "non-heart beating donors") do not qualify for brain = death=20 criteria, but rather are declared dead when their = heart stops=20 beating. In some protocols, if a person goes a mere = two=20 minutes without a heartbeat, he may be deemed a = candidate for=20 organ donation. Interestingly, this new definition of = death=20 has been gerrymandered solely for prospective donors = and not=20 for other dying persons. It should be that death and = dying,=20 much like dusk and dawn, should be regarded as clearly = separate for all persons=97whether they = are=20 candidates for organ donation or not. The dead = donor=20 rule=97which holds that an organ donor must = be=20 declared to be irreversibly and unequivocally dead = (and not=20 merely dying)=97has served transplantation well = and=20 should be universally retained. Asystolic protocols = break that=20 rule since asystolic persons are not dead.

Payment for organs has been proposed despite the=20 recognition that paid donors are often among the = exploited=20 poor. In India, 96% of paid donors donated their = organs in=20 order to pay debts (JAMA 2002; 288:1589-1593). = The=20 average payment for a kidney was a mere $1070, and the = middleman brokering the deal received substantially = more than=20 this. Average paid donor family income actually=20 decreased after organ donation, with 86% of the = donors=20 reporting a decline in their health.

Another questionable supply-side solution is called = the=20 living adult liver donation. Presently, organ = donations from=20 the living outnumber those from the dead. = Unfortunately,=20 however, living individuals who donate part of their = liver to=20 adults die at a rate exceeding live kidney = donors (1%=20 vs. .03%, respectively). Some donors in this context = have=20 required liver transplants themselves due to liver = failure=20 incurred as a result of the donation. Although this = model has=20 increased the supply of livers, at what cost has this = end been=20 accomplished?

The most recent proposal to increase the supply of=20 transplantable organs has been termed a "preferred" = organ bank=20 such as LifeSharers (www.lifesharers.com). The=20 premise is simple: upon joining LifeSharers, a member = promises=20 that when she dies, her organs will be offered first = to a=20 member of LifeSharers, and then secondly to UNOS if no = one in=20 LifeSharers can use the organ. This is called = "directed"=20 donation and is perfectly legal since no money changes = hands.=20 According to the LifeSharers web site, their reason = for=20 existing is because "when organs do become available, = about=20 80% of them go to somebody who hasn't agreed to donate = their=20 own organs when they die. That's not fair. By joining=20 LifeSharers you help make sure that you'll get treated = fairly=20 if you ever need an organ."²

David J. Undis, Executive Director of LifeSharers, = has=20 already responded to a number of initial criticisms of = his=20 program. To those who worry that LifeSharers will = "create a=20 preferred class of organ recipients leaving needy = people to=20 die," he insists that they are worried about the = "wrong=20 thing." He explains that needy people who might die = are likely=20 to be helped, not hurt (provided that they join the = program).=20 He contends that if enough people join LifeSharers, = the mutual=20 pact will generate more transplantable organs. = However, one=20 problem is that if brain death is the sole criterion = utilized=20 for donor eligibility, Mr. Undis=92s expectations may = be=20 unreasonable. Given that the cessation of all brain = function=20 without heart, kidney, and liver damage is a rare = occurrence,=20 LifeSharers would need at least 17,500 members to = achieve a=20 50% chance that one member per year would become an = organ=20 donor.³ However, after 8 months of = LifeSharers=20 activity, only 361 people have registered. It = would be=20 unacceptable to improve these numbers by adding = asystolic or=20 other potentially harmful live donor protocols to the=20 "preferred" mix. Such a change=97which would = constitute a=20 disregard for the dignity of donors=97lies at the = heart of the=20 problem. If a dying LifeSharers member sincerely = believed that=20 the use of asystolic criteria were unethical but such = a=20 definition of death was legal, would he still be = obligated to=20 donate his organs? Such possible ramifications have = not yet=20 been discussed by preferred organ banks with adequate=20 precision.

In arguing that his system improves upon the = present=20 reality that 80% of contemporary organ transplant = recipients=20 have not agreed to donate their organs upon their = death, Mr.=20 Undis is hoping to apply a type of "Golden Rule" to = organ=20 donation=97"be willing to be an organ donor if you = want other=20 people to be an organ donor for you (should you ever = need=20 it)." LifeSharers is certainly creating a higher moral = standard in the field or organ donation, but it will = likely=20 have the unintended effect of (at least occasionally) = causing=20 a member of LifeSharers to leapfrog over another more = needy=20 UNOS person. This effect, while not desirable, is = ethically=20 acceptable if the system improves the overall number = of organs=20 available and ultimately saves more lives as Mr. Undis = hopes.

While I have concerns over preferred organ = networks, I=20 would like to commend Mr. Undis on many levels. While = he is=20 responding to the supply-side crisis of organ donation = in a=20 way that in my estimation might not be completely = practical,=20 he is earnestly trying to achieve equity in organ = supply and=20 distribution. A necessary improvement to such networks = is a=20 clear rejection of potential use of asystolic criteria = in=20 death. This, at the least, should be affirmed.

Isn=92t it about time that we reconsider the = fundamental=20 question here? Should we be simply searching for = any=20 method of generating more organs, or, rather, seeking = a=20 solution that protects the dignity of donor and = recipient=20 equally? Many of the recent modifications to the "dead = donor=20 rule," to adult liver donation, and to the = consideration of=20 payment for organs are simply addressing the wrong = question.=20 It should come as no surprise, then, that as a = contingent they=20 are coming up with the wrong answer. As more and more = venues=20 seeking to increase the supply of organs are suggested = and=20 piloted, society must not lose sight of the profound = ethical=20 ramifications. The dignity of the living and dying = remains at=20 stake and must be factored into the equation. CBHD

¹ = For example,=20 patients who have become too ill to receive a = transplant are=20 removed from the waiting list and are not counted in = the=20 mortality statistics, though their deaths are likely = due to=20 the fact that they did not receive a life-saving organ = before=20 their condition grew irreversibly grave. The average = waiting=20 time for a liver transplant has recently ballooned to = 514=20 days!

² = Due to the=20 current experimental nature of xenotransplantation=20 (cross-species organ transplantation), this option is = not=20 discussed here.

³ = http://cbhd.org/resources/aps/rutecki-comment1.htm=

⁴ = http://lifesharers.com/whyjoin.htm,=20 accessed February 10, 2003

⁵ = B. McMenamin,=20 Organ Pact, http://www.forbes.com/forbes/2002/1028/062a.html;=20 article date October 28, 2002.

Printer- Friendly=20 Version

Copyright 2003=20 by The Center for Bioethics and Human = Dignity
The=20 contents of this article do not necessarily = reflect the=20 opinions of CBHD, its staff, board or = supporters. =20 Permission to reprint granted as long as The = Center for=20 Bioethics and Human Dignity and the web address = for this=20 article is=20 = referenced.

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