Thursday, August 27, 2009

Medical Ethics and Organ Donation: Greasing the Slippery Slope

Organ donation is a white hot medical ethics issue. In the last month alone, there have been two scandalous reports alleging criminal and immoral donation practices. First, we read about a man, a rabbi no less, arrested for trafficking in kidneys. He referred to himself as a ‘matchmaker’, not quite the Fiddler on the Roof image of the wizened Yenta character who arranged marriages. The second story exploded after an article appeared in a Swedish newspaper that accused the Israel Defense Forces (IDF) of harvesting organs from wounded or killed Palestinians. Unlike the arrested rabbi, the Israeli Prime Minister vociferously denied the scurrilous charges.

I suspect that the rabbi is guilty, by his own statements, but I do not believe the diabolical allegations against the Israelis. Charges of this nature should never be publicized in the absence of sufficient evidence.

The reason that organ trafficking exists is because there is a shortage of available organs. We need a legal and ethical way to increase the limited supply of kidneys, livers, hearts and other organs and tissues. Thousands of Americans die every year waiting for an organ rescue. This perennial shortage has stimulated new thinking among bioethicists, politicians and the medical profession. Some of these ideas are welcome, others are controversial and a few are downright dangerous.

All agree that educating the public and encouraging organ donation is a critical strategy. If a person dies and takes viable organs with him to the grave, then others will follow after him who could have been saved. There are some who advocate a new system where consent to donate organs would be assumed unless the person opts out of the program. This would dramatically enlarge the donor pool as everyone would be a potential donor unless the person actively joined the ‘Do Not Donate’ list, similar to what most of us have done to avoid dinnertime telemarketers.

KevinMD reported a proposal in South Carolina where inmates who donated organs would have their sentences reduced. China has a more ghoulish prison program of obtaining the gift of life. It harvests organs from executed prisoners 'with their consent', and has been accused of timing executions to meet recipients' medical needs. China has just announced a voluntary organ donation program to compete against a thriving black market industry. Since 2003, only 130 Chinese citizens have offered to donate their organs, while each year, one million Chinese need one.

Bioethicists are now revisiting the issue of offering compensation to organ donors to provide an incentive to donate. Drafts of a bill advocating this approach are now circulating in the U.S. Senate. While direct cash payments are not being considered, and are currently illegal, insurance benefits and funeral expenses may be offered. In the past, ethical policy dictated that donors should be motivated by altruism only, and should not receive material gain. This categorical prohibition may be cautiously relaxed. Compensation for organs creates many avenues to exploit donors, so any legislation or policy changes would need to be carefully crafted with appropriate ethical safeguards.

Harvesting organs at the end of life poses the most intense ethical challenges. There is a conflict between the individual whose life may be ending and a desperately ill person who needs a new organ to live. The latter person may be a young executive while the potential donor may be tethered to a respirator with limited or absent higher brain function. Bright ethical lines are necessary to protect the patient who is under our direct care and to guard the healing mission of the medical profession. One life should never be sacrificed to save another.

I do not believe that any measure should be taken to hasten death. Additionally, I am very concerned that today’s zeal for organ donation creates a real risk that over time we may view critically ill or moribund individuals as organ donors, rather than as living patients to be treated. If this occurred, then physicians and nurses would be distracted from their professional responsibility to be solely focused on their patients’ interests. It might also pressure families to pull the plug prematurely. I worry also that the definition of death may be diluted in order to enlarge the organ donor pool. What if we decided that those who are in a chronic vegatative state –legally alive today – were now dead? It doesn’t take much imagination to see where this mission creep could lead to.

These are vexing ethical issues. I admit that I might have a different view if one of my kids needed a new liver to survive. However, while the views of those who need organs are valuable and should be heard, it is important that ethical policies be fair and just for society, rather than address the interest of an individual. If we let our emotions for a a child, for example triumph over sound ethical policy, then we steepen the slippery slope that we are already standing on. If we don’t have sturdy ethical guardrails to prevent our descent, then we risk the soul of the medical profession.


Evinx said...

I am not an organ donor simply bcs I want control over who may get my organs. I do not want to risk them going to someone whose belief/value system is contrary to mine. As an example, there is no way I am willing to risk giving my kidney to say a member of an Al Qaeda sleeper cell. That is simply an extreme example but the larger point is control over one's organs.

The basic problem goes back to day one in Econ 101 -the pricing system is the best way to allocate scarce resources. What we have now is a schizophrenic lottery system.

I see nothing wrong with direct payments for kidneys with safeguards in place to make sure the naive or less intelligent are not taken advantage of. If one does not use the pricing system to allocate kidneys (as an example), it is incumbant to come up with a comprehensive system to allocate them. IMO, that would only emulate the Soviet system for resource allocation with shortages, gray markets, corruption, and political pull.

The issue is not necessarily organs; the issue is how to best allocate a very scarce resource. My vote would go for a market mechanism with some regulatory safeguards.

misterc said...

you say: One life should never be sacrificed to save another.

But they are, and in record numbers. It's almost anachronistic to come out and say it shouldn't be done. This is no longer a debate or a possibility. The horse is out of the barn, long gone and we're stuck way out here with no way to get to town.

The problem is that in real time, all head injured people are dying terrible deaths. They are trapped with their terror and physical agony concealed. This practice is not about saving lives, It's about money for organs, money to be saved/gained by family and governments getting rid of the brain damaged.

The word "donation" makes everyone feel better about being out-and-out criminals.

Maggie Knowles said...

$ for R&D to grow organs from stem cells - is this not viable?

Anonymous said...

I'm against 'donating' my organs. Number one, in the rest of the economy, the word 'donation' actually refers to a choice made between selling and donating. Here, with organs, we are forcibly denied that choice, so I refuse to use the label 'donation' to refer to this practice that goes on now, simply because it is a dishonest term. The reality is, the only option for doing anything with your organs right now, is handing them over to a ridiculous lottery over which you have no control. This is like saying when I die I have no right other than to 'donate' my possession to the government, who will then drop them out of a helicopter over some random suburb and give them to random people. The issue here is bodily ownership, and control.

I like to think I own my body... although many coercive medical interventions from cradle to grave, from male genital mutilation, forced vaccination, forced psychiatric drugging, forced HIV tests when immigrating internationally, forced tranquilization as an elderly person in a 'nursing' home, forced autopsy, forced exhumation possiblilities, the list of coerced interventions in your body during life and after death are the cardinal thing in this life that truly disgusts and appalls me to the core....

So, it doesn't surprise me that governments spit in your face when it comes to the issue of organs too by offering you such pathetic limited control over what happens to what is supposedly your possession, your organ.

There is no way I would ever sign up to one of these 'handing over your organs lock, stock and barrel to the government schemes'... NEVER!

If I could dictate to whom the organs do to, then maybe.

Ideally, I'm for the removal of the prohibition on the sale of organs. It is nonsensical that you cannot sell something that is legal to give away.

However, under the current government regime, I would happily take someone elses 'donor' organ. I don't see any reason why I shouldn't. And I'm not a hypocrite.

I'm allowed to take a complementary breath mint from the bowl at the dentist, even if I in my own life don't provide a bowl of complementary breath mints at my own office.

If that donor that benefited me, was given the right, as he should have, by his government, to stipulate that his organ not be given to a non fellow donor, I'd respect his wishes completely.

The fact is, all the muddle and confusion around this issue, stems from the government's pathetic current scheme.

It is the government who is killing people on waiting lists. The government CREATED the waiting list with its policy.

The organs are a commodity. Their trade, need not be stifled by ridiculous trade barriers.

There are many more reasons not to 'donate', the main one being it immediately destroys your guarantee your doctor is serving you, and you alone...

But then again, that guarantee is never that strong in any aspect of medicine. Half the time Docs are serving Big Pharma anyway, or themselves.

What kind of an idiot would add another unwelcome stranger into the mix of competing loyalties your doctor has?

It's this artificial shortfall and urgency that the government created that fuels all this. Open the market, let the price fall where it may, like everything else in life.

As for where I stand right now with the current system. No way is any vulture organ procurement clown coming near me when I am sick. No way! I'll get it tattooed on my damn chest if I have to.

Anonymous said...

A local man took his grandson to a hospital in the next state. The exact circumstances I am unsure but the child was mobile in the emergency room. Supposedly there was a long wait. After the child went in the back for treatment the grandfather was told his grandchild died. I do not know enough to draw conclusions other than the grandfather's frustration, lack of communication, led to the grandfather contacting many agencies and eventually making a threat that he would go to the hospital and physically knock out the doctor. By the time I heard about the case on the news the man was in jail as a result of the phone call threat. I called and spoke to the man's wife. His wife kept telling me that as soon as they learned the grandchild would not live, something they did not expect, they were approached and pressured to donate from their grandchild for another child. Keep in mind I was not there but the people told the same story over and over consistently. The grandfather turned out to be a black man and according to his wife the other child was a white child. The shock of the death, unexpected, and no time to get through that process the grandfather began to think their grandchild's death was too convenient with such an obvious need for an organ for a white child in Florida. Ohhhhh, so initially I didn't intend to get involved in a racial conflict. I offered to help the man get an attorney. The man already had an attorney, who wasn't doing much but finally did. As time passed, at least a year, the grandfather called and he was still spending hours a day writing agencies, searching, SAD. He said communication shut down once something happened to the child. The lack of understanding and the pressure to donate all happening at once was too much. I am curious if the man is online now writing agencies.

A lady neighbor went to the hospital and after viewing an x ray the doctor said she had to have one kidney removed because the x ray showed something that shouldn't be there? I don't know the exacts. Her kidney was removed and then, not sure how long later, it was explained to her that the spot turned out to be a mistake and her problem had only been a kidney infection. Is a normal kidney with just a kidney infection just dumbed in the trash or can't be used again or ? The lady neighbor handled what happened okay.

To my shock and surprise my brother donated his body. His death was sudden and he never had enough medical to cause distrust I suppose. He had a brain tumor which took up one entire side of his brain and had started pushing into the other side. The day he fell and learned about the tumor he had worked all day and run five miles.

I am a lady only having a medical history of two kidney stones and two babies so at one time somewhat innocent of the medical world. A while back I was caught up in what seemed a never ending journey through the dental world. I did not have anything wrong with my teeth and refused any cosmetics. Once entering that world for a check up it took a long time to find my way out of the maze. Of all professions, the dental profession must have the largest number of seriously disturbed people! One of them eventually said that ladies and children are at risk at dental offices just as if ladies are more taken when having their cars repaired. It took a while but finally a smart scientist told me a story about being on an airplane with something wrong on the wing. He said you do what you must do to survive. A man crawled out on the wing to do something to prevent disaster. The scientist said for me to never to enter a dental office again in attempt to address what went wrong. He said I might have to figure a way to fix it myself. Oh, thanks. I have never been back and I am fixed.

If tonight I started passing a kidney stone you can bet I will be screaming for a doctor. There are those times. How to safely navigate the medical world? I get the shakes at just the thought.

Anonymous said...

If you still believe in what "Government" or any establishment then you deserve to be treated as a slave.

Anonymous said...

i am a living kidney donor. it was a life changing experience for me as well as the recipient. as for some of the above comments....what selfish, self centered, uncaring people. how can anyone justify wanting to bury organs, organs that would save lives, just because you can't pick who gets them? oh, how quickly your hypocritical views would change, were you or a loved one in need of an organ. the feeling i got after donating, an overwhelming feeling, made me understand the concept of objective good. i was able to provide a means for life to continue, to allow a person to live, love and be loved. to give grandchildren an oportunity to know a grandmother, to allow a husband to enjoy the companionship of his beloved wife, children to have a mother. if it were up to some of you people, you would deny a person life, just for the satisfaction of being able to take your organs to the grave to rot. i hope you take them to the grave sooner than later because this world would be a much better place with out people like you in it.

Anonymous said...

So. People believe their dead bodies are precious temples, they want 'control' over their corpse after death (as if), and the 'Man' is harvesting children's organs...

It's all a bunch of hogwash, paranoia, superstition and petty vanity. Face it - once you're on the slab, you're no better than a slab - you may as well make yourself useful.

Think of it this way - chances are your life had little meaning - donating your organs could be the best thing you ever did.

Anonymous said...

I am completly appalled at the ignorance and selfishness that I have just read concerning organs and "taking them to the grave" because of the "government" control

Really people, there are critia that is used and it's not just the lottery if that is even still used.

The organs go to the ones that need it the most to have a productive life. The only thing I do disagree with is that one must be able to pay for the surgrey, post surgrey regimens just to be put on the UNOS list.

While this is an issue that will always be controversial, ethical issues are and always will be but refusing donation AFTER death simply because you can not choose who gets them, is not only childish, selfish, ignorant, but also a major ethical situation all in itself. What does it really matter? You are not going to be around to resent anything, know anything, or even care. So grow up, be responsible and help where you can!

Eva said...

I am an organ donor because I feel it is selfish (and childish) not to be one in a world where so many people need help. I almost died and a blood donor helped me.
Think of what would have happened if that person didn't decide to help someone else (me). So I am paying it forward by giving someone else my organs.
I would be dead right now if that person didn't help me. I wouldn't have seen my daughter growing up. That's why people give this amazing second chance at life. Somewhere there is a mother that won't see her child grow up. Or a father that will never be able to teach his son to play baseball because their organs are failing. Most people need to get off of their moral "high horses" and just do it. Otherwise you and your organs will just rot.

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