The Giving PolicyThe Giving PolicyThe The solesole source of cadaver organs is a source of cadaver organs is a gift, either from those who agreed to gift, either from those who agreed to donate prior to death or from family donate prior to death or from family members of the deceased.members of the deceased.The giving policy is exemplified in the The giving policy is exemplified in the Uniform Anatomical Gift Act (1968), Uniform Anatomical Gift Act (1968), the main provisions of which have the main provisions of which have been adopted in each state.been adopted in each state.

It is illegal to buy or sell human It is illegal to buy or sell human organs for transplantation in the US.organs for transplantation in the US.

Section 274e of the US Public Health Section 274e of the US Public Health Code says: “It shall be unlawful for Code says: “It shall be unlawful for any person to knowingly acquire, any person to knowingly acquire, receive, or otherwise transfer any receive, or otherwise transfer any human organs for valuable human organs for valuable consideration for use in human consideration for use in human transplantation …”transplantation …”

Persons who violate this law may be Persons who violate this law may be fined up to fined up to $50,000$50,000 and imprisoned and imprisoned up to up to five yearsfive years..

Main provisions of the Uniform Main provisions of the Uniform Anatomical Gift Act:Anatomical Gift Act:

1.1. Anyone at least 18-years-old and of Anyone at least 18-years-old and of sound mind may donate all or part sound mind may donate all or part of his or her body for transplantation of his or her body for transplantation or research.or research.

2.2. One may indicate this by signing a One may indicate this by signing a donor card (or indicating so on one’s donor card (or indicating so on one’s driver’s license).driver’s license).

3. If the person is not known to have 3. If the person is not known to have objected, his next-or-kin may donate objected, his next-or-kin may donate for him.for him.

4. If there is more than one next-of-kin, 4. If there is more than one next-of-kin, all must agree.all must agree.

5. Now if you have a health care agent, 5. Now if you have a health care agent, he or she may donate your organs.he or she may donate your organs.

The next-of-kin is not supposed to be The next-of-kin is not supposed to be able to revoke one’s gift. But in the able to revoke one’s gift. But in the US today, most transplant centers US today, most transplant centers will not take organs against the will not take organs against the wishes of the family. Why? (1) It is wishes of the family. Why? (1) It is traditional for traditional for familiesfamilies to make to make decisions about the newly dead. (2) decisions about the newly dead. (2) Organs taken against the family Organs taken against the family wishes would result in bad publicity.wishes would result in bad publicity.

AdvantagesAdvantages of the Giving Policy: of the Giving Policy:

1.1. It respects individual autonomy.It respects individual autonomy.

2.2. It gives people opportunities to It gives people opportunities to perform significant acts of perform significant acts of generosity.generosity.

DisadvantagesDisadvantages of the Giving Policy: of the Giving Policy:

1.1. It is not working well; too few people It is not working well; too few people agree to donate. Why?agree to donate. Why?

mistrustmistrust of the medical profession of the medical profession cynicismcynicism about who gets organs about who gets organs doubtsdoubts about whether transplants work about whether transplants work misconceptionsmisconceptions (financial matters, (financial matters,

funerals) funerals)

Disadvantages cont.Disadvantages cont.

2. To make the Giving Policy work, 2. To make the Giving Policy work, many think that we would have to be many think that we would have to be inappropriately aggressive in inappropriately aggressive in approaching potential donors.approaching potential donors.

3. The Giving Policy requires us to 3. The Giving Policy requires us to approach families at the worst approach families at the worst possible time.possible time.

““Required Request”Required Request” laws are now in laws are now in place. Hospitals must approach place. Hospitals must approach families about organ donation in families about organ donation in cases where there may be a suitable cases where there may be a suitable donor.donor.

This law is designed to (1) educate This law is designed to (1) educate the public about the need, and (2) the public about the need, and (2) increase the supply of available increase the supply of available cadaver organs.cadaver organs.

The Trading PolicyThe Trading Policy This policy assumes that the This policy assumes that the

available supply of cadaver organs available supply of cadaver organs for transplantation will increase for transplantation will increase onlyonly ifif people are given an people are given an incentiveincentive to to allow organs to be harvested.allow organs to be harvested.

There are There are twotwo versions of the Trading versions of the Trading Policy:Policy:

1.1. TradeTrade forfor paypay: provide people a : provide people a financial incentive to contribute financial incentive to contribute organs.organs.

2.2. TradeTrade forfor accessaccess: Pool all cadaver : Pool all cadaver organs and give first preference to organs and give first preference to those who have previously agreed to those who have previously agreed to contribute their organs.contribute their organs.

AdvantagesAdvantages of the Trading Policy: of the Trading Policy: Proponents say that Proponents say that onlyonly this policy this policy will increase the pool of available will increase the pool of available organs because people are either too organs because people are either too selfish or too lazy to contribute selfish or too lazy to contribute without an incentive. (Each version without an incentive. (Each version of the policy provides an incentive.)of the policy provides an incentive.)

DisadvantagesDisadvantages of “trade for pay”: of “trade for pay”: The system will be too costly The system will be too costly

(because many will be paid whose (because many will be paid whose organs turn out to be unprocurable)organs turn out to be unprocurable)

Most contributors are apt to be poor, Most contributors are apt to be poor, and so some think that this and so some think that this constitutes exploitation.constitutes exploitation.

DisadvantagesDisadvantages of “trade for access”: of “trade for access”:When must people declare their When must people declare their intention to contribute? If it is “any intention to contribute? If it is “any time,” people will wait until they are time,” people will wait until they are sick and this will defeat the purpose.sick and this will defeat the purpose.If we require the decision when If we require the decision when people turn 18, this seems a bit harsh.people turn 18, this seems a bit harsh.

The Policy of Presumed ConsentThe Policy of Presumed ConsentThis policy allows society to salvage This policy allows society to salvage any person’s usable organs upon any person’s usable organs upon death death unlessunless she has explicitly she has explicitly requested that this not be done. requested that this not be done. (Adopted in some European countries.)(Adopted in some European countries.)This is called “opt out.” [Giving Policy This is called “opt out.” [Giving Policy is called “opt in.”]is called “opt in.”]

AdvantagesAdvantages of Presumed Consent: of Presumed Consent:

1.1.This will increase the supply of This will increase the supply of organs. [The only policy that would organs. [The only policy that would procure more would give individuals no procure more would give individuals no choice.]choice.]

2.2.Can be efficient and not too costly.Can be efficient and not too costly.

3.3.Still respects individual autonomy.Still respects individual autonomy.

ObjectionsObjections to Presumed Consent: to Presumed Consent:

1.1.Puts an unfair burden on sick pts to Puts an unfair burden on sick pts to express their wishes not to give.express their wishes not to give.

2.2.Deprives people of an opportunity to Deprives people of an opportunity to be generous.be generous.

3.3.Some deaths may be hastened to Some deaths may be hastened to procure organs.procure organs.

4.4.Will be too costly to administer Will be too costly to administer because people will change minds.because people will change minds.

ResponsesResponses to objections: to objections:To (1): The policy will be To (1): The policy will be publicpublic and and known to all. People who have known to all. People who have religious objections will not wait until religious objections will not wait until they get sick.they get sick.To (2): (a) Few are using this way to To (2): (a) Few are using this way to be generous. (b) There are many be generous. (b) There are many other opportunities for generosity.other opportunities for generosity.

To (3): (a) If this is a worry, it applies To (3): (a) If this is a worry, it applies to to allall policies, not just Presumed policies, not just Presumed Consent. (b) From a practical view, Consent. (b) From a practical view, this objection is unrealistic.this objection is unrealistic.

To (4): This assumes that people’s To (4): This assumes that people’s preferences about organ donation preferences about organ donation will change frequently. Why assume will change frequently. Why assume this?this?

Strategy (3): “Modifications” in the Strategy (3): “Modifications” in the Giving Policy that may increase the Giving Policy that may increase the supply of donations:supply of donations:

1.1. Allow organs to be procured without Allow organs to be procured without the consent of the family if the newly the consent of the family if the newly deceased has deceased has bothboth signed a donor card signed a donor card and indicated on his driver’s license a and indicated on his driver’s license a preference to be a donor.preference to be a donor.

Modifications cont.Modifications cont.

2.2. “Hope through Sharing”: this is a “Hope through Sharing”: this is a program that allows relatives (spouse, program that allows relatives (spouse, parent, sibling) to donate a kidney to a parent, sibling) to donate a kidney to a stranger so that his or her loved one stranger so that his or her loved one can move up on the waiting list for a can move up on the waiting list for a kidney.kidney.

3.3. “Paired Exchange” or “Swaps”: First “Paired Exchange” or “Swaps”: First tried at Fairfax Hospital in Virginia. tried at Fairfax Hospital in Virginia. Each of two husbands wanted to Each of two husbands wanted to donate a kidney to his wife. Neither donate a kidney to his wife. Neither was compatible with his own wife, but was compatible with his own wife, but was compatible with the other’s. The was compatible with the other’s. The hospital arranged an exchange. hospital arranged an exchange. Recently these “chains” have been as Recently these “chains” have been as long as 30 patients.long as 30 patients.

4.4. “Futures Contract”: An individual “Futures Contract”: An individual signs a contract in which she agrees to signs a contract in which she agrees to contribute organs upon death. The contribute organs upon death. The contract specifies that contract specifies that ifif any organs any organs are salvaged, the deceased’s estate are salvaged, the deceased’s estate will be paid a specified sum of money.will be paid a specified sum of money.This gives the next-of-kin an incentive This gives the next-of-kin an incentive notnot to override the deceased’s wishes. to override the deceased’s wishes.

Questions about “Futures Contracts”:Questions about “Futures Contracts”:

1.1.Will it increase the supply?Will it increase the supply?

2.2.Will it make families less likely to Will it make families less likely to donate if their loved one had no such donate if their loved one had no such contract?contract?

3.3.Under the current system, how many Under the current system, how many families contribute when their loved families contribute when their loved ones had not explicitly agreed?ones had not explicitly agreed?

It is It is notnot clear whether any of these clear whether any of these “modifications” will make a “modifications” will make a significant impact on the supply of significant impact on the supply of cadaver organs. But cadaver organs. But ifif the the alternative policies are unacceptable alternative policies are unacceptable to people in the US, these may be to people in the US, these may be the only hope.the only hope.

What about using prisoners on What about using prisoners on “death row” who volunteer to be “death row” who volunteer to be organ donors?organ donors?

Physicians regard themselves as Physicians regard themselves as bound by the Hippocratic maxim, bound by the Hippocratic maxim, “First do no harm.” This made them “First do no harm.” This made them reluctant to use reluctant to use livingliving kidney donors kidney donors because of the risk that the donor because of the risk that the donor incurs.incurs.

Transplant physicians operate with Transplant physicians operate with the “dead donor” rule. Organs will the “dead donor” rule. Organs will not be procured until the donor is not be procured until the donor is dead. But if prisoners on death row dead. But if prisoners on death row have organs extracted, physicians have organs extracted, physicians will be causing death.will be causing death.

The usual way of executing prisoners The usual way of executing prisoners makes organs unusable.makes organs unusable.

Reluctance to using living kidney Reluctance to using living kidney donors was overcome because:donors was overcome because:

1.1.The loss to the donor of a single The loss to the donor of a single kidney does not adversely affect kidney does not adversely affect quality of life.quality of life.

2.2.The donor normally has a The donor normally has a specialspecial relationship with the recipient.relationship with the recipient.

In the case of a donation from a In the case of a donation from a living donor to a stranger, (2) above living donor to a stranger, (2) above is not satisfied. This led many in the is not satisfied. This led many in the transplant community to resist such transplant community to resist such donations. But today they are more donations. But today they are more common. [It is quite common with common. [It is quite common with bone marrow.]bone marrow.]

If death row inmates (who volunteer) If death row inmates (who volunteer) are used as organ donors, obviously are used as organ donors, obviously (1) above is not satisfied. [Their (1) above is not satisfied. [Their quality of life is adversely affected!]quality of life is adversely affected!]

As a result, the transplant As a result, the transplant community will not use death row community will not use death row inmates because (a) it seems to inmates because (a) it seems to violate “do not harm” and (b) it violate “do not harm” and (b) it seems to violate the dead donor rule.seems to violate the dead donor rule.