by Miriam Meijer

Since the early twentieth century, when the first successful transplant surgery took place, organ donation and transplants have become routine procedures for many nations worldwide. Uprooting an organ and replanting it in another human body can be done under three conditions: (1) brain death of a donor; (2) bone marrow and double organs like kidneys and lungs that can be removed from a living donor (humans can live with one kidney or one lung); and (3) corneas, heart and liver harvested only from cadavers. Up to nine people ("recipients") can benefit from the multiple organ and tissue donations of a single donor (two kidneys, heart, two lungs, liver, pancreas, small bowel). Tissues include corneas (eyes), heart valves, skin, and bone marrow. In many cases, donors unsuitable for organ donation are eligible for tissue donation. From repairing severe fractures and degenerative conditions to helping increase the chances of survival for burn victims, tissue grafts are saving lives. Over one million people worldwide have received an organ transplant and some have already survived more than 25 years. Five-year survival rates for most organs are now at least 70%. The number one problem in organ transplantation is the shortage of organ/tissue donors.

Organ and tissue transplantation is possible only through people generously deciding that in the event of their death they would like to donate their organs and tissues to help others. Each day, about 60 people around the world receive an organ transplant, while another 13 die because of organ deficiency. Organ shortage —the main limitation to saving the lives of more patients—is due to individuals and their families not considering organ donation out of fear, ignorance or misunderstanding.

Some argue for the alternative of xenotransplantation, the use of various body parts, tissues, organs and cells of healthy animals for implantation into unhealthy human recipients. However, many oppose xenotransplantation for medical and humanitarian reasons. The strong international consensus is that the only acceptable course of action is to make every effort to maximize the procurement of cadaveric organs for transplantation.

In some countries outside Europe and the United States, adults have voluntarily sold one of their kidneys in exchange for money or some other kind of compensation. There have been rumors of kidnapping and coercion to force the donation of a kidney although these are fortunately mostly unfounded. Organ trafficking not only poses major ethical problems, but makes it difficult to guarantee the quality and safety of the organ. Organ donation and transplantation have to be beyond reproach. The organ donation/transplantation process is a complex process involving a number of discrete but interconnected steps: (1) donor identification, (2) donor screening, (3) donor management, (4) consent/authorization, (5) organ retrieval, and (6) organ allocation. Transplantation comprises the process of organ donation and the process of subsequent implantation or grafting. Historically, the latter has received far more attention than the former, even though the two parts are totally interdependent.

The future of organ transplantation is dependent upon the availability of donor organs. Around 1% of all people who die are possible organ donors. However, organ donation can only take place under very special circumstances. In practice this means that, for most organs, only relatively young donors are suitable who are admitted into Intensive Care Units (ICUs) and subsequently declared brain dead so that organs can be retrieved while the donor's heart is still beating.

Brain death is the cessation of brain function. There is no blood flow to the brain and the brain will never recover. In contrast, a coma is a state of unconsciousness. The patient in a coma is medically and legally alive and may breathe without mechanical assistance. The brain in a coma still functions (and may heal) and there is blood flow to the brain. The clinical criteria for a diagnosis of brain death are well recognized, explained in specialized publications, and accepted worldwide.

The Partnership for Organ Donation Gallup poll showed that while a majority of Americans believe that organ donation was a decent idea, less than half were prepared to sign an organ donor card and discuss their wishes with family. Some members of minority groups in the United States speak openly of their distrust of organ procurement and allocation. Yet nearly half of the more than 70,000 persons on the national transplant waiting list represent minorities. The National Minority Organ/Tissue Transplant Education Program (MOTTEP) has been working to solve the shortage of organ/tissue donors since 1993.

The public attitude toward organ donation is the single most important determinant of whether someone will be given a chance at receiving a transplant. Bad publicity about matters like brain death or fairness of access to transplantation can have an adverse effect on the public's predisposition to agree to organ donation. Rumors about organ trafficking (mainly false) have caused significant damage to altruistic attitudes to organ donation all over the world. While local and national organizations speak to people in schools and meetings, most people get their information about donation and transplantation from television and movies. All kinds of drama, adventure, and soap opera shows base their plots on the worst myths and urban legends that have been spread around the world in the last two decades. TV programs like "Law and Order," "Chicago Hope," "Strange Luck," "The X-Files," "ER," and "Voyager" leave the impression that organ donation is potentially harmful.

The power of the press can also be demonstrated in the so-called "Nicholas Green effect." Nicholas was a 7-year-old American child, shot dead by a bandit in Italy in 1994. His parents agreed to donate his organs and the Italian reporters added to the positive impact of the parents' decision on organ donation rates.

Gallup surveys demonstrate that fewer than 10% of those persons polled were aware that their religion has doctrines that favor organ and tissue donation. At the 1987 First International Congress of the Society for Organ Sharing, an international group of medical experts established to facilitate and set up guidelines for organ transplants around the world, Pope John Paul II stated: "With the advent of organ transplantation, which began with blood transfusion, man has found a way to give of himself, of his blood and of his body, so that others may continue to live."

Protestants favor organ donation. Methodists are encouraged to receive or to donate their organs and tissues that will restore any of the senses or that will enhance health. The use of a signed donor card is part of the recommended arrangements to be done by Lutherans, as long as organs are not sold. The Presbyterian religion respects individual conscience and the right to make decisions regarding one's own body. Organ donation is a matter of individual conscience for Mormons. The Jehovah Witness faith bans blood transfusion but does not oppose donating or receiving organs as long as the organs and tissues are first completely drained of blood.

While the human body is sanctified in Judaism, saving a human life is considered to be superior to maintaining the sanctity of the human body. The donor must be brain dead, and a direct transplantation is preferred. The Rabbinical Council of America (RCA) approved organ donation as permissible, even required from brain dead patients. The endorsement put the world's largest body of Orthodox rabbis at odds with other Orthodox authorities who argue that the cessation of brain function does not indicate death according to Jewish law.

No religious law prohibits Hindus from donating their organs and tissues. Hindu mythology even contains traditions of use of body parts to benefit others. In the story of Dadhichi, the earth was terrorized by a demon, Vrtra. Only the bones of a great sage, (Dadhichi), could be used to make a weapon that could be later used as an antidote to Vrtra. The Sage donated them unhesitantly. In the tale of Lord Ganesh, Lord Shiva, out of rage, cut off the head of his son Ganesh. Later, upon remorse, the lord fixed the head of a elephant on Ganesh's trunk.

Based on several sayings from the Quran (Allah's words) and the Hadith (the Prophet Muhammad's sayings and examples from his life), the Islamic Code of Medical Ethics approved organ donation in 1981. Organs of Muslin donors must not be stored in organ banks but must be transplanted immediately. In Jordan, for example, the first successful kidney transplant occurred in 1972 and the first corneal transplant in 1977. In 1997 the Jordan Society for Organ Donation (JSOD) was established under the auspices of Her Majesty Queen Rania. Usually the recipient's relatives donated the kidney and bone marrow transplants.

Since there is no specific law or doctrine that governs organ donation in Buddhism, it is a matter of individual conscience. In Singapore, a small, highly developed parliamentary democracy where the main religions are Buddhism, Christianity, Hinduism, Islam and Taoism, Dr. Khoo Oon Teik, a nephrologist [kidney specialist] whose own brother died from kidney failure, established The National Kidney Foundation of Singapore (NKFS) in the early 1960s. From its humble beginnings as a fledging dialysis unit at Singapore General Hospital, the NKF has grown to become the world's single largest not-for-profit provider of dialysis care. In 1983 NKF created history with the first overseas transplant in Singapore. The NKF supported the Human Organ Transplant Act, an act passed in 1986 that allows the kidneys of accident victims to be used for transplants. In 1991 the nation-wide Muslim Organ Donation Campaign was launched and in 1992 the Singapore Buddhist Welfare Services (SBWS)-NKF Dialysis Centre was set up. By 1992 the NKF organized the First International Congress on Transplantation in Developing Countries with delegates from 70 countries.

Cadaver donation is undeveloped in Japan because the Japanese find it hard to believe doctors' declarations of a relative's brain death when the patient is still breathing with the help of respirators and the person's body remains warm. In 1968 Juro Wada performed Japan's first heart transplant, which triggered controversy when the 18-year-old recipient died 83 days after the operation. Wada faced allegations of manslaughter but prosecutors did not indict him. In 1997 the Japanese Diet (parliament) opened the way for Japan's first organ transplant in 30 years by approving an amended version of a bill that authorized organ transplants from brain-dead donors under strict conditions. The original bill raised controversy because it plainly defined brain death as human death. The legal definition of death as adhered to by the police in Japan currently requires confirmation that the heart and lungs have stopped and that the pupils of the eyes have dilated. The revised law sidesteps the issue of legal definition of brain death and instead provides that brain death signifies human death only when a donor is tested and confirmed to be brain dead by two or more doctors before the removal of organs and their transplant. Japanese doctors can only remove organs from a brain-dead donor when the donor gives written consent in advance to brain-dead testing and the removal of organs, and when the donor's relatives do not object to the procedures. In February 2000, a 44-year-old woman who was declared brain dead following a brain hemorrhage and stroke donated all four of the organs used in recent transplants. The woman's heart went to a man in his 40s. Three other patients later received the donor's liver and kidneys, and all of the operations reportedly went smoothly. The donor carried a donor card and her family consented to the procedure. Only about 2.5% of the Japanese carry donor cards, but more than 13,000 Japanese are waiting for transplants.

There is a serious organ shortage in the United Kingdom. In 1998, 7% fewer transplants were carried out than in 1997, while waiting lists increased by 3%. There are fewer fatal car accidents thanks to seat belt legislation, but efforts to increase the donor pool by advertisements urging people to carry donor cards have not been successful. Patients and their doctors are frustrated by long waiting lists, which for many means a steady deterioration in their condition. From 1995-1999, about 1,000 patients died while waiting for a heart, heart and lung, lung or liver transplant. The current regime in America, the United Kingdom, and Australia are described as "encouraged voluntaristic" or "opting-in" systems that require the direct, expressed consent of the donor and, almost always, the donor's family. The English situation contrasts with some of Europe's success stories, notably that of Spain.

The Organizacíon Nacional de Trasplantes (ONT), established in 1989, transformed Spain's transplant service from having a shortage to exporting surplus organs to neighboring countries. Spain rose from one of the lowest donation rates in the world to become one of the highest, going from 14 to 25 donors per million population (pmp). This increase followed nationwide implementation of a standard donation process, focusing responsibility for handling the donation process with hospital-based donation teams. Hospitals are held responsible for their performance in donation. The first transplants were performed in Madrid and Barcelona in 1965. In 1986, a law was passed that allowed obligatory donation unless a refusal was registered in the national computer. The ONT was formed to address the problem of declining donation rates and instituted a formal but flexible management structure. Their integrated approach, with the appointment of national and regional people in charge of ensuring that the Transplant Coordinators (TCs) working at the "grass roots" have a sense of involvement and accountability for performance, led to a steady increase of organ donor rate from 14.3 pmp in 1989 to 22.6 by 1993. Spain's 43.8 kidney transplants in 1996 was achieved despite the fact that Spain also reached the largest reduction in traffic road accidents of the European Union during the last 3 years.

Nations debate about the relative merits of laws that "presume consent" (unless the individual has "opted out") and those that require either the positive consent of the donor (via donor card or register) or the consent of relatives. Belgium, Austria, Finland, France, Norway, Spain, and Singapore implement "presumed consent" (sometimes referred to as "implied" consent) public policies. Since 1976, France's presumed consent (PC) law has produced increases in organ donation approaching 5,000%. Austria passed its PC law in 1982. By the end of 1990, the number of patients receiving kidneys was nearly the same as the number on the waiting list. Belgium passed its version of PC in 1986, and organ donation climbed by 183%, with multi-organ retrieval significantly increased to 119% for kidneys.

Some think that countries condoning "presumed consent" approximate "routine salvaging of organs." William Person describes the French "Caillavet Law" as based on the "Good Samaritan" principle but that it gives "greater weight to the needs of the transplant recipient than to the possibility that the individual will of the donor has been violated." The origin of divergence between the advocates and opponents of presumed consent lies in the ethical assessment of tolerable risk. Advocates of presumed consent find cases of false positives permissible. Opponents perceive a "statist," non-individualistic intent behind presumed consent. "Statism" is the principle of concentrating extensive economic and political controls in the state. Liberal societies assume that the individual, not the state, should control his or her physical disposition. Exceptions to liberal individualism must meet a severe test, as in wartime when the coercive military draft is premised on the need to serve vital national interests.

Currently the policy status quo in the United States is a state-centered approach relying on the use of the back of driver's licenses, applications for driver's licenses, or the distribution of donor cards to be carried with or attached to the driver's license. Fifteen states require Department of Motor Vehicles employees to ask applicants for driver's licenses if they would like to be a donor. Twenty states include the donor question on the driver's license application itself. However, the approach is uncoordinated across the states. Not only is there no centralized collection of donation preferences but not even the same data points are collected. The United Network for Organ Sharing (UNOS) Ethics Committee recommends a national policy of "required response" to replace wasteful uncoordinated state-level programs with a uniform method of collecting and disseminating donation preferences to procurement organizations. They believe that it would accelerate the historical increase in the number of Americans who have indicated a willingness to be organ donors. As adults increasingly "opt-in" to the donation system by expressing "yes" via required response, the practical necessity of checking the database recording preferences would diminish over time.

"Mandated choice" laws require citizens to declare whether they want to donate their organs or not. In 1996, Sweden instituted a mandated choice law, in which all adults were required to choose between donating or not donating their organs. There was an immediate increase of 600,000 potential donors. A similar 1990 law in Denmark increased their donor registry by 150,000.

Several economists and lawyers in America have proposed providing financial incentives or rewards to promote organ donation. In such a system the donor's beneficiaries would receive some type of benefit (e.g., monetary or hospital care credits) as part of the donor's estate. Such payments would be made if the organs were retrieved and used. J. Blumstein of the School of Law Vanderbilt University argues that this solution would eliminate "the exclusive reliance on altruism" as well as adhere "to principles of autonomy and individual choice of donors and their families." Lloyd Cohen, Professor of law at George Mason University, claims that financial incentives or rewards for donors and/or their beneficiaries would alleviate America's organ shortage. Congressman James Greenwood of Pennsylvania introduced legislation to use federally-financed life insurance programs as an incentive for people to donate their organs. They conclude that financial incentives would produce enough organ donations each year to meet current clinical demands. Evidence from Egypt and India suggests that such inducement works, involving a contract for sale of organs upon the donor's death. This policy is not to be confused with the sale of organs from living donors, which ethicists maintain should remain unsupported.

There is an organ shortage crisis but it is a crisis with a cure. Encouraging people to speak about organ donation and transplantation and to make their wishes known to their relatives could change the picture resulting in 93-94% of people allowing donation. When the wishes of the deceased are not known, only 50% of people will agree to organ retrieval from their relatives. The approach to the relatives of a potential donor is most sensitive, given that it coincides with the distress surrounding death, particularly if that death is sudden or unexpected as is so often the case when the patient is young. There is evidence that relatives will rarely refuse to allow organ donation if the donor has previously made clear his/her willingness to donate. Many donor relatives have stated that donating their loved one's organs does not make the pain of their death disappear but that it gives their death meaning: that something so positive comes from tragedy. Bereaved families can experience comfort that their loved one's gift gave another person a second chance at life.

It is hard to discuss your own death; that stops many people from talking about organ donation. Some people may discuss it when making their prepaid funeral arrangements. Mentioning organ and tissue donation in a will is too late for transplantation by the time the will is read.

Remember that the most important thing that you can do is to tell your family about your decision. Remember also that any one of us could one day require an organ or tissue transplant. It's a two-way street.

The author would like to thank Christine Wilson, a kidney transplant recipient, for assisting her with the initial research.


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