November 1982 IV/3
WHO SHALL LIVE?
A few months ago, a two-year-old child in Massachusetts was dying because of a diseased liver. Her father, a hospital administrator, spoke at a convention of pediatricians requesting that they keep his child in mind if they encountered a potential liver donor. The request received significant publicity and the parents of another dying child specified that after death their child's liver be donated to the child in Massachusetts. The transplantation seems to have been successful.
We rejoice with the parents of the child whose life was prolonged. But imagine that your child had been waiting for a liver transplant for a longer time than the child in Massachusetts. How would you feel if your child's opportunity to live had been sacrificed because other parents had been able to gain more publicity for the plight of their child?
Need for Ethical Norms
In the immediate future, we shall witness a dramatic increase in the ability to transplant human organs and an even more dramatic increase in the demand for human organs. Kidney transplants have become rather commonplace, but hearts, lungs, and livers are also being transplanted. Moreover, experiments are underway in animals to pave the way for transplantation of the small bowel and the grafting of adrenal gland tissues into the human brain for the treatment of Parkinson's Disease. How will we as a society handle this demand? Will we allow or encourage a free market or a black market to develop for the sale of human organs? Recently, a woman in Rock Island, suffering from heart disease, offered to sell one of her kidneys for $20,000. In Brazil, ads appear daily in newspapers offering corneas, kidneys, and blood for sale. Scientists, physicians and ethicists have agreed that donation of organs should proceed from a charitable, not a monetary motive. This conviction stems from a realization that the donation of an organ is in a certain sense a donation of life and, therefore, is above monetary value. Moreover, if organs were sold to the highest bidder, then the wealthy would have first choice, and this is contrary to the principles upon which our society rests. Dr. Thomas Cooper, president of the St. Louis Metropolitan Medical Society, believes that the Red Cross should be responsible for the collection and distribution of vital organs as it is for the collection and distribution of blood. While this is a valuable suggestion, vital questions still remain: what ethical norms will the Red Cross use when determining the recipients of vital organs, and who will make the decisions?
The Principles
As a step in providing some ethical norms for selecting organ recipients, the following thoughts are put forward:
1. All persons in dire need of organ donation should be enrolled in a regional organ donation center. Physicians or transplant teams would be requested to work through the center.
2. Because the purpose of the transplant is to prolong life for as long as possible, an attempt must be made to judge both the need of the transplant and the potential for success. Those more in danger of death would receive a higher priority (need), but among these, those with potential for better survival (success) would be chosen first. Patients would not be disqualified because of age alone. However, because age often presages development of complications after surgery, older patients would be given a lower priority than a younger person in the same general physical condition. The etiology of the disease should also be considered because a person who is in need of a liver transplant because of alcoholism or a person in need of a lung transplant because of smoking would not be as good a health risk as persons whose difficulties resulted from other causes.
3. The contribution to society of the person must be taken into consideration as well; otherwise, there is danger that people with money, prestige, or higher education automatically would be considered more worthy candidates. In a democratic society, where all in theory are equal, there might be a tendency to eliminate consideration of worth to society. However, there is some justice in trying to save the father of a family instead of an unmarried person, if all other criteria are equal. Hence, one's position in a family, one's actual and potential contribution to society should be considered.
4. If candidates seem to be equal in other criteria, then those who register first should be given higher priority. Hence this criterion would not be the most important, but would be considered if the others do not offer a clear classification of candidates.
5. At the present time, permission of family, spouse or legal guardian is required in order to harvest organs for transplant from a cadaver. (In the future as transplantation becomes more successful and common, our laws in this regard may change.) Allowing the family, spouse or legal guardian to specify the person who will receive the organs, however, does not seem fitting. Certain donations of organs among living members of a family should be allowed, but having the family or spouse of the dead person specify the recipient could defeat the ethical purpose of a selection system.
6. After attempting to classify people according to the above criteria, there still may be doubt about the most apt candidate. If so, then final selection from among those with highest priority should be made by lot. While this does not provide that the ultimate choice will be made in accord with reasoned principles, it does provide that unfair and prejudicial standards will not predominate in the final selection.
7. Who will make these decisions that not even Solomon would have attempted? When in doubt, organize a committee. The talents needed to make fair decisions would require people with different skills and sensitivities and so four or five people would be called upon to work as volunteers under the sponsorship of the Red Cross.
Conclusion
As medical knowledge and technique make it possible to prolong the lives of more people, we are forced to make choices. Choices always involve value decisions. Unless we have agreed upon norms and standards for our value decisions, we foster injustice, violence and anarchy. Hence, in the matter of determining norms for recipients of organ transplantation, we are discussing something of more than casual concern.
Kevin O'Rourke, OP
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