ORIGINAL ARTICLE
Issues in Organ
Transplantation
Dr B N
Colabawalla
When we scan the history of human civilisations it
becomes evident that the evolution of ethical concepts has preoccupied
philosophers, ethicists, sociologists, theologians, professionals and indeed all
of society. We then have to assume that evolving ethical concepts is deemed as a
necessity for guiding individuals and societies with a view to furthering their
wellbeing.
To begin with we must be clear as to what we mean
by ‘ethics’, a word often used synonymously with ‘morals’. Morals or moral
philosophy pertain to the prevailing attitudes, beliefs and rules of behaviour
in a given society, are influenced by the thought processes propagated in the
environs of the time, and are therefore subject to change. Ethical philosophy is
concerned with the analysis of these moral values to offer some guidelines on
whether the moral philosophy is appropriate or otherwise.
Ethical value systems and moral principles must be
pervasive in all sections of society and particularly in those expected to
provide leadership, such as in politics, the administrative services and the
professions. A down-gradation in one section can have unwholesome effects on
other sections. Witness today the consequences of the low standards of ethics
and morals in politics in our country. Medical professionals are a part of
society; they cannot stand on a separate pedestal, and must be on their guard
against such down-gradations affecting them.
To summarise, ethical philosophy is necessary to
evolve principles which aim at preserving those parts of the heritage of human
societal structures which have served us in good stead and which further the
well-being, integrity and dignity of human beings.
Evolution in medical
ethics
We have come a long way from the ethical
principles enunciated by Hippocrates. Since then have evolved the Hammurabi
Code, the Islamic Code, those laid down by Sushruta and Charaka, and down to the
Geneva Declaration of the International Code of Medical Ethics formulated in
1947 and amended in 1968, 1983 and again in 2000.
Medical ethics is closely interwoven with societal
morality in each era of civilisation and is influenced by philosophical,
theological, and scientific advances. Today we are experiencing an unprecedented
explosion in science and technology which in turn influences concepts in medical
practice. Whilst they have undoubtedly benefited mankind in many areas, they has
often been mis-utilised. Medical professionals have become over-dependent on
technology, dehumanising medical practice. These advances then pose dilemmas of
an ethical, moral, sociological and theological nature.
By its very definition the word ‘dilemma’ implies
that there can be more than one answer to a specific question. We have then to
discern between a technology’s beneficial effects and those ineffective, even
harmful to the individual patient. It may be argued that concepts of ethical
philosophy are too abstruse and generalised and may not be applicable to
specific instances in which moral philosophy is causing a dilemma. This is a
misconception. The tenets of ethical philosophy can be juxtaposed to such
specific instances where moral philosophy needs to be critically analysed. This
brings into relief what Peck has described as ‘code ethics’ versus ‘situational
ethics’. Application of the tenets of ethical philosophy can then offer an
ethically acceptable and practicable solution for society.
It becomes necessary then to keep up a constant
review of our ethical value systems without compromising its basic tenets but
taking into considerations economic and societal realities. There are four basic
pillars on which our concepts of medical ethics rest today. They
are:
Beneficence: this entails that
whatever treatment we utilise does not harm the patient. It also demands that
any intervention must be done with the purpose of preventing, removing or
mitigating any harm that may have been caused.
Non-maleficence:this means that
in the first place we should not act in any way which may cause harm to the
patient.
Autonomyof the individual is
today universally a well-accepted doctrine. This autonomy must be respected. The
days of ‘medical paternalism’ are gone.
Society has a vested interest in the profession and
expects that our actions will be based on social justice and responsibility.
Based on these foregoing introductory remarks, I
will venture now to offer some observations on ethics of organ transplant.
Evolution of ethics in human organ
transplantation
In 1831 when Jeremy Bentham wrote an essay entitled
‘Of what use is a dead man to the living?’ he could not have foreseen the advent
of modern technology which now makes it possible to transplant human tissues and
organs. I mention this to re-emphasise that scientific and technological
advances call for a constant re-orientation of prevailing concepts.
Secular and theological thinking has for centuries
considered the ‘principle of totality’ inviolable in order to maintain the total
integrity of the human being. Hence any destruction of the human body or its
parts is contrary to this principle. However, in the past four or five decades,
this principle has been analysed in view of the need for tissues and organs for
transplantation, to benefit other human beings. Thus ethical principles have
evolved to suggest that transplantation would be within the bounds of ethics if
certain criteria are fulfilled, in instances of living donor transplantation.
These are:
- The removal of the tissue or organ does not impair
the health or functional integrity of the donor.
- The benefits expected to be given to the recipient
bear an acceptable proportion to the harm likely to the donor.
- The donation should be altruistic and is given
without any coercion or any other form of external pressure.
- The donor must be fully informed of the nature of
the procedure and the possible — even if rare — complications. This
entails the need for follow-up of the donor’s health in the
future.
- The views of close relatives such as the spouse or
adult children are taken into account.
- There must be no element of commercialisation or
exploitation in the donation.
It is not always easy to establish with any degree
of certainty that all these criteria were met in an individual case. However
these criteria offer a basis on which we can comprise our ethical
principles.
Ethics in genetically-related living donor
transplantation
It will suffice here to say in this context that if
the criteria for donation enumerated earlier are satisfied, there is ethical
justification in accepting the donation. I will still stress that the donor must
be made fully aware of the nature of the procedure. His or her psychological
make-up should be taken into consideration, as should be the views of the donor
family. We must, to the best of our ability, establish that there has been no
undue coercion. All these require communication skills (which, along with
concepts of ethics and the history of medicine, are never imparted to us as
undergraduates).
Ethics in non-related living donor
transplantation
This form of transplantation raises some specific
issues of ethics for medical professionals and grave issues of social morality,
since it is inevitably connected with the commodification of human organs. The
shortage of donor tissues and organs has encouraged ‘market forces’ and the
commerce in human organs. I restrict my remarks to our country and the
experiences in live non-related donor transplantation of kidneys.
The question we need to pose is: can the criteria
as laid out for live donor transplantation be fulfilled in non-related donor
transplantation?
Take the basic criterion of altruism and its
negation by commercialisation. Whilst altruism may be a genuine motive in the
rare case, we all know that in the vast majority of cases the motivation is the
financial reward. As for voluntariness, what greater coercion can there be than
dangling the promise of Rs 30,000-40,000 before a poor donor?
As for informed consent, I wonder if illiterate and
economically depressed donors are given full details in a language understood by
them, and whether their families are taken into confidence. Informed
consent consists of more than a signature on the dotted line. Do medical
professionals confirm voluntary informed consent through a personal discussion,
and is it duly and faithfully recorded in the case papers?
The other important criterion is that there shall
not be any commecialisation or exploitation. Commercialisation is self-evident.
Exploitation should be a matter of concern to society. The most lurid is that by
the middleman or broker who thrives on the gullibility of the illiterate or on
the economic strain of the weaker sectors of society. How much of the sum
actually goes into the donor’s pocket is a matter of guess work. Then there is
the exploitation of the donor’s poverty by the rich recipient. It is argued that
the poor man needs the money which the rich man has with him to give and thereby
a little redistribution of wealth is made. I venture to suggest that it is a
redistribution of health from the poor — who can ill afford it — to the
rich. The inequity of the situation is surely against the grain of social
ethics.
It is argued that individuals are free to donate
their kidney for a price, as much as they are free to sell their labour or
other services. It is also argued that individuals have freedom of action. There
are grave dangers to moral values of society in such propositions.
The freedom of individuals to behave as they wish
is always circumscribed by the needs of the greater good of social morality. The
proposition pits a distorted value system of individuals in need and their
methods of obtaining that need against established value systems of organised
society. If society accepts the trade in human organs, it will be replacing the
concept of the human organism’s intrinsic value with the extrinsic value of the
human body or its parts, making them a commodity. This destroys individuals’
autonomy and dignity. There are also dangers of extortion and even
criminalisation, as the recipient’s identity may be known to the donor and his
family.
In this situation, the dilemma before the medical
fraternity is acute when faced with a patient who has no family donors or
chances of obtaining a cadaver donation within a reasonable time, and cannot
afford chronic dialysis. Do we let such patients die? Do we refuse them a
non-related donor transplantation? Out of sympathy for such patients, I
would like to evolve a strategy which separates transplantation from the nexus
of commercialisation. But I find myself groping in the dark. I am aware that the
latest Human Organ Transplantation Act provides for some safeguards, but there
are many loopholes. Non-related donor transplantation can be carried out
provided all aspects of the procedure are approved by what an ‘approval
committee’. But who does this committee consist of besides medical bureaucrats?
Does it receive advice from lawyers, ethicists, sociologists, psychologists,
etc. to help it make its judgements? I am skeptical of that.
A rather novel concept has been floated, of
‘rewarded gifting’. I consider this merely a terminological subterfuge. It
represents the commodification of human organs while placating professionals. I
did not realise that one gives a gift and expects a reward! I find the
arguments of protagonists of this concept specious and am unable to find an
ethical compromise which safeguards social morality.
Obligation to the recipient and
family
Recipients must be fully informed about the nature
of their illness. They must be given a choice in the modalities of treatment,
namely haemodialysis and transplantation. They must be given a clear picture of
the nature of the operation and its likely sequelae, both immediate and long
term. Recipients and their families have to be informed of the economics of the
treatment, particularly the need for post-transplant medications which can be
expensive. It is distressing to see families face economic ruin on account of a
transplant, with the liquidation of all their assets and the compromise of other
family members’ future. In this context, professionals must exercise
extreme judgement in advising transplantation for patients with
contraindications to the procedure. They must estimate the chances of success.
They must take the moral responsibility of advising the family clearly on the
issue.
Ethics in relation to cadaver organ
transplantation
It might seem that that there are no serious
ethical problems in this form of organ transplantation but there are some
issues.
There are many theological and religious concepts
expressing the inviolability of the human body even after death, in the belief
that the body should reach the other world as a whole. However, it has been
argued that if we believe in the concept of reincarnation, we are concerned only
with the ‘spiritual passing away’ of life, leaving our physical bodies as empty
shells. It would then be within the bounds of ethical principles, both
theological and sectarian, to allow such bodies or their parts to be used for
the benefit of humanity. Today many theologians of various religions share this
view. Still, there will be groups and families who adhere to the stricter
religious concepts. Professionals are ethically bound to respect their
sentiments when approaching the subject of organ donations.
This brings us to some of the ethical dilemmas in
cadaver donation programmes, namely of establishing priorities in the
choice of patients to receive a cadaver kidney, as the demand will far outstrip
the supply. This will be all the more applicable when one donor matches more
than one potential recipient. The question is: what parameters should we employ
when excluding so many in need? Is it age? Should a judgement of whether the
patient’s economic resources will allow for for long-term success be made? Is it
dictated by the need of the family to have an earning member restored to health?
Is it by the importance of the individual to society? Should it be purely on
medical grounds? Or shall we make the final choice by drawing lots? Such
dilemmas cannot be easily resolved but need to be addressed.
Ethics in relation to
society
Throughout history we observe that the practice of
medicine has been closely intertwined with the social, economic and moral
texture of society. All advances in medical science have always promised an
impact on society. But the medical technological advances of the past two or
three decades have been so phenomenal that society is often left bewildered.
There is always a time lag between the advent of such advances and the time
required for society to absorb their impact. This places a moral and
ethical duty on professionals to be explicit in our approach and
explanations. We have to help society make what Illich calls ‘social
assessment of technological progress’. We are an integral part of society and we
cannot isolate ourselves on a pedestal by assuming a posture that we are only
concerned with our technical perfections and service without reference to social
needs and morality. Morality in medical practice has no different dimensions
than morality in other sectors of society. The finger that points to lack of
morality and ethics in other sectors may also be pointing at us.
The concept of brain death — or more
precisely brain stem death — has created problems for society to understand.
This places two types of ethical and moral burdens on professionals. They must
convince society of the ethics of brain stem death, and if the concept is
accepted ensure that the criteria of brain stem death are clearly articulated
and scrupulously enforced.
If society expects (and rightly so) medical
professionals to maintain high levels of ethical and moral standards in the
execution of organ transplantation programmes, professionals will expect that
society will also undertake to bear its responsibilities — to mobilise its
economic, man-power and other resources for the purpose. It must promote
awareness of the issue and the need. It must reorient social ethics on these
issues. Society will have to foster and sustain such activities and thereby also
act as a watchdog. If society shirks its responsibilities today, it may not have
a second chance tomorrow.
I would like at the end of this article to say that
the views expressed in this article arise from my personal perceptions of the
issues. Let them be debated by society as a whole and medical professionals in
particular.
Dr B N Colabawalla, Ben Nevis, Bhulabhai Desai Road, Mumbai 400
026.
