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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 3  |  Page : 375-382
Moral and Ethical Issues in Liver and Kidney Transplantation

UPCSE, University College, London, United Kingdom

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How to cite this article:
Taher LS. Moral and Ethical Issues in Liver and Kidney Transplantation. Saudi J Kidney Dis Transpl 2005;16:375-82

How to cite this URL:
Taher LS. Moral and Ethical Issues in Liver and Kidney Transplantation. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2023 Jan 30];16:375-82. Available from: https://www.sjkdt.org/text.asp?2005/16/3/375/32870

   Introduction Top

The first successful kidney transplant was performed between monozygotic twins in Boston in 1954. Hardly a decade later, liver transplants were conducted to treat patients with chronic liver failure. In the short span of twenty years, most of the technical, surgical and immunologic hurdles to organ transplant­ation were removed. Currently, hepatic and renal transplants are commonly done as the treatments of choice for patients with liver and kidney failures respectively.(Schrier 1997, p.2480)

This remarkable scientific achievement has resulted in a great demand for transplanted organs. The mismatch between the large number of patients waiting for a transplant and the limited availability of donors has led to numerous ethical and moral issues. Contro­versies revolve around two main areas: the ethically acceptable sources of donation and the system of organ allocation.

Organs are taken either from deceased or living donors. Cadaveric transplant is proble­matic because the availability of the organs means that someone has died. Usually, the donor is a young, healthy person who was injured or killed violently (Cummings 1997, p.2853-2863). This setting creates several ethical and religious issues, including the acquisition of the appropriate consent and the various interpretations of brain-death in different cultures. Because of the limited number of cadaveric organs, the ethical principal of equity looms large in the allocation of this scarce resource. Long waiting lists have been the prominent means of assigning priorities in all countries. Globally, more kidneys are being transplanted from living related donors. Living donation infringes the Hippocratic Oath to "First, do no harm". However, the informed consent, the absence of coercion and the careful planning to minimize the poten­tial risks, justify this divergence from the oath. To extend the donor pool, new categories of donors have recently emerged. These groups include emotionally related donors, children, altruistic unrelated donors and executed prisoners. In addition, two questionable means of providing incentive for donation are "re­warded gifting" and rampant commercialism.

Finally, attempts at increasing the donors to include genetically modified animal organs have led to a new set of ethical and medical concerns. Xenotransplant is in the realm of the distant future.

   Cadaver Donors Top

Religious and Cultural Issues

Cadaveric transplant is hampered by religious beliefs, cultural traditions, social norms and ethical principles. In some regions, cadaveric donation is diminished for religious grounds. In Islam, the majority of scholars have decreed that cadaveric donation is permitted. However, two major Muslim scholars, Bin Othaimeen in Saudi Arabia and Al-Sha'arawi in Egypt, have published edicts against cadaveric donation. Culture also plays part. In Japan, death is not considered to occur at an exact instant but is a continuum that requires several days. Thus, the body must remain whole. A dead person with an incomplete body before burial or cremation is associated with mis­fortune. The reason for refusing donation is fear of injuring the dead person's "itai" (remains) by his or her own will (Schrier 1997, p.2858).

A kidney or a liver is harvested from a donor whose brain is dead but his heart is still beating. This concept of "Brain Death" is now accepted by the majority of people. Strict medical criteria must be fulfilled before undergoing a transplant from a brain dead donor .The acceptance of the concept of brain death is essential for retrieving healthy viable organs. This view is not universally accepted. For example, Orthodox Jewish beliefs identify death as the termination of the heart's function, not the brain. Throughout most parts of Asia, brain death is not recognized.

Non-heart-beating donation is an inferior yet acceptable option for donation. The kidney remains viable for up to 60 minutes after the heart stops, allowing transplant to be performed during this period. The ethical problem is obtaining the relative's consent in this short period of time (Bowman 2002, p.192-195).

It is imperative that consent for donation is obtained prior to transplantation. The donor must have expressed, before death, a desire to donate or his family have no objection to donation. This system, which most countries follow, is known as "opting-in". An ethical hurdle is to approach the relatives at a time when they are greatly stressed. In an attempt to increase the size of the donor pool, some European countries like Spain have changed to an "opting-out" or "presumed consent" system, where the individual has the respons­ibility to register any objection he/she may have on donating an organ. This presumed consent would provide the transplant team the authority to remove any organ with no further explicit consent. Even in these countries, surgeons feel that it is desirable to discuss organ donation with the relatives if they are available (Hakim 1997, p.145).

Organ Allocation and the Equity of the Process

As the shortage of organs remains a problem, the methods and criteria used for organ allo­cation are debatable. All suitable candidates are placed on a waiting list. The number of organs available each year is much lower than the patients in need of the organs. As an example, in Saudi Arabia, 8,000 patients are on haemodialysis awaiting kidney transplant while only 100 cadaveric kidneys were trans­planted in 2002. In the USA, there are 82,000 patients currently waiting for an organ; 6,000 patients die yearly while waiting (Schrier 1997, p.2853). Unfortunately, their numbers will continue to ascend. Hence, the basic dilemma is which patient has the highest priority of the donated organ. Organs are usually allocated based on blood type, tissue match, immune status, medical urgency and the length of time on the waiting list. Two main competing principles are considered in all organ allocation decisions. They are justice and utility. The allocation of organs faces a classic dilemma: any system designed to distribute organs effi­ciently is likely to be seen as unjust or unfair. Proponent of maximizing utility focus on doing as much good as possible with a limited resource, while advocates of justice as the basis for distribution have their eyes on a pattern of distribution that they consider fair. In their view, justice means giving benefit to the worst off. Physicians tend to prefer utility, while governments generally advocate justice and fairness (Veatch 2004, p.57-66). Examples of such situations: Should a 40 year old working husband with three children be given pre­ference for a cadaveric liver over a man of 68 who lives alone? It is generally agreed that age should not be the determining factor. Should the severity of their disease determine which of these candidates receive the liver? The social utilitarian would be inclined to select the former while those who advocate justice may prefer to give it to the later if his suffering is more and the disease is more advanced. A medical utilitarian may not select either and would allocate the liver to a younger candidate who is less ill and is more likely to benefit more from the transplant and has better medical outcome.

Another recent case in the USA arose when a prisoner serving a life sentence for murder needed a liver transplant. He was placed imme­diately on a waiting list since any prisoner is the responsibility of the government. At the same time, a young woman with three children was a candidate and could not be placed on a waiting list. Her husband pro­tested - should a murderer receive more attention than his wife? (Mallia 2003, p.186-187). In addition, patients with mental and physical disabilities seldom receive organs despite their need for transplant. In brief, the main question is whether the allocation should be based on medical criteria which are biased towards utility, efficiency and medical outcome, or on fairness, justice and equity benefiting the needy.

Equity is a major ethical issue in the raging debate on organ allocation. In some hospitals in the USA, there are clear disparities in access and quality of health care for racial and ethnic minorities, regardless of their ability to pay. Sadly, African Americans represent 35 percent of all candidates to organ transplant (Daar, 2004). They wait longer for organs and are offered organs less often. Also, in the USA, livers are becoming more available to influ­ential and important politicians or famous athletes like the baseball idol Mickey Mantle who was given priority and received a trans­plant of his cancerous liver. Unfortunately, organ transplantation is becoming an example of exploitation of the weak by the powerful.

   Living- Related Donors Top

Biologically Related Donors

The essential ethical issue, in biologically related donors, is assuring the voluntary nature following full knowledge of the potential health risks. In most countries, living donation is becoming the most frequent modality. These donors are biologically related family members to the recipient. They eradicate the recipient's need for placement on the national waiting list. The surgery can be scheduled electively rather than performed as an emergency, which helps the recipient as he/she can be given immunosuppressant drugs well before the operation (Hakim 1997, p.46). This may help decrease the risk of acute rejection. Another important benefit of living related donation is psychological. The donor will be rewarded knowing that he/she contributed to the improved health of the recipient.

It is troubling to some surgeons to advice a person to undergo an operation which is of no direct health benefit to him/her but of benefit only to the recipient. This is justified by the principle of autonomy, which is the right to make a decision provided that the donor receives detailed explanation achieved through an "informed consent". This informed consent should contain all short and long-term complications including the rare possibility of mortality (less than 0.02%) (Caplan 1983, p.311-319).

Although, the health risks of donating one's kidney or part of a liver are limited, there can be negative psychological consequences. A living donor might feel pressured by his/her family to donate an organ to a relative or guilty if he/she is hesitant to proceed in the trans­plant. The donor should feel as free as possible in making his/her decision without any coer­cion or obligation.

Children as Donors and Emotionally Related Donors

To encourage donation, some additional sources, which are ethically questionable, are being considered. These include children and emotionally related donors (spouses and close friends). This is especially troubling when children are the only possible donors for their parents or siblings. The children may not be old enough to understand the informed consent process and the complications of donating an organ as they may feel pressured by their parents. On the other hand, a young girl might feel that that she should be given the oppor­tunity to save her mother through donation (Fost 1977, p.363). Therefore, the use of children as donors is a special circumstance and needs guidance, counselling and ethics committee approval.

An increasing number of transplant centres is now accepting donation from emotionally related donors. The close emotional relationship between recipients and either spouses or close friends is considered to be a motivation for donation that is as strong as the biological relationship. Many countries have modified their policies to include spouses and very close friends in the potential living donor pool. In fact, this is not a new practice. Such donors provided kidneys for nearly 10% of the 1488 recipients reported to the human renal trans­plant registry through 1966 (Hakim 1997, p.45). The ethical anxiety is usually based on the fear that the donor might regret the donation (Meslin 2003, p.163). Careful psychological assessment and consultation are required to protect against this possibility.

   Living -Unrelated Donors Top

In order to stimulate donation, various un­conventional categories of donors and methods of rewards are being hotly debated. The most active discussions in the transplantation circles revolve around the following topics: the inclusion of the altruistic stranger donor, "rewarded gifting" i.e. to provide financial incentive or public recognition for the donor, commercial transplants and finally the use of executed prisoners as organ donors (Tilney 2003, p.260). Each centre has its own acceptance criteria for unrelated donors. The central point in this debate is that the donor should not be exploited (Park 1999, p.336-338).

Altruistic Strangers

People may offer to donate a kidney to help a stranger. The medical community greets this with distrust and suspicion. However, a care­ful study in 1971 of 18 genetically unrelated living kidney donors revealed that none was coerced and there were no psychological or medical complications after donation. All of them experienced lasting feeling of high self­esteem and non regretted donation. The authors concluded "here, then, where a group of very fine human beings" (Cummings 1997, p.2855). More recent studies have confirmed that the offers of donation by living strangers may originate from healthy altruism rather than psychopathology or ulterior motive. This source of donation is considered ethically acceptable when protective procedures are followed and is being considered in some parts of the world.

Recently, a new category of incentives is employed. This is called 'rewarded gifting', in which the donor receives material or public recognition reward for the sacrifice. Such rewards are given in Saudi Arabia to living related donors, where these donors receive the King Abdul-Aziz Medal, grade 3. Similar rewards may be offered to altruistic donors.

Commercial Transplants

A more problematic category is practiced in some countries. 'Rampant commercialism' is the actual buying and selling of organs. In the 1980s in London, several surgeons in private clinics transplanted kidneys from impoverished Turkish or Indian peasants into rich foreign (often Arab) recipients, who claimed that the potential donors were related. Affluent foreigners still receive cadaver kidneys and poor local donors sell their organs in the United States (Kennedy 2002, p.17-46).

In addition, Italians travel to Belgium, Austria, Russia or China. These countries have relatively high donation rates for cadaver transplants. Likewise, Israelis fly to Turkey with their surgeons to be implanted with kidneys bought from the poor. An Israeli can have a success­ful, well-arranged and scheduled transplant in Turkey for $145,000 paid to a private broker. Indians receive only $1,000 for donating their organs. The rest of the money goes to the surgeon and the broker. Most of the Indian donors are women, who are low paid domestic workers with husbands in trouble or in debt (Cohen, 2005). In some South Americans countries, newspapers and advertisements appear from desperate persons willing to sell their kidney.

Claims of kidnapping orphans in Egypt and Brazil to sell their body parts for transplant­ation have recently been made. Careful investi­gations of the matter did not substantiate these claims. Trading organs has always been abhorrent to the members of the international transplant community and their governments with the exception of Iran (Tilney 2003, p.272).

Most countries have enacted laws to prohibit the practice of selling organs. The Islamic organisation for medical sciences has declared that buying and selling human organs was not allowed in Islam. In Kuwait, for example, the buying and selling of organs by any means or for any material consideration is a criminal offence. The proponent for such activity claims that money is already changing hand between related donors in India. What is wrong with using money for the unrelated? (Schrier 1997, p.2857). However, the overwhelming majority of professionals consider the practice to be contrary to the ethics of a civilized society and is reminiscent of the slave trade.

Executed Prisoners

One of the most unethical issues in organ transplantation is the use of body parts from executed prisoners. It has been estimated that out of 10,000 kidneys transplanted in China, yearly 4 to 6 thousands are from executed prisoners. In 1984, China enacted a law which legalised the usage of organs of executed prisoners if no one claimed the body or if the condemned prisoner volunteers and the family agree. However, permission is rarely obtained and neither prisoner nor family is informed of the donation. In the USA, a death­row prisoner can exchange a kidney for a sentence of life without parole. A prominent U.S. ethicist noted, ''in China, they kill you to get your organs; here we kill you unless you give your organs!''(Tilney 2003, p.270-274). Using the organs of condemned prisoners is unethical, repulsive and morally repugnant.

   Xenotransplantation Top

There are ethical problems in xenotransplant­ation. Firstly, the main question is if animals should be bred and used as organ donors. In this debate, "animal rights" and protection should be considered. The different opinions on this question start from the idea of comparing food and clothing to xenotransplant. If it is acceptable for animals to be used for food and clothing, why should they not be used for xenotrans­plant? (Tilney 2003, p.257).

Another ethical issue related to this topic is that serious animal viral infections can be transmitted to human recipients and may spread into human generations. Genetically modified animals are used for transplant. The improper disposal of these numerous animals has an impact on the environment and people's health. Specifically, the dumping of transgenic pigs is a health concern. Due to the inappro­priate disposal, the DNA of the animal sources can replicate and spread. It can then recombine and pick up genes from viruses in other species. New pathogens can be subsequently created. The main concern is whether breeding animals for xenotransplant is acceptable at a time when environmental pollution is becoming a major concern (Hakim 1997, p.49).

   Financial Issues Top

One final related ethical matter that needs to be addressed by the society is how to allocate meagre financial resource to different segments of heath care. Kidney and liver transplants are costly. Currently, one kidney transplant costs $116,000 and a liver transplant reaches up to $300,000 (Wright 2005, p.821-826). These costs may rise to about $400,000 for the follow-up care and immunosuppressive drugs needed (Mallia 1997, p.186-187). The strategic question facing societies is whether these huge funds should be spent on trans­plants that, if they ever succeed, would benefit a small minority of patients or they should be allocated to common health problems. Examples are: family welfare, communicable and non-communicable diseases, preventive medicine and maternal and child health.

   Future Prospects Top

The number of donated organs will remain inadequate and limited. Since the number of cadaver donors will be static, living donors are rising. Hence, some interesting alternatives are being approached. One of the most deve­loped ideas is the use of relevant functioning cells that could expand and regenerate to form an organ. Engineered tissues are under intense investigation (Singer, 2003). The possibility of manipulation or bioengineering stem cells to create new organs is being pursued and is fervently discussed. Using stem cells from umbilical-cord blood was used to create a stem cell donor for an older sibling. This was publicly and politically critiqued. Because of that, scientists are trying to use adult stem cells (Tilney 2003, p.276). If this procedure could be used, the advances would quickly accu­mulate. In the future, these new techniques will improve number of patients in ways we cannot visualise yet.

   Conclusion Top

This brief review highlights the ethical issues caused by kidney and liver transplantation. The clinicians must be conscious of these controversies. All clinical practice should be carried out within a strict ethical framework. The main problem causing these ethical con­cerns is the shortage of transplanted organs. Several dilemmas related to cadaveric donation stem from the multicultural differences in the concept of brain-death and how the consent is obtained. The allocation process, utility and equity in distribution, will remain debatable. In living related donation, the question of informed consent versus coercion is still argued worldwide. Another troubling question is whether executed prisoners should be a source of organs. Furthermore, the breeding of animals for acquisition of organs is of ethical concern. Finally, all societies and governments should urgently deal with the quandary of rampant commercialism. As technology advances, other techniques might be used to help solve these controversies.[21]

   References Top

1.Whetsine L, Bowman K, Hawryluk L. Prolcon ethics debate: is nonheart-beating organ donation ethically acceptable? Crit Care 2002;6:192-5.  Back to cited text no. 1    
2.Caplan AL. Can applied ethics be effective in health care and should it strive to be? Ethics 1983;93:311-9.  Back to cited text no. 2  [PUBMED]  
3.Cohen L, 2005. Where it hurts: Indian material for an ethics of organ transplantation. Looksmart. Available from: http://www.findarticles.com/p/articles/mi_qa3671/is_199910/ai_n8872213/print. (Accessed: 15/2/2005).  Back to cited text no. 3    
4.Cummings N. Ethical and legal consi­derations in End-stage renal disease. In: R. Schrier, ed. Diseases of kidney. London and Boston: Little Brown and Company, 1997.  Back to cited text no. 4    
5.Fost N. Children as renal donors. N Engl J of Med 1977;296:363-7.  Back to cited text no. 5    
6.Guttmann T, Daar A, Sells A. Ethical, Legal, and Social Issues in Organ Transplantation. Berlin: Pabst Science Publishers, 2004.  Back to cited text no. 6    
7.Hakim N. Introduction to Organ Transplant­ation. London: Imperial College Press, 1997.  Back to cited text no. 7    
8.Kennedy J. Paying for Kidneys. University of Pittsburgh Centre Policy and Procedure Manual 2002;12(3):17-46.  Back to cited text no. 8    
9.Mallia P. Biomedical Ethics: patients' rights. Student BMJ 2003;11:186-7.  Back to cited text no. 9    
10.Meslin E. Organ transplantation and medical ethics. Indiana: Indiana University School of Medicine, 2003.  Back to cited text no. 10    
11.Murray J, Gleason R, Bartholomay A. Second report of registry in human kidney trans­plantation. Transplantation 1964;40:660-7.  Back to cited text no. 11    
12.Murray JE. Ethics and Transplantation. Boston: Harvard Medical School, 2002.  Back to cited text no. 12    
13.Park K, Moon JI, Kim SI, Kim YS. Exchange­donor program in kidney transplantation. Transplantation 1999;67: 336-8.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.14. Sandvand J. Kidneys for Sale. Asia observer, 1999. Available from: ­. (Accessed: 8/3/2005).  Back to cited text no. 14    
15.Singer P, Daar A, Caulfield T. Not all cloning is alike. The Hill Times, 2003. Available from: http://www.gnenomeprairie.ca/media/caulfiled0203.htm.(Accessed: 18/2/2005).  Back to cited text no. 15    
16.Schrier R, Gottschalk C. Diseases of kidney. Boston and London: Little Brown and Company, 1997.  Back to cited text no. 16    
17.Tilney N. Transplant: from myth to reality. New Haven and London: Yale University Press, 2003.  Back to cited text no. 17    
18.Tokyo's women medical university. How long will the transplanted kidney work? (online). Tokyo: TWMU (kidney centre). Available from: http://www.twmu.ac.jp/TWMU/Medicine/RinshoKouza/094/Urology/tx_e/q06.html. (Accessed: 10/2/2005).  Back to cited text no. 18    
19.Veatch R. Justice, Utility, and Organ Allo­cation. In: T. Guttmann, ed. Ethical, Legal, and Social Issues in Organ Transplantation. Berlin: Pabst Science Publishers, 2004;57-67.  Back to cited text no. 19    
20.Wood J. More adult stem cell breakthroughs 2002. The Interim. Available from: http://www.theinterim.com/2002/aug/01moreadult.html. (Accessed 18/2/2005).  Back to cited text no. 20    
21.Wright L, Ross K, Daar A. Ethics in trans­plantation. Am J Transplant 2005;5:821-6. Lama Saadi Taher  Back to cited text no. 21    

Correspondence Address:
Lama Saadi Taher
UPCSE, University College, 136 Gower Street, London WC1E6BT
United Kingdom
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Source of Support: None, Conflict of Interest: None

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