Aug. 9, 2000 -- For years they were dismissed as well-meaning but misguided souls or even cranks, but people who volunteer out of the blue to be living organ donors -- to give a kidney not to a relative or close friend but to a total stranger -- are now receiving serious consideration from organ transplant centers.
People who willingly sacrifice all or part of a vital organ for strangers are becoming increasingly common. In 1999, Jane Smith, a 42-year-old teacher from Fayetteville, N.C., gave one of her kidneys to a 15-year-old boy, a student in her homeroom class whom she had known for only two weeks. "I said, 'I have two, do you want one?" Smith told The Associated Press.
Also last year, Ken Schuler, a 46-year-oldman from Linville, Va., volunteered to give a part of his liver to a total stranger, a 39-year-old in need of a liver transplant, whose plight he had learned about on local TV. "I looked at my wife and said, 'I'd do that in a heartbeat,'" he told the Washington Post.
And although some people who think nothing of giving blood are troubled by the notion of parting forever with a vital organ, there are others of quite sound mind who see organ donation as a way of saving a life.
"We have occasionally been approached by persons offering to donate [one of their two] kidneys to any patient on the waiting list ... a process we call 'nondirected donation,'" writes Arthur J. Matas, MD, in the Aug. 10 issue of The New England Journal of Medicine. "Our policy has been to turn down these offers. But in view of the excellent outcome with the use of transplants from emotionally related donors [ie, spouses, close friends], the long wait for transplants ... and the persistent offers of donor volunteers, we decided to establish a policy for nondirected donation." Matas is a professor of surgery at the University of Minnesota.
The policy of Matas and his colleagues at the university calls for telephone screening of potential kidney donors, rigorous informed consent about the risks (both in written form and personal interviews), and detailed psychological evaluation to ensure that the donor is not mentally disturbed and is fully competent to make informed decisions about an irreversible medical procedure such as kidney donation.
Liver donation is even more complicated. Unlike kidneys, the liver can regenerate itself to full size in less than two months, making it possible to remove about half of a donor's liver for implantation in someone in need of a new liver. But the surgery for donating and transplanting a liver is more difficult, and puts both the donor and the recipient at greater risk for serious complications than does the same procedure for a kidney transplant. For that reason living-donor liver transplantation is rarely performed.
However, there is a critical shortage of donor organs, and many people who need a new kidney languish for as long as five years on waiting lists, making the idea of nondirected donation worth considering. In addition, advances in surgical techniques and in drugs that prevent the recipient's body from rejecting an organ from a nonrelated donor have made the surgery more successful.
"There has been an evolution of thought," Matas tells WebMD. "Twenty years ago our argument was that there are risks to the donor operation and that there would be no advantage to a living unrelated donor vs. a cadaver donor, therefore there's no justification to put the donor through those risks. Over the last two decades we've learned that the results of living unrelated donor [kidney] transplants are similar to living related donor transplants, and it sort of changes the equation in terms of risks and benefits, because now you have the same risks as we're putting the related donors through and in fact the same benefits."
Although accepting the sacrifice of healthy organs from altruistic individuals could help to ease the growing shortage of donor organs -- already at critical levels, transplant surgeons say -- it could also be the start of a slippery slope toward the competition and commercialization of organ procurement, some observers warn. And there is also the fear among some people that there may be an unintentional tendency to downplay the risk of donation in order to get an organ.
"The program as described from Minnesota strikes me as well put together and reasonable, but my concern is that they will not be the only transplantation program to institute this way of getting living donors [for kidney transplantation]," Norman Levinsky MD, tells WebMD. "In a competitive environment where it's important to a program to shorten the wait of their recipients to less than three, four, or five years -- in other words to get some of their most needy recipients to the head of the line -- there might be shadings of meaning or body English, which are totally unintended but which minimize the risks of discomfort at the least, and the remote but not zero risk of death," says Levinsky, professor of medicine at Boston University Medical Center, who wrote an editorial accompanying the article.
"It's a gray area, but I think if you look at it both from an ethics perspective, and perhaps from a basic science perspective, it's not a surprise, and it's something that people have been thinking and talking about for a long time," bioethicist Mary Faith Marshall, PhD, tells WebMD. "I actually have seen it as something inevitable and I don't see it as a bad thing. From a moral perspective I see nothing wrong with [nondirected donation] as long as there are procedural safeguards in place, and especially psychological ones, for the people who are involved." Marshall is director of the Program in Bioethics at Medical University of South Carolina in Charleston.
Levinsky concedes that some would-be donors may indeed have altruistic motives, just as bystanders sometimes rescue complete strangers from perilous situations, and that unrelated donors may not be subject to the same pressures, overt or implicit, that a relative of a critically ill patient might be subject to. But he also points out that the rate of death from an operation to remove a kidney is low. "If 10,000 unrelated kidney donors were recruited each year, three might die, and as many as 1,000 might have various complications."
To prevent solicitation of donations by the medical community, Levinsky suggests applying the same rules that currently govern organ procurement and distribution from people who've died to the harvesting and distribution of nondirected donations. If organs were distributed according to a nationally agreed-upon formula, medical personnel at the institution where the donor surgery is performed would not necessarily expect the donated organ to go to a recipient on their own list. That could eliminate any motives, no matter how unconscious or unintended, for putting the volunteer under pressure to give up a body part.
As controversial as the idea of nondirected donation may be at present, advances that hold promise for the ability to grow new organs in the body or replace them with artificial substitutes, may in the not too distant future make ethical concerns about organ donation obsolete, Marshall tells WebMD.
"As with any new or developing technology, it's best to think about the issues beforehand rather than trying to think about them in retrospect and clean up a mess that's already happened," she says, "so I really do think that it's good to have this discussion and this ongoing debate, and that's exactly what's happening."