Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation

Organ donation after cardiac or circulatory death (DCD) has been introduced to increase the supply of transplantable organs. In this paper, we argue that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the consequential ethical and legal ramifications. We also outline serious deficiencies in the current consent process for DCD with respect to disclosure of necessary elements for voluntary informed decision making and respect for the donor's autonomy. We compare two alternative proposals for increasing organ donation consent in society: presumed consent and mandated choice. We conclude that proceeding with the recovery of transplantable organs from decedents requires a paradigm change in the ethics of organ donation. The paradigm change to ensure the legitimacy of DCD practice must include: (1) societal agreement on abandonment of the dead donor rule, (2) legislative revisions reflecting abandonment of the dead donor rule, and (3) requirement of mandated choice to facilitate individual participation in organ donation and to ensure that decisions to participate are made in compliance with the societal values of respect for autonomy and self-determination.     

Autonomy,constraining options,and organ sales

Although there continues to be a chronic shortage of transplant organs the suggestion that we should try to alleviate it through allowing a current market in them continues to be morally condemned, usually on the grounds that such a market would undermine the autonomy of those who would participate in it as vendors. Against this objection Gerald Dworkin has argued that such markets would enhance the autonomy of the vendors through providing them with more options, thus enabling them to exercise a greater degree of control over their bodies. Paul Hughes and T. L. Zutlevics have recently criticized Dworkin's argument, arguing that the option to sell an organ is unusual in that it is an autonomy–undermining "constraining option" whose presence in a person's choice set is likely to undermine her autonomy rather than enhance it. I argue that although Hughes' and Zutlevics' arguments are both innovative and persuasive they are seriously flawed — and that allowing a market in human organs is more likely to enhance vendor autonomy than diminish it. Thus, given that autonomy is the preeminent value in contemporary medical ethics this provides a strong prima facie case for recognizing the moral legitimacy of such markets.     

Three views of organ procurement policy: moving ahead or giving up?

The supply of organs for transplant remains inadequate to meet the needs of waiting patients, in spite of many programs and approaches to increase rates of donation. Over the years there have been numerous proposals to introduce schemes that would move toward the outright sale of organs. Three articles in this issue of the Journal propose methods for increasing organ supply--two by moving toward a market approach and the third by advocating a change in social culture. All three suffer from shortcomings, including the endorsement and encouragement of the exploitation of those who may offer organs. Although the shortage of organs must be addressed, the social price of a market in organs is too high, and proposals to encourage a rethinking of social responsibility are unlikely to be effective.     

Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death.     

Death anxiety,altruism, self‐efficacy,and organ donation intention among Japanese college students: A moderated mediation analysis

The shortage of organs for transplantation in Japan has alerted health professionals to the low organ donation rate among Japanese people. The unique cultural view of death and altruism has been suggested leading to their low intent to donate cadaveric organs. A cross‐sectional survey was conducted in Japan to investigate the interplay of death anxiety, altruism, and self‐efficacy in influencing Japanese college students' intention to sign donor cards, in order to mobilise this large potential source of organ donors in the future. Six hundred and seven Japanese non‐donor card signers voluntarily completed a self‐administered questionnaire. The results of mediation and moderated mediation analyses with bootstrap approach suggest that death anxiety indirectly hinders Japanese people's intention to become a donor card signer through lowering of self‐efficacy, while altruism intensifies the positive impact of self‐efficacy on signing intention. These findings provide useful insights for organ procurement organisations seeking behavioural change not only in Japan but also in multi‐ethnic societies with a substantial Japanese population.     

Ambivalence,Autonomy, and Organ Sales

Recent philosophical arguments in favor of legal markets in human organs such as kidneys claim that respect for autonomy justifies such markets. I argue that these arguments fail to establish the moral permissibility of commercialized organ sales because they do not show that those most likely to serve as vendors would choose to sell autonomously. Pro‐market views utilize hierarchical theories of autonomy to demonstrate that potential organ vendors may autonomously consent to selling their organs even in the absence of any practical alternative to doing so. But central to hierarchical accounts of autonomy is the idea that persons my experience volitional ambivalence, a condition in which the will is irreconcilably conflicted. Because commercialized organ sales would create volitional ambivalence in many of those who opt to sell an organ, the choice to sell an organ would not be an autonomous one.     

Marketing human organs: The autonomy paradox

The severe shortage of organs for transplantation and the continual reluctance of the public to voluntarily donate has prompted consideration of alternative strategies for organ procurement. This paper explores the development of market approaches for procuring human organs for transplantation and considers the social and moral implications of organ donation as both a “gift of life” and a “commodity exchange.” The problematic and paradoxical articulation of individual autonomy in relation to property rights and marketing human body parts is addressed. We argue that beliefs about proprietorship over human body parts and the capacity to provide consent for organ donation are culturally constructed. We contend that the political and economic framework of biomedicine, in western and non-western nations, influences access to transplantation technology and shapes the form and development of specific market approaches. Finally, we suggest that marketing approaches for organ procurement are and will be negotiated within cultural parameters constrained by several factors: beliefs about the physical body and personhood, religious traditions, economic conditions, and the availability of technological resources.     

Earning points for moral behavior: organ allocation based on reciprocity

Anticipating the reevaluation of the Dutch organ procurement system, in late 2003 the Rathenau Institute published a study entitled 'Gift or Contribution?' In this study, the author, Govert den Hartogh, carries out a thorough moral analysis of the problem of organ shortage and fair allocation of organs. He suggests there should be a change in mentality whereby organ donation is no longer viewed in terms of charity and the volunteer spirit, but rather in terms of duty and reciprocity. The procurement and allocation of donor organs should be seen as a system of mutually assured help. Fair allocation would imply to give priority to those who recognize and comply with their duty: the registered donors. The idea of viewing organ donation as an undertaking involving mutual benefit rather than as a matter of charity, however, is not new. Notwithstanding the fact that reference to charity and altruism is not required in order for the organ donation to be of moral significance, we will argue against the reciprocity-based scenario. Steering organ allocation towards those who are themselves willing to donate organs is both an ineffective and morally questionable means of attempting to counter organ shortage.     

An "opting in" paradigm for kidney transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

An “Opting In” Paradigm for Kidney Transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors.

An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive.

An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

Non-heart-beating organ donation: personal and institutional conflicts of interest

While procurement of organs from donors who are not "brain dead" does not appear to pose insurmountable moral obstacles, the social practice may raise questions of conflict of interest. Non-heart-beating organ donation opens the door for pressure on patients or families to forgo possibly beneficial treatment to provide organs to save others. The combined effects of non-heart-beating donation and organ shortages at major transplant centers brought about by the 1991 United Network for Organ Sharing (UNOS) local-use organ allocation policy created potential conflicts, including the fact that candidates for organs become potential donors far more frequently than previously. Hospitals with a major emphasis on transplantation have economic and academic interests that may have been hurt by the relative organ shortage. Some may view non-heart-beating organ donation as a way to restore weakened programs and thus unconsciously compromise recognition of problems associated with non-heart-beating donation.     

Harvesting the living?: separating "brain death" and organ transplantation

The chronic shortage of transplantable organs has reached critical proportions. In the wake of this crisis, some bioethicists have argued that there is sufficient public support to expand organ recovery through use of neocortical criteria of death or even pre-mortem organ retrieval. I present a typology of ways in which data gathered from the public can be misread or selectively used by bioethicists in service of an ideological or policy agenda, resulting in bad policy and bad ethics. Such risks should lead us to look at alternatives for increasing organ supplies short of expanding or abandoning the dead donor rule. The chronic problem of organ scarcity should prompt bioethicists to engage in constructive dialogue about the relation of the social sciences and bioethics, to examine the social malleability of the definition of death, and to revisit the question of the priority of organ transplants in the overall package of healthcare benefits provided to most, but not all, citizens.     

History of organ donation by patients with cardiac death

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.     

Non-heart-beating organ donation: a reply to Campbell and Weber.

In the preceding commentary, Campbell and Weber raise two valid and important issues concerning non-heart-beating organ donation (NHBOD). First, because the procedure links withdrawal of life support and the potential for subsequent organ donation, the desire for organs may create a situation in which care of the dying individual has relatively less importance and the dying may receive suboptimal care. Second, even if concerns about care of the dying were dealt with adequately, there will not be enough non-heart-beating donors to significantly decrease the organ shortage that exists, making the procedure not worth the risk. We agree that attention to the important details of caring for the dying are, and must be, the primary concern of all health care workers caring for those individuals. Ensuring the patients' comfort, dignity, and autonomy, and providing for family and social support are the mainstays of this care. All policies for NHBOD should clearly support and mandate these concepts. Regarding the second concern, we agree that NHBOD is currently rare; however, evidence is increasing that this type of donation has great potential. Continued growth of the practice in this country will depend largely on public acceptance, which we believe will be directly influenced by whether the public perceives that care of the dying is not compromised by this procedure.     

论器官资源的开拓与公平分配

器官移植在我国正处于快速发展阶段,目前除技术层面的问题外,供体数量严重不足和分配不公的问题也十分突出。本文对我国器官资源短缺原因、器官移植立法的迫切性、器官移植市场的规范化引导等问题做了全面论述,尤其对如何建立可靠的供体库和器官分配公平性的实现等问题做了较为深入细致的探讨。     

Cognitive obstacles against organ donation: The influence of negative attitudes,norms, and traditional beliefs on Chinese people's intention to donate organs after death

In China, the organ supply is severely insufficient to cover all people on the waiting list for donated organs, and numerous patients die awaiting transplant. To achieve a better understanding of cadaveric organ donation in Chinese culture, this study examined 300 Chinese adults, in both Fujian Province and Macao, regarding attitudes towards organ donation, subjective norms about organ donation and traditional beliefs about the body and death, examining the influences of these factors on respondents' donation intentions. Multiple hierarchical regression results suggest that more negative attitudes, unfavourable norms and traditional beliefs lead to lower donation intentions. Copyright © 2010 John Wiley & Sons, Ltd.     

The use of prisoners as sources of organs--an ethically dubious practice

The movement to try to close the ever-widening gap between demand and supply of organs has recently arrived at the prison gate. While there is enthusiasm for using executed prisoners as sources of organs, there are both practical barriers and moral concerns that make it unlikely that proposals to use prisoners will or should gain traction. Prisoners are generally not healthy enough to be a safe source of organs, execution makes the procurement of viable organs difficult, and organ donation post-execution ties the medical profession too closely to the act of execution.     

Towards a Global Human Embryonic Stem Cell Bank

An increasingly unbridgeable gap exists between the supply and demand of transplantable organs. Human embryonic stem cell technology could solve the organ shortage problem by restoring diseased or damaged tissue across a range of common conditions. However, such technology faces several largely ignored immunological challenges in delivering cell lines to large populations. We address some of these challenges and argue in favor of encouraging contribution or intentional creation of embryos from which widely immunocompatible stem cell lines could be derived. Further, we argue that current immunological constraints in tissue transplantation demand the creation of a global stem cell bank, which may hold particular promise for minority populations and other sub-groups currently marginalized from organ procurement and allocation systems. Finally, we conclude by offering a number of practical and ethically oriented recommendations for constructing a human embryonic stem cell bank that we hope will help solve the ongoing organ shortage problem.     

Towards a global human embryonic stem cell bank

An increasingly unbridgeable gap exists between the supply and demand of transplantable organs. Human embryonic stem cell technology could solve the organ shortage problem by restoring diseased or damaged tissue across a range of common conditions. However, such technology faces several largely ignored immunological challenges in delivering cell lines to large populations. We address some of these challenges and argue in favor of encouraging contribution or intentional creation of embryos from which widely immunocompatible stem cell lines could be derived. Further, we argue that current immunological constraints in tissue transplantation demand the creation of a global stem cell bank, which may hold particular promise for minority populations and other sub-groups currently marginalized from organ procurement and allocation systems. Finally, we conclude by offering a number of practical and ethically oriented recommendations for constructing a human embryonic stem cell bank that we hope will help solve the ongoing organ shortage problem.     

Safety Engineering for Artificial General Intelligence

Machine ethics and robot rights are quickly becoming hot topics in artificial intelligence and robotics communities. We will argue that attempts to attribute moral agency and assign rights to all intelligent machines are misguided, whether applied to infrahuman or superhuman AIs, as are proposals to limit the negative effects of AIs by constraining their behavior. As an alternative, we propose a new science of safety engineering for intelligent artificial agents based on maximizing for what humans value. In particular, we challenge the scientific community to develop intelligent systems that have human-friendly values that they provably retain, even under recursive self-improvement.