By Matthew Snow
On December 23, 1954, a surgical team at the Peter Bent Brigham Hospital in Boston led by Dr. Joseph Murray transferred a kidney from a live donor to his identical twin, marking the first successful live organ transplant. Several years later, Dr. Murray made headlines again when his team performed the first successful transplant using an organ from a deceased donor. Since that time, scientific advances have made the donation of other organs and tissues, including the heart, liver, lung, cornea, hand, and even the face, a possibility. Many of these, particularly the essential organs, are more easily, or by necessity, harvested from deceased donors. As the human body becomes increasingly available for transplantation, the range of viable treatment options, and the spectrum of patients that can benefit from them, expands accordingly. Indeed, the clinical importance of developments in transplant medicine are underscored by the fact that Dr. Murray and other organ transplant pioneers have received Nobel Prizes in Physiology or Medicine for their achievements.
Despite the auspicious innovations in organ transplantation, the clinical applicability of transplant medicine is limited by a relative scarcity of donors. The realities of demand far outweigh supply, and patients continue to die while on extraordinarily long waitlists. At the same time, the Canadian Institute for Health Information estimates that only one in six eligible organ donors actually makes a successful donation, despite the fact that, according to the Canadian Transplant Society, at least 90% of Canadians support the process. This situation has provided a rich substrate for bioethical discussion, particularly regarding the practical policies that regulate organ donation.
A common strategy to obtain organs from deceased donors, currently used in Ontario, appears in the form of opt-in organ donation programs, which are sometimes referred to as “encouraged voluntarism.” These programs typically involve a process through which individuals voluntarily register with a government agency (such as the Trillium Gift of Life Network in Ontario) to donate their organs upon death. Opt-in programs capitalize on the public’s sense of social and ethical responsibility while theoretically upholding the value of autonomous decision-making. Nevertheless, in Ontario and elsewhere, it is common practice for the government agency to reaffirm the donor’s wishes with their family at the time of their death. Many families honour the wishes of their loved one, but they do have the power to override them. This has become a problem in Ontario, where up to one in five families of deceased organ donors have refused to provide consent according to the Trillium Gift of Life Network.
At the other end of the spectrum are opt-out programs, which operate on the basis of “presumed consent.”. In this model, every capable individual is automatically registered to be an organ donor upon their death, unless they specifically request otherwise. Opt-out programs are in place in many European countries, including France, Sweden, and Hungary, and have been definitively identified as a factor contributing to the increased rates of organ donation in those regions. Despite this, critics object that presumed consent programs unfairly burden individuals who wish to opt out by requiring them to take action, and could lead to coerced or unwilling donations. Moreover, to receive adequate support amongst the public, extensive and expensive education campaigns may need to be undertaken, which may not be feasible.
A third policy, which might be considered a balance between strictly opt-in and opt-out programs, involves mandating the choice to be an organ donor. In other words, individuals still have the autonomy to choose whether or not they want to donate their organs after death, but are legally obligated to make that choice. There is potential in theory for such a policy to increase the number of voluntary donors, as it may cause people who otherwise would not grapple with the issue of organ donation to take a stance. A secondary feature of such a policy is that families are legally barred from overruling the choice of the individual. However, when such a policy was temporarily implemented as an experiment in Texas in the 1990’s, more than three quarters of people still chose not to donate organs.
Other controversial strategies to improve organ donation have also been explored. For instance, some have proposed introducing incentives, ranging from providing memorial plaques or charitable donations to covering funeral costs or paying money directly to the family of the deceased. Despite having the potential to be effective, strategies involving monetary gain might be considered coercive and stand to divert essential funds from healthcare systems that are financially stressed as is. A small number of individuals have also suggested legislating the removal of organs from prisoners sentenced to death even in countries without presumed consent policies. These views largely arise from the thought that, given the problem of organ shortage, it would be wasteful not to use otherwise-viable organs for the greater good. Nevertheless, such arguments are opposed by most bioethicists.
It is clear that the present state of the organ donation system in Ontario and elsewhere is insufficient to address the needs of patients. Moreover, for existing policies that give people the autonomy to make decisions about donating their organs to be effective, they require the public to trust that doctors will fulfil their wishes after death and that their quality of care will not be affected by their decision. On the other hand, although other options that more forcibly mandate organ donation may be most helpful at increasing organ availability, they stand to limit individual autonomy and carry with them significant ethical concerns. Perhaps a better solution to the supply-demand imbalance will be found with the continued progression of transplant medicine. Moving forward, it will undoubtedly be interesting to see how advances in this field, including xenotransplantation and transplants of organs grown de novo from stem cells, will change the clinical transplant landscape and influence the ethical discussions surrounding organ donation.