Organ Transplantation

Key ideas• Transplantation: the taking a section of tissue or

complete organ from its original natural site and transferring it to a new position.

• Autotransplantation: when an organ is transplanted into a different site in the same individual (a kidney with a long section of damaged ureter moved down to the iliac fossa). Autotransplantation also refers to transplantation of an organ from one individual to another of the same species (one person to another).

• Xenotransplantation: involves transplantation between different species (pigs to humans).

Ethical Issues in Transplantation• Transplantation of an organ or tissue from a dead to a living

person presents no ethical problem per se. • With few exceptions religious groups, Christian or non-

Chnstian, have recognised the worth of such transplants. • Questions tend to arise from factors other than the transplant

itself:

brain death

elective ventilation of potential donors

opting in or opting out of organ donation

the use of living related and unrelated donorsthe sale of organs

the cost of transplantation in a world of finite resources

the use of organs from animals

Introduction to Christian responses:

• The Bible does not say a lot about transplantation, although the Old Testament has a great deal to say about the moral responsibilities of the individual, and the controlling theme throughout the New Testament is that the Christian has to be Christ-like in his attitude and behaviour.

• Jesus is the model and example for the Christian. It is believed that he left the glory of heaven because of his great love for humans, which led him to the cross.

• Jesus’ command is for us to love one another as he has loved us.

Brain Death• It is impossible to discuss transplantation without considering

brain stem death. • The majority of cadaveric donor operations are carried out on

brain stem dead patients, on life support machines. • Dr Christopher Pallis, a respected neurologist, defines death as

follows:• 'There is only one kind of death. The irreversible loss of the

capacity for consciousness combined with the irreversible loss of the capacity to breath (and therefore sustain a spontaneous heartbeat)'

• Brain stem death did not evolve to satisfy the needs of transplant surgeons, but in response to the increasing medical technology that is now part and parcel of all intensive care units. lf transplantation was superseded tomorrow by better treatment of organ failure, patients who are brain stem dead would still occur wherever intensive care units are established and ventilators would continue to be switched off.

Health Economics Financial Pressures

• In health care systems throughout the world, cost effectiveness is becoming a major driving force for directing strategies of health care.

• The resources available for administering health care are finite, forcing difficult choices to be made in the use of finances, in the use of time, and ultimately in which patients are treated and in what way.

• As medical knowledge advances, public expectations rise and pressure mounts to provide more and more from the same resources.

• Transplantation is often considered to be an expensive option.

• It is often more cost effective than other treatment options:

May avoid expensive drug bills

May avoid repeated hospital admissions

Avoids dialysis, in the case of renal failure

Avoids a high level of dependency in the community

Health Economics The Shortage of Available Organs

• The number of available organs falls short of those required.

• For example, in the field of heart and lung transplantation 456 organs were transplanted in the United Kingdom in 1992 while the waiting list had grown to 750 patients. In 1993 in the USA, approximately 1 in 20 kidney patients, 1 in 5 liver patients, 1 in 4 heart patients and 1 in 3 lung patients died waiting for the appropriate transplant.

• Careful pre-operative assessment of the potential recipients is crucial to exclude those who are likely to develop so many post-operative problems that they become more incapacitated than before. (For such patients, it is argued, transplantation would be an unfair option, both for the individual in question and also for other patients who would be denied a transplant.)

Important issues for consideration:

• Who is transplanted first? – Those waiting longest? – The sickest?

(on the one hand they may not survive until the next opportunity, but on the other hand they have a much higher mortality rate than the less sick patient)

– Should a 19 year old in his formative years be preferred to a fully trained 49 year old with dependent children?

– Does the society which pays for the transplant have the right to demand some return for its investment?

Living Donors

• The continuing limitations in the number of cadaveric organs, along with better results, have encouraged the taking of one organ from living donors where humans have two, such as kidney transplants.

• In renal transplantation, for example, the 1 year graft survival is 93% and at 5 years 85% compared with 83% and 68% respectively for first cadaveric grafts.

• All operations involve some risk to life, and only in exceptional circumstances can this risk be justified in a person who is both fit and healthy.

• It puts intense pressure on the surgeon who is operating on a person who does not need an operation and will not benefit physically from it.

• Some theologians speak of the principle of fraternal love or charity justifying the transplant, as long as there is only limited harm to the donor. – They distinguish between anatomical integrity (the

physical integrity of the body) and functional integrity (the efficiency of the body).

– Losing one kidney leads to a lack of anatomical integrity but not functional integrity because the efficiency of the body is not impaired.

– However loss of a cornea (for example) leads to a lack of functional integrity as well as anatomical integrity as the efficiency of the body is impaired by a loss of depth perception.

The brain stem tests are as foolproof as anything in medicine can be. They involve three phases:

1. The diagnosis must be established, in a patient in a coma on a ventilator.

2. Endocrine, metabolic causes and the effects of drugs and hypothermia must be excluded.

3. Tests may begin - these consist of tests of apnoea and brain stem reflexes. They are done by two clinically independent doctors who have been registered for five years or more and have experience in intensive care. A death certificate can be issued, and turning the ventilator off at this stage is not withdrawing treatment and allowing the patient to die, but it is ceasing to do something useless to someone who is already dead. Keeping the patient on a ventilator at this point raises hope where there is no hope.