Ethical considerations for organ transplant

KANISA GEORGE

As a die-hard Grey's Anatomy fan, I have become quite familiar with medical practices, ground-breaking medical research and state-of-the-art machinery that has taken the field of medicine by storm.

Episodes that feature 3D printing and the da Vinci Medical robot, which performs robotic-assisted minimally invasive surgery, are high points in my obsessive viewership. However, they somehow still don't hold a candle to organ transplantation. Isn't it fascinating that something that lives and breathes inside one human being can be used to save the life of another? How much-needed stem cells are harvested and used to cure diseases in the recipient's body, changing the course of their lives forever?

Domino surgeries, living donors, and cardiac xenotransplantation are mind-boggling concepts that some say challenge the "man playing God" theory but have generally been touted as revolutionary medical innovations.

Suffice to say, more than a handful of these procedures were initially deemed controversial, and where there is innovation, you'll be sure to find ethical standards that ensure safety and accountability.

According to the UK's National Health Service, organ and tissue donation is the act of giving your organs and/or tissues to help save or improve the lives of others and can include the donation of organs like the liver or tissue like the cornea. What's more interesting is that one organ donor can save or transform the lives of up to nine people.

Today, we are a far cry from the first wave of organ transplantation done in the 1950s, and in 2020 an estimated 130,000 organ transplantation procedures were done globally, with a total of 36,125 done using actual deceased organ donors.

Guiding principles on human cell, tissue and organ transplantation are regulated by national and international laws, with many countries placing immense focus on the ethical issues that may arise from deceased donor transplantation.

In 1988, TT was privileged to have its first organ transplantation, a kidney transplant from a living donor. Since then, the Human Tissue Transplant Act chapter 28:07 was implemented and invited deceased donor transplantation.

Section 4 of the Act deals with an adult's donation of regenerative tissue and lays down the condition in which this would be permitted. By virtue of section eight, a prohibition is placed on removing non-regenerative tissues from minors but allows for regenerative tissues to be removed once a parent or guardian gives consent in writing and the minor has a sound understanding of the process.

Of note are sections 16 and 17 of the act, which deal with removing tissue after death. Section 16 states that a designated officer may authorised the removal of tissue from the body of a person who has died in hospital or whose body has been brought into the hospital, for:-

(a) the transplantation of the tissue to the body of a living person; or

(b) the use of the tissue for other therapeutic purposes or medical or scientific purposes.

However, this can only be done if the consent and opt-out provisions in section 17 have been complied with.

Currently, living donations remain the primary type of transplant performed in TT and to meet the World Health Organisation's target of self-sufficiency, deceased organ donation is vital.

In order to deal with reduced donor numbers in England, the Organ Donation (Deemed Consent) Act 2019 was implemented to introduce the opt-out system. This means that all adults in England will be considered to have agreed to be organ and tissue donors when they die unless they recorded a decision not to donate or are in one of the excluded groups.

From the outside looking in, it is not clear how much work is being done towards developing a deceased organ transplantation network in TT or even basic education, as it appears a large number of citizens aren't aware of organ donation.

In countries like the US and the UK, organ transplant systems and databases are modelled after the WHO's set criteria and are used to regulate transplant waiting lists and organ procurement professionals. These systems are based on very high ethical standards, best practice guides and public education.

Sadly, systems are often predisposed to flaws and some countries, more than others, struggle to get things right. Unethical practices such as organ trafficking, organ commerce, and failure to achieve a balance between a living donor and recipient undermine organ transplantation's inherent good, leaving those most in need in a disadvantageous position.

Further, ethical issues with the timely and unequivocal definition of death are among the most debatable and complex dilemmas. As such, laws and policies governing the use of organs for transplantation have been shifting gears and finding ways to address ethical concerns and the shortages of transplantable organs.

While most living donors are family members or persons with purely altruistic intentions, some persons are motivated for financial reasons. This is typically frowned upon and viewed as highly unethical. It is generally accepted that organs and tissue should be given voluntarily and altruistically, with utmost respect for the donor's and recipient's autonomy. Ethical principles around live donations try to ensure little or no harm is done to the donor and that equitable opportunities and fairness in the allocation process are adhered to. One point of increased importance relates to physicians who determine brain death occurrence. Physicians in this position should not be directly involved in organ removal from the donor as this could potentially raise further ethical concerns.

Modern medicine has done the impossible in the last few years, and no doubt will continue to wow us. Yet, even with ground-breaking techniques, organ availability remains a stumbling block. So, should we accept what some deem to be the natural progression of life, or should we do more to ensure self-sufficiency?