Ethical issues in resolving the organ shortage: the views of recent immigrants and healthcare professionals.

• Author: Beattie, Owen
• Position: Canada

Introduction

Organ and tissue transplantation are increasingly presented as a solution for a number of serious and life-threatening health conditions. Advances in tissue typing, new generations of immunosuppressant drugs, and the refinement of surgical techniques have enhanced outcomes for transplant procedures, standardizing them as a form of therapy. These factors combined with the ever increasing human lifespan (particularly in developed countries) result in a larger number of people who would benefit by, and thus growing numbers in need of, an organ or tissue transplant. In addition, greater numbers of organs and tissues are needed for ongoing transplantation research. Yet there is a growing gap between the number of potential recipients and the number of donors in Canada and around the world.

In Canada, between 1996 and 2005, the number of transplant operations (excluding kidneys from living donors) increased by only 126, while the number of people on the waiting list increased by over 1,500. Likewise, data provided by the Canadian Organ Replacement Register and the American United Network, for Organ Sharing show the number of transplant recipients in waiting increased from 49.5 per million people (pmp) in 1993 to 56.8 pmp in 2002, with the disparity between operations performed and the wait list widening by 8.3 percent. (1) Internationally, Canada's transplant rate (14 pmp) is on par with other western countries. But while Canada's rate remains above those of countries such as Australia (10 pmp) and New Zealand (11.2 pmp), it remains well below that of Spain (35-40 pmp), which has the most successful cadaveric transplant program in the world (2) and which many people view as the example to follow for other countries' donation programs.

Policymakers are thus grappling with how best to narrow the donor-recipient gap and increase the availability of tissues and organs for research. In the past five years, several Private Member's Bills have been proposed to address the Canadian donor shortage. The adoption of these or similar bills will make significant changes to organ procurement and to ensuring informed consent. Beyond the myriad existing ethical issues surrounding organ donation, proposed changes will introduce further ethical challenges both for healthcare professionals in this specialty area and for potential donors.

Beyond the introduction of laws directly aimed at increasing donation numbers, there is an ongoing international discussion among healthcare providers, policymakers, ethicists, and philosophers regarding other means to increase the availability of organs. At the core of the debate is the legality, ethics, and effectiveness of broadening the category of eligible donors. Procurement agencies formerly considered only persons suffering from brainstem death who had indicated during their lifetime that they wished to donate. With the stagnating numbers of brain dead donors and the increased need for organs, new categories of persons under consideration as donors include: anencephalic newborns; non-beating-heart donors and persons revived after suffering cardiac death; executed prisoners (not applicable in Canada); (3) and persons with irreversible brain damage (4) or those persisting in prolonged vegetative states. (5) Among these categories, donation from persons who do not respond to resuscitation is considered to be one of the most effective and efficient methods for increasing donor numbers. (6) This mode of procurement has been called uncontrolled donation after a circulatory determination of death or Rapid Organ Recovery (ROR).

Attendant to the discussion of broadening categories of eligibility is the possibility of enlarging the donor pool by redefining "death." For instance, it has been argued that while anencephalic infants have functioning brainstems, placing them in a "special category of death" could make them eligible as brain dead donors. (7) Likewise, the concept of "imminent death" considers persons eligible due to ROR, irreversible brain damage, or prolonged vegetative states. And as researchers better understand "brainstem death," previously accepted definitions of "death" and "dead" are called into question. (8)

Amid these debates, policymakers and healthcare professionals are attempting to address the organ shortage at a more immediate, local level. Efforts include introducing new programs such as "domino donations," where potential recipients with non-matched relative donors are matched in sequence to other recipients and non-matched relative donors. In February 2009, Canada created the Living Donor Paired Exchange Registry, with the first surgeries occurring four months later. (9) There are also growing efforts to raise public awareness. In Ontario, the Trillium Gift of Life's Recycle Me educational program is aimed at adolescents and young adults. Since its launch in 2008, over 4,000 new potential donors have registered. Combined with these programs are recommendations for systemic shifts in organ procurement, which can involve small changes to everyday healthcare practice. In British Columbia, for instance, all persons admitted to hospital are now asked if they wish to donate their corneas upon death, a policy that has reduced the provincial cornea wait list to 14 weeks. By...