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Medical Ethics and Organ Donation: Greasing the Slippery Slope

Posted Aug 27 2009 12:00am
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.
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