Ethical Issues Regarding the Donor and the Recipients (1)

7/27/2019 Ethical Issues Regarding the Donor and the Recipients (1)

1/8

Introduction ( optional if i preprint para sa visuals naten)

Experiments continue to be done to try to improve the technology and possibilities regarding transplantation. For example, research isbeing done regarding human cell cultures, transplants from human fetuses, including brain tissue, and from animals to human beings.

The latter includes attempts to genetically design animals with organs that are less likely to be rejected by human beings. Some animalproducts (e.g. insulin and pig heart valves) are already used regularly. Research also continues to be done to improve artificial organsand other artificial aids to human functioning.

Since many people can benefit greatly in terms of length and quality of life from organ and tissue transplants, the demand usually

exceeds the supply. The costs related to some organ transplants are very high as well. Therefore, many questions are raised todayregarding how best to procure more organs, how to fairly distribute limited resources, and whether all transplants should be covered

by public funds.

1. Ethical Issues Regarding the Donor

a) From the Deceased

(situations)In general it is seen as praiseworthy to will one's body or parts of one's body for the benefit of others after one's death. In1956 Pope Pius XII summed up the Catholic view on this: A person may will to dispose of his [or her] body and to destine it to ends

that are useful, morally irreproachable and even noble, among them the desire to aid the sick and suffering. One may make a decision

of this nature with respect to his own body with full realization of the reverence which is due it....this decision should not becondemned but positively justified.

(situations)More recently (1985) the Pontifical Academy of Sciences stated: Taking into consideration the important advances made in

surgical techniques and in the means to increase tolerance to transplants, this group holds that transplants deserve the support of themedical profession, of the law, and of people in general. The donation of organs should, in all circumstances, respect the last will ofthe donor, or the consent of the family present.

Such a donation can greatly benefit others and cannot harm the donor who is dead. Not to offer such a donation can be a sign ofindifference to the welfare of others. To donate, however, is not considered obligatory. Transplantation is against some people's

consciences for religious or other reasons. Consideration for the sensibilities of the survivors may also make some people hesitate tosign over their bodies.


2/8

In any case proper respect should always be shown human cadavers. Although they are by no means on par with a living humanbody/person, they once bore the presence of a living person. The probably dying potential donor should be provided the usual care that

should be given to any critically ill or dying person. Because of a potential conflict of interest, it is widely agreed that the transplantteam should be different from the team providing care for the potential donor, who is not to be "deprived of life or of the essential

integrity of their bodily functions.... No organs may be removed until the donor's death has been authenticated by a competentauthority other than the recipient's physician or the transplant team." Various parts of the human body can often be kept in goodcondition for transplant purposes after the death, irreversible cessation of all brain functions, of the donor.

The Catholic Health Association of Canada (CHAC) considers transplantations of brain cells (presuming irreversible cessation of allbrain functions of the donor) in order to restore functions lost through disease as permissible "as long as the unique personal identity

and abilities of the recipient are not compromised in any way."

The German Bishops' Conference and the Council of the German Evangelical Church consider the transplant of "reproductive glands"as unethical, "since it intervenes in the genetic individuality of the human being."(374) This does not seem to exclude transplanting all

sexual body parts, but the gonads. Any child that resulted following an ovary or testicle transplant would have the dead donor and notthe living recipient as its biological mother or father. This would violate the rights of the child (see SCDF 1987, 23-26).

The case of the body of a pregnant woman in Germany, who had been declared brain dead, being kept alive with the hopes of the child

coming to term was recently given some media attention. Some criticized this as not giving proper respect to the woman. Can not thiseffort, however, be seen as similar in some ways to organ donation and, therefore, as commendable? The woman had at least

implicitly offered her body for the child's sake before her fatal accident. Her family also requested this.(Associated Press) Cases such

as this also raise the question of "ordinary" and "extraordinary" means of saving life.

The use and possible use of cadavers and "neomorts" (brain-dead individuals maintained on life support) for a variety of purposes

(transplants, research, training medical students), perhaps even a considerable time after the person's death, has provoked ethical andlegal debate. Various concerns include respect for the dead and their wishes, respecting the family's wishes, benefitting others and thecommon good. In light of this, anyone considering donating their organs and/or body after their death, highly commendable in itself,

may wish to specify certain limits.

b) From Living Persons (Adults, Mentally Disabled, Minors)

Transplants between living persons raise the question whether it can ever be ethical to mutilate one living person to benefit another.

Concerning this many distinguish between parts of the body that can regenerate (e.g. blood and bone marrow) and parts that do not


3/8

regenerate. Regarding the latter some are paired (e.g. kidneys, corneas and lungs), whereas others are not (e.g. heart). Beforetransplants of organs such as kidneys were performed, many Catholic theologians considered this unethical between living persons.

They thought it violated the Principle of Totality which allowed the sacrifice of one part or function of the body to preserve theperson's own health or life (i.e. a part could be sacrificed for the sake of the whole body), but did not allow one person to be related to

another as a means to an end. When such transplants began in the early 1950's ethicists gave the problem closer study.

Gerald Kelly (1956) argued that such donations which have as their purpose helping others could be justified by the Principle ofFraternal Love or Charity provided there was only limited harm to the donor. Some ethicists argued this did not violate the Principle

of Totality provided that functional integrity of the body was not destroyed, even though there is some loss to anatomical (physical)integrity. Donating one of one's kidneys could be justified for proportionate reasons, since one can function with one healthy kidney.

("Living kidney donors constituted some 15% of the donor pool in Canada in 1989." Donating one of one's functioning eyes, however,

can not be justified, since one's ability to see (functional integrity) would be seriously impaired.

Basic to medical ethics is the Principle of Free and Informed Consent. To be properly informed the potential living donor should be

given the best available knowledge regarding risks to him/herself, the likelihood of success/failure of the transplant and of anyalternatives. In some cases there is much pressure to donate (e.g. from family members if one is a good match). The courts haverightly refused to compel such donations. Motivated by charity, which includes a properly ordered love for others and oneself, one

could decide not to offer an organ.

The distinction of ordinary and extraordinary means is also applicable to transplants. The Catholic Church teaches that one is obliged

to use ordinary means to preserve life, but not extraordinary means, that is, means that are very burdensome (very painful, expensive,

inconvenient, risky, or even very psychologically burdensome) or do not offer reasonable hope of benefit, or are disproportionate.Some forms of organ and tissue transplant from a living donor, especially those involving invasive surgery, involve considerable

burden to the donor. If means are available that do not involve such burdens, such as a matching organ from a deceased donor, theseare certainly to be preferred.

The above principles would allow in some cases such procedures as "transplanting part of the liver from a living adult donor into a

child recipient, whereafter the adult donor's liver regenerates within a month and the child's new partial liver develops as the child

grows"(LRCC, 15), or donating one's heart if one were to simultaneously receive a heart and lung transplant (Garrett et al., 200).

A competent adult can give free and informed consent to be or not to be a living donor, but an incompetent person cannot. Can a

guardian ethically consent for a legally incompetent person, such as a severely mentally disabled adult or a minor, to be a livingdonor? Concerning this issue some distinguish, for example, between a young child and a mature minor's ability to comprehend the


4/8

implications of donating. Regarding medical decisions an incompetent person's guardian is to act for their benefit or best interests,and, as far as possible, their wishes, if known and reasonable. Some think children and the mentally disabled should never be living

donors. They are simply being used with a violation of their bodily integrity, risks to their health and life, and no benefit tothemselves. An argument against their being a living donor of an organ such as a kidney, is that an alternative such as renal dialysis is

often available until a suitable deceased donor can be found. Others argue that in some cases the psychological benefit to the donor(e.g. a child's sibling lives) could outweigh the risks (e.g. of donating bone marrow).The Catholic Health Association of Canada(CHAC) says that, "Organ or tissue donation by minors may be permitted in certain rare situations."

Can it be ethical to have another child for transplant purposes (e.g. for a bone marrow transplant)? Conceiving and having a child forthis motive alone would involve treating him/her as a mere means to another's benefit. This would violate the great dignity of a person,

created in God's image, who should be loved for his/her own sake.

Concerning the whole issue of living donors, the German Bishops' Conference and the Council of the German Evangelical Churchsay:

...No one is obliged to donate tissue or an organ; therefore no one can be forced to do so. The decision to donate one's organs while

still alive can only be made by the individual concerned personally. Not even parents are allowed to decide on an organ donation bytheir child; they are allowed to give their consent only for a donation of tissue (e.g., donation of bone-marrow). The doctor in this case

has a special responsibility because no one can control whether a donation is truly voluntary.

When a living person donates an organ as a result of a personal decision, then the organ's transplant is to be carried out with due

attention, and post-operative medical care of the donors as well as the recipients must be provided. Further, consideration must begiven so that no problems develop in the relationship between the donor and the recipients (dependence, excessive gratitude, guiltfeeling).

c) From Anencephalic Infants

Anencephalic infants are born with a major portion of the brain absent. If born alive they die within a few days, although in rare casessome survive for weeks or months. They can suck and cry and some argue that their degrees of consciousness or unconsciousness may

vary. According to the widely accepted criteria of death as irreversible cessation of all brain functions, they are living humanbeings/persons. To increase the likelihood of procuring viable organs from them, some would like to redefine death in terms of partial

brain death so that they could be considered dead (although still breathing spontaneously...), or for them to be exempt from the total

brain death criteria, or to consider them non-persons. Many others, however, argue that partial brain death criteria are invalid in light


5/8

of our present knowledge and/or such an arbitrary move would endanger other classes of living human beings and lead many morepeople to refuse to sign organ donor cards. Although extraordinary means of prolonging the life of anencephalic infants do not need to

be used, they should be given the normal care of dying persons.

d) From Human Fetuses

Is it ethical to transplant brain or other tissues from human fetuses to benefit others (e.g. those suffering from Parkinson's Disease)? If

the fetus has died of natural causes, the ethical issues would be similar to other transplants from the deceased. When the fetus has died

or will die as a result of procured abortion, however, other ethical issues arise. The Catholic Church considers direct abortion (theintentional killing of an innocent human being) to be gravely immoral. Some argue that to use tissues from a fetus killed by abortion

could be done without approving direct abortion (cf. using tissues or organs from a murder victim). Such use, however, could "justify"abortion (i.e. to benefit others) for many women who otherwise are unsure about having an abortion. A good end though does not

justify an evil means. The timing of the abortion may be influenced as well. The widespread usage of electively aborted fetuses wouldestablish an "institutional and economic bond between abortion centers and biomedical science..."

Some argue that transplanting fetal brain tissue would require the fetus to be still alive, that is, the tissue would not be good for

transplant purposes after the fetus has experienced total brain death. Some say that other means of treating such diseases asParkinson's can and should be developed.

Another issue involves consent. Anyone involved in procured abortion would not qualify as the fetus' guardian since they hardly havehis/her best interests at heart. The Catholic Health Association of Canada (CHAC) concludes that, "Transplantations using organs and

tissues from deliberately aborted fetuses are ethically objectionable."

e) Using Animals

The shortage of various human parts for transplant purposes has in part motivated research in animal to human transplants. The use of

some animal parts such as insulin extracted from animal pancreases, catgut as absorbable sutures, and pig heart valves, are already

"accepted" medical treatments. Attempts, however, to transplant a baboon's heart to a human infant (Baby Fae) or a pig liver to adying woman, for example, have aroused considerable controversy. Some argue that the present state of transplants between species

does not justify such experiments which so far do not offer hope of therapeutic benefit to the human recipients. Defenders of suchexperiments argue that they can be justified if no other alternatives are available and for the knowledge gained. Some have questioned

whether such transplants involve irresponsible meddling with nature. Various animal rights groups have protested the sacrifice of

animals involved in this and other research, which uses them as "mere means" to human welfare. Concerning organ transplants from


6/8

animals to human beings research is being done with various immunosuppressive agents with the hope of finding a combination toovercome the rejection problem.(Johnston) Attempts are also being made to genetically engineer and breed new strains of some

animals such as pigs so that their organs can be transplanted into humans with less risk of rejection. If successful, the scientistsinvolved hope that this will overcome the large shortage of human donor organs.

Widely accepted directives for human experimentation call for both adequate preliminary animal experimentation to minimize the

risks to human subjects and that the welfare of animals used in research be respected. Pope John Paul II in an address to a Congress ofthe Pontifical Academy of Sciences said, "...animals are at the service of man and can hence be the object of experimentation.

Nevertheless, they must be treated as creatures of God which are destined to serve man's good, but not to be abused by him...."(p. 5)The Catholic Health Association of Canada (CHAC) stipulates that animals involved in research are to be properly respected and such

research "is to be allowed only when other methods involving non-living subjects are no longer helpful. When use of such subjects is

justified, pain relief must be used or suffering reduced to a minimum."

With respect to tissue transplants between individuals of different species, Pope Pius XII on May 14, 1956, spoke of the transplant of a

cornea, for example, as moral, if possible and warranted. He, however, considered the transplant of the sexual glands of an animal to ahuman being as immoral. Thomas O'Donnell interprets the condemnation of the latter as aimed at transplants that would "envision anact of attempted generation."

The Sacred Congregation for the Doctrine of the Faith excludes, among other things, attempts of fertilization between human andanimal gametes and to gestate human embryos in the uteruses of animals as contrary to human dignity. It considers genetic

interventions that are therapeutic, for proportionate reasons, however, as licit.

The Catholic Health Association of Canada (CHAC) considers transplants from living animals to humans as

...permissible as long as these can fulfill an essentially beneficial human function in the recipient. The human dignity of the recipient

is not to be compromised in any way and due respect is to be paid to the non-human donor in the whole transplant procedure.

f) Artificial Substitutes for Tissues and Organs

The shortage of various human parts for transplant purposes has also in part motivated research in the development of artificial andsynthetic substitutes for tissues and organs. There are a number of substances that the human body does not reject. A number of

artificial replacement technologies including false teeth, artificial limbs and joints, hearing aids, synthetic lenses, pacemakers,mechanical and synthetic heart valves, genetically engineered insulin and growth hormone, and renal dialysis, are already routinely


7/8

used in treatment. Other technologies such as the implantable artificial heart are still experimental or are used temporarily with thehope of keeping the person alive until a suitable human donor organ is found.

Artificial replacement technologies are generally very costly to develop. If they prove to be successful and are mass produced, their

long-term costs can be significantly reduced. A number of routinely used replacement technologies such as long-term renal dialysis,however, remain expensive. Some ethical questions concerning such costs will be considered in section 3.d below.

Another issue is that the recipient of some artificial parts may need to make certain psychological adjustments. Consider, for example,

the implantable artificial heart (also a heart transplant from another animal species) in light of the "popular belief that the heart is thecenter of human emotions, the organ of love."(Varga, 239. Cf. ibid, 238-41; LRCC, 20-22; and Thomas and Waluchow, Case 7:3.)

The Catholic Health Association of Canada (CHAC) states that artificial substitutes for tissues and organs are permissible providedthey "can fulfill an essentially beneficial human function in the recipient" and the "human dignity of the recipient" is not compromised

in any way.(46)

2. Ethical Issues Regarding the Recipient

...nobody [i.e. no potential recipient] has a claim on organs or tissue of any person, living or dead. The sick should thus accept thetissue and organs freely offered by others as a gift.

This position is widely accepted.

Another moral issue involving the recipient is free and informed consent. A competent person who could possibly benefit fromreceiving a transplant should be adequately informed regarding the expected benefits, risks, burdens and costs of the transplant and

aftercare, and of other possible alternatives. So should the guardian(s) of an incompetent person. A legally incompetent person who

can understand some things that are relevant to their condition, a proposed transplant, and decisions that they are capable of making,should be informed of these in an appropriate way. Guardians should respect the wishes, if known and reasonable, of incompetent

persons in their care. No unfair influence should be put on someone to be a transplant recipient. Potential recipients and their familiescan be tempted to pressure, blackmail or bribe a potential living donor to donate or a health care professional to give them a privileged

position on the waiting list. Such practices are unethical because they fail to properly respect the freedom of the donor or they violate


8/8

other potential recipients' rights regarding acess. Recipients should also avoid any unethical cooperation in any abuses (e.g. the organsor tissues have been procured immorally/illegally) that are sometimes associated with transplantation.

A potential transplant recipient and/or their guardian(s) could also consider their decision in light of ordinary and extraordinary means

of preserving life (see above, under 1.b). The competent adult Jehovah Witness who refuses a life-saving blood transfusion, forexample, because this is against a tenet of their religion, can be understood to be refusing means that would be "very burdensome" for

them. Courts, however, sometimes override the decision of natural guardians including parents when this is judged clearly against thebest interests of incompetent persons including a child (e.g. to allow a life-saving blood transfusion to the child of Jehovah Witness

parents). This issue is more difficult when the child begins to develop his/her own value system, but is still considered legallyincompetent.

Proper safety measures should be followed to protect transplant recipients from receiving AIDS and hepatitis viruses, etc.

Documents

Ethical Issues Regarding the Donor and the Recipients (1)