“Despite continuing advances in medicine and technology, the demand for organs drastically outstrips the number of organ donors,” states a United Network for Organ Sharing (UNOS) fact sheet. UNOS is a nonprofit charitable organization that, under the authority of the federal government, maintains the United States’ organ transplant waiting list and works to develop organ transplantation policies and raise awareness about organ donation. According to UNOS, the chronic shortage of organ donors is the most critical issue facing the field of organ transplantation. While 22,854 lifesaving organ transplant operations were performed in 2000, over fifty-eight hundred people died while waiting for a transplant— an average of more than fifteen every day. In February 2002, there were over seventy-nine thousand patients waiting for an organ transplant, up from less than fifty-five thousand in 1996.
Factors behind the organ shortage
Ironically, the increasing success rate of organ transplant procedures is one reason that organ transplant waiting lists have risen so dramatically since the late 1980s. The first organ transplants, performed in the late 1950s and 1960s, were characterized by high mortality rates; a major problem was that patients’ immune systems often rejected the foreign organ. The introduction of the drug cyclosporine in the 1980s helped mitigate this problem, and organ transplants subsequently became less experimental and more routine. Statistics indicate that in 1998 organ transplant procedures were successful 70 to 95 percent of the time, depending on the organ being transplanted. With these increasing success rates, more doctors have recommended the procedures.
Another factor behind the organ shortage is that, according to UNOS, “relatively few deaths occur under circumstances that make [cadaveric] organ donation possible.” There are two main types of organ donation: living-donor donation and cadaveric donation. Kidney transplants make up 95 percent of living-donor donations; the other 5 percent are largely from liver donations, a rare procedure in which an adult donates a portion of his or her liver to an infant. But the majority of kidney and liver donations, and virtually all pancreas, heart, and lung transplants, are removed surgically from donors shortly after their death. (By law, organs are only removed if the deceased carried an organ donor card or if family members give permission.)
Since the organs must be removed so quickly after death, cadaveric donors usually are individuals who have died in circumstances that make a swift determination of death possible: Among cadaveric donors in 1999, head trauma and cerebrovascular stroke accounted for 85 percent of all deaths. Thus, even if the number of people willing to donate organs in- creased at the same level as the demand for organ transplants, demand would outpace supply since only a minority of people die in circumstances that make cadaveric donation possible.
A final explanation for the organ shortage is Americans’ general reluctance to become organ donors. In a 1993 Gallup poll, 85 percent of those surveyed said that they support organ donation, but only 37 percent said that they were “very likely” to donate their own organs, and 25 percent said they were “not at all likely.” There are a variety of reasons that people may be uncomfortable with organ donation, but the Gallup poll zeroed in on a major one: 36 percent of respondents agreed that “thinking about your own death makes you uncomfortable.” Organizations such as UNOS are dedicated to encouraging Americans to overcome this reluctance to become organ donors. To this end they often stress that organ donation is a lifesaving act, not one that should be associated with death.
Proposals to increase the number of organ donors
However, raising awareness about organ donation is a slow process, and the need for more organs is immediate. Thus the biggest dilemma facing the transplant community is, “How can the number of organs available for transplant be increased?”
One proposal is to reverse the current system in which doctors must obtain a patient’s (or his or her family’s) consent in order to remove organs after death. Under a policy of “presumed consent” all patients would be presumed to want to become organ donors unless they explicitly state otherwise. Presumed consent proposals have consistently been met with strong opposition, however, on the grounds that they violate an individual’s right to make medical decisions for themselves.
“Mandated choice” or “required response” policies are less extreme alternatives to presumed consent. Advocates of mandated choice policies argue that rather than waiting for people to volunteer for organ donation, hospitals or government organizations should require individuals to state their preference about organ donation, perhaps when they obtain their driver’s licenses or file tax returns. Texas, Colorado, and several other states have implemented required response policies, but, on average, rates of organ donation have not risen dramatically as a result.
One of the most controversial proposals is to provide individuals with some type of incentive to become organ donors. Such incentives could range from straight cash payments for living-donor organs to government assistance with funeral expenses for the families of cadaveric donors. Currently, proposals for compensated donation would likely be in violation of the 1984 National Organ Transplant Act, which makes it illegal to buy or sell human organs. Critics also charge that payment for organ donation could lead to a black market for human organs. In fact, such a black market already exists in India, where, according to a 1998 investigative report in the New York Review of Books, wealthy foreigners with end-stage renal disease pay thousands of dollars for human kidneys “donated” by impoverished Indians.
Given the ethical dilemmas surrounding proposals to increase organ donation, the medical community has searched for other ways to alleviate the organ shortage. Xenotransplantations, or cross-species transplan- tations, have been offered as one such solution. Surgeons transplanted a baboon heart into an infant nicknamed “Baby Fae” in 1982, but the child died three weeks later. More recently, pigs have been heralded as a potential source of organs. In January 2002, for example, scientists from the same laboratory that cloned Dolly the sheep in 1997 announced that they had genetically modified five piglets to make their organs more suitable for transplantation into humans.
Xenotransplantation raises a different set of ethical questions, however. Animal welfare activists have been very vocal in their opposition to xenotransplantation research. They also point to possible dangers associated with pig-to-human transplants. Xenozoonosis—the transmission of animal diseases to humans via blood or organ transplants—is a serious concern among scientists working on pig-to-human transplants. In 2000, the International Society for Heart and Lung Transplantation issued a report advising against further xenotransplantation until the virus risks are known, but the organization also concluded that “xenotransplantation has the potential to solve the problem of donor organ supply, and therefore research in this field should be actively encouraged and supported.” Despite both the ethical and the epidemiological issues associated with xenotransplantation, the research holds promise for the thousands of patients on organ transplant waiting lists.
Researchers are also working on developing artificial organs. As of February 2002, five people have received fully self-contained artificial hearts. The artificial heart has rarely been used because it is still highly experimental and because recipients must be willing to have their own heart removed to make room for the artificial replacement. Although there are many technical hurdles to overcome in the field of artificial organs, researchers are hopeful: Various laboratories in the United States and around the world are developing artificial hearts, lungs, livers, pancreases, bladders, and blood.
In addition to developing artificial organs, scientists are working on techniques to grow human organs from a patient’s own cells. Instead of waiting for a donor, for example, a patient in need of a heart transplant might one day only have to wait until researchers can grow one in the laboratory. Some of the research involved in tissue engineering is tied up with cloning and stem cell research, and thus raises ethical questions. Such research is also at the cutting edge of biotechnology, and therefore it may be decades before it bears fruit. Nevertheless, the medical community is eager to explore this potential solution to the organ shortage.
Alleviating the organ shortage
Although tissue engineering, artificial organs, and xenotransplantation provide hope for the future, the thousands of people currently on organ transplant waiting lists are counting on altruistic organ donation. As bioethicist Arthur Caplan explains,
What is truly distinctive about transplantation is not technology but ethics. Transplantation is the only area in all of health care that cannot exist without the participation of the public. It is the individual citizen who while alive or af- ter death makes organs and tissues available for transplantation. If there were no gifts of organs or tissues, transplantation would come to a grinding halt.
The field of organ transplantation is one of the miracles of modern medicine, but its power to save lives depends directly on the availability of organs. The authors in At Issue: Organ Transplants debate the various ways to increase the number of organs available for transplant and thus reduce the number of patients who die every day waiting for a new heart, liver, or kidney.