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Ethical considerations in transplantation.

Volunteerism versus commercialism in the procurement of blood for transfusion was the subject of considerable debate a decade ago. Proponents of an altruistic system won the day on the basis of real or imagined risks of hepatitis resulting from the act of payment.

A vocal minority insisted that the act of payment was irrelevant--the socioeconomic status of the prospective donor pool determined the risk. This argument fell on deaf ears, however. The other side prevailed with threats of litigation in the event that hepatitis ensued from transfusion of purchased blood. But that was not the only reason favoring volunteerism.

Blood and bone marrow are uniwue tissues for transplantation in that they are renewable. When you remove a unit of blood from a donor, or marrow from his bones, it regenerates in a short time. There are no permanent adverse effects of donation that will compromise the health, appearance, or longevity of the donor. This is not the case with other tissues or organs. A kidney once removed leaves the donor permanently compromised.

Then, too, prospective recipients of transfusions can receive blood from a large percentage of donors. The number of alleles in the ABO and Rh blood group systems, and the low antigenicity of all but the D antigen in the Rh system, make it relatively easy to supply blood in virtually unlimited quantities to patients requiring hemotherapy.

The histocompatibility system is more complex. Many more alleles are involved, and the ability to provide a transplant tissue or organ that is appropriately matched with the HLA designation of the recipient is extremely limited. If a similar limit had applied to peripheral blood, the volunteerism versus commercialism debate might have ended differently.

As we enter an era of increasing sophistication in the technology of transplanation--from HLA typing to harvesting, preserving, and implanting donor organs, and most recently, preventing rejections--increasing numbers of transplant procedures are being undertaken. These operations provide a better quality of life for some recipients and prolong life for others. But with the technology come serious ethical dilemmas, akin to those addressed by the blood banking community a decade ago.

Two such cases have recently been addressed in the courts. In the first of these, Robert McFall, a 39-year-old construction worker, developed aplastic anemia. It was determined that only a marrow transplantation offered hope of saving his life. McFall's cousin, David Shimp, was found to be HLA compatible but refused to donate. A Pennsylvania judge upheld Shimp's right not to donate. McFall died two months latter (Viewpoint, MLO, November 1978).

In the second case, william Head, a 26-year-old Louisiana man, was found to have leukemia. Mrs. X, A woman in another state whose HLA type had been determined for unrelated reasons, happened to be HLA compatible. She was asked whether she'd be willing to serve as a marrow donor. The patient's name, age, and dire circumstances were not made known to her. Mrs. X elected not to be a donor, whereupon Head appealed to the University of Iowa to recontact her and explain the relevant facts of the case in detail. The university refused on grounds that such a contact would be "unduly coercive."

Head went to court, and the judge ordered the university to advise Mrs. X that no one but she could help the patient. As of this writing, that ruling is being appealed.

The Head case, like the McFall case, raises important ethical questions. Can a suitable donor of renewable tissue be coerced into donating, if only he or she had the appropriate genetic constitution to insure a successful transplant? Should the prospective donor and recipient or their representatives be advised of each other's circumstances and identities, or should such information be kept confidential?

If a reluctant or unwilling donor of a renewable tissue is ready to sell rather than donate his tissue, would this be ethically acceptable to the public? To the prospective recipient? How would the price be established? Is the donor's participation worth as much as or more than the fees charged by the medical team and hospital for the performance of their services? If a sale takes place, just the donor--or his estate--declare the proceeds as earned income or as capital gains?

Finally, any transfusion or transplant carries a risk of transmitting infectious illness. If a receipient acquires hepatitis, cytomegalovirus, or AIDS along with the marrow or other organ, is the donor responsible under the doctrines of strict liability and implied warranty?

Different problems arise when the donation is one part of a paired organ, such as a kidney. In these circumstances, the donor is often a living relative. While there is no legal obligation to serve as a donor, coercion is practiced in such cases on a family level. What are the ethical implications of "laying a guilt trip" on a reluctant donor of a nonrenewable paired organ? If the prospective donor is a minor, must an attorney represent him as a safeguard against reckless compromise of his future health?

Is a sale or barter appropriate within a family unit? How about unrelated donors? Should prison inmates be permitted to barter their renewable tissues or paired organs for reductions in sentences? If not, why not?

Donations of vital organs--hearts, heart-lung combinations, and livers--pose fewer ethical problems than do the situations outlined above. The donors are characteristically brain-dead, and the necessity for timeliness precludes the intervention of courts with stay orders, appellate decisions, and so forth. But these events often take place in full public view, with the media turning the drama into a three-ring circus.

This destroys the anonymity of the individuals involved and creates a melodramatic atmosphere of hope and despair more appropriate to a TV soap opera. Such spectacles are clearly not in the public interest. There's an urgent need for mechanisms to protect the bereaved families of brain-dead donors from this type of exploitation.

As more transplants are undertaken, we must scrutinize the ethical problems in the relationship between donor and recipient, the rights and obligations of each, the liabilities for defective parts, and the relationship between the media and the individuals involved. Already technology has outstripped the ability of ethicists to advise us what is proper and what is not. We must act quickly, though not in haste.
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Author:Soloway, Henry B.
Publication:Medical Laboratory Observer
Article Type:column
Date:Feb 1, 1984
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