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Organ donation

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Organ donation is the removal of specific tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting or grafting them into other persons. Organs and tissues are removed in procedures similar to surgery, and all incisions are closed at the conclusion of the surgery. People of all ages may be organ and tissue donors.

In terms of numbers donations from dead donors are far outweighing the importance of donations by living donors. The laws of different countries either allow the potential organ donor to consent or dissent to the donation during his life time, or his relatives to consent or dissent. Due to these different legislative possibilities, the number of donations per million people varies substantially in different countries.

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[edit] Organs and tissues which can be donated

Organs that can be donated include:<ref>Which Organs Can Be Donated for Transplantation?. New York Organ Donor Network.</ref> the heart, intestines, kidneys, lungs, liver, pancreas. The following tissues can be grafted: bones, corneas, femoral veins, great saphenous veins, heart valves, skin grafts, small saphenous veins, tendon. Organs that can be donated from living donors include the lung, partial liver and the kidney.

[edit] Legislation regarding organ donation

There are basically four different legislative approaches to regulate organ donations. The most restrictive is the "consent solution", according to which the donor has to explicitly consent to a donation during his lifetime. The "extended consent solution" includes the possibility of near relatives to consent to the donation, if the donor has not explicitly dissented to a donation. The least restrictive legislative approaches is the "dissent solution", according to which the donor has to explicitly dissent to a donation during his lifetime. According to the "extended dissent solution" also relatives may dissent in the event the potential donor has not consented during his lifetime.

Countries that implemented the dissent solutions include: Austria, Luxembourg, Poland, Slovakia, Slovenia, Spain, Hungary and the Czech Republic. Countries that have implemented the extended dissent solution include Belgium, Finland, Italy, Russia, France, Norway, Sweden and Cyprus.

Countries that have implemented the consent solution include some parts of Switzerland, Estonia, Bulgaria and the United States. The extended consent solution has been implemented by Denmark, Germany, Greece, UK, Netherlands, Rumania and Turkey.

The different legislative approaches are the main reason that some countries like Spain (27 donors per million inhabitants) or Austria (24 donors per million inhabitants) have higher "donor rates" than for instance Germany (13 donors) or Greece (6 donors). In most countries with the dissent solutions no or rather short "waiting lists" for donations exist, while most countries adhering to the consent solutions do have substantial "organ shortfalls".

Under United States law, the regulation of organ donations is left to states. A Uniform Anatomical Gift Act seeks to streamline the process and standardize the rules among the various states, but it still requires that the donor make an affirmative statement during her or his lifetime that she or he is willing to be an organ donor. Many states have sought to encourage the donations to be made by allowing the consent to be noted on the driver's license. Still, it remains a pure consent system rather than an extended consent system or even a dissent system opt-out system.

[edit] Safety issues

Donated organs, blood, and tissues have the potential to spread disease. While donated blood is screened for a wide variety of pathogens, donated organs are usually screened only for the most common and dangerous pathogens, typically HIV, hepatitis, and syphilis. Organ screening is complicated by two factors. First, organs spoil quickly and must be transplanted within hours of being obtained. This limits the amount of time available for pathogen screening. Second, an organ donor is often an accident victim who has succumbed to traumatic injuries — such a patient has a much higher likelihood of having received blood transfusions in an effort to save his or her life.

Doctors have reported serious complications and death due to organ transplants from donors infected with herpes,[citation needed] West Nile Virus,<ref> (September 6, 2002) "Public Health Dispatch: West Nile Virus Infection in Organ Donor and Transplant Recipients --- Georgia and Florida, 2002". Morbidity and Mortality Weekly Report 51 (35): 790.</ref><ref> (October 14, 2005) "West Nile Virus Infections in Organ Transplant Recipients --- New York and Pennsylvania, August--September, 2005". Morbidity and Mortality Weekly Report 54 (40): 1021-1023.</ref> cytomegalovirus, Epstein-Barr virus, and even (in one case) rabies.<ref> (July 9, 2004) "Investigation of Rabies Infections in Organ Donor and Transplant Recipients --- Alabama, Arkansas, Oklahoma, and Texas, 2004". Morbidity and Mortality Weekly Report 53 (26): 586-589.</ref> Infection from non-viral pathogens, including candida<ref> (March 28, 1997) "Candida albicans Endocarditis Associated with a Contaminated Aortic Valve Allograft -- California, 1996". Morbidity and Mortality Weekly Report 46 (12): 261-263.</ref> and the parasite Trypanosoma cruzi<ref> (March 15, 2002) "Chagas Disease After Organ Transplantation --- United States, 2001". Morbidity and Mortality Weekly Report 51 (10): 210-2.</ref><ref> (July 28, 2006) "Chagas Disease After Organ Transplantation --- Los Angeles, California, 2006". Morbidity and Mortality Weekly Report 55 (29): 798-800.</ref> have also been reported.

Currently there is a lot of interest in how certain transplants (including bone marrow, stem cell, and bowel) can cause so-called "adoptive transfer" of diseases thought to have a genetic basis (such as Crohn's disease and other autoimmune disorders). While adoptive transfer of genetic disease is clearly not a desirable outcome, the cases so far reported may offer significant insight into how genetic susceptibility leads to a phenotypic manifestation of the disease.

[edit] Bioethical issues in organ donation

Since the mid 1970s, a relatively new ethics field, bioethics, has emerged at the forefront of modern clinical science. Many philosophical arguments against organ donation stem from this field.

Generally, these arguments fall into two camps: deontological and teleological ethical considerations.

[edit] Deontological Issues

Pioneered by such giants as Paul Ramsey and Leon Kass, few modern bioethicists disagree on the moral status of organ donation. Certain groups, like the Roma ("gypsies"), oppose organ donation on religious grounds, but most of the world's religions support donation as a charitable act of great benefit to the community. Issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur. In issues relating to public health, it is possible that a compelling state interest overrules any patient right to autonomy.

From a philosophical standpoint, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definition of life, death, human, and body is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for harvesting is an ongoing problem in clinical bioethics.

Further, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own. Cloning is still a controversial topic, more so when the clone is created with the express purpose of being destroyed for harvesting. While the benefit of such a cloned organ is a zero-percent chance of transplant rejection, the ethical issues involved with creating and killing a clone may outweigh these benefits.

A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation, or the transfer of animal (usually pig) organs into human bodies promises to eliminate many of the ethical issues while creating many of its own. While xenotransplantation promises to increase supply of organs considerably, the threat of organ transplant rejection coupled with the general anathema to the somewhat alien idea decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.

[edit] Teleological Issues

On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. Insofar as those that donate organs are often impoverished and those that can afford black market organs are typically well-off, it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time — many die while still on a waiting list.

Organ donation is fast becoming an important bioethical issue from a social perspective as well. While most first-world nations have a legal system of oversight for organ transplantation, the fact remains that demand far outstrips supply. Consequently, there has arisen a black market often referred to as the transplant trade outside of the United States.

The issues are weighty and controversial. On the one hand are those who contend that those who can afford to buy organs are "exploiting" those who are desperate enough to sell their organs. Many suggest this results in a growing inequality of status between the rich and the poor. On the other hand are those who contend that the desperate should be allowed to sell their organs, and that stopping them is merely contributing to their status as impoverished. Further, those in favor of the trade hold that "exploitation" is morally preferable to "death," and insofar as the choice lies between abstract notions of "justice" on the one hand and a dying person desperately in need of an organ on the other hand, the organ trade should be legalized.

Legalization of the organ trade carries with it its own sense of "justice" as well. Continuing black-market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade would lead to increased supply, lowering prices so that the poor might be able to afford such organs as well.

Exploitation arguments generally come from two main areas:

  • Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor.
  • Financial exploitation suggests that the donor (especially in the Indian subcontinent and Africa) are not paid "enough." This argument generally relies upon the assumption that there exists some financial amount that does indeed constitute "enough," but that the donors in question are not receiving this amount of money in return. Some evidence suggests that in an operation for a kidney the transplantee pays $125,000 USD. Of this, $20,000 is received by the donor, $40,000 is paid to a private hospital, $10,000 goes on flights and accommodation. This leaves the broker with a profit of $55,000. Some would suggest the donors are not receiving enough and hence are exploited. Other evidence describes brokers as only receiving $10,000. The high prices and profits may be partly attributed to the black-market status of the transaction.

If, however, neither of the above arguments are valid, the act generally cannot be condemned on a utilitarian basis. Still, the issue remains controversial.

[edit] Political issues

There are also extremely controversial issues regarding how organs are allocated between patients. For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes.

Healthy humans have two kidneys, a redundancy that enables living donors (inter vivos) to give a kidney to someone who needs it. The most common transplants are to close relatives, but people have given kidneys to other friends. The rarest type of donation is the undirected donation whereby a donor gives a kidney to a stranger. Less than a few hundred of such kidney donations have been performed. In recent years, searching for "good Samaritan" donors via the internet has also become a way to find life saving organs.

The Spanish transplant system is one of the most successful in the world, but it still can't meet the demand. [citations needed] Donations from corpses are anonymous, and a network for communication and transport allows fast extraction and transplant across the country. Under Spanish law, every corpse can provide organs unless the deceased person expressly rejected it. Nonetheless, doctors ask the family for permission, making it very similar in practice to the United States system. [citations needed]

[edit] Issues specifically arising in countries that have implemented the consent solution

[edit] Organ shortfall

A persistent issue relating to organ donation is the scarcity of organ donors relative to the number of potential recipients on organ donation waiting lists. In the United States, the waiting list is quoted to be about 94,000 people long.<ref>Organ Donation and Transplantation. United Network for Organ Sharing. Retrieved on 2006-08-07.</ref> It is not uncommon for those on the waiting list to die before receiving a suitable organ.

Approaches to addressing this shortfall include:

  • monetary incentives for signing up to be a donor
  • an opt-out system ("dissent solution"), in which a potential donor or its relatives must take specific action to be excluded from organ donation, rather than specific action to be included
  • social incentive programs, such as LifeSharers, whose members sign a legal agreement to direct their organs first to other members of LifeSharers on the waiting list

[edit] Reasons for not consenting to be a donor

A 1999 report on donor intention compiled by the Australian Bureau of Statistics (as reported in CHOICE magazine) gave a list of reasons people (Australians, in this report) gave for not becoming a donor: It includes the concern about being too old or too young, the concern that illnesses might cause a problem, the concern about disfigurement of the body, causing problems for a funeral, the concerns about religious views, the concerns about organ recipient and anonymity , the concern that the donor's family would have to bear costs, the concern that the prospective donor might not receive the best possible medical care because of donation agreement and the concern that the prospective donor might not be dead.

Responses were given regarding each of the above listed items, explaining that age, illness, and (usually) religion should not prevent someone from being a donor. The article goes on to assure that there is no cost to the family for procedures & treatments related to the donation after death is certified, and that anonymity would be preserved for both donor and recipient. Furthermore, the article stated that "[h]ospital staff, particularly in intensive care, are dedicated to saving [lives and have] nothing to do with donation agencies or transplant teams until brain death is confirmed", and clarified that organ donation does not involve disfigurement of the body.

The most important reason however for people not to consent to be a donor is simple lack of interest to do so, as it does an act that does not help the donors themselves and the time that is required to inquire about the legislation or where to register, if necessary, the donor's consent.

[edit] See also

[edit] References

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[edit] External links

he:תרומת איברים nl:Orgaandonatie pt:Doação de órgãos sr:Донација органа

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