The growing gulf between patients requiring organ transplants and the number of persons willing to give them is spurring some ethicists to call for new—and sometimes radical—ways to encourage donations.
The proposals range from loosening current restrictions on qualified donors to far more drastic measures, including “organ conscription,” which would require donations from all who die with adequately healthy body parts.
Some ethicists even are calling for debate on changing the legal definition of death to allow patients in permanent comas or vegetative states to become candidates for donation before cardiac death.
Transplant list wait times have increased dramatically in the United States. More than 92,200 persons were on U.S. waiting lists as of early May. That's nearly five times the number waiting a decade ago, according to the United Network for Organ Sharing, the nonprofit group that oversees organ allocation in the United States.
Despite the demand, numbers of donations have risen only slightly. Just over 28,000 Americans donated organs last year, up from 19,000 a decade ago, according to the network.
The shortage has led some experts to call for new incentives to encourage donations. One option would let prospective recipients move up on wait lists if members of their family donate. Another would require citizens to make an affirmative choice whether or not to donate before receiving a driver's license.
Federal law bans offering money or other inducements in exchange for organs. But policy makers should consider altering the law to allow for new incentives, said Robert Veatch, Ph.D., a professor at the Kennedy Institute of Ethics at Georgetown University, Washington.
Dr. Veatch calls an organ conscription policy the “nuclear option.” But he has called for experimentation with policy that many officials consider nearly as radical: cash payments for organs.
“There are too many people dying. I think its time to begin limited experiments with cash payments,” he said at a meeting of the President's Council on Bioethics.
But a cash-payment system of organ procurement is strongly opposed by both liberal and conservative ethicists, and also by a host of medical groups. Dr. Francis L. Delmonico, a transplant surgeon at Massachusetts General Hospital and a professor of surgery at Harvard, both in Boston, warned that groups including the National Kidney Foundation, the American Society of Transplant Surgeons, and the Organ Procurement and Transplantation Network/United Network for Organ Sharing, would offer “staunch opposition” to any congressional attempt to legalize a market in human organs.
“That [waiting] list is growing because of inadequate medical care, and it's not just solvable by buying organs,” Dr. Delmonico, also president of the board for OPTN/UNOS, said.
Others warn that assigning organs market value would undermine human dignity. “Isn't there really something disquieting about entering into a society in which certain parts of the body are treated as alienable things like automobiles?” asked council member Dr. Leon R. Kass, a University of Chicago ethicist who is also a vocal opponent of embryonic stem cell research.
Still, Dr. Veatch predicted that a combined policy of limited payments, forced donation decisions, and waiting list incentives could boost U.S donations by up to 75%. He also called for new policy that would let very ill patients choose to receive transplants from donors now deemed too high risk to donate, including injection drug users and men who have sex with men, who both have high rates of HIV and hepatitis.
Going to a new system that uses a “higher-brain” definition of death, rather than a cardiac definition—along with allowing donations from high-risk sources—could boost donations up to 200%, Veatch said.
Dr. Daniel W. Foster, a member of the council and a professor of internal medicine at the University of Texas Southwestern Medical Center, Dallas, pointed out that more than 65,000 Americans are waiting for kidney transplants, most of whom will die before a match is found.
“I think we have to do something radical about it,” he said.