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Markkula Center for Applied Ethics

The Case of the Missing Kidneys

Doctors in an operating room

Doctors in an operating room

Madeline Eiken

Madeline Eiken was a Hackworth Fellow for the 2018-2019 school year. She graduated from Santa Clara University in 2019 where she majored in bioengineering and minored in chemistry. She was awarded the Ethics Center Markkula Prize in June 2019. She currently works at Allosource, a tissue bank in Colorado.

Introduction

Organ donation is the process of surgically removing an organ from a living or deceased donor and transplanting it into another person. The organ recipient needs the donated organ because their organ has failed, either due to disease, injury or malfunction. Organ recipients are typically similar to their donor in age, blood type, tissue type, and geographic location to ensure efficiency of the procedure and to reduce the chance of organ spoilage and rejection.

The shortage of donated organs is one of the most pressing medical issues today. There are over 100,000 people on the national organ transplant waiting list, and the gap between available donated organs and the number needed continues to grow. Another person is added to the list every 10 minutes and 20 people die per day while waiting for an organ.[1] Alternatives need to be investigated in order to address this issue and save lives.

Policy Options

In the U.S., there are two primary non-medical donation restrictions that greatly limit supply. Donors cannot be offered financial compensation for donating their organs, and they must provide explicit consent for donating their organs.

What ethical frameworks support such restrictions? Are we so concerned about possible coercion and violations of autonomy (self-determination) that we are willing to let people die for the sake of these principles?

Since one donor can save the lives of up to eight patients, even small increases in the donor pool can save many lives. Other countries have different criteria for organ donation, which could be applied in the U.S. There are several policy-focused options that the U.S. could pursue in order to increase the rate of organ donation to try to match that of other countries.

Many countries, such as Austria, have an opt-out policy of presumed consent for organ donation. Unlike in the U.S., being an organ donor is the default position and people must explicitly sign up to not be organ donors. Rates of organ donation in Austria are extremely high compared to the U.S.; donation rates are 90 percent and 15 percent for Austria and the U.S., respectively. An opt-out system has been shown to have a psychological influence on people, making them more willing to donate their organs because it becomes the norm.

Argentina has a similar opt-out policy; all citizens over age 18 are automatically registered as organ donors. Argentina recently took this policy one step further by requiring that the individual must personally opt out of being a donor; the family does not need to consent to an organ donation on someone’s behalf after death. This further increases the rate of organ donation.

Does the family of a deceased person have the the right to determine what happens to their loved ones’ organs after they die? If so, what is the ethical basis for this right? If not, why not?

Iran is the only country in the world that offers compensation for living kidney donors.[2] The policy was established in 1988. People needing a donated kidney are referred to the Dialysis and Transplants Patients Association, who match them with a potential donor. The organization pays for both surgeries. Donors are offered a few thousand dollars and free health care for one year in exchange for one of their kidneys. Iran’s kidney waitlist has been effectively eliminated since 1999 because of this policy. However, critics say that the policy preys on the poor. The World Health Organization opposes such commercializing of organs.

A similar program in the U.S. would save many lives, and kidney recipients in the U.S. fare better than those in Iran. Three physicians and an economist have proposed a similar structure for the U.S. in which the government would pay living donors $45,000 and families of deceased donors $10,000 in exchange for their kidney donation.[3] Another option would cover funeral costs for a deceased donor, or we could adopt “profi-neutral” donation, where donors receive enough financial compensation to make up for the costs associated with their medical care and time lost from work.

How might this policy be coercive for donors and their families? Does this policy infringe on an individual’s autonomy or threaten fair play? Are the potential ethical challenges of this policy overcome by the utilitarian benefits of saving lives?

Scientific Options

The organ donation crisis in the U.S. can also be addressed with scientific advances. Scientific improvements could increase the donor pool, reduce rejection rates, and increase survival for those with diseased or damaged organs. Read the three scientific options below and weigh their ethical implications as potential solutions to the current problem of heavy demand and limited supply.

Currently, only a tiny portion of people who die are medically eligible to become organ donors. Many people with pre-existing diseases are rejected as organ donors, because recipients are often already immunosuppressed and cannot fight off diseases that they may contract from the organ after transplant. However, new research has shown promise in expanding organ donor eligibility to patients with Hepatitis C.

A new antiviral drug has been introduced that prevents the spread of Hepatitis C to recipients of infected organs. Thus, patients who have Hepatitis C can become organ donors once they die, with no additional risks to the recipient thereby dramatically increasing the pool of potential organ donors. One hospital was able to transplant 50 hearts provided by Hepatitis C infected patients because the recipients could now be protected from infection. One of the largest populations of people with Hepatitis C are heroin users, who contract the disease at a higher rate than the general population due to high rates of needle sharing. The recent opioid epidemic has led to a spike in heroin use in the U.S., which has, in turn, led to a higher number of overdose deaths among patients with Hepatitis C, making this an especially large potential donor pool.

What are the issues associated with a specific group having a higher rate of eligibility to become organ donors than the general public, if they are not eligible to receive a larger number of transplanted organs? What ethical issues arise if the organ donor pool is a marginalized community, such as heroin users, who suffer from addiction, which is a serious and stigmatized disease? Under what conditions can heroin users consent to becoming living or deceased organ donors?

Another potential solution to the organ shortage crisis is xenotransplantation. Xenotransplantation involves taking an organ from an animal and transplanting it into a human. This is promising for kidney transplants, the most commonly needed organ, since pig kidneys are very similar to human kidneys in size. However, there are some biological barriers. Pigs can be carriers of porcine diseases, which could be deadly in transplant recipients, and pig organs may be more easily rejected than human organs by the recipient.

Researchers have proposed that the best way to make xenotransplantation a viable intervention for addressing the organ shortage crisis would be to breed pigs in sterile environments, like in a hospital. This reduces their chance of contracting porcine diseases. Additionally, the pigs need to be genetically modified to remove the GAL gene, which leads to high rates of rejection in humans.

The “yuk factor” describes the belief that a response of disgust towards something can be evidence for the intrinsically bad or harmful nature of that thing. How might people emotionally react to having an organ transplanted from another species, even if it is a medically safe procedure? Does this reaction affect the ethics of xenotransplantation? Other than the yuk factor are there other ethical constraints to xenotransplantation? If so, what are they?

One promising option for addressing the shortage of organs is 3D bioprinting. This involves using 3D printing technology and an “ink” made of cells and collagen to create an organ for the recipient. This technology is extremely promising. It can use cells from the organ recipient, completely eliminating concerns about rejection of the organ. The organ can be printed to be precisely the appropriate dimensions for a patient. If the technology progresses, it could be a solution for “off the shelf” organs that are available to any patient who needs an organ transplant, eliminating the need for an organ waitlist.

3D printing has already been used in several patients with structural issues in their airways. However, this technology is a long way from being implemented as a solution for transplanting more complex tissue types or organs, such as kidneys or hearts. There are a variety of barriers to implementation. First, scientists do not fully understand how cells form three dimensional tissues; this makes developing the structure of organs difficult. The number of cells in a given tissue numbers in the millions, and scaling up lab processes would be very difficult. There are also issues with tissue vascularization and tissues requiring multiple cell types adding to the challenges of 3D printing. There is a great deal of excitement about the field of 3D bioprinting, and research seems very promising. However, some researchers worry that overemphasizing the progress that has been made in the field is misleading and gives the field a bad name.

Who are the stakeholders who are affected by overly positive reporting on the state of the field? Are hyped reports preying on the vulnerable? Are such reports dishonest?

Consider the four scientific options above to improve the current system of organ donation by increasing supply. If you were a lawmaker who had to choose just one of the options for government funding, which would you choose? Why? What ethical framework could you use to justify this decision?

Prevention-Focused Options

Many of the ethical issues associated with organ donation can be traced to the mismatch between supply-and-demand. The demand for organs far outpaces the supply. Most of the previously discussed solutions address only the supply side of the issue. However, it is important that the demand side is addressed as well as it seems likely that a two-pronged approach consisting of increasing supply and decreasing demand will be needed to address this seemingly intractable problem.

Rising rates of chronic illness throughout the world simultaneously increases demand for and reduces the supply of organs. Patients with chronic illnesses are more likely to need a donated organ and less likely to be able to donate one. One third of patients with diabetes will develop a kidney disorder, and rates of Type II diabetes, which is preventable, are increasing rapidly. Furthermore, alcohol-related liver diseases are on the rise, necessitating liver transplants.

There are several approaches that can be taken to reduce the rate of chronic organ-damaging diseases in the American population, including increasing surveillance of the development of chronic diseases, improving environmental conditions, strengthening health care systems, and connecting medical services with community-based organizations.

Ultimately, solutions to the organ shortage crisis need to address both the supply and demand sides of the curve. Public health measures designed to improve the health of the population must be coupled with scientific advances and policy interventions in order to meaningfully increase the supply of transplantable organs.

[1] https://www.americantransplantfoundation.org/about-transplant/facts-and-myths/

[2] https://www.statnews.com/2016/08/25/organ-donation-kidneys-iran/

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5057320/

Aug 28, 2019