Aug. 11, 2000 -- When your life depends on a transplant, what are you willing to compromise? Would you accept a less-than-perfect replacement organ? Would you or your family pressure your brother or sister or child to donate a kidney or part of a lung? Would you buy an organ from a person who is desperately poor?
There is a huge gap between the number of people who need an organ transplant and the number of organs available. Each year, 3,000 U.S. patients die while waiting for a transplant -- and another 100,000 people die before they can even be put on the transplant list. There are some ways to narrow this gap -- but they raise both ethical and practical problems.
The most important new source of organs already may be waiting in hospitals, suggests Giuseppe Remuzzi, MD. In the current issue of The New England Journal of Medicine, Remuzzi notes that more than half of donated U.S. organs are rejected -- not by transplant recipients, but by physicians who will accept only near-perfect tissues from patients who have died. Remuzzi is director of transplantation at Italy's Bergamo Hospital.
"We are of the opinion that if there were an organized system of looking at refused organs, the majority could be used," Remuzzi tells WebMD. "The problem is to change the cultural mentality. Organs have been refused by the age of the donor or for certain diseases. But for some of these diseases, we don't know when the organ will fail or [exhibit] the disease. This time may exceed the remaining life span of older patients."
Remuzzi points to medical evidence suggesting that livers from deceased donors between 50 and 60 years of age function as well as those from younger donors. Kidneys from donors older than 60 years -- even those from diabetics -- are used in his institution if they meet minimum standards.
"In the majority of donors older than 60, you can find so-called 'marginal' kidneys," he says. "Each one is too [weak] to give kidney function, but if we transplant two into the same recipient -- an operation usually not done -- the two 'marginal' kidneys may provide more function than a normal kidney. These used to be discarded. This is a concrete way of using kidney material to increase the amount of kidneys available."
The United Network for Organ Sharing (UNOS) coordinates U.S. transplant programs, organ procurement programs, and tissue-typing laboratories. UNOS spokesman Joel Newman says that increased use of organs, while helpful, will not fill the widening gap between donation and demand. "Other countries have different demographics -- and Belgium and Spain have presumed consent that organs will be donated upon death," he tells WebMD. "It is hard to compare, but certainly the demand continues to grow in the U.S. Each year, the waiting list grows faster, while the increase in donation is stable at about 1%. The gap continues to widen."
There are other ways to increase the demand for organs -- but none is more controversial than the use of living donors. Advances in transplant biology make it increasingly possible even for an unrelated person to donate an organ to another.
New techniques also make it possible to donate only part of an organ. For example, two people can each donate part of one lung to build a new lung for a person needing a transplant. This most often occurs when two parents give part of their lung to a child with cystic fibrosis. Provided that the risk to the donor is minimal, few ethicists have a problem with this kind of donation. But as the distance of the relationship increases, so does the ethical dilemma.
"My personal feeling is that the success of kidney transplant is so dramatic, and life on dialysis is so miserable, that any effort to expand living transplantation has to be encouraged," Remuzzi says. "Living donations from one's spouse, parents, or children -- these are the most important ones normally done. We also often see brothers or sisters or emotionally related donors, such as a patient's fiancée. But it is another issue whether to encourage normal people to give kidneys to others that are in need. I think this debate has to be opened and widely discussed. The problem is that civilized countries have to do everything they can to avoid a person selling part of his body for money. So contracts that are more or less unclear must be avoided."
Transplant expert Yves Vanrenterghem, MD, PhD, from the University of Leuven, Belgium, is more cautious. He tells WebMD that live donation is not popular in his country. "One reason is that we have a rather high number of organs [donated upon death]. In that case, the need for organs from living donors is less important. I do not have an ethical problem with live donors as such, but it is never our first choice. If patients ask and a living donor is available we will not refuse to do that.
"We have done some spouse donations, and there I don't see any involvement of third parties. In many cases this concerns older patients where children have left home, and the two people are just responsible for themselves, then there is no coercion. This is often not the case with brothers and sisters, which quite often brings more psychological problems than between spouses. Using spouses who have reached the age of 60 or so is more acceptable than organs from brothers and sisters where you never can exclude a kind of coercion. That said, I should be very, very careful in using really nonrelated -- emotionally nonrelated -- donors. This is already a step much further than using organs from spouses," Vanrenterghem says.
Newman of UNOS tells WebMD that one U.S. organ procurement center has established a protocol for anonymously matching volunteer organ donors with unrelated recipients. "There are risks to living donation that need to be considered," he says. "There will be a growing number of people coming forward, not for a family member but for someone in need to have a kidney or a part of another organ. The concern in the U.S. is less with coercion than with compensation or the potential donors' expectation of something like compensation. Most living donors are altruistic, but some are looking for some form of recognition. Coercion is probably more of a problem within the family setting. There's a lot of work being done in the psychosocial realm. But there is no established protocol across the country -- it is still more a practice-based than a protocol-based approach."