Should we allow organ donation from non-related living donors? Dr ROSNIZA ABD AZIZ examines this prickly issue
THE era of organ transplantation began just 45 years ago when Dr Joseph Murray performed the first successful kidney transplant in Boston, Massachusetts. Organ transplantation is a triumph of modern medicine. Indeed, it is a technologically sophisticated, relatively high cost, often life-or-death intervention for patients with end-stage organ disease.
With improved immunological management and much longer waiting times for cadaveric organs, however, the medical benefits of transplantation from either related or unrelated living donors have become clearer.
In Islam, it is permissible for a living person to donate part of the body such as the kidney to save the life of another, provided that the organ donation would not endanger the donor’s life and that it might help the recipient. The Prophet (peace be upon him) said: “Whoever helps a brother in difficulty, God will help him through his difficulties on the Day of Judgment.”
In countries where cadaveric donors are not readily available such as Malaysia, living donation constitutes the only possible treatment where organ demand is increasing faster than supply.
The idea of a live person giving away organs is not new. Living donor liver transplantation was first performed in the United States at the University of Chicago in 1989, after extensive discussion of the ethics of this procedure.
In Malaysia, the first liver transplant was a living related transplant in 1995. Interestingly enough, despite new regulations that allow cadaveric organ transplantation, living donor liver grafts remain practically the only significant source of grafts for Malaysians.
Successful liver and heart transplantations are lifesaving. However in Malaysia, the gap between the need for organs and their supply has widened progressively over the past decade. Organ donation in Malaysia is less than one per million of the population (pmp) compared to 27 pmp in the US, 16 pmp in Britain, 10 pmp in Australia and seven pmp in Singapore.
In the United States, the median waiting time for a cadaver kidney transplant increased from 400 days in 1988 to 824 days in 1994. In 1996, 4,022 patients died while waiting for a transplant in the United States, up from 1,504 deaths reported in 1988.
The lack of alternatives results in a high demand for cadaver livers. About 19,000 people are now on the waiting list for those organs, but only 5,000 will get transplants, and about 2,000 die each year waiting for livers.
While the data here is somewhat limited, the evidence that is available reveals that for kidney, liver and heart transplants, waiting times have increased substantially. According to the Malaysian National Renal Registry, up to Dec 31, 2001, half of the 7,330 patients on dialysis are eligible for renal transplantation, but the number of organ donors is only less than 20 per year. The limited increases in the number of cadaver and living organ donors during this period have thus been far too small to keep up with the increasing demand, resulting in a steadily worsening shortage of transplant organs. Patients’ suffering and the considerable expense of keeping those patients alive while they wait for an organ are prolonged.
The urgency for pressing ahead with liver transplantation is further exacerbated by the fact that there is 10% incidence of death among liver transplant candidates waiting for a suitable organ. It is estimated that some of the patients will die while waiting for transplantation.
Even more tragic is the realisation that many of these deaths are preventable. The patients’ health often deteriorates as time passes, so that they are less able to withstand the physical stress of the transplant operations, a factor that reduces success rates. Many of these patients die as a direct consequence of the inability to obtain a suitable organ for transplantation within a shorter time period. Some patients might die without ever being placed on a waiting list. At least a transplant might have saved some of those patients’ lives.
There are a few advantages of living donor transplants. These include the ability to do the operation electively, the ability to optimise the recipient’s condition pre-transplant, shorten preservation time for the donor organ and the option to do a pre-transplant cross-match between donor and recipient.
The operation to transplant a liver, however, is a lot trickier than to transplant a kidney. Not only is the liver packed with blood vessels, it also makes lots of proteins that need to be produced in the right ratios for the body to survive. The extraordinary ability of the liver to regenerate is what makes living donor transplants possible.
An obvious advantage of living donor transplants is that they provide the benefits of transplantation to patients who might otherwise die while waiting for a cadeveric transplant.
Outcome reports on these procedures are comparable with those on cadaveric organ transplants, with one year survival rates for both partial liver and lung recipients above 70%. But, then the major drawback of these procedures is the risk to donors of a complex surgical procedure and possible long-term complications.
In many countries, including Malaysia, various strategies have been proposed to increase the supply of organs from living donors. The use of organs from living donors raises ethical questions, because the donors are subjected to surgery that is not performed to treat an illness and that has definite rates of mortality and morbidity. This practice is contrary to the medical precept, “first, do no harm”. However, since the first kidney transplantation between identical twins was performed, both the medical profession and society at large have agreed that the donor experiences the altruistic satisfaction of having assumed a risk in order to help another person.
The impact of unrelated living donor liver transplantation on the public and on the professionals in the field in Malaysia has been highlighted following recent developments in the country. It has forced many to think about the ethical implications and the limit between what is technically feasible and what is morally acceptable. Should we permit people to become liver donors? Are doctors violating the “do no harm” rule by operating on healthy donors, causing them pain and risking their lives, yet bringing them no medical benefit?
These questions need urgent answers; for end-stage liver disease, we have no effective treatment other than transplantation. The lives of people in kidney failure can be extended considerably by dialysis, and an implantable pump can often sustain those with heart failure, but we have no machines capable of taking over the liver’s functions.
While the risks to emotionally related donors and non-related donors are the same, they may not be perceived as such by the surgeons or by the community at large. The media might characterise the death of a sibling as a result of being an organ donor as a valiant, but tragic attempt to save the life of a loved one. However, the media might castigate an institution for unethical practices if an individual died while donating to a stranger.
Media coverage can influence public opinion regarding organ donation both positively and negatively and the influence can go beyond the specific issue at hand. Transplant teams may decide that the threat of bad publicity from the tangible risk of death to living donors justifies restrictions on who can serve as a donor and which organs they may donate.
Basically, the ethics of living donation revolves around three main issues:
l The balance of the risks and potential benefits of donation.
l The influence of the relation ship between the donor and recipient on how to under stand both the risks and
benefits of donation.
l The quality of the consent by the prospective donor.
The argument against organ donation by a non-related prospective donor rests on the claim that a doctor’s first responsibility is not to do harm, and that removing an organ from a healthy individual puts the individual at risk from acute complications due to surgery and anaesthesia, as well as peri-operative complications, and even possible long-term complications from the surgery itself.
An absolute injunction not to cause harm, then, would prohibit all living solid organ donation, even those within families. We need to understand the principle of non-malfeasance within the context of a harm-benefit ratio. It is morally acceptable to permit an individual to serve as a donor if the benefits are expected to outweigh the harms.
The issue of the benefit versus the risk of obtaining organs from unrelated living donors is even more troubling in the case of the liver. The mortality rate associated with partial removal of the liver, which has been performed many times (often in the case of a donation from parent to child), is uncertain, but probably in the range of 0.2%, and the rate of morbidity is about 10%.
However, a liver transplant is potentially lifesaving, whereas a kidney transplant may extend life or improve its quality, but it does not save the life of a patient on dialysis. How can we balance the potential for a greater benefit to one person against the greater risk to another? Is there a point at which the risk of the procedure is so great that we should not subject volunteers to it, not even those with the most unequivocally altruistic motives?
If the risk-benefit ratio of living organ donation is acceptable, the assessment should apply to all healthy donors, and it should not matter whether the prospective donor is related by genetics or emotional ties or is an altruistic stranger.
The quality of informed consent to donate is critical. Can the donor, under the pressure to save the life of another person, sufficiently understand the risks and benefits and arrive at a decision regarding donation without feeling coerced? When consent is valid, are doctors harming liver donors while bringing them no benefit? That might be true, but only under an overly narrow understanding.
When informed consent is valid, living donors can be viewed as exercising their autonomy and doctors can legitimately be viewed as helping both patient and donor.
Even though we don’t have the exact data here, I believe that the waiting list for liver transplantation in this country grows exponentially while the cadaver donor resource expands only minimally. Those numbers are never going to match. It would be wonderful if we had a sufficient supply of donor organs to meet recipient demands and did not require subjecting healthy people to an operation of this magnitude, but the reality is that we don’t and we will not for the foreseeable future.
The only practical way to transplant in a timely fashion, and circumvent the development of serious or life-threatening complications in many of these patients, is going to be through the option of living donor transplantation.
Lastly, before making a final judgment about the issue, we should also explore and consider the views of the public and potential recipients whose lives may depend on our answer. Living organ donation offers a premising future for helping alleviate the ever-growing shortage of solid organs for transplant, but only if we continue to address the ethical issues it raises.
There is a steady stimulus to scientific advance in emergent areas of xenografting and tissue engineering. Until these become a reality, thus rendering operating on a healthy subject part of medical history, living donor liver transplantation, either related or non-related, remains the best option to support cadaveric transplantation in the cure of patients with end stage liver disease.
My special thanks to A.P Dr Zabidi AM Hussin, A.P Dr Faridah Rashid, Dato’ Dr KC Tan, National Transplant Resource Centre, Malaysian Organ Sharing System, National Renal Registry and Ramayee from Institut Jantung Negara for their help while preparing this article.