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Jul-Sep2002-10(3)
REPORTS
Discussion on transplant
ethics
Rajan Patil
I would like to share comments made during a lively
debate at the first international medical sociology conference in Chennai on May
25-26, 2002.
The debate revolved around issues of informed
consent and the ethics of live unrelated donation. What should the transplant
surgeon do when recipient and donor are unrelated but produce papers to legally
establish their biological relationship? What if donor and recipient admit they
are unrelated but the donor claims that he is willing to donate a kidney on
altruistic grounds? Transplant surgeons participating in the debate said that
very often the donor is an employee of the recipient, who has voluntarily
consented to be part of the operation, fully knowing the possible risks
involved. Surgeons confessed that they were helpless when they were sure that
their patient is biologically unrelated to the donor, but the patients possessed
the required legal documents in support of their claim; one knows how easy it is
to get forged affidavits from the concerned authorities in India.
The broader predicament for surgeons is: should
they be judgmental in such situations when there are no legal impediments to the
transplant? When unsure, surgeons are required to refer the issue to the ethical
clearance committee concerned with the kidney transplantation. Mr N Ram, editor
of Frontline, mentioned that in Karnataka the committee had received more than
1,000 cases for clearance - and only 22 cases were rejected, because the
papers were not in order. Some of them subsequently brought 'appropriate' papers
and got clearance.
Two transplant surgeons felt that they need not be
judgemental when donor and recipients are medically eligible and fit for the
transplantation, their legal documents are in order (genuine or otherwise), and
the donor has given voluntary informed consent. They also said the HLA typing
test carried out to verify the relationship claim is not 100 per cent reliable.
In this context, surgeons have no option but to undertake the operation.
Moreover, they say it is especially warranted, since the demand for kidneys far
exceeds the availability from cadaver (brain stem death) organs.
This view was strongly contested by those who felt
surgeons could always take a moral stand and refuse to be part of a operation
when they suspected the donor of participating for an incentive.
On the question of gender bias in organ transplants
(there are more live unrelated female donors than male donors), a participant
questioned the ethics of denying a woman's freedom to make an independent and
informed decision, when she is desperately in need of money and wishes to donate
her kidney to repay a debt. Failing this option, she may see prostitution as an
option.
Transplant surgeons also questioned the integrity
of kidney transplants among related donors. They cited examples of sons
donating a kidney to the father in exchange for educational sponsorship or other
financial incentives. Should such transplants be allowed just because they are
biologically related, even though it is clear that compensation is involved? How
does one verify the integrity of the relationship in related kidney
donation?
Others feared that if unrelated donation were not
regulated, people would prefer (buying) kidneys from unrelated donors - cheap
for Rs 40,000-60,000 and without risk to their relatives.
Rajan Patil, Community
Health Cell, No: 367, Srinivasa Nilaya, Jakkasandra, Ist Main, Ist Block,
Koramangala, Bangalore, 560 034. Email:rajanpatil@yahoo.com