RE-EVALUATING DONOR CRITERIA: LIVE DONORS

John D. Lantos, M.D.
Mark Siegler, M.D.
The Center for Clinical Medical Ethies
The University of Chicago

The use of living, rather than cadaveric, donors for organ transplantation remains
controversial.`+ Physicians who consider using living donors face a unique
ethical dilemma. They subject a healthy person to a procedure which entails some
medical and surgical risk and which does not improve or maintain that person's
health. Instead, the risk to the donor is justified by the benefit to the recipient.

This dilemma is often mistakenly perceived as a problem of patient consent.
However, Woodruff noted as early as 1964 that consent is not the crucial issue.
Many competent adults freely consent to self-sacrificial actions for altruistic
reasons. Instead, Woodruff wrote, "The question is not whether the donor is right
to offer to give up his kidney, but whether the doctor is right to allow him to do
so?

Woodruff proposed that solutions to this dilemma would not be found in moral
absolutes but in clinical judgments based on probabilities. He proposed four
relevant considerations for physicians who would consider allowing a person to
undergo the risk of kidney donation. First, he thought that it must be established
that the proposed recipient would die without the kidney (this written in 1964,
before dialysis was available and before brain death made the use of cadaver
organs feasible). Second, the donor must be in good health. Third, the donation
must be entirely voluntary. Woodruff was so concerned about possible coercion
that he thought the potential recipient should not be told that transplant was under
discussion until the decision was made to proceed. Finally, the donor must be
informed of risks, and of the fact that, given the state of the art at that time, there
was a considerable chance that his organ donation would turn out to be of little or
no benefit to the patient. These arguments, Woodruff thought, justified renal
donation in 1964. Many physicians agreed. Live kidney donation became a widely
used procedure.

Since 1964, the circumstances under which live donation is offered have changed.
With regard to renal transplantation, the development of dialysis and the
acceptance of brain death, which allows the timely harvesting of cadaver kidneys
for transplant, have led to alternatives to live donation which can extend the lives
of patients with end stage renal disease. Use of live donation can no longer be
justified as the only alternative to death. Instead, it must be justified as a better

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therapy than alternative therapies, either because it offers better quality of life or
because it offers better long-term outcome. Similar arguments must be made to
justify pancreatic transplants, although they are tougher to make since the
alternative therapy is relatively less burdensome. For patients with end stage liver
or lung disease, by contrast, no alternative to transplant presently exists, so
patients must either wait for a cadaveric organ or consider a transplant from a
living donor.

In spite of these modifications, the approach taken by Woodruff, `which involves
probabilistic balancing of risks and benefits, is still relevant today. Most transplant
surgeons do not consider live donor transplants as unacceptable because they
involve donor risk, however minimal. Instead, in deciding whether to use living
donors, they weigh the relative risks to the donor, which must be low, against the
potential benefits to the recipient. Prudent people might be allowed to consent to
a small personal risk in order to give another person a great benefit, but not a great
risk for a small benefit. Decisions about whether the risks outweigh the benefits
allow for individual variations within areas of general consensus among both
physicians and potential donors.

This paper will focus on what is now known of the risks and benefits of kidney,
`pancreas, liver, and lung transplantation using living donors. We will then consider
ethical and policy issues surrounding live organ donation.

KIDNEY DONATION

j-listory

The first successful kidney transplant, in the mid 195Os, involved a genetically
identical live donor.7 Attempts at unrelated transplants over the next 5 years
were universally unsuccessful. * In the early 196Os, immunosuppression with
azathioprine and corticosteroids led to improved results and cautious optimism.g
By the late 196Os, transplantation using both cadaveric and live donors had
become a standard therapy." During the 196Os, dialysis also developed to the
point where it could be routinely offered. By the 197Os, patients with end stage
renal disease and their doctors faced a choice between live donor transplant,
cadaveric transplant, or hemodialysis. By the late 197Os, peritoneal dialysis
become another widely used alternative. Nevertheless, living donors continued to
be used. By 1984, 32 percent of all kidney transplantations done in the United
States involved living donors."

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Donor Risks

Live kidney donation requires general.anesthesia. Data on the risk of general
anesthesia are controversial. A large recent analysis by Lund and Mushin
estimated the mortality associated with general .anesthesia at 0.1 /l OOO.`*
Mortality estimates from older studies, many of which did not carefully distinguish
anesthesia-related deaths from other post-operative deaths, range from
0.6/l 000'3*`4 .
      to 19 3/l OO0.15 The American Society of Anesthesiologists
lists the mortality risk for the healthiest (Class I) patients as 1 /1250, or
0.8/l 000."

In addition to anesthesia risk, nephrectomy may be associated with post-operative
mortality. An analysis by Bay and Herbert of 2495 donor nephrectomies reported
in the literature, and 5698 donor nephrectomies reported from the 12 largest
centers that transplant kidneys from living donors, indicates an approximate
incidence of 1 donor death per 1600 nephrectomies.'  Margreiter estimates that
20 living kidney donors had died by 1987, for. a mortality rate of at least
1/1000.`7

In addition, there is some risk of long-term morbidity as a result of the loss of a
kidney. Sobh et al compared 45 living related kidney donors with 20 healthy sex-
and age-matched controls.  Donors had minor abnormalities in renal function,
including lower glomerular filtration rate, higher creatinine, and a greater incidence
of albuminuria than controls." However, they had no difference in the incidence
of hypertension. Foster, in an uncontrolled study, reports similar findings among
13 patients who had single kidneys and were at least 5 years status post
nephrectomies for renal cancer--mild increases in creatinine and albuminuria that
appear to be stable over time. lg. Wikstad reports on 36 patients who were born
with a single kidney. Patients were followed for 7-40 years. They found
microalbuminuria in 47 percent of patients with a single kidney, although none of
the patients had renal insufficiency or hypertension.*'  Other studies indicate
similar long-term complications of kidney donation.2'*22

Taken together, these small single-center studies offer some reassurance about the
long-term prognosis for kidney donors. However, they offer no guarantees about
the long-term safety of living with a single kidney. Each study was small enough
to have missed rare but serious complications. In each study, a number of patients
were lost to follow up. It is surprising that no long-term multicenter follow-up on a
large cohort of renal donors have been reported. Such a study could help quantify
donor risks.

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Recbient Benefits

Kidneys from living donors are in greater supply than those from cadavers, so one
of the primary benefits of using live donors is increased organ availability.23
However, 86 percent of transplant centers say that they would continue to use
living donors even if there were an adequate supply of cadaver kidneys.24 Thus,
in addition to increasing organ supply, live donor transplants are perceived as
having other advantages over cadaver transplants. These are primarily related to
outcome.

Kidneys from unrelated living donors probably do not confer a better prognosis for
the recipient than kidneys from cadavers. In'one study comparing 41 patients who
received grafts from living unrelated donors with 41 patients who received
cadaveric grafts, graft survival rates at 3 years were 81 percent for unrelated living
donors and 86 percent from cadaveric transplants.25 In this study, the grafts
from live donors functioned more rapidly than cadaver grafts, with no need for
post-transplantation dialysis. Preliminary data on 809 transplants from the
International Collaborative Transplant Study also indicates no differences in graft
survival between cadaveric and unrelated living grafts. (Newsletter 1, Feb 6,
1991). There are currently no large, multicenter, long-term follow-up studies
which address this question. However, that may be remedied soon with the
International Collaborative Study and with the UNOS registry.*'

Kidney grafts from related living donors fare considerably better than grafts from
cadavers. The North American Pediatric Renal Transplant Cooperative studied 761
transplants, of which 42 percent were from living related donors. Children who
received kidneys from living relatives required less immunosuppressive therapy and
had a longer period of time between their transplant and their first rejection (36 v
156 days). One year graft survival was 88 percent in the live donor group and 71
percent in the cadaver group.27

A study from the University of Miami compared results from 368 adults who
received cadaveric kidneys with those of 263 adults who received living related
kidneys. Both patient survival and graft survival were better in the living related
group. Ten year actuarial patient survival rates were 72 percent and 58 percent in
the two groups. Graft survival rates were 56 percent and 36 percent
respectively.*'

Improvement in survival among recipients of kidneys donated by living relatives
appears to be explained by HLA matching. In one study, which had only a small
number of living related transplants, survival was no different between those and
transplants between HLA A, B, and DR-identical cadaver donors.29 Nevertheless,
the likelihood of finding perfect matches is higher among relatives than among
unrelated donors.

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Altogether, the sum of risks and benefits have led many renal transplant centers to
conclude that continued use of living donors is justified.

PANCREAS DONATION

History

Partial pancreas transplantation- from living donors has been performed at the
University of Minnesota since 1977. The Minnesota group began exploring the
use of live donors with hopes that pancreatic grafts from living donors would be
rejected less often than grafts from cadavers3' Data showing that partial
pancreatic resection would not lead to diabetes was cited to justify the donor risk,

Pancreas transplantation has not been used as extensively as other organ
transplants, primarily because insulin therapy for diabetes is believed to be safer
than transplantation, even though it may be less effective. A large part of the risk
of transplantation comes from the need for long-term immunosuppression. Thus,
for patients who are receiving a kidney transplant for renal failure, the additional
risks of pancreatic transplant diminish. Such patients have been the primary target
population for pancreatic transplants.

Donor risks

Partial pancreas donation is a complicated operation. Some partial pancreas donors
have developed pancreatic fistulae and psuedocysts with post-operative
pancreatitis. Pancreas donors also face the risks of general anesthesia discussed
above.

In addition to operative mortality, partial pancreas donors are at risk of developing
pancreatic insufficiency and diabetes. Kendall et al, from the University of
Minnesota, found that partial pancreatectomy was associated with deterioration in
insulin secretion and glucose tolerance in all of 28 donors when they were
evaluated 1 year post-operatively.31 However, fasting serum glucose levels,
fasting serum insulin levels, and daily fluctuation in serum glucose levels during a
24-hour sampling period were all within normal range in the donors. Eight donors
were followed for 1 to 6 years, and none showed any further deterioration in
pancreatic function. Altogether, 1 of 54 donors in the Minnesota series developed
diabetes, and this donor would not have been accepted for donation by the pre-
donation screening criteria now in use.32 Given this small experience, however,
there is not enough data to accurately determine the risk of a partial pancreas
donor's developing diabetes.

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benefits
Recibent

Before examining the benefits of live donor pancreatic transplant, we acknowledge
that there is serious debate about the indications for any pancreatic transplant.33
Successful pancreatic transplantation, using either cadaver or living donor
pancreas, cures diabetes. Transplant recipients no longer require exogenous insulin
for the maintenance of normoglycemia. Pancreatic transplantation also improves
some of the complications of diabetes, such'as peripheral neuropathy and
nephropathy,34.35 although it is not clear how .much improvement
transplantation can confer. Retinopathy is not improved by pancreatic
transplantation, but early transplantation may prevent the development of
retinopathy.3e

Thus, the potential benefits of pancreatic transplants are for patients who are
prone to complications and who do not yet ha.ve severe complications.37
Unfortunately, there is no reliable method for predicting which patients will develop
complications, except by selecting those with early complications, such as early
renal disease or pre-proliferative retinopathy.38 Diabetic children whose disease is
associated with major neurovascular disease may also be candidates for grafting,
although, as of June 1988, only 6 transplants had been done in patients under the
age of 20.3g

Pancreatic transplantation results have been steadily improving. Comparing results
from 1966-77 and 1986-89, l-year recipient survival rates have gone from 39
percent to 87 percent and l-year graft survival rates have gone from 5 to 56
percent4' Results are even better for those United States cases reported to the
UNOS Registry. From 1987-89, l-year patient and graft survival rates were 91
percent and 69 percent respectively.40

Grafts from live donors appear to be less prone to rejection than cadaver grafts. In
Minnesota, at a time when l-year functional graft survival rate for technically
successful transplants in non-uremic, non-kidney transplanted patients was 32
percent for cadaver donors, the graft survival rate was 73 percent for living related
transplants." This probably reflects better HLA matching, as l-year graft
.survival in cadaver transplants varies from 67 percent for transplants with O-2
HLA-AB mismatches to 58 percent for patients with 3 or 4 mismatches
(p =0.058).42

Thus, to the extent that pancreatic transplantation is indicated, there may be some
benefit to the recipient to receive a segmental graft from a live donor rather than
from a cadaveric donor. However, the current controversy over the indications for
pancreatic transplantation, combined with the relatively high risk to the living
,pancreas donor, make the use of live donors for pancreatic transplantation difficult
to ethically justify.

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The number of living pancreas donation procedures has decreased over the past 2
years, suggesting that even the proponents of the procedure may feel that the risk-
benefit balance currently does not justify use of this procedure.

LIVER TRANSPLANTATION

History

Liver transplantation was developed throughout the 19.60s and 1970s. By 1983,
an NIH consensus panel concluded that whole liver transplantation was standard
therapy for a number of indications, including biliary atresia, inborn errors of
metabolism and nonalcoholic cirrhosis43; Technical advances in the 1980s
allowed surgeons to transplant reduced-size livers,44*45 split Iivers,4" and
eventually to use a portion of a liver from a living donor for transplantation into a.
childe4' Liver transplants from live donors have now been performed in at least
five centers in four countries.

Donor Risks

The donor requires a general anesthesia for a partial hepatectomy. Anesthesia
risks have been discussed above. A partial hepatectomy can be quite risky in the
face of underlying cirrhosis, and some surgeons have reported operative mortality
rates as high as 11 percent.48-48  In a number of series involving non-cirrhotic
patients, however, the operation has been performed with no or very low
mortaIity.50-54

Liver donors have developed operative complications. One patient required
splenectomy as a result of ah intra-operative laceration of the spleen. Two donors
have required non-operative management of bile leaks. As of May 1, 1991, 50
living liver donor procedures had been performed without a death in the donor
group (Whittington PF, personal communication). Long-term risks to the donor
appear to be low. After partial hepatectomy, the liver regenerate$" so liver mass
is expected to return to normal within 4-6 weeks, although this has not been
studied in the living donor situation. Thus, although no long-term data on donors
are currently available, there is clinical evidence from comparable patients and
some physiologic reason to believe that donors will not have inadequate hepatic
function as a result of partial liver donation.58

Recbient Benefits

In contrast to kidney and pancreatic transplants, there is no alternative medical
therapy for patients dying of end stage liver disease. The primary benefit to the
recipient is the availability of an organ suitable for transplant at a time when the
recipient is still medically suitable or appropriate for transplant. For a number of


patients, especially children and adults with fulminant hepatic failure, the shortage
of suitable cadaveric livers leads to their death or clinical deterioration while
waiting for an organ. The use of reduced-size and split livers ameliorates the organ
shortage for children, but the shortage remains.

Liver transplantation from living donors,, rather than cadavers, may confer other
benefits as well. The transplanted organs may be healthier, since there would be
decreased ischemic time between organ harvest and transplantation. Cadaver
organs may have suffered ischemic injury as a result of the events'that led to the
donors' death. Furthermore, in other organ transplant situations, .organs from
family members are less likely to be rejected, most likely as a result of better HLA
matching. This may be true for livers as well.

It is hard to evaluate the efficacy of living liver donation since the procedure is so
new. Initial results are comparable to results after whole liver transplants from
cadaver donors. Preliminary data shows that, for liver transplants from living
donors, graft survival rates are 72 percent (36/50). Graft survival rates in the U.S.
and Japan, the countries with the most experience, are 80 percent (35/44). The
period of follow-up varies from l-l 5 months. These are comparable to 6-month
graft survival rates of 69 percent for cadaveric liver transplants.57

If graft survival is comparable or better, and living liver transplants allow patients
who would have died while waiting for an organ to survive, then many people will
judge the recipient benefits to outweigh the small known and unquantified
unknown risks to the donor. '

LUNG TRANSPLANTS

History

Partial lung transplants from living donors have been successfully carried out in
animals for a number of years.58 The first use in humans took place in 1990,
with the transplant of a lung lobe from a mother to a daughter.5g To date, only
one such procedure has been performed. As a result, little is known of the
feasibility, the risks and benefits, or the likely outcomes of this procedure.

Donor Risks

Because only one such procedure has been done, the donor risks are difficult to
assess at this point. However, lobectomies have been done in patients with
underlying pulmonary disease, that is, patients who might be expected to be sicker
than prospective lung donors, with very low operative mortality.60*6' The
feasibility pf this operation makes the use of living lung donation ethically possible.

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ReciDient Benefits

The shortage of acceptable cadaver lungs for transplant is more severe than for
other organs. e2 Patients who become brain dead usually have suffered some lung
injury, and the incidence of pulmonary infection, a contraindication to transplant,
among ventilated patients is high.e3 Furthermore, lungs may be used either alone
or as part of a combined heart lung transplant, which increases the demand for
donor lungs. As a result, patients who may benefit from lung transplants are likely
to die while awaiting a suitable organ. The use of living donors could improve the
chances of such patients receiving a transplant.

ETHICS AND PUBLIC POLICY

Some major differences exist in the four organ transplant situations described
above. For kidney and pancreas failure, alternative medical therapies are available,
so patients rarely require a transplant to prevent imminent death. Instead, the goal
of transplantation is to improve quality of life.64*65 By contrast, patients with
end stage lung or liver failure must either receive a transplant or die. There are
differences in operative risks for the donation procedures, although clearly each
procedure is associated with some risk -- at least the risk of general anesthesia. In
each case, there is some uncertainty about the long-term risks to the donor,
especially whether they are at higher risk for disease as a result of donation.
These facts and uncertainties must form the basis for judgments about whether
the benefits to the recipient outweigh the risks to the donor. These judgments will
change as more experience and information is accumulated about each procedure.
Nevertheless, in each situation, certain ethical concerns arise that must be
addressed.

Beneficence and Nonmaleficence

Physicians set limits on the types of procedures which are offered to patients, and
thus, on the procedures to which patients may consent. Generally, physicians are
guided in establishing these limits by considerations of beneficence (i.e. the desire
to do what is good for the patient) and nonmaleficence (i.e. the desire to avoid
harm). Most physicians feel that the donor risks must be minimal, and will not
allow patients to donate unless they are in perfect health. Only 10 percent of renal
transplant centers will allow patients who are less than optimal donor candidates
to donate.66

Studies show that many patients would be willing to consent to donation, even if
they were in poor health or there was a significant mortality risk to donation,
especially if the potential recipient is a relative. " This has led some to argue that
physicians should loosen the acceptability criteria for donors, allowing patients to

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assess risks and benefits for themselves. *8 Regardless of the acceptability
criteria used, physicians will still -.be in the role of deciding whether to consider a
particular person for orga.n donation. In doing so, the physicians' concerns about
doing harm to the patient will be weighed against patients desires to act
altruistically.

Physicians may consider not only the physical risks of donation but the
psychological sequelae as well. For many kidney donors, donation is a difficult,
anxiety producing, and painful experience.eg Kidney donors often have
moderately severe depressions for 1 to 2.weeks after the operation."  Some
donors have even gone on to commit suicide." For most, however, the anxiety
and depression resolves after a few weeks and most donors then experience a
considerable boost in self-esteem.72,73  Long-term follow up shows that most
donors experience positive psychological sequelae from donation.74 There are no
data on the number of adults who, when asked, refuse to donate, to see whether
not donating causes psychological problems. Interestingly, when Gouge et al
studied adults who were considered as donors and who went through HLA
matching but were not selected as the donor,75 there were no differences in
objective or subjective assessments of quality of life or psychological well-being
between this group and the actual donors when assessed a number of years after
the transplant occurred.

On the whole, then, it appears that the risks of psychological harm to donors are
low, and the potential for long-term.psychological benefits quite high. Here again,
however, physicians are in the position of having to make clinical judgments about
whether, for a particular person, the risk of harm outweighs the likelihood of
benefit.

Patient Autonomv and Informed Consent

In most cases, donation is only acceptable if an autonomous patient consents to
the procedure. (Possible exceptions include children or incompetent adults.) Valid
consent has three elements. First, the patient must have the cognitive capacity to
make decisions; second, the patient must be given sufficient information to
understand the medical situation; and finally, the decision must be made without
undue coercion.

As healthy individuals who are choosing to undergo potentially risky surgery, living
organ donors must meet the highest standards of decision making capacity. On
rare occasions, such as when the only compatible donor is a minor or an
incompetent adult, difficult decisions may arise about the appropriateness of using
a donor who lacks decision making capacity.78*77 The circumstances under
which donation by a minor or incompetent adult is acceptable are beyond the
scope of this paper, but have been discussed elsewhere."

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it is axiomatic that organ donors should have access to all relevant information
about the risks of donation. This should include both, short-term risks and long-
term risks, and must include discussions of current areas of uncertainty, such as
the long-term risk of renal failure for kidney donors or the long-term risk of diabetes
for pancreas donors. Although standards for disclosure of risks in informed
consent for any medical procedure are not well defined, standards for donation
should be especially rigorous since the donor does not stand to benefit from the
procedure.

Such information may not, however, be a key factor in donor decision making.
Empirical studies show that most kidney donors make their decision to donate
immediately after the subject of transplant is first mentioned to them, and no
additional information has any effect on their decision.78.7g*80 Nevertheless,
because some potential donors may change their decisions based on medical data,.
detailed information about the risks of donation must be provided.81 Because
potential donors appear unwilling or incapable of evaluating information about
risks and benefits, physicians may recommend that donors undergo psychological
or psychiatric evaluation to determine whether their decision is truly
voluntary.82*83 Unfortunately, since this is an area of psychology that is seldom
evaluated in a medical context, it is not clear what evaluative tools psychiatrists
should use to assess voluntariness, or whether psychiatrists are truly better than
other physicians or social workers in making this assessment.

Given high standards of decision making capacity and adequate disclosure of
information about donor risk, the potential for coercion becomes the key element
of informed consent. Three possible components of donor coercion should be
distinguished. The first is psychological or internal coercion created by the donor's
own feelings of guilt because the patient may die without donor participation.84
This negative or coercive psychological response may, of course, be balanced by
positive emotional responses to donation, such as feelings of loyalty, responsibility,
love, or duty toward a family member.

Psychological coercion may be unavoidable, but may also be indistinguishable, in
many cases, from laudable psychological motivations for donation. In any case,
this sort of coercion is not unique to organ transplantation. The need to balance
selfishness and altruism is a universal feature of an individual's relationship with
his or her family. Because this is a universal element of human interaction, we do
not think that it invalidates voluntary consent.

The second .element of donor coercion is external. Pressure upon an unwilling
donor to consent may come from family members or even from health care
workers.85 If family pressures appear to be unduly coercive and the donor seems

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conflicted about the decision to donate, psychiatric evaluation and counseling of
both the potential donor and the family may be necessary.86 Although
controversial, physicians might also, with the consent of the patient, inform a
family that the decision not to donate was based. on medical criteria, such as tissue
incompatibility, rather than lack of consent. This would offer the potential donor
psychological protection from family pressures.

Pressure from the transplant team may be more difficult to avoid. Surgeons can
counter the risk that they will unconsciously,coerce donors by highlighting the
potential risks of donation, and emphasizing that a decision not to donate would be
understandable and acceptable. A "donor advocate," independent of the
transplant team, may counsel the potential donor and help work through the tangle
of conflicting emotions.87 However, the use of a mandatory "donor advocate"
would subject donors who have no emotional conflicts to a needless and
potentially unpleasant psychological evaluation.

A third form of coercion could come from financial incentives to donate. Some
people argue that the legalization of organ selling would be coercive, as it would
create an irresistible financial incentive, Further, this coercion would be strongest
on the poor, who may yield to financial incentives and make decisions that they
otherwise would not want to make.88 Thus, by this argument, remuneration for
donation is inherently discriminatory against the poor. Others argue that the
coercive elements of a market in organs could be regulated so that the public
policy benefits outweigh the ethical risks. 8g We will now examine arguments for
and against financial incentives. For the purpose of this paper, we will not discuss
the sale of cadaver organs, but will focus on arguments for and against the sale of
organs by living persons.

The most compelling argument for financial incentives is that they might increase
the supply of organs for transplant. .At present, the use of organ transplants is
limited by the supply of available organs. Thus, for each of the four procedures
discussed above, there is a permanent waiting list of patients for transplant. For
liver and lung transplants, in which no alternative therapy is available, a number of
patients die because no suitable organ becomes available.

Opponents of policies permitting the purchase or sale of organs argue that other
policies might also increase the supply of organs. Such policies include the use of
driver's license check-offs to consent to organ donation, required request laws,
physician education, and public awareness campaigns. Until such policies are fully
implemented and their results evaluated, opponents of markets argue, we can't say
that the organ shortage is irremediable, and so should not make a drastic,
controversial change in public policy.go Opponents further argue that permitting
payment for organs will taint organ donation, drive voluntary donors away, and
that the organs obtained under a free market system will likely be of inferior or

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uncertain quality compared to those obtained today." Thus, they argue,
payment for organs may actually decrease the supply or quality of organs.

These opposing positions are based on predictions of how people would respond to
particular policies, and on the problems that those predicted responses would
create. However, since we don't know whether people would respond that way,
the differences between the two positions do not seem solvable hypothetically or
rhetorically. The only way to determine the effect of policies which would permit
reimbursement for organ donors would be to try them and evaluate them. Policies
designed to increase the recovery of cadaver organs have been tried for a number
of years and have been only marginally effective.

A second argument supporting policies allowing individuals to sell their nonvital
organs is that, if we respect autonomy, we should allow adults to use and dispose
of their bodies as they see fit.`* Opponents also argue that respect for autonomy
is not absolute. Society may prohibit certain activities if it deems them too
dangerous, as it has done for activities such as bare fist boxing, riding motorcycles
without helmets, and working in dangerous work environments. Society may also
ban morally reprehensible activities, such as prostitution, baby selling, or selling
oneself into slavery.

The question is whether selling organs for transplant is either too dangerous or too
demeaning to permit. This question can be further refined. Clearly, it is morally
acceptable to many people to allow competent adults to donate organs. People
who choose to donate are considered morally praiseworthy for donating. Andrews
points out that "It is difficult to justify a prohibition on payment for what would
otherwise be a legal and ethical act -- giving up body parts for someone else's valid
use.`lg3 Does the addition of fihancial incentives tip the balance of moral
considerations so steeply that we must reverse our moral judgments? If it does, it
is only because we fear that it would turn a voluntary act into an involuntary one.

The arguments on both sides are compelling, and suggest that a compromise
position might be appropriate. Some degree of financial reimbursement or
remuneration for people willing to give up their organs might increase the supply of
organs. Thus, although outright sale of organs might be prohibited, some
reimbursement to donors for hospital expenses, or lost wages as a result of
donation might be considered acceptable. Harvey suggests that a distinction can
be made between payment for organs and commercial exploitation of organs.84
Policies to allow payment without exploitation might require that people who agree
to give up organs for reimbursement wait 30 days to reconsider their decision, to
prevent rash or poorly-considered decisions. They might also prohibit individual
organ buying transactions, requiring instead that reimbursement be limited to
donors who register with an organ bank, as potential bone marrow donors now do,
and who agree to be available for donation when an appropriately matched

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recipient becomes available. Careful medical screening of such donors, as takes
place now, should insure the quality of donated organs.

Under such circumstances, some reimbursement seems justifiable -- at least for
pain, suffering, inconvenience, and lost income -- although careful regulation to
prevent exploitation would be necessary. With such regulation, it should be
possible to increase the incentives for people who might consider giving an organ,
without necessarily realizing the worst fears .of the opponents of reimbursement for
organ donation. Reimbursement would not necessarily turn a morally praiseworthy
action into a morally reprehensible one, any more than paying soldiers decreases
the altruism and heroism which leads them to risk their lives for their country. The
real moral concern is not whether money changes hands but whether exploitation
is taking place.

CONCLUSIONS

The use of living donors for kidney, pancreas, liver, and lung transplantation is
likely to increase. In many cases, the use of living donors offers transplant
recipients a better outcome than cadaver transplantation. It also increases the
supply of available organs. Thus, live donor transplantation saves lives.

In deciding whether the use of live donors is acceptable for any particular clinical
situation, it is always necessary to weigh the potential benefits to the recipient
against the risks to the donor. Physicians should set guidelines for when donation
using living donors is acceptabje. Patient autonomy, though important, is not
absolute. It is constrained by the traditional professional ethical obligation of
physicians to do no harm.

Guidelines for deciding when donation is acceptable and for selecting donors
should reflect clinical data on outcomes, the normative values which prohibit
donors from undergoing more than minimal risk, and procedural safeguards to
prevent coercion. Criteria for determining what constitutes minimal risk may vary
between centers. Each center should publish their guidelines so that public
scrutiny and peer review might refine them. Published guidelines and prompt
reporting of outcomes should allow critical evaluation of the clinical and ethical
acceptability of different approaches to live organ transplantation. This will allow
transplantation using living donors to continue while safeguarding the rights of
patients, donors, and doctors.

284


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