Organ Transplantation and Biomedical Ethics: An Analysis of Hospital Organ Transplantation Policy and a Proposal of Ethical Guideline

Han, Sung Suk; Hwang, Kyung Sig; Meng, Kwang Ho; Lee, Dong Ik; Um, Young Rhan; Koo, Young Mo

Abstract

AIMS: This study was done to develop an ethical guideline for organ transplatation, a life-saving treatment which helps improve the quality of life.
METHODS
This study begins with a survey of the Korean current state of affairs concerning organ transplantation. This study used a survey questionnaire and received responses from 31 hospitals out of 45 hospitals where organ transplantation are being done. After this survey, followed by a discussion of ethical considerations in arranging organ transplants. Before proposing an ethical guideline, this study discusses a series of interesting ethical issues in transplanting(both living and cadaveric)organs including ethical foundations of organ transplantation, distributive justice and matters of donor's consent in organ transplatation.
RESULTS
The foremost research for this study boils down to a survey paper titled, "An Analysis of the Current State of Affairs Concerning Organ Transplantation and Ethical Considerations in Domestic and International Hospitals." Based upon data collected from various hospitals, this work analyzes items, such as the frequency and types of organs transplanted in a hospital, the existence of organ transplant coordinator, the performance of the hospital ethics committee, and ethical considerations in obtaining consents from the living donor. Although thousands of organs are annually transplanted in domestic hospitals, virtually none of them are found to meet ethically proper standards. The paper points out the need to institutionalize a nationwide cadaveric organ distribution organization like UNOS(United Network for Organ Sharing) in the U.S., and proposes to stretch out the national health insurance to extensively cover transplanting expenses. "The Ethical Foundation of Organ Transplantation", the author counts three key ethical principles in organ transplantation: the principle of respect for autonomy; the principle of beneficence; and the principle of justice. He argues that in cases of living donor no principle should take precedence over the principle of respect for autonomy and thus it is very important for a hospital to obtain the donor's consent. As for cadaveric organ transplantation, he holds reservation because he is worried that serious shortage of organs for transplantation in conjunction with pure utilitarian considerations could change the definition of death so that the brain death gains more popularity than ever. In addition, the author claims that the proponent of organ transplantation must distinguish the moral dimension of the discussion from the legal one because otherwise she would hardly be able to defend herself from the slippery slope argument against organ transplantation. This paper concludes with a note that we must implement restrictions to avoid undesired effects if organ transplantation could ever be justified. "A Discussion of Distributive Justice in Organ Transplantation" comprises two parts. The first half delineates above mentioned ethical principles in the context of organ transplantation, while the second half goes generally over the UNOS Point System. This work is focused entirely upon cadaveric organ transplants, because the vast majority of organs available for transplants comes from cadavers and the number is still increasing. The UNOS allocates cadaveric organs based upon both medical and justice criteria. Following are summaries of the UNOS policy on organ distribution. Every potential recipient of organ transplants must be listed on the UNOS computer system waiting list. Allocation of cadaveric kidneys consider factors such as waiting time, six antigen match, panel reactive antibody, blood group and age. The UNOS Point System allocates livers to the local patients first, followed by regional and national patients respectively, in order to limit ischemic time. A recipient of liver transplant belongs to one of five(0~4) medical status levels where status 4 is the most medically urgent. At the regional and national levels pancreas are allocated first to patients with excellent HLA matches, while at the local level waiting time is the sole factor. The intestinal organ allocation system is based on two(1~2) patient status codes, ABO blood type identity and time waiting. In heart or lung tranplants ischemic time seriously matters. "A Biomedical Study of Informed Consent from the Organ Donor" investigates several topics: the relevance of the principle of respect for autonomy as the basic principle of informed consent; how the autonomy of the organ donor to be respected; and the role of the hospital ethics committee in obtaining informed consent from the donor. The author finds the principle of respect for patient's autonomy not sufficient for the basic principle of the living donor's informed consent because there is some danger in which the patient may be left uncared-for, and thus she suggests that the principle of nonmaleficence and the principle of care also be considered. That the principle of respect for autonomy turns out not sufficient even for cadaveric organ donation, and so judgment based upon the best interest of the deceased may seem appropriate for people from some special groups. A medical team must make efforts to identify the donor's competence and voluntariness, i.e., preconditions of informed consent. All the relevant medical information should be disclosed to the living donor. Once the donor makes a judgment, medical experts should respect the donor's decision. This article puts an emphasis on the role of the hospital ethics committee in such activities as identifying donor's voluntariness, confirming the disclosure, and evaluating the minority's benefit. The last work in this paper, "A Moral Theological Investigation of the Presumed Consent in Organ Transplantation" talk about Principium Riflexum(the principle of reflection) in an attempt to explain the possibility that we may harvest cadaveric organs from the deceased who while alive had never expressed their wishes concerning organ donation. To apply the principle in the context of presumed consent, the author, a Catholic priest, introduces two elements of the principle. Probabilismus allows us to feel free to choose when we face dubious matters(in dubio libetas), and by the rule of selection we are justified in choosing whatever our consciousness mandates. He takes both elements to support the presumed consent of the deceased because he believes the good that people may contribute to their neighbors by donating organs would obviously override opposing reasons. Although the author argues for the presumed consent from the deceased, he does not overlook the family grief in donating the cadaveric organs. He concludes with a suggestion that we should work to keep the public aware of cadaveric organ donation and to form public opinions education should play a key role.
CONCLUSION
Researcher suggest an Ethical Guideline for Organ Transplantation as our study conclusion. 1) Body organs may be transplanted to protect the health and well-being of the patient, but not for the medical or scientific research. 2) Body organs may be taken for transplantation, only with the consent from the donor. In cases of cadaveric donors who have left no formal consent in the lifetime, they are to be presumed to refuse to donate body organs. 3) In principle, cadaveric transplantation is preferred. Living donors are limited to competent adults who have blood ties with the patient, e.g., parents, children, or siblings of the patient. However, reversible tissue like bone marrows donation may be an exception to this limitation. In particular, no living donors may be put under inappropriate pressure or influences. Body organs may be taken from the living donor only if based upon sufficient and easy-to-understand information provided, the donor voluntarily consents after (s)he deliberately balances benefits against harm. 4) Under no circumstances human bodies, organs, or tissues may be sold or purchased for transplantation. A physician should not participate in any transplanting operations if (s)he becomes to know that the transplant has been obtained through a transaction. 5) Recipients of organs for transplantation should be determined in accordance with the principle of justice on the allocation of limited medical resources. 6) When a vital, single organ is to be transplanted, the death of the donor shall have been determined by at least one physician other than the recipient's physician. 7) Transplant procedures of body organs should be undertaken (a) only by physicians who possess special medical knowledge and technical competence developed through special training, study, and laboratory experience and practice, and (b) in medical institutions with adequate facilities. 8) All decision procedures in transplanting body organs should be objective, open to parties involved, kept accurately on record, and maintained for a given period of time.