World J Surg DOI 10.1007/s00268-014-2639-3
Organ Shortage: The Greatest Challenge Facing Transplant Medicine David Shafran • Eric Kodish • Andreas Tzakis
Socie´te´ Internationale de Chirurgie 2014
Abstract The success of organ transplantation as a treatment for end-stage organ disease has yielded a series of ethical quandaries originating from the issue of organ shortage. Scarcity of organs for transplantation necessitates formulation of just and fair allocation policies as well as ethically viable solutions to bridging the vast gap between organ supply and demand. The concept of ‘‘triage’’ provides a useful paradigm in which to contextualize the organ shortage issue. This entails subjugating the welfare of the individual patient for the benefit of the wider community as an ethically justified response to the challenge of scarcity.
Introduction Allocating organs for transplantation in the context of a dire scarcity of resources presents a formidable ethical challenge to the transplant community. The Hippocratic Oath morally binds physicians to treat illness indiscriminately without regard for race, creed, or social or economic standing. Yet the advent of organ transplantation as a successful life-saving therapeutic intervention juxtaposed with a paucity of organs to transplant places medical professionals in an ideologically vexing position of having to decide who lives and who dies [1]. While the healthcare community’s ethical commitment to patients extends only so far as meaningful help can be provided, distributing scarce resources such as organs in a just and fair manner represents a significant ethical imperative [2].
D. Shafran (&) E. Kodish A. Tzakis Department of Bioethics and the Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail: [email protected]
Organ allocation evokes the concept of ‘‘triage.’’ Derived from the French word trier and initially used with respect to sorting of agricultural products, the use of triage now occurs almost exclusively in the medical setting and requires three elements: at least a modest scarcity of resources, a formal assessment of medical need, and implementation of an algorithm that delineates treatment priority [3]. Triage systems champion the values of human life, health, efficient use of resources, and fairness, and they generally subjugate the values of autonomy, fidelity, and ownership of resources [4]. The implementation of triage, ‘‘doing the greatest good for the greatest number of people,’’ occurs daily in emergency rooms and has been utilized for centuries on the battlefields of the world [5]. Organ transplantation, now a mainstream therapeutic intervention for end-stage organ disease, represents a relatively novel yet every bit appropriate use of the triage concept. The transplant community, and those within it charged specifically with articulating allocation policies, continually challenge themselves to identify and prioritize the principles that will achieve maximum ‘‘good’’ for potential transplant recipients, knowing that these decisions both grant life to some and deny it from others. Triage in organ transplantation requires society at large, as opposed to individual people or institutions, to consider carefully its values, come to consensus, and render policies that will benefit the collective transplant community most effectively. Achieving this ambitious objective requires transparency and flexibility in policy formulation. Discussion surrounding allocation policies is therefore open to public forum for comment and consideration [6]. Additionally, within each system with respect to a specific organ, appeals processes exist by which individual institutions can present exceptional cases to the Organ Procurement and Transplantation
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World J Surg Table 1 Annual transplant and mortality rates of specific organ waitlists Annual transplant rate (%)
Annual mortality rate (%)
Kidney
17
6
Liver
39
15
Heart
74
15
Network (OPTN), the national governing body for transplant policy, for additional consideration. The appropriate organ-specific governing board subsequently convenes and renders a decision [7, 8]. As an example of the evolving nature of these policies, the new Lung Allocation Score, finalized in 2005, explicitly included a plan to update and revise the model periodically to ensure that it keeps current with emerging statistics and new ethical considerations [9].
Background The first successful kidney transplant took place in Boston in 1954 between identical twins. Successful heart and liver transplants followed in 1967. However, transplantation as a conventional therapy for end-stage organ disease became prominent only in the 1980s with the discovery of cyclosporine for immunosuppression and the new potential it brought for combatting graft rejection. By 2000, over 600,000 transplants had been performed worldwide [10]. The success of organ transplantation turned what was once a death sentence in many circumstances into the possibility for meaningful life. However, the shift of transplantation from an untried, experimental intervention into a viable, mainstream treatment option yielded a new set of difficult ethical questions, including the issue of organ shortage. As of August 22, 2013, the total waitlist for organs in the US was nearly 120,000, whereas the total number of transplants performed between January and May of 2013 was only 11,580, a pace certain to leave an enormous gap between supply and demand by year’s end [11]. Historically, the 2011 annual data report of the Scientific Registry of Transplant Recipients (SRTR), the organization that works alongside the OPTN to compile national data on transplantation in the US, demonstrated the discrepancy between supply and demand for nearly all major organs and the potential for fatality that results from increased wait time [12] (Table 1). Perhaps most prominently, the kidney transplant waiting list continues to grow commensurate with the number of end-stage renal disease (ESRD) patients, which increased by (has increased) 600 % in the US between 1980 and 2009. Yet, the number of donors between 2004 and 2011 remained relatively stagnant at 13,000, making the gap
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Table 2 Organ-specific waitlists and transplants 2001
2009
2011
Waitlist
46,649
79,397
86,547
Transplant
14,279
16,829
16,814
Waitlist
16,545
15,094
15,330
Transplant
5,195
6,320
6,342
Waitlist
3,631
2,674
2,813
Transplant
2,202
2,211
2,322
3,572 1,034
1,630 1,659
1,798 1,753
Kidney
Liver
Heart
Lung Waitlist Transplant From [11, 13]
between organ supply and demand even larger [13, 14]. The waitlist for liver has similarly increased in the US, though that for heart and lung declined between 2001 and 2011 [13] (Table 2). Internationally, in 2011 an estimated 112,631 solid organ transplantations were performed, filling less than 10 % of the global need [15]. New and effective strategies to address the growing gap between organ supply and demand must be implemented just to this prevent gap from widening further.
Discussion of Distributive Justice and Development of Allocation Policies in US In 1984, the US Congress passed the National Organ Transplantation Act (NOTA) with the objective of formally addressing and improving organ allocation systems [7]. Prior to that time, organs were usually allotted to the patients of the surgeons who extracted them [16]. In addition to prohibiting organ sales and establishing the Task Force on Organ Transplantation, NOTA led to the establishment of the OPTN, an organization overseen by the US Department of Health and Human Services and charged with maintaining a national registry and creating equitable organ allocation policies. The United Network of Organ Sharing (UNOS), subcontracted by the government in 1986, administers the activities of the OPTN. Currently, the US is divided into 11 OPTN regions and further subdivided into 58 donor-specific areas (DSA), each one generally assigned one Organ Procurement Organization (OPO) [7]. An important shift in the approach to organ distribution occurred when the US Department of Health and Human Services issued the ‘‘Final Rule,’’ published in 1998 before going into effect in 2000. The ordinance was borne out of a
World J Surg Table 3 UNOS principles and objectives of equitable organ allocation Principles The UNOS policy for equitable organ allocation strikes a balance among the following principles. The policy must: Enhance the overall availability of transplantable organs Allocate organs based on medical criteria, striving to give equal consideration to medical utility (i.e., net medical benefit to all transplant patients as a group) and justice (i.e., equity in distribution of the benefits and burdens among all transplant patients) Provide transplant candidates reasonable opportunities to be considered for organ offers within comparable time periods, taking into consideration similarities and dissimilarities in medial circumstances as well as technical and logistical factors in organ distribution Respect autonomy of persons Objectives The goal of the UNOS organ allocation system is to achieve, in balance with one another, the following objectives: Maximize availability of transplantable organs Maximize patient and graft survival Minimize disparities in consistently measured waiting times until an offer of an organ for transplant is made among patients with similar or comparable medical/demographic characteristics Minimize deaths Maximize opportunity for patients with biological or medical disadvantages to receive a transplant Minimize effects related to geography Allow convenient access to transplant Minimize overall transplantation-related costs Provide for flexibility in policy making Provide for accountability and public trust From [18]
concern for the large disparities in waiting time based on geographic location and advocated for development of allocation policies that focused more on objective medical criteria and medical urgency as opposed to waiting time and geographic location. In a report published in 1999, the Institute of Medicine (IOM) reviewed and supported the assertions of the Final Rule and also projected its potential impact on the following: access to transplantation services for low-income people and ethnic minorities, organ donation rates, waiting time for transplant, survival and graft failure rates leading to retransplantation, and cost of organ transplantation [17]. In creating its objectives, UNOS grounded its policies for distribution in four fundamental ethical principles: equity, justice, beneficence, and utility. The UNOS principles and objectives of equitable organ allocation, among other considerations, explicitly state that organs should be allocated ‘‘based on medical criteria striving to give equal consideration to medical utility (i.e., net medical benefit to
all transplant patients as a group) and justice (i.e., equity in distribution of the benefits and burdens among all transplant patients)’’ [18]. The organ subcommittees of UNOS continuously endeavor to incorporate and balance these principles into their respective allocations systems, a process that often takes years to finalize (Table 3). The organ subcommittees of UNOS formulate their respective allocation policies independent of one another and therefore vary in their application of prescribed ethical principles. Although in June 2013 UNOS approved a revised policy for distribution and a point system for scoring deceased donor organ quality, due to be implemented in 2014, kidney allocation currently prioritizes potential recipients based on waiting time over medical urgency [8, 19]. Liver and heart allocation policies, on the other hand, are urgency-based and prioritized based on pretransplant mortality risk [7]. Finally, the Lung Allocation Score (LAS), first utilized in 2005, designates its recipients based on a calculation of pre- and post-transplant survival [9]. As organ allocation falls into the ethical purview of distributive justice, a discussion of social standing and its place in allocation policy formulation, if any, naturally ensues. Beauchamp and Childress define distributive justice as ‘‘fair, equitable, and appropriate distribution in society determined by justified norms that structure the terms of social cooperation.’’ They then list a series of principles to be weighed and applied within the context of distributive justice. These include: ‘‘To each person an equal share…according to need…according to effort…according to contribution…according to merit…according to free market exchanges’’ [5]. Similarly, Rescher [1] alludes to these principles in a strategy he designed for allocating ‘‘exotic medical lifesaving therapy.’’ Rescher asserts that choosing who should benefit from a scarce resource should involve considerations such as relative likelihood of success, life expectancy, family role, potential contributions, and past services rendered. The stated objectives of UNOS, however, deliberately exclude considerations of social worth. Allocation policies are largely utility- and equity-based and do not incorporate social considerations such as family value or potential for societal contribution. Stated succinctly, transplant in the US fundamentally focuses foremost on the extension of life as opposed to its enhancement. Conspicuously devoid of social considerations, the UNOS point system balances three principles within its policies: sickest first, first-come first-served, and prognosis [20]. According to Rhodes et al. [2], organ allocation policies might be likened to ‘‘wartime triage.’’ They differentiate between war and peacetime triage, stating that in wartime, treatment decisions are made based on who will benefit from intervention, whereas in peacetime, as seen in emergency rooms, decisions are made based on medical
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urgency. They assert that ignoring factors like life expectancy and medical urgency, while fair, is unjust when resources are scarce. They state, ‘‘A policy that is both fair and just examines differences among people and then treats those differences similarly.’’ The Rhodes et al. approach, posited before the implementation of the Final Rule, represents a strongly utilitarian one aimed at achieving the maximal collective ‘‘good’’ even at the expense of individual rights. A fundamental question that underlies the motivation behind organ transplantation and has implications for how we formulate allocation policies is this: Do we perform transplant to prolong life or enhance it? In the current climate of organ shortage and consistent with the principle of triage, allocation policies ignore social role and quality-of-life assessments of potential recipients and allocate with the goal of minimizing deaths [18]. The Federal Task Force on Organ Transplantation stated that transplant teams ‘‘hold organs as trustees and stewards on behalf of the community’’ [21]. While the job of formulating allocation policy falls on designated professionals, ultimately their decisions must reflect the values of the collective community that has designated them for the task. As it currently stands, considerations of distributive justice in organ allocation give precedent to communal good over individual entitlement.
Past and current US policies for increasing organ donation A myriad of strategies for increasing the number of deceased donors have been proposed and implemented. In the US, brain death, as initially discussed in 1968 by the Ad Hoc Committee at Harvard and then formally addressed in the Uniform Determination of Death Act in 1980, has been adopted as a criterion for death, in addition to cessation of circulatory function. Improvements in mechanical ventilation and other supportive measures that permit the body to be sustained, sometimes indefinitely, necessitated clarification of the definition of death [22]. The declaration of neurologic death permits organs to be maintained, minimizing ischemic damage, while arrangements for transplantation are made. The emergence of brain death as an acceptable criterion occurred differently in Japan and its acceptance continues to be met with opposition in the mainstream. Only recently in Japan was brain death legally viewed as actual death. Prior to passing the Organ Transplant Law in 2009, brain death could be considered actual death only for organ donation purposes, but legal death did not occur until cessation of cardiopulmonary function. The new law now designates brain death as legal death. Opposition to this change argues that considering brain death the new
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standard for legal death runs contrary to an ingrained Japanese value that perceives life to reside in the entire body rather than merely relegated to the brain. The new law also potentially violates the custom of ‘‘Mogari’’ which entails allowing the body to sit for 10 days after death to ensure that the soul does not return to it. Not permitting this allotted time with an appropriate funeral might ‘‘keep the soul from rest’’ and ‘‘prevent it from going to the other world’’ [23]. Further addressing their organ shortage issue, Japan has pursued a number of innovative approaches, including utilization of marginal organs and developing protocols for ABO incompatibilities [24]. In an effort to maximize the number of potential deceased donors, the US has undergone an evolution in its recruitment policies. The 1980s saw the emergence Required Request laws, which tied recruitment of potential donors to Medicare reimbursement and Joint Commission accreditation. While initially hospital staff made inquiries to families of potential donors, in light of its negligible success, in 1998 a policy of routine notification emerged in which specially trained Organ Procurement Organization (OPO) staff assumed the role of requester. This innovation also had little impact on donation rates. In 1994, Pennsylvania was the first state to enact a first-person authorization or ‘‘donor designation’’ law. Now in all 50 states, the law permits an individual to designate his/her donor status on a driver’s license, donor card, or donor registry. However, while the expressed preference is legally binding, potential conflict with family of the deceased when ascertaining donor status still remains relevant [25]. In 2003, the Health Resources and Services Administration’s (HRSA) Division of Transplantation established the Organ Donation Breakthrough Collaborative. Endeavoring to aggressively increase donations, the collaborative targeted 800 hospitals that were calculated to have the highest donor potential to engage with specialized teams from their respective OPOs. The initiative, a policy of enhanced ‘‘routine notification,’’ fostered stronger ties between OPOs and the hospitals to collaboratively reapproach families that had refused donating a member’s organs, implemented policies for donation after cardiac death (DCD), and meticulously monitored the entire donation process from referral to recovery. As of 2008, the HRSA reported that as many as 4,000 additional transplants resulted directly from the collaborative [26].
Proposed policies for increasing organ donation Abouna [27] asserts that education to increase public awareness and better prepare hospital staffs for their obligations in the recruitment of potential donors is foremost in addressing the issue of organ shortage. He cites the
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increased donation rates in Europe that resulted from ‘‘Donor Action Programs,’’ education-based initiatives that target the media, schools, and hospitals. He refers to the Organ Donation Breakthrough Collaborative as a program with success attributable to its education qualities and also notes that UNOS itself has made official recommendations that physicians educate their patients about organ donation. Next, Abouna advocates for the increased use of expanded criteria donors, which include the elderly, pediatric donors, diabetic donors, donation after prolonged ischemia times, donation after cardiac death (DCD), and donors with infection, hypertension, and compromised renal function. Donation after cardiac death, once the primary source of transplantable organs, fell out of favor with the acceptance of the brain death criterion but it represents a significant opportunity for expanding the donor pool. In their 2005 report analyzing the organ shortage issue, the IOM estimated that DCD could possibly contribute 22,000 additional donors per year [26]. A study of 122 transplants performed at the University of Zurich between 1985 and 2000, all using organs procured after cardiac death, showed a higher rate of delayed graft function but long-term outcome similar to that of a matched group of transplants from donors with a heartbeat [28]. DCD is on the rise and might further be increased through campaigns that increase public awareness and education.
Presumed consent A number of European countries utilize a policy of presumed consent to increase organ donation. Under this system, all potentially suitable deceased donors are considered viable for donation unless they ‘‘opt out’’ during their lifetime or their family impedes donation upon death. Arguments against presumed consent are embedded in the potential usurpation of autonomy and self-determination [29]. Brazil withdrew its system of presumed consent because it increased mistrust in the healthcare system. English and Wright [30], however, argue that a system of presumed consent might very well capitalize on the already existing predominant public support for organ donation. They assert that increased awareness and education before moments of grief might make families less likely to refuse donation of a loved one’s organs at the time of death. Spain, Italy, Belgium, Austria, and France all use systems of presumed consent. Yet despite using a strategy similar to that of these other countries, Spain has a higher deceased donor rate. While Spain legislated a presumed consent policy in 1979, it did not observe marked increases in donation rate until 1989 when it created the National Transplant Organization (ONT), a national program in which physicians were specifically trained to direct the donation process. The program is intricately organized to incorporate three levels of
coordination: national, regional, and hospital. Italy implemented a similar system in 1999 and enjoyed increased donorship as well. Given the discrepancy in donation rates among countries that have adopted presumed consent, it is posited that increased rates of donation might have less to do with the policy and more to do with elaborate infrastructures that increase public awareness and effectively disseminate transplant education [31]. In its report on strategies for increasing organ donation issued in 2005, the IOM recommended against implementing presumed consent in the US from a procedural standpoint rather than an ideological one. The IOM posits that prior to establishing an ‘‘opt-out’’ system, greater social support for and understanding of the value of organ donation must be garnered in order to maintain public trust in the healthcare system. Readiness for a shift to a system of presumed consent indicates that the value of organ donation has been appreciated and internalized by society at large. Therefore, in a sense the transition would be a natural one. If such a switch were to occur, however, reliable and accessible opportunities to opt out would need to be in place [32].
System of cooperation Robertson [33] argues that we should view organ donation as a system of cooperation rather than a unilateral altruistic action. Underlying this shift of perspective is the question of whether those unwilling to donate organs themselves should be permitted to be organ recipients. Robertson posits that in the current system where all are potential recipients yet only some are potential donors, a shortage of organs is inevitable. Organ transplantation is a cooperative venture in which those who choose to participate are the ones deserving to benefit. He analogizes organ transplantation to holding stock in a company. Just as a company would first offer financial distributions to those with a vested interest, organ transplantation should be offered first to those who have previously committed to participation in the system. The current system, asserts Robertson, violates the principle of justice because it doles out benefit to noncontributors or ‘‘free-riders.’’ He ‘‘encourages people to think of their society as cooperative enterprise to which they can contribute to in death and benefit from in life’’ [33]. In his argument, Robertson [33] alludes to the concept of reciprocity in organ donation, that only those willing to donate should be potential recipients. In 1986, however, the Task Force on Organ Transplantation asserted that, in practical terms, it is unfair to ask the impoverished of society to donate since they themselves, unable to shoulder the financial burden imposed on a recipient, would not be able to receive organs. Many potential recipients do not receive organs merely because they are uninsured rather than for medical reasons. The Task Force concludes that universal health coverage
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represents the only means of establishing a fully reciprocal system of organ procurement and distribution [34].
Live donation The gap between organ supply and demand might also be addressed by the increasing rate of living-donor organ donation. Despite broad public support for organ donation, the percentage of total transplants performed using livingdonor organs actually decreased between 2009 and 2012 from 6,609 to 5,868 [35]. Garonzik-Wang et al. [36] suggest that the barrier to increasing live donations extends beyond lack of public awareness and education and involves the discomfort potential recipients have with approaching potential donors. They conducted a study and found that by using ‘‘living donor champions,’’ i.e., designated representatives who approached potential donors on behalf of the recipient, more donors were identified and more transplants were consequently performed. Other forms of live donation include altruistic or nondirected donation and paired donation. Ethical issues with altruistic donation stem from an unfavorable risk:benefit ratio. The risk of performing a procedure with no medical benefit, i.e., procuring an organ from a live donor, is not clearly outweighed by the psychological benefit of donating when the relationship between the donor and recipient is not readily apparent. Arguments against paired donation include decreased psychological benefit to the donor, issues with voluntariness, issues with confidentiality, and the logistical concerns associated with performing four operations at the same institution around the same time [37].
Disease prevention While the issue of organ shortage can be approached from the aspect of increasing organ supply, it might also be addressed by focusing on strategies for decreasing demand. Disease prevention and slowing disease progression ensure that fewer potential recipients are added to the waitlist. Specifically with respect to chronic kidney disease, lifestyle modification and timely pharmacologic intervention can slow the momentum towards end-stage renal disease. Also, maximizing patient compliance with immunosuppressive regimens and ensuring their affordability diminishes graft failure and the eventual need for retransplantation [38].
Organ sales A system of compensated organ donation has been proposed as a possible solution to the issue of organ shortage.
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Opposition to this approach arises from perceived commodification of the human body and degradation of human dignity. Media reports of organ trafficking have repeatedly depicted the exploitation of poor and vulnerable populations coerced by financial need. In 2004, CNN reported rampant kidney sales in Pakistan, with the donors using the money to pay off family debt [39]. In 2008, the New York Times broke a story about day laborers lured by the promise of work only to have their organs harvested and sold [40]. The international response to organ sales has been virtually uniform. The US outlawed the sale of human organs with the National Organ Transplant Act of 1984 (publication 1. pub. L. 1984; No. 98-507:§301) and India resolved similarly in 1994 with the Human Organ Transplantation Act (Act No. 42). In 1991, with further update in 2010, the World Health Organization (WHO) presented the Guiding Principles on Human Organ Transplantation, which state that the selling of organs ‘‘is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation…and conveys the idea that some persons lack dignity, that they are mere objects to be used by others’’ [41]. Pope John Paul II stated that commodification of human parts ‘‘violates the dignity of the human person’’ [42]. Finally, in 2008, 150 representatives from around the world convened in Istanbul, Turkey, to author the Declaration of Istanbul which both addressed the morality of organ sales and offered structured suggestions for addressing organ shortage [43]. Supporters for a monitored system of organ sales argue for optimization of outcomes amidst the inevitability of transplant commercialism. Transplants that occur in an unmonitored context have a higher risk for disease transmission such as hepatitis B and HIV [44]. Additionally, outcomes tend to be less favorable due to suboptimal perioperative and follow-up care. A study of 23 UK transplant tourists who purchased their organs in India revealed increased graft loss, morbidity, and even death largely due to infection. Similarly, a study performed on Indonesian patients living in the UK who traveled abroad for transplantation showed decreased graft and patient survival compared to Indonesians transplanted locally [45]. In addition, supporters of organ sales assert that an organized and monitored system of compensation would minimize human abuses and would not violate human dignity. In Iran, the Dialysis and Transplant Patient’s Association is the only nationally sanctioned program of compensated live unrelated donors in the world. Established in 1988 and offering modest compensation as well as lifetime health insurance to donors, the kidney waiting list was effectively eliminated in Iran by 1999 [46]. While the system affords impartial accessibility, follow-up studies on donors who participated in this program revealed troubling
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psychological outcomes, a lack of improvement in financial status, and donor regret in many [47]. Matas [48, 49] asserts that with an average wait time of 5 years and a 7 % annual waitlist mortality rate in the US, saving lives should be the preeminent concern in organ procurement and a monitored system of donor compensation provides a highly effective solution. Matas disputes claims that organ sales violate human dignity, stating that dignity is ‘‘conveyed in our attitudes and behavior’’ rather than any one body part. In addition, rigorous informed consent upholds rather than breeches donor autonomy. Matas argues that compensated donors, like miners or policemen, take a calculated risk.
Conclusion The issue of organ shortage is the greatest challenge facing transplant medicine. At the request of the US Congress in 1998, the Institute of Medicine outlined a comprehensive approach to the organ shortage issue, including a systems approach that addresses awareness and education, and strategies for expanding the pool of potential donors and promoting and facilitating family decisions to donate, presumed consent, incentives for deceased donation, and protection of living donor rights [17]. Additionally, preventing disease progression and ensuring that transplant recipients care appropriately for their grafts represent additional means of reducing the discrepancy between organ supply and demand [39]. However, as long as there is an organ shortage, ethical policies must be in place for deciding issues of organ allocation. The concept of triage provides a potentially useful paradigm to which organ allocation can be compared and from which policies can be shaped. As it currently stands, the US system favors a utilitarian approach, maximizing the collective good for the transplant community and disregarding social assessments in the formulation of its policies. At least in the realm of transplant, the individual is subjugated to the collective. Scarcity of organs for transplant requires the medical community to diverge from a deeply embedded ethic of relentless fiduciary commitment to the individual patient in favor of the broader good of an entire patient community, ultimately and tragically bestowing life on some of its members while denying it to others. Conflict of interest The authors have no conflicts of interest or financial ties to disclose.
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38. El Nahas AM, Bello AK (2005) Chronic kidney disease: the global challenge. Lancet 365:331–340 39. Quraishi A (2004) Pakistan’s lucrative kidney trade, CNN, August 4, 2004. http://www.cnn.com/2004/WORLD/asiapcf/08/ 04/pakistan.organ/. Accessed 30 April 2013 40. Gentleman A (2008) Kidney thefts shock India, The New York Times, January 30, 2008. http://www.nytimes.com/2008/01/30/ world/asia/30kidney.html. Accessed 4 Jan 2013 41. World Health Organization guiding principles of human cell, tissue, and organ transplantation. Resolution WHA63.22 (63rd World Health Assembly) May 2010. http://apps.who.int/gb/ ebwha/pdf_files/WHA63/A63_R22-en.pdf?ua=1 42. Paul PJ II (1995) Evangelium Vitae. Encyclical letter on the value and inviolability of human life, March 25, 1995. http:// www.catholic-pages.com/documents/evangelium_vitae.pdf 43. Participants in the International Summit on Transplant Tourism and Organ Trafficking Convened by the Transplantation Society and International Society of Nephrology in Istanbul, Turkey, April 30–May 2, 2008 (2008) The declaration of Istanbul on organ trafficking and transplant tourism. Transplantation 86(8):1013–1018 44. Jafar TH (2009) Organ trafficking: global solutions for a global problem. Am J Kidney Dis 54(6):1145–1157 45. Inston NG, Gill D, Al-Hakim A, Ready AR (2005) Living paid organ transplantation results in unacceptably high recipient morbidity and mortality. Transpl Proc 37(2):560–562 46. Barsoum RS (2008) Trends in unrelated-donor kidney transplantation in the developing world. Pediatr Nephrol 23(11):1925–1929 47. Ghods AS, Savaj S (2006) Iranian model of paid and regulated living-unrelated kidney donation. Clin J Am Soc Nephrol 1:1136–1145 48. Matas A (2005) Living kidney donation: Controversies and realities. The case for a regulated system of living kidney sales. Program and Abstracts of the American Transplant Congress 2005: 6th annual joint meeting of the American Society of Transplant Surgeons and the American Society of Transplantation, Seattle, WA, May 21–25, 2005 49. Matas AJ (2006) Why we should develop a regulated system of kidney sales: a call for action! Clin J Am Soc Nephrol 1:1129–1132
Organ Shortage: The Greatest Challenge Facing Transplant Medicine David Shafran • Eric Kodish • Andreas Tzakis
Socie´te´ Internationale de Chirurgie 2014
Abstract The success of organ transplantation as a treatment for end-stage organ disease has yielded a series of ethical quandaries originating from the issue of organ shortage. Scarcity of organs for transplantation necessitates formulation of just and fair allocation policies as well as ethically viable solutions to bridging the vast gap between organ supply and demand. The concept of ‘‘triage’’ provides a useful paradigm in which to contextualize the organ shortage issue. This entails subjugating the welfare of the individual patient for the benefit of the wider community as an ethically justified response to the challenge of scarcity.
Introduction Allocating organs for transplantation in the context of a dire scarcity of resources presents a formidable ethical challenge to the transplant community. The Hippocratic Oath morally binds physicians to treat illness indiscriminately without regard for race, creed, or social or economic standing. Yet the advent of organ transplantation as a successful life-saving therapeutic intervention juxtaposed with a paucity of organs to transplant places medical professionals in an ideologically vexing position of having to decide who lives and who dies [1]. While the healthcare community’s ethical commitment to patients extends only so far as meaningful help can be provided, distributing scarce resources such as organs in a just and fair manner represents a significant ethical imperative [2].
D. Shafran (&) E. Kodish A. Tzakis Department of Bioethics and the Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail: [email protected]
Organ allocation evokes the concept of ‘‘triage.’’ Derived from the French word trier and initially used with respect to sorting of agricultural products, the use of triage now occurs almost exclusively in the medical setting and requires three elements: at least a modest scarcity of resources, a formal assessment of medical need, and implementation of an algorithm that delineates treatment priority [3]. Triage systems champion the values of human life, health, efficient use of resources, and fairness, and they generally subjugate the values of autonomy, fidelity, and ownership of resources [4]. The implementation of triage, ‘‘doing the greatest good for the greatest number of people,’’ occurs daily in emergency rooms and has been utilized for centuries on the battlefields of the world [5]. Organ transplantation, now a mainstream therapeutic intervention for end-stage organ disease, represents a relatively novel yet every bit appropriate use of the triage concept. The transplant community, and those within it charged specifically with articulating allocation policies, continually challenge themselves to identify and prioritize the principles that will achieve maximum ‘‘good’’ for potential transplant recipients, knowing that these decisions both grant life to some and deny it from others. Triage in organ transplantation requires society at large, as opposed to individual people or institutions, to consider carefully its values, come to consensus, and render policies that will benefit the collective transplant community most effectively. Achieving this ambitious objective requires transparency and flexibility in policy formulation. Discussion surrounding allocation policies is therefore open to public forum for comment and consideration [6]. Additionally, within each system with respect to a specific organ, appeals processes exist by which individual institutions can present exceptional cases to the Organ Procurement and Transplantation
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World J Surg Table 1 Annual transplant and mortality rates of specific organ waitlists Annual transplant rate (%)
Annual mortality rate (%)
Kidney
17
6
Liver
39
15
Heart
74
15
Network (OPTN), the national governing body for transplant policy, for additional consideration. The appropriate organ-specific governing board subsequently convenes and renders a decision [7, 8]. As an example of the evolving nature of these policies, the new Lung Allocation Score, finalized in 2005, explicitly included a plan to update and revise the model periodically to ensure that it keeps current with emerging statistics and new ethical considerations [9].
Background The first successful kidney transplant took place in Boston in 1954 between identical twins. Successful heart and liver transplants followed in 1967. However, transplantation as a conventional therapy for end-stage organ disease became prominent only in the 1980s with the discovery of cyclosporine for immunosuppression and the new potential it brought for combatting graft rejection. By 2000, over 600,000 transplants had been performed worldwide [10]. The success of organ transplantation turned what was once a death sentence in many circumstances into the possibility for meaningful life. However, the shift of transplantation from an untried, experimental intervention into a viable, mainstream treatment option yielded a new set of difficult ethical questions, including the issue of organ shortage. As of August 22, 2013, the total waitlist for organs in the US was nearly 120,000, whereas the total number of transplants performed between January and May of 2013 was only 11,580, a pace certain to leave an enormous gap between supply and demand by year’s end [11]. Historically, the 2011 annual data report of the Scientific Registry of Transplant Recipients (SRTR), the organization that works alongside the OPTN to compile national data on transplantation in the US, demonstrated the discrepancy between supply and demand for nearly all major organs and the potential for fatality that results from increased wait time [12] (Table 1). Perhaps most prominently, the kidney transplant waiting list continues to grow commensurate with the number of end-stage renal disease (ESRD) patients, which increased by (has increased) 600 % in the US between 1980 and 2009. Yet, the number of donors between 2004 and 2011 remained relatively stagnant at 13,000, making the gap
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Table 2 Organ-specific waitlists and transplants 2001
2009
2011
Waitlist
46,649
79,397
86,547
Transplant
14,279
16,829
16,814
Waitlist
16,545
15,094
15,330
Transplant
5,195
6,320
6,342
Waitlist
3,631
2,674
2,813
Transplant
2,202
2,211
2,322
3,572 1,034
1,630 1,659
1,798 1,753
Kidney
Liver
Heart
Lung Waitlist Transplant From [11, 13]
between organ supply and demand even larger [13, 14]. The waitlist for liver has similarly increased in the US, though that for heart and lung declined between 2001 and 2011 [13] (Table 2). Internationally, in 2011 an estimated 112,631 solid organ transplantations were performed, filling less than 10 % of the global need [15]. New and effective strategies to address the growing gap between organ supply and demand must be implemented just to this prevent gap from widening further.
Discussion of Distributive Justice and Development of Allocation Policies in US In 1984, the US Congress passed the National Organ Transplantation Act (NOTA) with the objective of formally addressing and improving organ allocation systems [7]. Prior to that time, organs were usually allotted to the patients of the surgeons who extracted them [16]. In addition to prohibiting organ sales and establishing the Task Force on Organ Transplantation, NOTA led to the establishment of the OPTN, an organization overseen by the US Department of Health and Human Services and charged with maintaining a national registry and creating equitable organ allocation policies. The United Network of Organ Sharing (UNOS), subcontracted by the government in 1986, administers the activities of the OPTN. Currently, the US is divided into 11 OPTN regions and further subdivided into 58 donor-specific areas (DSA), each one generally assigned one Organ Procurement Organization (OPO) [7]. An important shift in the approach to organ distribution occurred when the US Department of Health and Human Services issued the ‘‘Final Rule,’’ published in 1998 before going into effect in 2000. The ordinance was borne out of a
World J Surg Table 3 UNOS principles and objectives of equitable organ allocation Principles The UNOS policy for equitable organ allocation strikes a balance among the following principles. The policy must: Enhance the overall availability of transplantable organs Allocate organs based on medical criteria, striving to give equal consideration to medical utility (i.e., net medical benefit to all transplant patients as a group) and justice (i.e., equity in distribution of the benefits and burdens among all transplant patients) Provide transplant candidates reasonable opportunities to be considered for organ offers within comparable time periods, taking into consideration similarities and dissimilarities in medial circumstances as well as technical and logistical factors in organ distribution Respect autonomy of persons Objectives The goal of the UNOS organ allocation system is to achieve, in balance with one another, the following objectives: Maximize availability of transplantable organs Maximize patient and graft survival Minimize disparities in consistently measured waiting times until an offer of an organ for transplant is made among patients with similar or comparable medical/demographic characteristics Minimize deaths Maximize opportunity for patients with biological or medical disadvantages to receive a transplant Minimize effects related to geography Allow convenient access to transplant Minimize overall transplantation-related costs Provide for flexibility in policy making Provide for accountability and public trust From [18]
concern for the large disparities in waiting time based on geographic location and advocated for development of allocation policies that focused more on objective medical criteria and medical urgency as opposed to waiting time and geographic location. In a report published in 1999, the Institute of Medicine (IOM) reviewed and supported the assertions of the Final Rule and also projected its potential impact on the following: access to transplantation services for low-income people and ethnic minorities, organ donation rates, waiting time for transplant, survival and graft failure rates leading to retransplantation, and cost of organ transplantation [17]. In creating its objectives, UNOS grounded its policies for distribution in four fundamental ethical principles: equity, justice, beneficence, and utility. The UNOS principles and objectives of equitable organ allocation, among other considerations, explicitly state that organs should be allocated ‘‘based on medical criteria striving to give equal consideration to medical utility (i.e., net medical benefit to
all transplant patients as a group) and justice (i.e., equity in distribution of the benefits and burdens among all transplant patients)’’ [18]. The organ subcommittees of UNOS continuously endeavor to incorporate and balance these principles into their respective allocations systems, a process that often takes years to finalize (Table 3). The organ subcommittees of UNOS formulate their respective allocation policies independent of one another and therefore vary in their application of prescribed ethical principles. Although in June 2013 UNOS approved a revised policy for distribution and a point system for scoring deceased donor organ quality, due to be implemented in 2014, kidney allocation currently prioritizes potential recipients based on waiting time over medical urgency [8, 19]. Liver and heart allocation policies, on the other hand, are urgency-based and prioritized based on pretransplant mortality risk [7]. Finally, the Lung Allocation Score (LAS), first utilized in 2005, designates its recipients based on a calculation of pre- and post-transplant survival [9]. As organ allocation falls into the ethical purview of distributive justice, a discussion of social standing and its place in allocation policy formulation, if any, naturally ensues. Beauchamp and Childress define distributive justice as ‘‘fair, equitable, and appropriate distribution in society determined by justified norms that structure the terms of social cooperation.’’ They then list a series of principles to be weighed and applied within the context of distributive justice. These include: ‘‘To each person an equal share…according to need…according to effort…according to contribution…according to merit…according to free market exchanges’’ [5]. Similarly, Rescher [1] alludes to these principles in a strategy he designed for allocating ‘‘exotic medical lifesaving therapy.’’ Rescher asserts that choosing who should benefit from a scarce resource should involve considerations such as relative likelihood of success, life expectancy, family role, potential contributions, and past services rendered. The stated objectives of UNOS, however, deliberately exclude considerations of social worth. Allocation policies are largely utility- and equity-based and do not incorporate social considerations such as family value or potential for societal contribution. Stated succinctly, transplant in the US fundamentally focuses foremost on the extension of life as opposed to its enhancement. Conspicuously devoid of social considerations, the UNOS point system balances three principles within its policies: sickest first, first-come first-served, and prognosis [20]. According to Rhodes et al. [2], organ allocation policies might be likened to ‘‘wartime triage.’’ They differentiate between war and peacetime triage, stating that in wartime, treatment decisions are made based on who will benefit from intervention, whereas in peacetime, as seen in emergency rooms, decisions are made based on medical
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urgency. They assert that ignoring factors like life expectancy and medical urgency, while fair, is unjust when resources are scarce. They state, ‘‘A policy that is both fair and just examines differences among people and then treats those differences similarly.’’ The Rhodes et al. approach, posited before the implementation of the Final Rule, represents a strongly utilitarian one aimed at achieving the maximal collective ‘‘good’’ even at the expense of individual rights. A fundamental question that underlies the motivation behind organ transplantation and has implications for how we formulate allocation policies is this: Do we perform transplant to prolong life or enhance it? In the current climate of organ shortage and consistent with the principle of triage, allocation policies ignore social role and quality-of-life assessments of potential recipients and allocate with the goal of minimizing deaths [18]. The Federal Task Force on Organ Transplantation stated that transplant teams ‘‘hold organs as trustees and stewards on behalf of the community’’ [21]. While the job of formulating allocation policy falls on designated professionals, ultimately their decisions must reflect the values of the collective community that has designated them for the task. As it currently stands, considerations of distributive justice in organ allocation give precedent to communal good over individual entitlement.
Past and current US policies for increasing organ donation A myriad of strategies for increasing the number of deceased donors have been proposed and implemented. In the US, brain death, as initially discussed in 1968 by the Ad Hoc Committee at Harvard and then formally addressed in the Uniform Determination of Death Act in 1980, has been adopted as a criterion for death, in addition to cessation of circulatory function. Improvements in mechanical ventilation and other supportive measures that permit the body to be sustained, sometimes indefinitely, necessitated clarification of the definition of death [22]. The declaration of neurologic death permits organs to be maintained, minimizing ischemic damage, while arrangements for transplantation are made. The emergence of brain death as an acceptable criterion occurred differently in Japan and its acceptance continues to be met with opposition in the mainstream. Only recently in Japan was brain death legally viewed as actual death. Prior to passing the Organ Transplant Law in 2009, brain death could be considered actual death only for organ donation purposes, but legal death did not occur until cessation of cardiopulmonary function. The new law now designates brain death as legal death. Opposition to this change argues that considering brain death the new
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standard for legal death runs contrary to an ingrained Japanese value that perceives life to reside in the entire body rather than merely relegated to the brain. The new law also potentially violates the custom of ‘‘Mogari’’ which entails allowing the body to sit for 10 days after death to ensure that the soul does not return to it. Not permitting this allotted time with an appropriate funeral might ‘‘keep the soul from rest’’ and ‘‘prevent it from going to the other world’’ [23]. Further addressing their organ shortage issue, Japan has pursued a number of innovative approaches, including utilization of marginal organs and developing protocols for ABO incompatibilities [24]. In an effort to maximize the number of potential deceased donors, the US has undergone an evolution in its recruitment policies. The 1980s saw the emergence Required Request laws, which tied recruitment of potential donors to Medicare reimbursement and Joint Commission accreditation. While initially hospital staff made inquiries to families of potential donors, in light of its negligible success, in 1998 a policy of routine notification emerged in which specially trained Organ Procurement Organization (OPO) staff assumed the role of requester. This innovation also had little impact on donation rates. In 1994, Pennsylvania was the first state to enact a first-person authorization or ‘‘donor designation’’ law. Now in all 50 states, the law permits an individual to designate his/her donor status on a driver’s license, donor card, or donor registry. However, while the expressed preference is legally binding, potential conflict with family of the deceased when ascertaining donor status still remains relevant [25]. In 2003, the Health Resources and Services Administration’s (HRSA) Division of Transplantation established the Organ Donation Breakthrough Collaborative. Endeavoring to aggressively increase donations, the collaborative targeted 800 hospitals that were calculated to have the highest donor potential to engage with specialized teams from their respective OPOs. The initiative, a policy of enhanced ‘‘routine notification,’’ fostered stronger ties between OPOs and the hospitals to collaboratively reapproach families that had refused donating a member’s organs, implemented policies for donation after cardiac death (DCD), and meticulously monitored the entire donation process from referral to recovery. As of 2008, the HRSA reported that as many as 4,000 additional transplants resulted directly from the collaborative [26].
Proposed policies for increasing organ donation Abouna [27] asserts that education to increase public awareness and better prepare hospital staffs for their obligations in the recruitment of potential donors is foremost in addressing the issue of organ shortage. He cites the
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increased donation rates in Europe that resulted from ‘‘Donor Action Programs,’’ education-based initiatives that target the media, schools, and hospitals. He refers to the Organ Donation Breakthrough Collaborative as a program with success attributable to its education qualities and also notes that UNOS itself has made official recommendations that physicians educate their patients about organ donation. Next, Abouna advocates for the increased use of expanded criteria donors, which include the elderly, pediatric donors, diabetic donors, donation after prolonged ischemia times, donation after cardiac death (DCD), and donors with infection, hypertension, and compromised renal function. Donation after cardiac death, once the primary source of transplantable organs, fell out of favor with the acceptance of the brain death criterion but it represents a significant opportunity for expanding the donor pool. In their 2005 report analyzing the organ shortage issue, the IOM estimated that DCD could possibly contribute 22,000 additional donors per year [26]. A study of 122 transplants performed at the University of Zurich between 1985 and 2000, all using organs procured after cardiac death, showed a higher rate of delayed graft function but long-term outcome similar to that of a matched group of transplants from donors with a heartbeat [28]. DCD is on the rise and might further be increased through campaigns that increase public awareness and education.
Presumed consent A number of European countries utilize a policy of presumed consent to increase organ donation. Under this system, all potentially suitable deceased donors are considered viable for donation unless they ‘‘opt out’’ during their lifetime or their family impedes donation upon death. Arguments against presumed consent are embedded in the potential usurpation of autonomy and self-determination [29]. Brazil withdrew its system of presumed consent because it increased mistrust in the healthcare system. English and Wright [30], however, argue that a system of presumed consent might very well capitalize on the already existing predominant public support for organ donation. They assert that increased awareness and education before moments of grief might make families less likely to refuse donation of a loved one’s organs at the time of death. Spain, Italy, Belgium, Austria, and France all use systems of presumed consent. Yet despite using a strategy similar to that of these other countries, Spain has a higher deceased donor rate. While Spain legislated a presumed consent policy in 1979, it did not observe marked increases in donation rate until 1989 when it created the National Transplant Organization (ONT), a national program in which physicians were specifically trained to direct the donation process. The program is intricately organized to incorporate three levels of
coordination: national, regional, and hospital. Italy implemented a similar system in 1999 and enjoyed increased donorship as well. Given the discrepancy in donation rates among countries that have adopted presumed consent, it is posited that increased rates of donation might have less to do with the policy and more to do with elaborate infrastructures that increase public awareness and effectively disseminate transplant education [31]. In its report on strategies for increasing organ donation issued in 2005, the IOM recommended against implementing presumed consent in the US from a procedural standpoint rather than an ideological one. The IOM posits that prior to establishing an ‘‘opt-out’’ system, greater social support for and understanding of the value of organ donation must be garnered in order to maintain public trust in the healthcare system. Readiness for a shift to a system of presumed consent indicates that the value of organ donation has been appreciated and internalized by society at large. Therefore, in a sense the transition would be a natural one. If such a switch were to occur, however, reliable and accessible opportunities to opt out would need to be in place [32].
System of cooperation Robertson [33] argues that we should view organ donation as a system of cooperation rather than a unilateral altruistic action. Underlying this shift of perspective is the question of whether those unwilling to donate organs themselves should be permitted to be organ recipients. Robertson posits that in the current system where all are potential recipients yet only some are potential donors, a shortage of organs is inevitable. Organ transplantation is a cooperative venture in which those who choose to participate are the ones deserving to benefit. He analogizes organ transplantation to holding stock in a company. Just as a company would first offer financial distributions to those with a vested interest, organ transplantation should be offered first to those who have previously committed to participation in the system. The current system, asserts Robertson, violates the principle of justice because it doles out benefit to noncontributors or ‘‘free-riders.’’ He ‘‘encourages people to think of their society as cooperative enterprise to which they can contribute to in death and benefit from in life’’ [33]. In his argument, Robertson [33] alludes to the concept of reciprocity in organ donation, that only those willing to donate should be potential recipients. In 1986, however, the Task Force on Organ Transplantation asserted that, in practical terms, it is unfair to ask the impoverished of society to donate since they themselves, unable to shoulder the financial burden imposed on a recipient, would not be able to receive organs. Many potential recipients do not receive organs merely because they are uninsured rather than for medical reasons. The Task Force concludes that universal health coverage
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represents the only means of establishing a fully reciprocal system of organ procurement and distribution [34].
Live donation The gap between organ supply and demand might also be addressed by the increasing rate of living-donor organ donation. Despite broad public support for organ donation, the percentage of total transplants performed using livingdonor organs actually decreased between 2009 and 2012 from 6,609 to 5,868 [35]. Garonzik-Wang et al. [36] suggest that the barrier to increasing live donations extends beyond lack of public awareness and education and involves the discomfort potential recipients have with approaching potential donors. They conducted a study and found that by using ‘‘living donor champions,’’ i.e., designated representatives who approached potential donors on behalf of the recipient, more donors were identified and more transplants were consequently performed. Other forms of live donation include altruistic or nondirected donation and paired donation. Ethical issues with altruistic donation stem from an unfavorable risk:benefit ratio. The risk of performing a procedure with no medical benefit, i.e., procuring an organ from a live donor, is not clearly outweighed by the psychological benefit of donating when the relationship between the donor and recipient is not readily apparent. Arguments against paired donation include decreased psychological benefit to the donor, issues with voluntariness, issues with confidentiality, and the logistical concerns associated with performing four operations at the same institution around the same time [37].
Disease prevention While the issue of organ shortage can be approached from the aspect of increasing organ supply, it might also be addressed by focusing on strategies for decreasing demand. Disease prevention and slowing disease progression ensure that fewer potential recipients are added to the waitlist. Specifically with respect to chronic kidney disease, lifestyle modification and timely pharmacologic intervention can slow the momentum towards end-stage renal disease. Also, maximizing patient compliance with immunosuppressive regimens and ensuring their affordability diminishes graft failure and the eventual need for retransplantation [38].
Organ sales A system of compensated organ donation has been proposed as a possible solution to the issue of organ shortage.
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Opposition to this approach arises from perceived commodification of the human body and degradation of human dignity. Media reports of organ trafficking have repeatedly depicted the exploitation of poor and vulnerable populations coerced by financial need. In 2004, CNN reported rampant kidney sales in Pakistan, with the donors using the money to pay off family debt [39]. In 2008, the New York Times broke a story about day laborers lured by the promise of work only to have their organs harvested and sold [40]. The international response to organ sales has been virtually uniform. The US outlawed the sale of human organs with the National Organ Transplant Act of 1984 (publication 1. pub. L. 1984; No. 98-507:§301) and India resolved similarly in 1994 with the Human Organ Transplantation Act (Act No. 42). In 1991, with further update in 2010, the World Health Organization (WHO) presented the Guiding Principles on Human Organ Transplantation, which state that the selling of organs ‘‘is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation…and conveys the idea that some persons lack dignity, that they are mere objects to be used by others’’ [41]. Pope John Paul II stated that commodification of human parts ‘‘violates the dignity of the human person’’ [42]. Finally, in 2008, 150 representatives from around the world convened in Istanbul, Turkey, to author the Declaration of Istanbul which both addressed the morality of organ sales and offered structured suggestions for addressing organ shortage [43]. Supporters for a monitored system of organ sales argue for optimization of outcomes amidst the inevitability of transplant commercialism. Transplants that occur in an unmonitored context have a higher risk for disease transmission such as hepatitis B and HIV [44]. Additionally, outcomes tend to be less favorable due to suboptimal perioperative and follow-up care. A study of 23 UK transplant tourists who purchased their organs in India revealed increased graft loss, morbidity, and even death largely due to infection. Similarly, a study performed on Indonesian patients living in the UK who traveled abroad for transplantation showed decreased graft and patient survival compared to Indonesians transplanted locally [45]. In addition, supporters of organ sales assert that an organized and monitored system of compensation would minimize human abuses and would not violate human dignity. In Iran, the Dialysis and Transplant Patient’s Association is the only nationally sanctioned program of compensated live unrelated donors in the world. Established in 1988 and offering modest compensation as well as lifetime health insurance to donors, the kidney waiting list was effectively eliminated in Iran by 1999 [46]. While the system affords impartial accessibility, follow-up studies on donors who participated in this program revealed troubling
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psychological outcomes, a lack of improvement in financial status, and donor regret in many [47]. Matas [48, 49] asserts that with an average wait time of 5 years and a 7 % annual waitlist mortality rate in the US, saving lives should be the preeminent concern in organ procurement and a monitored system of donor compensation provides a highly effective solution. Matas disputes claims that organ sales violate human dignity, stating that dignity is ‘‘conveyed in our attitudes and behavior’’ rather than any one body part. In addition, rigorous informed consent upholds rather than breeches donor autonomy. Matas argues that compensated donors, like miners or policemen, take a calculated risk.
Conclusion The issue of organ shortage is the greatest challenge facing transplant medicine. At the request of the US Congress in 1998, the Institute of Medicine outlined a comprehensive approach to the organ shortage issue, including a systems approach that addresses awareness and education, and strategies for expanding the pool of potential donors and promoting and facilitating family decisions to donate, presumed consent, incentives for deceased donation, and protection of living donor rights [17]. Additionally, preventing disease progression and ensuring that transplant recipients care appropriately for their grafts represent additional means of reducing the discrepancy between organ supply and demand [39]. However, as long as there is an organ shortage, ethical policies must be in place for deciding issues of organ allocation. The concept of triage provides a potentially useful paradigm to which organ allocation can be compared and from which policies can be shaped. As it currently stands, the US system favors a utilitarian approach, maximizing the collective good for the transplant community and disregarding social assessments in the formulation of its policies. At least in the realm of transplant, the individual is subjugated to the collective. Scarcity of organs for transplant requires the medical community to diverge from a deeply embedded ethic of relentless fiduciary commitment to the individual patient in favor of the broader good of an entire patient community, ultimately and tragically bestowing life on some of its members while denying it to others. Conflict of interest The authors have no conflicts of interest or financial ties to disclose.
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