Ethical issues in organ transplantation

Critical care clinicians are central to the organ transplantation process and therefore should be aware of the myriad ethical issues it raises. Organ donation can transform the lives of transplant recipients. However, it also warrants particular ethical scrutiny. Organ procurement is a procedure that cannot physically benefit the patient upon whom it is performed. Moreover, the potential donor incapacitated by terminal illness is usually unable to actively consent to donation. This article reviews contemporary debates in vital organ transplantation, including the definition of death, perimortem interventions and research, and merits of ‘opt-in’ versus ‘opt-out’ donor registries.     

Ethical issues in organ transplantation

Critical care clinicians are central to the organ transplantation process and therefore should be aware of the myriad ethical issues it raises. Organ donation can transform the lives of transplant recipients. However, it also warrants particular ethical scrutiny. Organ procurement is a procedure that cannot physically benefit the patient upon whom it is performed. Moreover, the potential donor incapacitated by terminal illness is usually unable to actively consent to donation. This article reviews contemporary debates in vital organ transplantation, including the definition of death, perimortem interventions and research, and merits of ‘opt-in’ versus ‘opt-out’ donor registries.     

Ethical issues in penile transplantation

This article provides an overview of the ethical issues associated with penile transplantation, a form of composite tissue allografting. There is only one reported case of human penile transplantation, and, as such, this technique is considered to be experimental. The ethical issues at stake involve both the graft donor and the graft recipient. With regard to the recipient, there are significant concerns relating to surgical risks and benefits, informed consent, body image （including surgical expectations and outcomes） and compliance. Donor issues may include family consent and privacy, as well as graft harvesting （leaving the donor cadaver without a penis）. Many of these ethical issues can be explored during the recipient＇s assessment and consent process. Because no medium-term or long-term outcome data for this procedure exist---only one such operation has ever been performed--the burdens and ethical issues concerning penile transplantation remain unknown.     

Ethical issues in living donor kidney transplantation

The ethical issues of living donor kidney transplantation, which is the treatment of choice for patients with end-stage renal failure, are the focus of intense debate. Some of those issues are related to the safety of the operation for the donor, and others are related to the motivation of the donor, the approach to and evaluation of the donor, donation by strangers, the commercialization of donation, surrogate consent for donation, and the acceptance of minors as donors. The lack of clear consensus regarding these issues results in differences in practice, not only among countries but also among transplant centers. We believe that after an open debate, agreement on certain generally accepted principles can be achieved. Such an agreement would protect potential donors and recipients and would ensure the future of living donor kidney transplantation.     

Ethical issues in organ and tissue transplantation

Clinical organ transplantation provides a way of giving the gift of life to patients with terminal failure of vital organs, which requires the participation of other fellow human beings and of society by donating organs from deceased or living individuals. The increasing incidence of vital organ failure and the inadequate supply of organs, especially from cadavers, has created a wide gap between organ supply and organ demand, which has resulted in very long waiting times to receive an organ as well as an increasing number of deaths while waiting. These events have raised many ethical, moral and societal issues regarding supply, the methods of organ allocation the use of living donors as volunteers including minors. It has also led to the practice of organ sale by entrepreneurs for financial gains in some parts the world through exploitation of the poor, for the benefit of the wealthy. The current advances in immunology and tissue engineering and the use of animal organs, xenotransplantation, while offering very promising solutions to many of these problems, also raise additional ethical and medical issues, which must be considered by the medical profession as well as society. This review deals with the ethical and moral issues generated by the current advances in organ transplantation, the problem of organ supply versus organ demand and the appropriate allocation of available organs. It deals with the risks and benefits of organ donation from living donors, the appropriate and acceptable methods to increase organ donation from the deceased through the adoption of the principle of 'presumed consent', the right methods of providing acceptable appreciation and compensation for the family of the deceased as well as volunteer and altruistic donors, and the duties and responsibilities of the medical profession and society to help fellow humans. The review also deals with the appropriate and ethically acceptable ways of utilizing the recent advances of stem cell transplantation from adult versus fetal donors, tissue engineering and the use of organs from animals or xenotransplantation. It is emphasized that clinical organ and tissue transplantation can be more beneficial and life saving if everyone involved in the process, including physicians and medical institutions, respect and consider the best interests of the patients, as well as honor the ethical, moral and religious values of society.     

Ethical and legal issues associated with organ donation and transplantation

Organ donation and transplantation present many challenges to the medical community and society as a whole that require legal and ethical frameworks. This article sets out the legal framework and key principles of modern bioethics that underpin modern frameworks of organ donation and transplantation practice. In many cases there is no single answer to a problem and the concept is introduced that ethics and implementation of ethical principles to policy is often governed by societal values or represents a best compromise. Organ donation and transplantation will continue to throw up challenging questions for law and medical ethics and it is key that doctors understand the language and principles involved so that they can contribute to the debate.     

Ethical and legal issues associated with organ donation and transplantation

Organ donation and transplantation present many challenges to the medical community and society as a whole that require legal and ethical frameworks. This article sets out the legal framework and key principles of modern bioethics that underpin modern frameworks of organ donation and transplantation practice. In many cases there is no single answer to a problem and the concept is introduced that ethics and implementation of ethical principles to policy is often governed by societal values or represents a best compromise. Organ donation and transplantation will continue to throw up challenging questions for law and medical ethics and it is key that doctors understand the language and principles involved so that they can contribute to the debate.     

Ethical issues with nondirected ("good samaritan") kidney donation for transplantation

“Good samaritan” donation has been of great interest in Italy. At the request of the Presidency of the Council of Ministers, the National Committee on Bioethics expressed its opinion on the matter. While highlighting its controversial aspects, the assessment was favorable. The National Council for Health established working criteria. Yet eminent bioethicists sharing the same values have reached discordant conclusions. Legal developments leading to the authorization of living donor kidney transplants from blood relatives or emotionally close individuals may offer a path for ethical assessment of the practice.     

Ethical issues in surgical research

Higher standards of evidence for surgical procedures are likely to be demanded in the future by health insurance providers. Consequently, more formal and rigorous surgical research, including RCTs, will become more prevalent. Facing the ethical challenges of surgical research requires understanding of the ethically significant differences between surgical practice and research and the ways in which the ethical standards appropriate for the design and conduct of clinical research differ from the ethics of clinical care.     

Ethical issues in evidence-based surgery

Evidence-based medicine, although ostensibly concerned with the research evidence underlying claims of efficacy for surgical procedures,has a direct connection with the ethics of surgical decision making.Questions of whether new procedures should ever be performed on patients outside of a formal research protocol, what the patient should be told about the uncertainties inherent in the use of nonvalidated innovative procedures, when formal evaluation is necessary, what form that evaluation should take, and how the burdens and results of such research can be distributed fairly all involve balancing competing ethical principles. Good ethics requires good facts, and evidence from well-controlled experiments provides best information upon which to base decisions in these areas and to build ethical surgical practice.     

Ethical issues in palliative care

The relief of suffering is one of the aims of health care. Pain relief is a moral obligation in health care, not an optional extra. Doctors have moral obligations to strive to relieve pain, to be competent in basic pain control, and to endeavour to give patients an adequate understanding of their illness and painkillers. The most common moral problem in pain control in terminally ill patients is the conflict between the obligation to relieve suffering and the obligation to prolong life. The law prohibits intentionally causing the death of another person. Debates follow as to what constitutes an intention to cause death, and what actually constitutes a cause of death. At present, doctors are legally permitted to give sedatives and analgesics to terminally ill patients with the intention of relieving suffering, even if life is shortened. The moral principle of the ‘double effect’ relates to this and is explained. It relies on a distinction between intended and foreseen effects of treatment. Some people dispute the distinction between intended and foreseen effects and claim that the principle of double effect allows doctors who intend euthanasia to carry it out under cover of the law. This debate is explored in the article. Finally, is it ever morally justifiable to end the patient’s life on the grounds that this is the only way to end pain? Even if it is, should euthanasia be legalised? A brief comment on these issues, and the roles of law and morality, are made.