The purpose of the essay is to address a two-fold objective:
(1) to discuss organ donation; and (2) to identify legal and/or ethical issues relating to organ donation.
The last resort and treatment of choice for end-stage organ disease patients undergoing organ failure is organ donation or transplantation (Pozgar, 2010, 73). Organ donation is one of modern medicine’s miracles, which has made it possible to live longer and healthier for people with organ failure.
Organ donation is an evolving and growing practice in the health sector, as this care is pursued by many individuals with organ failure. Due to better patient selection, enhanced clinical and organizational management abilities, and the discovery of the immunosuppressive drug cyclosporine A, which solves the problem of tissue and organ donation, the picture of organ donation has continued to improve throughout history. The general public interest, legality, ethical concern, and medical practise have culminated in organ donation, despite the approval of the majority of the public. The paper will also aim to address the legal and ethical concerns concerning organ donation and the issue of mismatch in supplying organ demand. In addition, the paper would also answer the issue of whether a patient should be listed as deceased and a candidate for donation of organs, to which organs should be transplanted in compliance with current ethical and legal standards, and who will determine who will survive or die.
Organ donation can be traced back to history to tackle this issue. Three of the learning goals of this course will be explored in terms of ethical and legal dilemmas: review of the ethical values of human integrity, compassion, non-malfeasance, and social justice, examination of elements of autonomy, loyalty and confidentiality, and explanation of the process of organ donation and cultural diversity for ethical decision-making.
Organ donation began in the 1950s, when the first kidney transplant was performed by surgeon Joseph Murray in 1954. It was followed in 1967 by the first human heart transplant by Christiaan Barnard, a Cape Town, South Africa, surgeon.
Organ donations were heavy and angst-provoking throughout the 1950s. In periods when the availability of organs was scarce, surgeons were obliged to select who among the patients would survive or die by establishing criteria for organ recipients. That was also when, due to the unavailability of immunosuppressive cyclosporin A before 1978, the problem of organ rejection and insufficient and dangerous antirejection drugs became raised as an ethical dilemma.[sociallocker]
As time goes on, not just in quantity but also in complexity and variety, concerns surrounding organ donation and transplantation have increased. In the 1950s, ethical questions turned to social pressure for organ procurement as a result of the substantial disparity between worldwide demand for organs and availability and the question of morality and the legal concept of death during the 21st century. Since 2004, kidney donation has decreased, leading to contradictions between interventions aimed at increasing the availability of organs through increased donor and high-risk donor requirements, and the lack of sufficient risk adjustment in the analysis of patient outcomes (Klein et al. 2010, 974). In 2006, through the Secretary of the United States, OPTN (Organ Procurement Transplantation Network) began to develop policies for the donation and transplantation of living organs to facilitate protection, education, data collection and supervision. Human Services and Wellness. In 2007, when changes were made to the UAGA (Uniform Anatomical Gift Act) requiring the attending doctor to consult with the patient or surrogate as early as possible to assess and follow the patient’s wishes in terms of transplantable organs, the consent of patients and surrogates to organ donation was highlighted (Truog, 2008, 1209). Order to enhance the role of transplants, increase the donor pool, and balance organ demand to supply and minimize ethical, legal, and medical conflicts, researchers are actively looking for improvement in the current protocols.
Ethical Issues in Organ Donation
Human dignity, compassion, non-malfeasance, and social justice.
Respect for the patient who dies requires respect for human dignity (Bernat, 2008, 670). Owing to distinctions in the understanding of a respectable burial, human integrity is often undermined during organ donation. For instance, many are hesitant to organ donation because people believe that to die with dignity involves having intact organs. In addition, a patient may also view death with dignity as the process of withdrawing from life-sustaining therapy and the provision of palliative care (Bernat, 2008, 670). The family decision is also an essential category for respect for human dignity. Family members feel that they are treated with dignity and respect if information about organ donation is presented in a consented and understandable manner. Conflict arises when the family has a different perception of human dignity with the patient and when death is perceived differently from other members of the health care team. Thus, it is essential that the definition of death be clearly defined in order to provide a conceptual basis of death determination, explain the relationship between neurological and circulatory-respiratory grounds of death determination, and enhance the uniformity among legal boundaries of organ donation by proposing and justifying a standard model (Bernat et al. 2010, 963-964).
Meanwhile, compassion is an important and sensitive issue as the preservation of human dignity in patients and family members. Research in the United States has stated that some of the reasons why health team members are confronted with ethical dilemmas in organ donation include emotional exhaustion and inadequate staff sensitivity and compassion (Jacoby & Jaccard, 2010, 53). At times, the success or failure of organ donation is affected by how a member of the health care team shows concern for donor patients. By engaging with the families of the patients about organ donation and showing respectful treatment, nurses and doctors play a crucial role in delivering compassionate care. Members of the health care team must recognise that the decision to donate one’s organ is emotionally debilitating for the members of the family; therefore, it is vital that they encourage families to take their time in the decision to donate, provide information support on organ donation and brain death, give emotional support, and list instrumental support as these are all actions that will demonstrate compassion. Demonstrating compassionate care also encompassed non-maleficence because care rendered means no harm. Substitute consent to extracorporeal membrane oxygenation (ECMO) protocols in the donor after the death declaration enables much more than invasive intervention in organ donation, which requires the placement of arterial catheters before death because they agree that these procedures are minimally harmful to the patient and that they support the recipient of the organ (Bernat, 2008, 670). However, this act of non-maleficence contradicts with the ethical principle of dying with dignity and respect.
The emergence of ethical issues does not stop once a decision is made. Another moral problem arises when allocating donated organs to the needing population. A decision on who will decide a patient who will live or die is the most pressing and stressful decision on the part of the jury or judges. Since the 1950s, decision-makers have faced scarce health care resources, and the supply of organs and social justice is an ethical decision that decision-makers cannot overlook. First-come/ first-served is an example of a guideline for allocating organs to multiple recipients. First-come/ first-served is based on the principle of fairness and is the closest guideline to achieve social justice in organ donation. For instance, if a decision will be made based on the medical entitlement method, the sickest patient will be prioritized on the list. However, patients chosen under this criterion have a low success rate, and the donated organ may not fit the deteriorating condition of the patient. If donated organs would be allocated in terms of social worth, decisions of the jury might be perceived as a result of value judgment as recipients are selected based on their self-destructive behavior or potential for rehabilitation. Consider the case of an alcoholic patient. Does the decision team have the right to say that the alcoholic patient is not worthy of living because he is an alcoholic? This method of allocating organs will only ignite more ethical issues because it discriminates and attacks the previous behavior of the individual to justify ineligibility to organ donation. Another option is the utilitarian-consequential perspective, which is based on the long term survival and a higher quality of life. If this will be used to allocate organs to multiple recipients, how can the decision-makers determine who will survive longer? Just like the social worth method, the utilitarian-consequential perspective only raised ethical debates on how to distribute scarce resources.
Elements of autonomy, fidelity, and confidentiality.
Obtaining a valid informed consent for organ donations from patients or surrogates before the withdrawal of life-sustaining treatment and in organ donation is a better approach to organ procurement that protects the autonomy of the vulnerability of patients against possible abuse (Truog & Miller, 2008, 675). Consent from patients indicates their capability to decide on their own regarding organ donation. If there is a circumstance that the patient is mentally incapacitated, surrogates, or families have the right to decide whether they would donate the organ or not. In addition, it is not wrong for cadavers to retrieve vital organs before death provided that there is consent and anesthesia is administered to preserve the dignity of patients. For a valid informed consent, it must be obtained from the patient or patient’s legal decision-makers with all the information related to organ donation such as risks, complications, operating room, relevant hospital personnel, and withdrawal of ventilatory or organ-perfusion support being communicated to the decision-maker (Reich et al. 2009, 2007). A valid informed consent characterized all the ethical requirements for organ donation because it respects the autonomy and desire of those who wish to donate the organs, respects human dignity, and maximizes the number and quality of organs available to those in need. Thus, the available evidence suggests that informed consent is associated with increased organ donation rates (Rithalia et al. 2009, 7). In addition, Jacoby & Jaccard (2010) stated that the provision of informational support regarding organ donation is the strongest predictor of consent to donate organs (p. 59). Meanwhile, informed consent must not only encompass autonomy or self-determination but fidelity and confidentiality. Fidelity is the act of keeping promises, and this can be done by adhering to all the inclusion in the informed consent and providing care related to organ donation according to the standard protocol. Assurance of confidentiality must also be upheld because exposure of the identity of the recipients puts them at risk for individuals who wanted to earn money through organ selling.
The organ donation process and cultural diversity in ethical decision-making. The organ donation process starts with the selection of potential donors. Organ donors may include those who die trauma, stroke, primary brain tumor, cerebral anoxia, and even homicide and suicide victims with permission from a medical examiner (Westrick & Dempski, 2009, 132). Screening is done to detect ineligible candidates for organ donation, such as those with the transmissible disease. Donors are then classified as a cadaveric organ donor, living-related organ donor, or living related organ donor. Once preliminary criteria have been met, a health care team member or family member will alert the OPO for potential organ or tissue donation. Prior to donation, coordinators will evaluate the donor by obtaining information about the time and cause of death, past medical history, and immediate medical condition (Westrick & Dempski, 2009, 133). Medical contraindications are ruled out, and families are offered with the option for donation. Information about organ donation will be discussed, and informed consent will be obtained.
The choice of donating or accepting an organ varies between countries, cultures and religions. For instance, Singapore and Belgium encouraged kidney donation with evidence from the statistics stating an increased from 18.9 to 41.3 per million population per year over a three year period from Belgium and 4.7 to 31.3 per million population increased over a three year period from Singapore (Rithalia et al. 2009, 2-3). The culture of a country, particularly the religion, also affects organ donation. For instance, the Catholic favors organ donation as they value organ transplantation as a service of life. On the contrary, Jehovah’s Witnesses neither donate nor receive organs with respect to the gift originally given by their God (Rithalia et al. 2009, 4).
The most common legal issues surround the topics regarding confidentiality and informed consent. One of these legal issues concerning confidentiality is the Uniform Anatomical Gift Act (UAGA). Under this legislation, a person can decide to donate organs at the time of death, or a potential can carry an anatomical donor card (Pozgar, 2010, 75). The act also encompasses the right of the right to privacy of the donor and his or her family. Legality issues arise because there are deviations of this act or other laws dealing with a donation in some states and countries. Conflicts in the congruency of the law and in respecting the authority of next of kin may also be noted because the act supports the donation by the will, which becomes effective immediately on the death of the testator and is legally valid and effective even without the probate if acted on in good faith (Pozgar, 2010, 75). Even with the implementation of this law, the physician still seeks the permission of the surviving family members when, in fact, there is no need to ask permission due to the presence of legal documentation. In 2006, the UAGA provisioned to strengthen the language barrier in order to firmly establish the decision to make or refuse donations.
The Organ Procurement and Transplantation Network (OPTN) serves as one of the resources for organ donation. OPTN has United Network for Organ Sharing (UNOS), which contains the name of the candidates waiting for organ donation (Westrick & Dempski, 2009, 132). OPTN is also responsible for the policies related to procurement and transplantation. All organ procurement and transplant centers in the US must be members of Organ Procurement Organizations (OPOs). OPOs allocate organs to be donated equitably. Together with the OPTN, OPOs set the acceptance criteria for a donor and make studies and researches that would improve transplantation in the country. OPOs also assure that confidentiality of information is kept to a maximum (except in paired donation) to protect vulnerable persons from abuse and possible monetary again derived from selling organs.
- Bernat, J.L. (2008). The Boundaries of Organ Donation after Circulatory Death. The New England Journal of Medicine, 359(7): 669-671.
- Bernat, J.L. et al. (2010). The circulatory–respiratory determination of death in organ donation. Critical Care Medicine, 38(3): 963-970.
- Jacoby, L. & Jaccard, J. (2010). Perceived Support among Families Deciding About Organ Donation for Their Loved Ones: Donor Vs. Non-Donor Next of Kin. American Association of Critical-Care Nurses: 52-62.
- Klein, A.S. et al. (2010). Organ Donation and Utilization in the United States, 1999–2008. American Journal of Transplantation, 10(2): 973-986.
- Pozgar, G.D. (2010). Contemporary Ethical Dilemmas. Legal and Ethical Issues for Health Professionals (2nd ed.) (p. 47-96). Massachusetts: Jones & Bartlett Publishers, LLC.
- Reich, D.J. et al. (2009). ASTS Recommended Practice Guidelines for Controlled Donation after Cardiac Death Organ Procurement and Transplantation. American Journal of Transplantation, 9: 2004-2011.
- Rithalia, A. et al. (2009). Impact of presumed consent for organ donation on donation rates: a systematic review. British Medical Journal: 1-8.
- Truog, R.D. (2008). Consent for Organ Donation — Balancing Conflicting Ethical Obligations. The New England Journal of Medicine, 358(12): 1209-1211.
- Truog, R.D. & Miller, F.G. (2008). The Dead Donor Rule and Organ Transplantation. New England Journal of Medicine, 359(7): 674-675.
- Westrick, S.J. & Dempski, K. (2009). Organ and Tissue Donation and Transplantation. Essentials of Nursing Law and Ethics (p. 130-136). Massachusetts: Jones & Bartlett Publishers, LLC.[/sociallocker]