Istributive Justice: Access; Rationing; Futility

As organ transplantation becomes easier to do, the ethical questions become harder to answer.

When you care for patients who could benefit from a transplant, youll be drawn into conflicts that have no easy solutions. Here, well explore some of the most nettlesome issues surrounding organ transplantation so you can help patients and their families make sound decisions. AS OF JANUARY 1997, 50,288 PEOPLE were on the national waiting list for a donor organ. Most of them will die waiting. Because of spectacular medical advances, the successful transplantation of vital organs-notably the heart, liver, and kidney-has become routine at many medical centers. Patients facing death are restored to health; many can expect to live a near-normal life span.

Ironically, our success at organ transplantation has opened a Pandoras box of ethical questions involving the allocation of scarce donor organs. For example, should an organ go to the sickest patient on the waiting list, or to a more robust patient who may live longer? Is an alcoholic patient a suitable candidate for a liver transplant? Is taking a kidney from a living donor ethical? If so, should living donors be compensated for the lost organ-as blood donors may be for blood?

These and other questions surrounding organ transplantation have no easy answers and continue to be the subject of public controversy. As you care for patients who may be candidates for transplantation-and family members who are potential living donors-youll be drawn into the debate. In this article, Ill explore some of these issues and offer insights that you can share with your patients.

Approximately 25% of the transplanted kidneys in this country come from living donors; by far, most of these donors are related by blood to the recipient. Before a transplant involving a living donor occurs, several conditions should be met. First, the donation must not impair the donors life or health. Second, the donation must be completely voluntary. Finally, all risks should be fully explained.

Obtaining a kidney from a living donor has some clear advantages for the patient:

The results are generally better with living-donor kidneys than with those obtained from cadavers. For example, a living-donor kidney has a better chance of immediate postoperative function. With cadaveric transplants, a period of cold ischemia heightens the risk of postoperative acute tubular necrosis (ATN). Although ATN usually resolves, it makes the postoperative course much more unpredictable.

A patient receiving a kidney from a relative wont have to wait on the national list for a suitable kidney to become available.

The surgery can be performed as a planned elective procedure under optimal conditions.

But what about the risks to the donor? Statistically, serious complications following unilateral nephrectomy are rare. After the nephrectomy, the donors renal function rapidly returns to approximately 90% of the preoperative baseline. Although losing a kidney causes a slight functional decline, the deficit is clinically insignificant.

Nevertheless, the surgery is painful-generally more painful than surgery to implant a kidney-and recovery for the donor may be longer and more complicated than for the recipient. And while the donation may not affect the donors health at first, it will have serious consequences if disease or an injury impairs his remaining kidney later in life.

Is it ethical to expose a healthy donor to any risk for a procedure that wont benefit him and could cause harm? Many practitioners believe the answer is no.

You also have to consider psychological issues and family dynamics. I once cared for a woman who donated a kidney to her brother. After surgery, he didnt follow his medication schedule and, as a result, the donated kidney was rejected. The mans sister felt a good deal of resentment toward her brother because, in her eyes, shed given a precious gift and he hadnt respected it enough to take care of it.

You could argue that many living donors benefit emotionally when they help a relative by donating an organ. But it would be naive to believe that coercion never occurs. In a recent interview, prominent medical bioethicist Art Caplan said he believes telling Small liescan be ethical and even necessary to prevent a patient or other relatives from pressuring a potential donor.

With kidney donation, I began having questions on the way we were counseling family members whod been called upon to donate live organs,Caplan told a writer from The New York Times. I realized family ties could be coercive. So I went in and talked to our transplant team and said: Before we accept any more live kidney donations, wed better be prepared to give people a medical excuse, lie for them-so they feel they dont have to withstand the wrath of their family if they say no to having someone cut them up and take one of their kidneys. And I got a guy right away who, when offered the chance, said no to donating to his brother.

No doubt many reluctant donors are motivated by guilt-but guilt can cut both ways. I was once involved in the care of a man whod received a kidney from his wife. His surgery went well and he recovered quickly without complications. His wife, however, had a difficult postoperative course. During her extended hospital stay, her husband helped care for her, which was a role reversal because shed always cared for him. The husband experienced enormous guilt over his wifes discomfort.

Because of the potential for psychological and physical harm, some surgeons refuse to perform transplants involving living donors. But standards and policies vary among transplant centers-and even among practitioners at the same center.

The 1984 National Organ Transplant Act makes selling organs illegal in the United States. Some people think this policy should be reconsidered, for some fairly compelling reasons:

Offering compensation would encourage donation, increasing the number of organs available.

Everyone else involved in the transplant process is compensated. Why not the donor or his family?

We live in a free-market society. Why shouldnt an individual be permitted to do what he wishes with his own valuable organs?

People opposed to compensating donors would answer the last question by pointing to the potential for black-market commerce. In fact, many argue that just by accepting living-donor organs, weve already stepped onto that slippery slope.

Is the possibility of a black market for organs far-fetched in this country? Maybe not. Consider this scenario:

You work at a transplant center that routinely performs living-donor kidney transplants. As you help prepare a donor and recipient for surgery, they tell you that theyre close friends. The recipient, a hardworking family man, is a long-term dialysis patient who runs a successful business despite his health problems. The donor, a single mother of two small children who recently lost her husband in a car crash, now works as office manager in the patients business to make ends meet. Shes a healthy young woman and expects no health problems from donating her kidney to her friend. By the time you finish your preoperative assessments, you feel good about being part of a situation where both parties are so positive about their decisions.

On the way home, you stop at your attorneys office to sign an updated copy of your will. As youre waiting for your attorney, you open your file. Suddenly, you realize that a document belonging to someone else has been mistakenly placed in your file. The names catch your eye: the man and woman whose workups you just completed. The document outlines a lucrative financial support package that the recipient has set up on the donors behalf. The document doesnt mention the kidney donation, but you suspect that the woman is being rewarded for her decision to donate a kidney.

These circumstances raise several legal and ethical issues. You know its currently illegal a