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Organ Donation: Shadowy Side of a Generous Gesture

The increasing demand for organs to transplant has led to controversial new strategies

BY Nancy Guilfoyvalko

March 8-14, 1998 Issue | Posted 3/8/98 at 1:00 PM

 

In his encyclical Evangelium Vitae, Pope John Paul II called donating organs a “particularly praiseworthy” gesture when “performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope.”

Yet, the Holy Father also warned about remaining “silent in the face of other more furtive, but no less serious and real, forms of euthanasia. These could occur for example when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor.” The Pope's words, written three years ago, are taking on new meaning as the increasing demand for organs to transplant has led to controversial new strategies.

For example, last April, the CBS television program 60 Minutes conducted an investigation of the little-known policy at some hospitals that would allow taking organs for transplants from persons who could be, in narrator Mike Wallace's words, “not quite dead.” At the program's end Wallace predicted that, as a result of the broadcast, the practice called nonheartbeating organ donation (NHBD) was unlikely to continue. But he was wrong.

Transplant organizations immediately defended NHBD as ethical, and in December, a report by the Institute of Medicine—the research arm of the National Academy of Sciences—admitted that some hospitals use questionable methods to obtain organs for transplants. It called for setting national standards however, rather than recommending a ban on the growing practice of retrieving organs from people who do not meet the criteria for brain death—the common standard for organ donation, in which the heart continues to beat during while vital organs are removed.

In an intersection of the so-called “right to die” issue and organ donation, NHBD usually involves getting family permission to remove life support from a person considered by the doctor to be hopeless and then waiting as little as two minutes after the heart stops before harvesting organs. The Institute of Medicine report recommended five minutes. Critics contend that this is not enough to safeguard against taking organs from people who are not quite dead or who may even have a chance of recovery. Others also worry that NHBD further confuses the issue of removing life support and could pressure families of comatose patients to remove life support before that step is truly appropriate.

The report also examined other issues such as administering organ-preserving with potentially harmful medications before death and using surgical techniques without family permission to cool a recently deceased person's organs until a family member can be asked about organ donation. The report called these issues “problematic” but only recommended the development of guidelines.

The impetus for this change in organ donation rules is the growing disparity between people needing new organs and the low number of organs available. Despite the ethical questions, Michael DeVita, chairman of the ethics committee of the University of Pittsburgh Medical Center applauded the results of the report, telling The Washington Post that nonheartbeating donors are “a huge potential source of organs” and able to boost donation rates by at least 20%.

Using non-heartbeating organ donors is not the only controversy surrounding organ transplants, though. The increasing demand for organs has spawned a number of proposals to either increase the pool of potential donors or to better allocate the relatively few organs available.

Upping the Number of Organs

Although most people are aware of the need for organ transplants and support organ donation, the number of people signing organ donor cards remains low and families often refuse to donate organs when asked.

To solve that problem, publicity campaigns have been started to make signing an organ donor card more convenient and to encourage people to discuss donation with their families. Unfortunately, potential ethical problems are seldom discussed as part of the educational effort.

Last year 70 million taxpayers received organ donor cards with their tax refunds. In many states, drivers are routinely asked about organ donation when they renew their licenses. Parishes and churches often include organ donation information at their yearly health fairs and with other Church literature. In December, Vice President Al Gore unveiled new initiatives for increasing organ donation, including a proposed federal rule requiring hospitals to report all deaths to local organ procurement organizations, which can evaluate possible donors and discuss consent with family members. A similar law in Pennsylvania has been credited with increasing organ donation there by 20%.

The American Medical Association has recommended that states consider a mandated choice policy requiring all adults to register their choice of whether they would permit donation in the event of their death.

Other proposals run the gamut from the creative to the bizarre. A Tennessee judge now allows people placed on probation for misdemeanors to get up to 12 days taken from their community service obligation if they sign an organ donor card. A Missouri lawmaker recently submitted a bill to allow death-row inmates to have their sentences commuted to life imprisonment if they agree to donate one kidney or bone marrow.

Even Jack Kevorkian has chimed in by offering to harvest organs from his assisted-suicide victims as well as proposing that prisoners have the right to donate their organs after execution.

There is also renewed interest among many ethicists in exploring such possibilities as expanding the definition of brain death to include people considered permanently unconscious but able to breathe on their own, offering financial incentives to families who agree to donate a loved one's organs, and enacting “presumed consent” legislation which would allow organs to be harvested unless it was documented that the person refused donation.

Instead of being a “gift of life,” some even suggest that organ donation should be considered a societal obligation.

“When people refuse to donate, depriving individuals of organs that could save their lives, maybe we should consider that a homicidal act,” Roger Evens of the Mayo Clinic in Rochester, Minn., quipped in a recent Washington Post article.

Scientific research has also begun to herald other new possibilities. For example, when British scientists adapted cloning techniques to create a frog embryo without a head, some scientists speculated that such a technique could be adapted to grow human organs such as hearts, kidneys, livers, and pancreases in a headless human embryo. Such headless human embryos would be considered non-persons and thus sacrificed at will.

Allocation of Organs

With some 4,000 people dying each year waiting for a transplant, fair and just allocation of the organs available has become another hot button ethical issue. Following quick liver transplants for celebrities Larry Hagman and Mickey Mantle, many people were concerned that famous people jump to the front of the line of people waiting for transplants.

This has been vigorously denied by transplant organizations who maintain that only medical indications are taken into account when deciding who is to receive an available transplant.

The controversy of who receives organs first was recently revived, however, with proposed changes in the rules for liver transplants. One of the most controversial changes involved patients designated as “status one,” those first on the list for transplants. New rules would mean that patients with chronic liver failure would automatically be relegated to “status two.” Critics worry that this could mean that some sicker patients would be passed over for someone considered to have a better chance for success. Transplant experts reply that the relatively small number of people meeting status one criteria would mean that people with chronic liver failure still have a good chance of receiving a transplant. If such rules are accepted, many expect that changes in the distribution of other types of organ transplants would follow.

But even getting on a waiting list for transplantation can cause controversy. While many insurance companies cover the cost of transplantation, some do not- and the cost of a transplant often runs into hundreds of thousands of dollars. People who run out of health insurance before they become sick enough to need a transplant are usually asked to prove their ability to pay before a hospital will put them on the waiting list. This has led to patients desperately searching for financial resources and even whole communities holding fund-raising events for a local patient.

Dr. Lawrence Hunsicker, president of the United Network for Organ Sharing, told the Houston Chronicle in November that although it was unfair that anybody should be denied appropriate, needed medical care just because they are poor, he “cannot fault the hospitals that say they can't do transplants for free. If they did, then everybody would go there and they'd go broke and have to shut down.”

Money is not the only controversial barrier to getting on a waiting list for transplants. In 1996, Sandra Jensen, a young woman with Down's syndrome, was initially rejected for transplant surgery at both Stanford Medical Center and the University of California at San Diego. The hospitals relented after heavy lobbying from disability groups and an offer from California's Medicaid program to pay for the surgery and care afterward. Ultimately, this led to a 1997 California law that prohibits denying medical treatment based on a patient's disabilities.

The Limits of Science

Although science seems to raise new issues at an alarming rate, the Church has long offered guiding principles useful in evaluating ethical controversies. While people of good will may disagree on specific points, as the Congregation for the Doctrine of the Faith (CDF) observes in Donum Vitae (Gift of Life), “It would on the one hand be illusory to claim that scientific research and its applications are morally neutral; on the other hand one cannot derive criteria for guidance from mere technical efficiency, from research's possible usefulness to some at the expense of others, or, worse still, from prevailing ideologies.

“Thus science and technology require, for their own intrinsic meaning, an unconditional respect for the fundamental criteria of the moral law: that is to say, they must be at the service of the human person, of his inalienable rights and his true and integral good according to the design and the will of God.”

Nancy Guilfoy Valko, a registered nurse, writes from St. Louis, Mo.