LONDON – Organ transplantation is one of the most impressive achievements of modern medicine. It has brought hope to millions of patients suffering from previously fatal organ failure. For many, it has made life longer and better. It has benefited many professionals and industries, too, by becoming a new source of pride, funding, and profit. Struggling to contain costs, health-care payers are also among its beneficiaries. Kidney transplantation, for example, has proved to be less costly than dialysis. Yet, since its inception, transplant medicine has been grappling with a rapidly increasing gap between the supply of organs and demand for them. For most stakeholders, the often dire consequences gave rise to a whole set of solutions, all based on one general strategy: if we are short of organs, then let us get more of them. This strategy has come with a high price tag, however. On the one hand, it has given rise to some exceptionally corrupt practices, such as organ trafficking, transplant tourism, and many other ugly phenomena associated with a black market in organs. On the other hand, it has put transplant ethics under severe strain. Indeed, transplant ethics has been on a slippery slope almost since transplants began. The strategy of getting more organs has pushed, and continues to push, the ethical line to places that had previously been deemed immoral. To tackle insufficient supply from the dead, we first embraced an increasingly inclusive, and at any rate flexible, definition of death. This has often raised suspicions about the motivations of doctors in pronouncing a candidate donor’s death. We then came up with the idea of opt-out consent for deceased organ donation. This system, which allows organs to be harvested also from refusers who have failed to express their refusal, has not increased trust in medicine, either. As the organ crisis continued to deepen, we allowed donations from the living. This was particularly audacious, for it required us to abandon the supreme Hippocratic principle according to which it is unprofessional to injure a healthy person. In the category of living donations, we first permitted only directed donations by relatives and non-directed donations by non-relatives. We assumed that family ties and non-directedness would preclude coercion and commerce. However, the mechanisms we used to confirm that assumption were conveniently lax. They did not allow certain forms of coercion to interfere with the donor’s consent. Nor were they overly fastidious about clandestine commercial ties. By that time, we had already become aware that interests in organ commerce were constantly intensifying, and that those in need of organs or money were increasingly likely to turn to the black market or seek a legal loophole that would allow them to conceal the commercial transaction behind some legitimate gesture. Until recently, we have not done much about the black market (the 2008 Declaration of Istanbul marks the beginning of a determined struggle against this market), but we banned altruistic directed donations by living non-relatives out of fear that they would become that legal loophole. This fear did not last long, though. The increasing demand for more organs has driven us to legitimize this category as well. Indeed, it has helped a lot, but it has not sufficed, either. Currently, we peddle the idea of quasi-non-commercial incentives for organ donations from both the deceased and the living. For example, the new Israeli transplant law provides incentives for people to sign a donor card by giving them and their relatives priority on transplant waiting lists. This material incentive is in clear breach of the principle that organs should be distributed according to need only. Moreover, it is likely to discriminate against people who are either unaware of the donor-card system or tend to refuse to sign the card for reasons associated with religious beliefs or low trust in the medical authorities. The same law indeed forbids commerce in organs, but offers living donors reimbursement of expenses that contains fixed-sum elements. Moreover, the Israeli National Transplant and Organ Donation Center now openly encourages providers, insurance companies, and the Donor Card Institution, to pay families who consent to donate the organs of their deceased relative. Such arrangements, which should be described as government-sponsored commercialism, are considered unacceptable by all relevant international declarations. If things continue as they have, we will soon become tired of quick-fix remedies. Indeed, advocates of the increasingly popular idea of a regulated market in organs claim that it is the ultimate treatment. Perhaps it is. But let us not even go there! For even if we believe that buyers and sellers of organs can in principle enter the transaction on the basis of free choice, none of them has chosen to face the underlying dilemma in the first place. Both are victims: the buyer is a victim of morbidity and declining social solidarity, while the seller is a victim of poverty and other forms of financial distress. A regulated market would not challenge these man-made facts. Instead, it would reaffirm them more than any previous ethical solution has ever done. Many of the social crises that we currently face are just symptoms. Yet the underlying problems must be addressed as well if we are to lead the kind of life that human beings can and deserve to have. The organ crisis is no different. Instead of medicalizing and ethicalizing it, let us direct our main efforts at draining the swamp. Organ transplantation, like mosquito repellent, should be used sparingly, and only when there is no other choice. Miran Epstein is Senior Lecturer in Medical Ethics and Law at Barts and The London School of Medicine and Dentistry, Queen Mary College, University of London. Copyright: Project Syndicate, 2010.www.project-syndicate.org
