Sunday, February 6, 2011

Selling Human Organs for Transplantation: Ethics Under Siege

I have previously posted on the ethics of paying for organ donation. I find this notion to be ethically troubling, but I believe the issue deserves fair debate. In general, my belief is that a personal anecdote should not drive policy in medical ethics. There are many individual vignettes that are poignant and heartbreaking that tempt us to relax our ethical boundaries. For example, permitting us to harvest organs from folks who are ‘not quite dead’, would save lives, but society’s rights outweigh this benefit, in my view. For similar reasons, I resist efforts to relax the definition of death in order to increase the reservoir of available organs. If death is redefined as a result of a search for truth, then the process is ethically permissible. Participants in these discussions would include medical professionals, theologians, ethicists, legal experts and ordinary people. If a result of this process would be that there would be more organs available for transplantation, then I would be supportive. The distinction is that increasing organ supply would not be the primary objective. In other words, I reject the approach of ‘hey, we need more organs to save lives. Let’s roll back the definition of death to get there.’

Recently, two sisters who were serving life sentences in Mississippi for a crime related to armed robbery were released by Governor Haley Barbour. They were not pardoned, but their sentences were indefinitely suspended. A condition of their release was that one woman must agree to donate a kidney to her sister.

The women have always maintained their innocence, and supporters have argued that the verdict was wrong or disproportionate to the crime. I am not knowledgeable on the facts and offer no view on the whether the verdict and sentence were just.

More details on this case can be found at Everything Health, often among the first to present medical controversies to the blogosphere.

Governor Barbour cited the estimated $200,000 yearly cost of dialysis that the state would bear as a factor in his decision to release the women. This created ethical angst for many of us. Organ donation, at least currently, is supposed to be an altruistic event, when the donor does not receive monetary or other tangible benefits for the gift. (I am not referring here to compensating donors for their time, medical expenses, lost wages, etc. But donors should not view donation as a revenue stream.) If the Governor’s rationale became established policy, then we would become ethically unmoored. The drift that began with a Mississippi prison would seep out across society. Which of the following scenarios would we support?

  • Paying for organs on the open market
  • Organ auctions
  •  Selling your kids’ stem cells to support their college funds
  • Releasing female prisoners for serving as surrogate mothers or egg donors
  • Tax breaks for bone marrow donations
  • A pay raise and promotion if you give your boss a kidney
  • Admission to an Ivy League institution for a piece of your liver
You get the idea here. Too often in the medical ethical arena, an action precedes thoughtful discussion and debate. The danger here is that the action spreads out and becomes prematurely established as policy. It becomes harder to undo an action that has developed roots and is multiplying. Indeed, a change in medical ethics policies should be the final part of the process and not the opening act.

When do you think the proper time would be to debate human cloning? Now, or after several Whistleblowers have been cranked out in cloning farms around the country?

Two Mississippi women have been unshackled and released from prison. Is medical ethics now in handcuffs?

What's your view?


Michael Kirsch, M.D. said...

Someone has to comment first. Just finished a fascinating article on a debate over organ donation that is taking place 'across the pond'. Find out what the Talmud teaches about organ donation. The article is a bit longer than my post, but well worth it for those interested.

A. Bailey said...

You might not get many comments because this topic, especially approached from your perspective, is indeed mind-bending.

The slippery slope takes us where we don't want to go. How about conceiving, only to pith an otherwise healthy child at, say, 11 weeks of gestation, with the intention of harvesting the organs? An abortion is legal at that age, so why not make the best of it and harvest the body parts? Why let them go to waste?

I put this forward as someone who is resolutely pro-life (or anti-choice, if you're a member of NARAL).

Our culture is not morally armed to take on these kinds of questions. I fear most will fall back on a crude utilitarianism. Bravo to those who turn to the Torah for the answers, but you won't have many people who are sympathetic to that perspective.

Toni Brayer, MD said...

Thanks for the shout out to EverythingHealth. I'm not exactly sure what A. Bailey is saying. Is he saying we can't have moral discussions and discuss ethical questions? As a society we must tackle these issues or we have people acting randomly (like the judge) without considering all of the consequences. It should not be left up to ancient religious texts or to for-profit corporations. Ethicists, scientists, and "ordinary people" as Dr. Kirsch points out must all be engaged. More of these issues will occur as technology develops.

A. Bailey said...

Of course we must argue these issues. Unfortunately I think our contemporary moral lexicon leaves us unprepared for such discussions. I suspect that after an exchange or two we'd be bantering about "the greatest amount of good for the greatest number of people" or some such nonsense. For further reading I suggest "After Virtue" by Alasdair McIntyre.

Michael Kirsch, M.D. said...

@AB, just to clarify, do you support the governor's decision?

Jen Kriessler NP-C said...

Nice blog! It looks like you have quite a passion for this and have invested considerable time. I reviewed several of your posts and found them well written, easy to read and humorous at times. I look forward to following along.

Unknown said...

As the death toll from the organ shortage mounts, public opinion will eventually support paying for human organs. Changes in public policy will then follow.

In the mean time, there is an already-legal way in the United States to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

Americans who want to donate their organs to other registered organ donors don't have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs.

David J. Undis
Executive Director

Michael Kirsch, M.D. said...

Welcome to the blog, Jen. Thanks for the kind comments. Now, spread the word!

A. Bailey said...

No, I don't, and for the reasons you enumerated.

Ariella said...

Dr. Whistleblower, what do you think about David Undis' argument? I think he makes a good argument- why shouldn't donors go to the top of the queue?

Anonymous said...

Making organ donation an 'opt-out' rather than an 'opt-in' decision, I believe, would greatly increase organ donation. Combined with Mr. Undis' suggestion that those who 'opt-out' go to the end of the line would at least give pause for those who consider opting-out.


Michael Kirsch, M.D. said...

To Ariella & Melody, good points. I agree that those who are willing to give should be given preference if they ever need an organ. If someone is willing to donate, should this individual's immediate family also go to the head of the line if any of them need an organ?

Nicholas Fogelson, MD said...

Michael - to be honest, I think we stand on an ethical high horse when we deem to believe that there is one particular ethical interpretation that is correct. Ethics change over time, and activities considered proper and normal now may be considered barbaric in the future, and vice versa.

Many other countries have programs where organs can be procured for a regulated amount of money, and those countries by and large transplant a lot more organs than countries that don't have those systems. I read an article once that described the system in detail, and one of the main points was that a system like this tends to make organ donors out of many people who otherwise would have opted out, leading to a large net increase in the number of people who will donate.

Is this wrong? Is it right? I think its just different.

Michael Kirsch, M.D. said...

Nick, Nice to have you back. Regarding your comment, " I think we stand on an ethical high horse when we deem to believe that there is one particular ethical interpretation that is correct. Ethics change over time". I accept your point, to a point. Do you think that there are some ethical principles that should remaing absolute and fixed, or are all of them subject to natural evolution? I fear that the latter could lead to undesirable results.

Nicholas Fogelson, MD said...

Sure there are some absolutes. Don't kill people. Don't be violent. Try to love others.

But don't allow someone to be paid for donating an organ? Kind of gray in my mind.

Michael Kirsch, M.D. said...

Nick, I see some 'gray' in your absolutes. 'Don't be violent'. Many instances in history, and presently, where violence may be morally justified. Of course, I see your point, but hopefully you see mind. One man's absolute truth is another's...

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