CURRENT TECHNOLOGY

ISSUES AND DILEMMAS

ORGAN AND TISSUE PROCUREMENT; ORGAN
TRANSPLANTATION
DEATH AND THE DEAD DONOR RULE

Jellou Ray M. Macayan, RN

ORGAN TRANSPLANTATION
the moving of an organ from one body to
another or from a donor site to another
location on the person's own body, to
replace the recipient's damaged or
absent organ.

The emerging field of regenerative

medicine is allowing scientists and
engineers to create organs to be re-grown
from the person's own cells (stem cells,
or cells extracted from the failing organs)

ORGAN TRANSPLANTATION

Organs and/or tissues that are transplanted within the

same person's body are called autografts.
Transplants that are recently performed between two
subjects of the same species are called allografts.
Allografts can either be from a living or cadaveric
source.
Organs that can be transplanted are the heart,
kidneys, liver, lungs, pancreas, intestine, and
thymus. Tissues include bones, tendons (both
referred to as musculoskeletal grafts), cornea, skin,
heart valves, nerves and veins. Worldwide, the
kidneys are the most commonly transplanted organs,
followed by the liver and then the heart. Cornea and
musculoskeletal grafts are the most commonly
transplanted tissues.

VALUABLE ORGANS

ORGAN AND TISSUE

PROCUREMENT

The ethical and legal issues related to organ

and tissue procurement and transplantation are
often discussed in light of such principles as
autonomy, benevolence, non-maleficence, free
and informed consent, respecting the dignity,
integrity and equality of human beings,
fairness, and the common good. The JudeoChristian perspective affirms the great dignity
of each human person created in the image of
God.

 The various aspects, parts and functions of a

human person participate in this dignity. We are
also social beings who have a responsibility as
co-creators and stewards of God's creation. "In
the donation and transplantation of human
organs, respect is to be given to the rights of
the donor, the recipient and the common good
of society."

In a recent case described by Dr. Joseph Darby at

the University of Pittsburgh Medical Center, the
family of a man with devastating brain injury
requested withdrawal of life support. The man had
been a strong advocate of organ donation, but he
was not a candidate for any of the traditional
approaches. His family therefore sought permission
for him to donate organs before death. To comply
with the DDR, plans were made to remove only
nonvital organs (a kidney and a lobe of the liver)

while he was under anesthesia and then take him back to

the intensive care unit, where life support would be
withdrawn. Although the plan was endorsed by the clinical
team, the ethics committee, and the hospital
administration, it was not honored because multiple
surgeons who were contacted refused to recover the
organs: the rules of the United Network for Organ Sharing
(UNOS) state that the patient must give direct consent for
living donation, which this patient's neurologic injury
rendered impossible. Consequently, he died without the
opportunity to donate. If there were no requirement to
comply with the DDR, the family would have been
permitted to donate all the patient's vital organs.

Ethical Issues
Regarding the Donor

a) From the Deceased

1956 Pope Pius XII 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 be
condemned but positively justified
Pontifical Academy of Sciences - 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 the
medical profession, of the law, and of people in general.
The donation of organs should, in all circumstances,
respect the last will of the donor, or the consent of the
family present

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 to sign over
their bodies.
The Catholic Health Association of Canada (CHAC)
considers transplantations of brain cells
(presuming irreversible cessation of all brain
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." 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 not
the living recipient as its biological mother or father. This
would violate the rights of the child.

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 regenerate. Regarding the latter some are paired
(e.g. kidneys, corneas and lungs), whereas others are
not (e.g. heart). Before transplants 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 the person'sownhealth or life.

Gerald Kelly (1956) argued that such donations which

have as their purpose helping others could be justified
by the Principle of Fraternal 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.
Donating one of one's functioning eyes, however,
cannot 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/her, the
likelihood of success/failure of the transplant and of any

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., 2000).

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 be given
so that no problems develop in the relationship
between the donor and the recipients (dependence,
excessive gratitude and guilt feeling)

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 cases some 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 human
beings/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.
Many others, however, argue that partial brain death criteria
are invalid in light of our present knowledge and/or such an
arbitrary move would endanger other classes of living
human beings and lead many more people 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

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 (the intentional 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 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 would
establish an "institutional and economic bond between
abortion centers and biomedical science.

Another issue involves consent. Anyone involved

in procured abortion would not qualify as the
fetus' guardian since they hardly have his/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."

Ethical Issues
Regarding the
Recipient

Nobody has a claim on organs or tissue of any person, living

or dead. The sick should thus accept the tissue 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 from receiving 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.

DEATH AND THE DEAD

DONOR RULE

The ethics of organ transplantation

have been premised on the deaddonor rule (DDR), which states that
vital organs should be taken only from
persons who are dead. Yet it is not
obvious why certain living patients,
such as those who are near death but
on life support, should not be allowed
to donate their organs, if doing so
would benefit others and be consistent
with their own interests

Our society generally supports the view that

people should be granted the broadest range of
freedoms compatible with assurance of the same
for others. Some people may have personal moral
views that preclude the approach we describe
here, and these views should be respected.
Nevertheless, the views of people who may freely
avoid these options provide no basis for denying
such liberties to those who wish to pursue them.
Death must be declaredbeforeany cutting and
harvesting begins. Otherwise, the transplant
surgeons might be accused of causing death by
removing vital organs.Also the concepts of death
must be accepted by people who donate organs. If
there is too-subtle a difference betweenbeing
aliveandbeing dead, then those who must
approve donations will have qualms and

1. BRAIN DEATH
The definition of brain-death usually meansthatallof
the functions of the human brain have come to
apermanent stop. the complete and irreversible loss of
brain function (including involuntary activity necessary
to sustain life).
Drowning and freezing must be ruled out,since these
ways ofalmost dying show most of the same signs as
brain-death. However, in the Western world,braindeath has been accepted in all modern medical
practice.Laypersons do not always understand (since
they can see the body still breathing and the heart still
beating),but with enough explanation most people can
acceptthat their loved one has now passed over into
death.

COMA OR PERMANENT
UNCONSCIOUSNESS

In medicine, a coma is a state of unconsciousness in which a

person: cannot be awakened; fails to respond normally to
painful stimuli, light, or sound; lacks a normal wake-sleep
cycle; and does not initiate voluntary actions.
It is more controversial to consider transplanting organs from
donors who are 'merely' in a coma or who are permanently
unconscious. Such conditions are harder to define and more
difficult to certify. In the early days of considering this new
definition of death, it will probably only be used in those rare
caseswhere the patients have givenapproval in advancefor
using this definition of deathfor themselves.If a specific
patient and his or her proxies are all in agreement that
permanent unconsciousness can be certified as death, then
the doctor who is called upon to declare death will merely
have to determine scientifically that there isno chance that
consciousness will ever return to this body.

PERSISTENT VEGETATIVE
STATE

A disorder of consciousness in which patients with severe

brain damage are in a state of partial arousal rather than true
awareness. It is a diagnosis of some uncertainty in that it
deals with a syndrome. After four weeks in a vegetative state
(VS), the patient is classified as in a persistent (or 'continuing')
vegetative state.
It has emerged as a end-of-life condition because of advances
in medical science and technology. Our advances in
understanding how the body operates have empowered us to
keep thebiological functions of the bodygoing even when
thelife of the personis completely over. But because being in
PVS is such a hopeless state,
and because future advances in neurological science will make
it even easier to certify this condition, eventually well-proven
PVS will be acceptedas an adequate definition ofthe death of
a human person

ALZHEIMER'S DISEASE

It is a chronic neurodegenerative disease that

usually starts slowly and gets worse over time.
Gradually, bodily functions are lost, ultimately leading
to death.

People with Alzheimer's disease eventually

loseall of the capacities that make a human being a
person.But the millions of people in the USA with
various degrees of dementia shouldnever be defined
as dead no matter how debilitated they
become.However, when we foresee Alzheimer's as the
last phase of our own lives, we can leave detailed
instructions about what should be done, including
avoluntary death or a merciful death followed by
organ donation.

Conclusion
A number of the many ethical issues concerning
organ and tissue transplants have been treated in this
paper. These issues concern the donor, the recipient.
Organ donation, carried out under proper conditions,
is a beautiful and modern expression of Christian
charity: it gives dignity to the person who in death
becomes a life-support for another; it shows noble
concern for the respect of the life of others; and it
implies a sense of communion with humanity. The
Gospel proclaims that there is no greater love than to
give one's life for another. Jesus welcomes the good
done to another as though it were done to himself.

The dead-donor rule should continue to be

observed in transplant practice. But the definition
of death can advance over the centuries, as
science develops more precise tests of brainfunction. Progressively, we will accept organs from
thebrain-dead,from former persons who
arepermanently unconscious, from former persons
who are inpersistent vegetative state, and from
patients who have lost their personhood
toAlzheimer's disease. Giving our organs to people
who can make good use of them will allow these
other persons to havemany more years of
meaningful life.