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Re: Why Pick on China for selling organs, India wsas a major marketer of these items and in Turkey, Brazil, Japan, Egypt, Iraq, and the Philippines it is legal.
Chapman, Spira & Carson - Disscusion

From: Springhouse Corporation. Nursing 97, Karen K. Giuliano, RN, CCRN, MSN
Date: 5/17/99
Time: 7:58:41 AM
Remote User:

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In China, where the donors are prisoners, the general population does not have to utilize organ selling for the extra money because they are being taken care of by the government. In many other countries they are not and with many mouths to feed, they have to pick up a few bucks where they can. In many countries, people are willing will donate organs for a price and the practice is totally legal. Turkey, Brazil, Japan, Egypt, Iraq, and the Philippines according to the enclosed, Springhouse article are countries where paid donations are totally legal

In an article that analyzes the morality of payments for transplants this and other critical issues are raised. Robert A. Spira Chapman Spira and Carson LLC

Nursing97 May 1997

Organ Transplants: Tackling the tough ethical questions CE Offering, 2.5 ANCC/AACN Expiration Date: 04/30/99

Take the test online--and earn CE credit.

BY KAREN K. GIULIANO, RN, CCRN, MSN Critical Care Clinical Nurse Specialist Baystate Medical Center Springfield, Mass.

Formerly, Specialist in Kidney, Liver, and Pancreas Transplantation University of Virginia Charlottesville, Va.

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, you'll be drawn into conflicts that have no easy solutions. Here, we'll explore some of the most nettlesome issues surrounding organ transplantation so you can help patients and their families make sound decisions.

Should a patient's relatives be permitted to donate a kidney?

Should donors be compensated for their organs?

Do animal transplants offer a realistic alternative?

Should an alcoholic patient receive a new liver?

Are patients with hepatitis suitable candidates for liver transplant?

Is the current organ allocation program fair?

How do you answer the tough questions?

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 Pandora's 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--you'll be drawn into the debate. In this article, I'll explore some of these issues and offer insights that you can share with your patients.

Should a patient's relatives be permitted to donate a kidney?

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 donor's 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 won't 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 donor's 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 donor's 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 won't 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 didn't follow his medication schedule and, as a result, the donated kidney was rejected. The man's sister felt a good deal of resentment toward her brother because, in her eyes, she'd given a precious gift and he hadn't 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 lies" can 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 who'd 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, we'd better be prepared to give people a medical excuse, lie for them--so they feel they don't 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 who'd 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 she'd always cared for him. The husband experienced enormous guilt over his wife's 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.

Should donors be compensated for their organs?

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 shouldn't 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, we've 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 they're 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 patient's business to make ends meet. She's 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 attorney's office to sign an updated copy of your will. As you're 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 donor's behalf. The document doesn't 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 it's currently illegal and arguably unethical for a donor to accept payment of any kind for a kidney donation. However, it's also unethical to read someone else's confidential legal document. What's more, although you may suspect that the financial compensation is a direct result of the young mother's decision to donate a kidney to the recipient, you don't know this for a fact. And even if it's true, the agreement has probably been designed to get around the law.

From your own assessment of these two individuals, you believe that they're both happy with the decision. So, if they both willingly entered the agreement and they'll both benefit, is the arrangement really unethical? And if it is, should you speak up?

The answers in this case aren't clear-cut and may depend on your own values. In general, however, you should alert transplant team members if you suspect unhealthy (or illegal) donor/recipient dynamics. In most institutions, ethics consultants can help sort out conflicts.

To encourage organ donation without promoting black-market activity, some experts in the transplant field have suggested legalizing and strictly regulating limited forms of compensation. They point out that although the recipient's insurance generally pays for expenses associated with the procedure, the donor's lost work time may not be compensated under current policies.

Another proposal is to pay family members a death benefit for cadaver organs. This compensation would be a standard amount administered according to uniform rules. But that proposal raises a host of new questions and controversies. Could the possibility of a death benefit tempt relatives to consent to a donation that the donor himself wouldn't have agreed to? And if relatives can benefit from a donor's organs after the donor's death, why shouldn't people have the option of selling their own organs before death and benefiting themselves?

On the other hand, might families feel uncomfortable accepting payment for a loved one's body parts? If so, obtaining consent for organ donation could become more, not less, difficult.

Other societies wrestle with the compensation issue too. In the United Kingdom, for example, selling organs is illegal, and only under special conditions do patients receive organs from living donors who aren't blood relatives.

However, selling organs is legal in many countries, including Turkey, Brazil, Japan, Egypt, Iraq, and the Philippines. Until recently, the practice was also legal in India, but the law was changed in response to social problems the practice engendered. Between 1990 and 1995, more than 2,000 kidneys were sold annually to wealthy Middle Eastern recipients. At that rate, many of the poorest people in India would have been minus a kidney by the year 2000.

Typically, these donors were extremely poor, not necessarily healthy, and in desperate need of money for survival. Many eventually found themselves worse off than before--still poor, but now ill and debilitated too. Under those circumstances, can organ donation truly be considered free and uncoerced?

Do animal transplants offer a realistic alternative?

Xenografting--transplanting tissue between two different species--shows promise in several areas. Injecting islet cells from genetically engineered pigs into the hepatic circulation or abdominal cavity, for example, could reduce the need for pancreas transplantation, which is technically difficult. Using primates or even genetically engineered pigs for heart transplantation may also be scientifically possible.

But the ethical and practical barriers are formidable. When we consider using xenotransplantation, we need to ask these questions: What's the difference between killing animals for food and killing them for xenotransplantation? Is it acceptable to kill only certain animals for transplantable tissues? How will these animals be treated before death? What kind of psychological problems might a recipient face if his human heart is replaced with an ape's?

Many of us could accept procuring tissue from pigs. But are we willing to condone the routine procuring of organs from our fellow primates?

Besides ethical considerations, practical problems exist--for example, primates are difficult to breed in captivity, so the few organs we'd obtain probably wouldn't make much of a dent in the current shortage.

Finally, consider the real risk of transmitting animal diseases to human hosts. Animal diseases that can be transmitted to humans include rabies and strains of the Ebola virus. The danger is especially high when the human host is immunosuppressed (as most organ transplant patients must be) and the donor is a genetically similar primate.

To address this issue, the federal Public Health Service issued xenotransplant guidelines last September. Covering a range of xenotransplant therapies, the guidelines call on researchers to carefully screen animals for disease, preserve blood and tissue samples from the donor animal, and monitor patients for emerging diseases.

Should an alcoholic patient receive a new liver?

Except for the kidney, no organ is transplanted more often than the liver. In the United States, alcoholic liver disease is the most common cause of cirrhosis and liver failure, so patients with alcoholic cirrhosis represent the largest group of potential liver transplant recipients. But only about 20% of all liver transplants in this country are performed for patients with alcoholic cirrhosis. Other common reasons for liver transplant are primary biliary cirrhosis, primary sclerosing cholangitis, and chronic hepatitis.

The issue of providing transplants for alcoholic patients was brought into the public spotlight when baseball Hall of Famer Mickey Mantle, an acknowledged alcoholic, received a liver for alcoholic cirrhosis. At the time of the transplant, his physicians discovered liver cancer. He died in August 1995, just two months after surgery. His case illustrates two ethical questions:

Should alcoholic patients receive new livers, or should these scarce organs be reserved for individuals whose disease didn't directly result from their behavior? If so, should we place the same level of moral blame on people who overeat and smoke, and then want a new heart or lungs?

Should the most desperately ill patients receive preference when organs become available? Or should we give priority to healthier patients who are likely to benefit more? The answer to the first question varies from center to center. Some transplant teams won't perform liver transplants for alcoholic patients under any conditions. Others, following a recommendation by the United Network for Organ Sharing (UNOS), require 6 months of sobriety before a transplant; they may also require completion of an established treatment program. However, these guidelines are subjective and loosely followed.(See What Would You Decide?)

Some research suggests that the graft survival rate for liver transplants performed on alcoholics who continue to abstain is similar to the rate for nonalcoholic patients. However, the cost of the transplant procedure is higher for alcoholics, probably because alcoholism is typically accompanied by other morbid conditions. Long-term cost analyses have yet to be done.

This issue is as hotly debated within the medical profession as it is among the public at large. Personal prejudices and a view of alcoholism as a moral failing rather than a disease can influence decision making, and it often seems that alcoholics carry more than their fair share of moral blame. On the other hand, transplant professionals are rightly concerned about the risk of recidivism and graft failure. The lack of consensus guarantees that patients like Mickey Mantle will continue to generate controversy.

Are patients with hepatitis suitable candidates for liver transplant?

Graft failure is also an issue for patients with chronic hepatitis B and C, even when alcoholism isn't a factor. Because of the lifelong immunosuppression most patients need after a transplant, hepatitis can recur quickly. In a normal liver, chronic hepatitis B may not progress to cirrhosis for 10 to 20 years. When a liver is transplanted into an infected patient, however, cirrhosis usually develops in less than 2 years.

Information about treating hepatitis B or C after a liver transplant is just beginning to surface in the scientific literature. Several centers in the United States and Europe have used hepatitis B immune globulin (HBIG) to prevent disease recurrence with varying success, but no one knows enough about it to establish standard protocols. Although some centers report success with certain HBIG regimens, the treatment adds significantly to the already high price of a transplant. At one institution, for example, treatment costs between $40,000 and $50,000 for the first year of therapy, and from $6,000 to $10,000 for each following year for the rest of the patient's life. (An immune globulin for hepatitis C has also been developed; the issues surrounding its use are similar to those for HBIG.)

Patients with chronic hepatitis who seek a transplant must be listed at a center that performs such transplants. At present, however, relatively few transplant centers do. Without posttransplant immune globulin therapy, a transplanted liver has little chance of survival in these patients.

Is the current organ allocation program fair?

The second issue raised by Mickey Mantle's case--deciding which patients on the waiting list should get priority--is also controversial. In the United States, UNOS maintains a national waiting list for organs. In general, the sickest patients routinely move to the top of the list (see Allocating Organs: How Fair?).

In a controversial policy change, UNOS shifted its position on this issue for liver transplants late last year. Under the new policy, patients suffering from acute failure would get priority over those with long-term liver failure, because they have a better chance of full recovery. In March, however, UNOS put the new policy on hold pending further review.

UNOS has estimated that even under the new policy, over 95% of transplanted livers would go to people with chronic disease. The issue is scheduled for resolution this summer.

Allocating organs according to medical urgency remains the general policy for all organs. (However, this criterion plays a lesser role in kidney transplantation because most patients can be sustained indefinitely with dialysis.) Although intended to be as fair and unbiased as possible, the policy has flaws that can give some patients an unfair advantage.

For example, UNOS maintains a national list, but organs are distributed regionally whenever possible. This is both cost-effective and medically sound because limiting the time an organ is preserved enhances its viability.

But that means a patient can improve his odds of receiving an organ by getting himself listed at more than one transplant center; he may have a better chance at a distant center simply because its list is shorter. So a wealthy patient who can afford to travel to several centers will probably get an organ faster than a patient who can't.

What's more, a patient can be on waiting lists for more than one organ. Many people question the fairness of giving one person more than one organ when so many are waiting for just one.

This issue was publicized in 1994 when Pennsylvania Governor Bob Casey received a heart and liver transplant after spending virtually no time on the waiting list. Many people were outraged over what appeared to be a public figure's unfair access to donated organs.

At the time, UNOS maintained a separate list for combined transplants. Today, however, people needing two organs are placed on the list for each organ. They get priority when they reach the top of either list.

When a patient needs two organs, his chance of survival is best if both organs are taken from the same donor. So, depending on the urgency of his condition, he may take priority over two other patients waiting for the same organs.

How do you answer the tough questions?

When you field questions from people who are potential organ donors or recipients, don't expect to have all the answers. As you can see, many ethical issues surrounding organ transplantation are highly controversial and may be settled on a case-by-case basis. Your best bet is to keep current on general legal and ethical standards as well as specific policies at your institution. Alert the transplant team to possible problems (such as coercion) or refer questions to your ethics committee or ethical consultant.

To stay current on nationwide guidelines, rely on UNOS. You can contact UNOS at 1100 Boulders Parkway, Suite 500, P.O. Box 13770, Richmond, Virginia 23225-8770, (804) 330-8500, or via the Internet at www.unos.org. For a brochure on organ and tissue donation, call 1-800-355-SHARE.

SELECTED REFERENCES

"British, American Reports on Xenotransplantion," JAMA. 276(8):589-590, August 28, 1996.

DePalma, J., and Townsend, R.: "Ethical Issues in Organ Donation and Transplantation: Are We Helping a Few at the Expense of Many?" Critical Care Nursing Quarterly. 19(1):1-9, May 1996.

Dossetor, J.: "Rewarded Gifting: Is It Ever Ethically Acceptable?" Transplantation Proceedings. 24(5): 2092-2094, October 1992.

Dreifus, C.: "Who Gets the Liver Transplant? Which One's the Mother? When Do You Lie?" The New York Times Magazine. 41-45, December 15, 1996.

PROVIDER INFORMATION:

The Nursing Institute is an affiliate of Springhouse Corporation, publisher of Nursing97. The Institute is accredited as a provider of continuing education (CE) in nursing by the American Nurses Credentialing Center's Commission on Accreditation and by the AACN. This test qualifies for AACN CERP category A. The Nursing Institute is also an approved provider of CE in states where it is mandatory for license renewal.* Your Nursing Institute�issued CE contact hours are valid wherever you reside.

*Provider numbers: Alabama, ABNP0210; California, 5264; Florida, 27I0600; and Iowa, 136 (Category 4), Texas (Type 1), AACN 8227.

Organ Transplants Related Websites

Financial Incentives for Organ Donation, A Report of the UNOS Ethics Committee Payment Subcommittee, is on-line at the Yale University Biomedical Gopher. [gopher://info.med.yale.edu:70/00/Disciplines/Discipline/Transplant/ Ethics/ethic2.txt]

Learn British biologists' view on the ethical considerations of xenotransplantation, from the England's Institute of Biology web site. [http://www.primex.co.uk/iob/d13.html]

Take the test online--and earn CE credit.

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