argumentative research paper organ donation

Organ Donation for Social Change: A Systematic Review

First Online: 07 January 2020

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Amani Alsalem 2 ,
Park Thaichon 2 &
Scott Weaven 2

Part of the book series: Contributions to Management Science ((MANAGEMENT SC.))

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This chapter presents a critical review of the existing organ donation literature. The objective of this chapter is to identify the main gaps in the current body of literature on the organ donation context and the marketing discipline. This chapter initially discusses social marketing within the context of organ donation for social change. Following on, this chapter provides a systematic quantitative literature review of the existing organ donation studies from the period of 1985–2019. Then, this chapter details and discusses the review method. The literature review findings include the geographical distribution of 262 peer-reviewed organ donation studies around the world; the frequency of published articles over the period 1985–2019; the disciplinary scope of these studies; the sample characteristics; and the key theories and models used to inform organ donation studies. Finally, this chapter concludes with a discussion of the main limitations of existing organ donation studies.

Organ donation
Social change
Behaviour change
Systematic review

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Alsalem, A., Thaichon, P., Weaven, S. (2020). Organ Donation for Social Change: A Systematic Review. In: Ratten, V. (eds) Entrepreneurship and Organizational Change. Contributions to Management Science. Springer, Cham. https://doi.org/10.1007/978-3-030-35415-2_6

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Final Reflective Essay

The medical field utilizes a variety of techniques to save lives everyday. One way is to perform an organ transplant by replacing a patient’s failing organ with a working one. The problem with this is that working organs are very hard to come by, and when they do, it is not guaranteed that the organ can be transplanted. One way to obtain a transplantable organ is through donation. Organs can be donated by both living and deceased people, but very little people donate that it makes the waiting list long. One debate that is currently going on in the medical field is whether or not an opt-out system (A system where all citizens would be registered organ donors, and would have to manually opt out) should be implemented over our current opt-in system. However, there are arguments against this, stating that it would be easier to focus on smaller problems, because one giant system alone will not increase donation numbers. The best approach to increasing the number of organ donors is to improve the process by compensating donors, providing adequate support, and enact laws which strengthen the organ donation centers.

One way to increase the number of organ donors is to properly compensate donors. A big reason why people may feel hesitant to donate is because many fear that they have neither the time or the money to donate. Organ donation is not simply an appointment you make where you show up, give them a kidney, and be on your way. It is a process that takes up to three months to recover from (Thiessen C, Jaji Z, Joyce M, et al, 2017) Many are hesitant because they fear that they will be bedridden for a few month, and as a result, fear being unable to support themselves and their families. Some fear they will not be able to pay rent or even keep their job if they donate due to the healing process. Hospitals do not compensate nearly enough for most donors to live comfortably.

A fix to this problem would be to compensate fully for a person’s cost of living during their recovery, and also work with employers to give donors rights to their job. Since donation is a very rare event to begin with, the government would not suffer financing these people’s lives for a short amount of time.The government could receive the funds for donors by accepting monetary donation, and by cutting into the healthcare sector and setting aside more money for donors in these scenarios. Financial support could also be offered to help support funeral costs of deceased donors, to encourage more families to allow their loved one’s organs to be donated. If this problem were to be fixed, people might feel eager or better about donating in general. This could lead to more donations.

Another way to increase the number of organ donors is to provide adequate support for donors. One conflict that arises is that of a deceased’s wishes vs what their family wants. While someone can register themselves as a donor, it is ultimately up to their family to decide once they are deceased. As a result, many families choose not to have them donate, mostly due to what they do not know, or what they think will happen. Others feel obligated to either donate or have the deceased donated just because they believe it is moral. The problem here is that if organ donation has a reputation for guilt-tripping, less people will want to register.

The way to fix the inadequate support is to simply expand organ transplant centers, both by increasing the number of workers, and the number of educational resources. Educating the hesitant can lead to less of these ‘uncertain’ moments where they either feel obligated to make a decision that they do not have the information to make. There are a few ways to provide education, but one simple one would be to hire professionals to teach people the pros and cons of donating, the facts … etc. They could provide pamphlets that answer simple questions, and could even offer classes and a hotline for potential donors. By investing more money into professionals who can properly teach everything about organ donation, the support for donors would increase, and as a result, more would be informed enough to make the best decision for them.

By improving the process, more people may feel comfortable with either donating or not. Even in cases where donors decide to not donate, resources must be made available in order to decrease negative feelings of guilt. One study showed that most donors would prefer an alibi to break news to whoever needed a donation that they were not getting what they needed. While only a small sample of people, it still proves that many people can feel guilty by denying their receiver. These are the emotions that need to be eliminated if people are going to feel completely comfortable with donating.

The last way to increase the number of organ donations is to enact laws which strengthen organ donation centers. A problem found by a UK task force in 2008 found that one problem with organ transplantation is that the centers do not have a very tight network (Rudge C, Buggins E, 2012) Because Organ donation is a rare occurrence, and many cannot donate even if they are registered, organ donation centers are rather small (Not much is put into them) This means that these centers aren’t running as efficiently as they could be. Organs have to be properly retrieved within a certain time frame to still be usable. If the centers don’t work efficiently and cooperatively, the already small number of organs to use decreases. This applies to the U.S. as well since both countries have an opt in system, and neither have, or had the most money, or resources going into their centers. It only makes sense that if it works in the UK, it can work in the U.S. (

The way to fix this was based on the Task Force’s findings. They recommended that changes be made based on establishing official organizations that specialize in organ donation, and resolving ethical and legal issues. By doing this, the UK saw a 25% increase in deceased organ donors over three years. This suggests that if the U.S. improves its infrastructure in organ donation centers the number of donations will increase.

While the opt-out system does have its supporters, it is just not logical to enact this system over an opt-in one (By itself). While, yes, countries with this system do have a higher correlation of donations, there are a misconceptions. The best known example of a country with a opt-out system is Spain. Unsurprisingly, Spain has the highest rate of donations and donors. However, what some do not understand is that the numbers that increased were not just because of their switch to this system, Spain also improved their donation network and made access to donation easier around the same time. Over a decade, numbers started to rise, which means that the opt-out system alone is not enough to increase donation numbers.

While an opt-out system does have its benefits, it does not outweigh the benefits of improving the current system. Evidence has shown that by compensating donors, decreasing uneasiness about donating, and strengthening donation centers, donation numbers will increase. Despite the debate about which will do more, it is still important to remember that both want improvement. The issue at hand is increasing donor numbers, and more specifically, improving how to improve the number of usable organs. Neither side is wrong, and a compromise can certainly be met to synergize with each other. It is important that everyone works together in order to solve an issue as big, as timely, and as costly as organ donation is.

References Page

Henderson, M. L., & Gross, J. A. (2017). Living Organ Donation and Informed Consent in the United States: Strategies to Improve the Process. Journal of Law, Medicine & Ethics , 45 (1), 66–76. https://doi.org/10.1177/1073110517703101

Oh, T. (2015, January). Organ donation: how to increase the donor pool. Anaesthesia & Intensive Care , pp. 12–13.

Organ Donation and Transplantation Statistics. (2014, August 12). Retrieved October 31, 2017, from https://www.kidney.org/news/newsroom/factsheets/Organ-Donation-and-Transplantation-Stats

Rudge, C. J., & Buggins, E. (2012). How to Increase Organ Donation: Does Opting Out Have a Role? Transplantation , 93 (2), 141–144. https://doi.org/10.1097/TP.0b013e31823a2411

Thiessen, C., Jaji, Z., Joyce, M., Zimbrean, P., Reese, P., Gordon, E. J., & Kulkarni, S. (2017). Opting out: a single-centre pilot study assessing the reasons for and the psychosocial impact of withdrawing from living kidney donor evaluation. Journal of Medical Ethics , 43 (11), 756–761. https://doi.org/10.1136/medethics-2016-103512

Wilkinson, K., & Peet, D. (2014). Organ donation. InnovAiT , 7 (2), 109–116. https://doi.org/10.1177/1755738013506565

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93 Organ Donation Essay Topic Ideas & Examples

🏆 best organ donation topic ideas & essay examples, ⭐ good research topics about organ donation, 👍 interesting topics to write about organ donation, ❓ organ donation research questions.

Importance of Organ Donation Considering the huge number of people in need of different body organs today, and the many that are dying each day due to organ problems, a socially upright member of our society should not consider […]
Organ and Blood Donation However, ethical and legal issues, and unwillingness of many potential donors to provide consents have slowed down the rate of organ and blood donation in the county. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
Organ Donation: Willingness to Donate Organ Among Medical Students In conclusion, organ donation is a vital and life-changing procedure that can help save lives and improve the quality of life for those in need.
The COVID-19 Impact on Organ Donation The official statistics of the United States government also support the idea that with the onset of the pandemic, the number of organ transplantation procedures has decreased. The pandemic appears to be the main cause […]
The Organ Donation Legislation Critique She expresses outrage and condemnation of the current organ donation legislation and the politicians who drafted it. If the global majority accepts such a perspective, it will lead to a worldwide spike of violence and […]
Researching of Xenograft and Organ Donation Doctors have been searching for methods to save lives all along, and xenograft has shown to be one of the most reliable, particularly when it comes to organ replacement. A xenograft is fraught with dangers, […]
Organ Donation: Donor Prevalence in Saudi Arabia Donating organs does not pose a threat to the life of the donor; however, it can save the lives of many other people who need organ transplants.
Organ Donation Registry Beginning 16th February 2010 through to the 18th the Ypsilanti Lions club organized the organ donation registry table whose main purpose was to invite people from all walks of life to literally give a piece […]
Organ Donation: Postmortem Transplantation The ethicality of such actions has been questioned, as this procedure may be ambiguously perceived by the relatives of the deceased patient and the recipient of organs.
The Issue of Compensation for Organ Donation Nevertheless, in spite of the fact that proponents of the compensation for the organ donation indicate obvious advantages of using this approach for the healthcare system, opponents emphasize the unethical character of such approaches.
Organ Donation: Ethical and Legal Considerations The other approach is by requesting the family of the deceased to give consent for the donation in a case where the deceased did not permit earlier on.
Organ Donation in Saudi Arabia: Survey Results A total of 27 participants answered the questions that were asked in the survey. The problems that are behind the ambiguity that people have over this issue are some of their limitations and perceptions.
Organ Donation: Ethical Dilemmas An example of an ethical dilemma surrounding the procedure is the case of rich man vs.poor man, or rather, the case of a person who can afford to buy an organ on the black market […]
Ethics of Organ Donation After Human Death In reference to this case, the ethical dilemma is related to the fact that the hospital administrator needs to disregard the necessity of informed consent for organ donation.
Medical Ethics of Child’s Organ Donation Obviously, the parents are the only people who represent the wishes of the patient in the case. The above-mentioned position seems to be viable when it comes to the concept of the greatest good used […]
Gene Patenting and Organ Donation Profitability is the key to violating the law, and that is the reason for the lack of transparency in the tissue market.
Organ Donation and Transplantation Medicine Although money and financial support will be a major factor in the process of body transplant that Canavero expects to take two years, pegging human life on money is unethical.
Organ Donation Myths: Critical Thought This essay is aimed at subverting three of the most common myths about the subject matter by considering the facts closely, relating them to the values concerning the organ donation, and isolating the issues related […]
Organ Donation: Importance Information Because of the improved and advanced technology, the practice of organ transplant is becoming more popular and acceptable in the society.
Ethical Issues in Organ Donation According to the authors of the study, death is defined as, “the irreversible loss of the integrated and coordinated life of the person as a single living organism”.
Organ Transplantation and Donation Since people donate organs to others regardless of their locations, nations need to be cautious in order to avoid spread of diseases in the process.
The Ethics of Organ Donation in Modern World The patient is referred to a transplant center and is to their “dismay” put on a national waiting list, after a “series of interviews, physical and medical tests” to determine the suitability of the recipient […]
Pros and Cons of Paying for Organ Donation: Arguments for Prohibition Although the potential of people to purchase organs might bring in profits to health care and increase supply and demand of transplanted organs, the fact of increased supply rates is doubtful because recent surveys prove […]
The Nebraska Laws on Organ Donation in the United States
Factors Influencing Organ Donation Among African Americans
Pros and Cons of a New Opt-Out System of Organ Donation
An Argument in Favor of Encouraging Organ Donation After Death for Transplantation Opportunities
Beneficence Justice Malfeasance and Autonomy in Organ Donation
The Cases of Brain Death and Organ Donation in Children and Adults
Comparison of the Organ Donation in the U.S. and Sweden
Compensation for Organ Donation: The Sale of Organs
Could Death Row Inmates Be a Viable Source for Organ Donation
Overview of the Dutch and Belgium Organ Donation Acts
Donation of the Organs and Their Harmful Effects on the Society
Knoweldge and Attitudes of Health Professionals on Organ Donation
Financial Compensation for Organ Donation
Analyzing the Importance of the Organ Donation
The Benefits and Shotrcomes of Organ Donation
Improving Organ Donation Through Clarification and Education
Increasing Organ Donation via Changes in the Default Choice or Allocation Rule
Organ Donation: Why Everyone Should Be a Donor
Legal and Ethical Issues Regarding Organ Donation
Mandatory Organ Donation: Ethical or Unethical
Organ Donation: How Recipients Are Chosen and Should Donors Be Compensated
The Discussion of the Legalization of Organ Donation
Effects of the Organ Donation on the Lives of Thousands of Recipients
Ethical Issues Surrounding Organ Donation
Why Cash for Kidneys Is Better Than Organ Donation
Organ Donation Issues and Laws: Federal and California State
Social Madia Initiative May Help Increase Organ Donation
Organ Donation: Life That You May Have the Power to Save
The Best Ways to Decrease the Shortage of Organs for Transplantation
Public Policies in the Question of Consent for Organ Donation
Organ Donation: Keeping the Gift of Life Alive
Description of the Commercial Market for Organ Donation
The Controversy Associated With the Opt-Out Organ Donation
The Life Saving Benefits of Organ Donation
Comparing Organ Donation Programmes Across the World
The Global Need for Organ Donations
Why Organ Donation Should Be Encouraged
Organ Donation: Two Deaths or One Life
Neonatal and Pediatric Organ Donation: Ethical Perspectives and Implications
Organ Donation and Forest Depletion Depicted in Fitzhugh’s “The Organ Grinders”
Is There a Black Market for Organ Donation?
What Are the Advantages and Disadvantages of Organ Donation?
How Is Organ Donation a Lucrative Business?
Why Do Muslims Disagree With Organ Donation?
Is Organ Donation Against God and Nature?
What Are the Ethical Issues in Organ Donation?
Is the US Opt-in or Opt-Out for Organ Donation?
Why Is Organ Donation a Moral Issue?
How Does the Process of Organ Donation Work?
What Ethical Theory Is Against Organ Donation?
Does Islam Support the Concept of Organ Donation After Death?
What Is the Most Complicated Organ Donation?
Are Organ Donations Compulsory in China?
Why Can’t Organ Donation Be Mandatory?
Is There an Age Limit for Organ Donation?
What Do Religions Think About Organ Donation?
Why Is Organ Donation in Exchange for Money Illegal?
Is an Opt-in or Opt-Out More Effective for Organ Donation?
What Are the Disadvantages of Organ Donation After Death?
Are Religious Beliefs Keeping Organ Donations From Going Mainstream?
What Cultures Don’t Believe in Organ Donation?
Why Is Organ Donation Uncommon in India?
Should Presumed Consent for Organ Donation Be Used in the US?
What Are the Laws Behind Organ Donation?
How Does the Debate on Deontology vs. Consequentialism Stand When It Comes to Organ Donation?
What Are the Emotional Tolls of Organ Donation for the Donor?
How Do Living Organ Donations Compare to Deceased Organ Donations in the United States?
What Are the Challenges of Organ Donation?
Are There Barriers to Organ Donation in the US?
Why Are Donated Organs Sometimes Rejected?
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Essay Examples on Organ Donation

Brief description of organ donation.

Organ donation is the selfless act of giving one's organs or tissues to help save the lives of others. It plays a crucial role in addressing the shortage of organs for transplantation and has the potential to improve and even save the lives of those in need.

Importance of Writing Essays on This Topic

Essays on organ donation are significant as they provide a platform for individuals to explore the ethical, medical, and societal implications of organ donation. They also encourage critical thinking and awareness of this life-saving practice.

Tips on Choosing a Good Topic

Consider the ethical implications of organ donation
Explore the impact of cultural and religious beliefs on organ donation
Examine the role of public policy in promoting organ donation

Essay Topics

The ethical considerations of organ donation
Cultural and religious perspectives on organ donation
The impact of organ donation on recipient and donor families
Public policy and organ donation incentives
The role of social media in promoting organ donation awareness
Organ donation and the medical community
Organ trafficking and illegal organ donation
The future of organ donation and transplantation
Organ donation and the concept of altruism
The psychological impact of waiting for an organ transplant
Organ donation and the concept of brain death
Organ donation and age restrictions
The economics of organ donation and transplantation
Organ donation and the role of family consent
Reflective essay on personal experiences with organ donation
Argumentative essay on the need for a change in organ donation policies
Compare and contrast the organ donation system in different countries
The impact of organ donation on diverse communities
The role of education in promoting organ donation awareness
The importance of organ donation for pediatric patients

Concluding Thought

Exploring the topic of organ donation through essays can lead to a deeper understanding of the ethical, medical, and societal issues surrounding this life-saving practice. Engaging in critical dialogue and exploration of organ donation can contribute to greater awareness and potential solutions for addressing the shortage of organs for transplantation.

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Pros and Cons of a New Opt-out System of Organ Donation

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Discussion on Whether Organ Donation Should Be Mandatory

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Medical Black Market in Venezuela and Problems in Organ Transplantation

Donation of the organs and their harmful effects on the society , the nebraska laws on organ donation in the united states, organ transplantation: bioartificial organs as the future, baby theresa and the ethics of organ donation, relevant topics.

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Organ Donation (Argumentative Essay Sample)

Organ donation.

Organ and tissue donation has become a key part of the healthcare sector. The number of patients whose organs are failing continues to increase. Consequently, the number of those in need of donated organs continues to rise, despite the limited number of donors. At times, it becomes a business as some immoral individuals and groups work in cahoots with medical personnel to illegally acquire organs and sell to needy patients at extremely high prices. The killing of the Falun Gong in China for organ harvesting highlights the high demand for organs. In light of the debate surrounding organ donation, this paper argues that it is a necessary procedure that needs to be embraced by potential donors and patients.

Kidneys, corneas, heart, lungs, liver, intestines, and several other body parts of living or deceased people can be donated to those in need. It is a heroic thing to help a fellow human being who is facing death unless he receives a functioning organ from another person. Organ and tissue donation gives sick people a second chance at life. It saves lives and patients who might not otherwise survive get a chance to live.

Some of the reasons identified by opponents of organ donation are religious. Some religions believe that when one donates his organs during his lifetime, he will suffer torments in the afterlife. Family beliefs have also been cited by some opponents. Some families bar their members from donating organs.

In some cases, the opponents of organ and tissue donation merely ride on misconceptions. For instance, some people believe that during the operation, the donor would have to fund all the costs involved. However, in reality, the costs are usually borne by the organ recipient. In other cases, some people believe that once someone donates organs, doctors would be reluctant to save the donors’ lives once they realize that the patient had donated sometime earlier in their life. This is a fallacy as doctors are legally and ethically required to provide the requisite services to patients at all times.

Contrary to the popular fallacies perpetuated and believed by individuals who are hesitant to donate organs, it is a noble thing to do. It can save the life of not only the recipient but numerous other people. A donor touches the lives of tens of people. When one person donates, he is encouraging many others to do the same. The recipient remains grateful and every single day, he or she knows that without the donor’s generosity and sacrifice, they would be dead.

One can also donate to science. By donating to science, scientists are able to carry out more research, a starting point in the discovery of cures for diseases and the improvement of human life. Scientists’ knowledge of body organs relies to a great extent on donation thus the cure for such diseases as cancer depends on the sacrifice and generosity of individual donors. In a way, donation enhances the wellbeing of humanity.

In conclusion, organ and tissue donation are not just a noble thing to do; it is a human duty. Saving human life overrides any religious and family beliefs. In this regard, a donor does more good by offering their liver, kidney, or other body parts with little or no regard for misconceptions as human life is sacred and worth saving.

Research Paper

Organ donation research paper.

This sample Organ Donation Research Paper is published for educational and informational purposes only. If you need help writing your assignment, please use our research paper writing service and buy a paper on any topic at affordable price. Also check our tips on how to write a research paper , see the lists of research paper topics , and browse research paper examples .

Organ donation has the potential to save and enhance lives. However, the increasing imbalance between demand and supply for transplantable organs has led to ethical challenges. This research paper discusses some of these ethical challenges in light of the social, cultural, and spiritual issues that deceased and living organ donation raises in different contexts around the globe.

Introduction

Nowadays we tend to take for granted that organ donation can save and enhance lives. Yet the transplantation of solid and vital organs is a relatively recent biomedical and technological intervention. The ﬁrst renal allograft (a transplant from a donor of the same species) was performed in 1936, but it was not until 1954, when Joseph Murray took a kidney from identical twin Ronald Merrick and transplanted it in his brother, Richard, that the ﬁrst successful kidney transplant was carried out at the Harvard Medical School’s Peter Bent Brigham Hospital (Munson 2002). Since then, the range of transplantable human organs has broadened to include the heart, liver, lungs, kidneys, intestines, and pancreas. With the introduction of powerful immunosuppressant drugs such as cyclosporine to assist in preventing organ rejection, transplantation became increasingly routinized. However, unlike body tissues such as corneas, bone marrow, blood, cells, heart valves, and skin, the demand for solid organs exceeds supply in most countries. This raises ethical, cultural, and social issues on a micro-, meso-, and macro-level scale.

The retrieval of organs for transplantation occurs in two main ways. The option to donate organs is raised by health-care professionals as a component of end-of-life care when a person dies. Alternatively, living persons can donate kidneys, liver segment(s), lung lobe(s), or a portion of intestine or pancreas. In very rare cases, a heart lung recipient can donate his or her healthy heart to someone who is waiting for a heart transplant.

Deceased Organ Donation

The term deceased (formerly cadaveric) donor is the preferred descriptor for persons who have been declared brain dead in the context of a hospital intensive care unit (ICU) and whose organs have been donated for transplantation by family or next of kin. Brain death has been described as a cultural and technological artifact (Lock 2002), the legal criteria and acceptance of which vary globally. The notion of brain death was ﬁrst formulated by an ad hoc committee of the Harvard Medical School in 1968 and has been the accepted clinical deﬁnition of death since then, having been endorsed by a presidential commission on brain criteria in 1981 and formally adopted by most states and many western countries thereafter (Benjamin 2001). Brain stem death refers to the complete and irreversible loss of brain function and occurs as a result of traumatic injury to the part of the brain that controls heartbeat and ventilation. For accomplishing organ donation, mechanical ventilation and other “life-support” measures are employed to maintain the breathing of brain-dead donors until surgical removal of organ(s) of interest for transplantation.

As the demand for transplanted organs rises, low rates of deceased donation in many countries present a problem. The reasons for the organ shortfall are multifactorial. First, the percentage of people in the western world who die in circumstances where they could be deceased organ donors is only 1.2–3 % of all deaths. These statistics reﬂect improvements in road safety, such as wearing seat belts, improved car design, better road layouts, the greater use of motorcycle helmets, speed control and reduced speed limits, as well as advances in intensive care practice which have prevented patients with traumatized brains from becoming brain dead. Meanwhile, the demand for human organs is increasing due to the expectation in developed countries of continued quality of life, even in advancing years. Additionally, progress in transplant surgery has meant more organs can be transplanted and a greater range of conditions can now be treated by transplantation than previously. The increasing imbalance between demand and supply puts pressure on supply side practices, thereby leading to further ethical challenges.

Deceased Donation And Bioethics

Although national surveys and opinion polls demonstrate support for organ transplantation and a willingness to donate, this does not always translate to actual donation. Some countries have legislated “opt out” or presumed consent policies to increase donation rates, with some success (e.g., Belgium, France, and Spain). Presumed consent operates on the basis that all eligible persons are organ donors at the time of their death unless they have speciﬁcally indicated their explicit objection. “Opt in” systems, by contrast, are based on expressed voluntarism and require consent from the potential donor or their next of kin. Detractors argue that “opt out” systems can only work where there is a high level of education and awareness about organ donation. In this view, presumed consent potentially undermines the idea of organ donation as a gift by treating the body as a resource that can be taken without the donor’s knowledge or consultation with their family. The concern is that presumed consent will erode patient autonomy and trust in the health-care system. Many religious groups also express concern about the desacralization of the human body when it is treated as a resource to be harvested as “spare parts” for transplanting from one person to another.

Cultural and religious beliefs also present external barriers to deceased donation, speciﬁcally in relation to the determination of death (i.e., when death occurs), and when it is morally acceptable to retrieve organs from the deceased. Each of the world religions (e.g., Judaism, Islam, Christianity, Hinduism, and Buddhism) has a perspective on deceased donation (Veatch 2000, ch. 1). However, there is often a signiﬁcant disconnection between theological and doctrinal debate permitting deceased donation and lay understanding of religious beliefs stipulating deceased donation as impermissible. For example, beliefs about preserving the bodily integrity of the dead inﬂuence donation rates in countries such as Mexico, where lay understandings of Catholic doctrine require the body to be interred whole to enable resurrection (Lock and CrowleyMatoka 2008). Yet, within Catholicism, a belief in bodily resurrection may simultaneously exist with an emphasis on charity and altruistic acts.

Many western countries accept the legal and medical criteria for the posthumous procurement of organs based on brain death, but the clinical deﬁnition of brain death as a diagnostic category used in medical practice to determine “a moment of death” is not accepted everywhere. Some cultures subscribe to the traditional deﬁnition of death as the irreversible cessation of cardiorespiratory functions. They also share an understanding of death as a process, not an event. For example, brain death was only accepted into Danish law in 1990, alongside cardiorespiratory criteria after a long period of public discussion and debate (Rix 1999). In Denmark, the legally brain-dead organ donor is dead for transplantation purposes and has entered the “death process,” but for Danes, it is cessation of cardiopulmonary function that deﬁnes death in everyday terms.

Studies show that deceased donation in the ICU disrupts the bereavement and grieving process for families confronted with the death of a loved one, thus making it difﬁcult for them to consent to organ donation. Taking organs from a dead person also violates social norms and attitudes which require respect for the dead. Although individuals in western cultures may think of the donor’s spirit as “living on” in the body of the transplant recipient through the donative act or seek solace in the belief that some good may eventuate from catastrophe, many people tacitly reject deceased donation due to the lack of consensus for criteria around the notion of brain death. They may recognize the patient in the ICU context as “socially dead” but not a cadaver. Because the body of a brain-dead person looks and feels alive or asleep and is warm to touch, some individuals have difﬁculty “letting go” and imagine they are allowing hospital staff to cut up or mutilate their loved ones’ body.

In some societies, legislation relating to anonymous deceased donation is complicated by cultural and religious practice. Brain death was enacted in Japanese law only in 1997. This law enables an individual to give advance notice of their willingness to donate upon death, but their family must also approve organ removal before the individual is recognized as medically dead. At the same time, formal gift-exchange rituals exist in Japanese society, and these practices require reciprocation between people who know one another. This conception of gift-giving is not in line with the prevailing view of organ donation as a gift of life. For instance, Part 18 of the European Union Tissue and Cells Directive endorses organ donation as a unidirectional altruistic act (Eurolex 2014). In Japan, however, it would be socially unacceptable to view the donated organ as one way, with no expectation of any kind of return, as is the custom in the United Kingdom or United States (Lock and Crowley-Matoka 2008).

Analogously, a gift-exchange ethic is part of the traditional philosophies of many indigenous cultures around the world and extends to the idea that the organ donor’s identity, essence, or spirit is inserted in the donated organ (Mauss 1990). This set of beliefs, which contains elements of what psychiatric literature deems magical thinking, contrasts with a scientiﬁc view of organs as spare parts no longer needed by one body but potentially life-saving to another. For cultures subscribing to gift-exchange practices (such as the indigenous peoples of Australia, the Paciﬁc, and North America), a kidney or a heart is not an inanimate object of individual ownership, but forms an intercorporeal and spiritual link between donor and recipient. The exchange of body parts binds donor and recipient to an entire genealogical system that extends to kin networks, linking physical and spiritual worlds in the past and to the future. An “intact body” upon death is important, to allow life to be returned from where it originated and for the continuation of the ancestral line (Lewis and Pickering 2003). From this perspective, organ transfer from an anonymous deceased donor of an alien or foreign body part to a transplant recipient marks an ambivalent process, as it potentially transforms participants’ biographies as well as the sacred and social organization of the groups to which they belong. Given the implications of organ transfer for group identity, decisions to donate are not an individual matter but a decision to be deliberated and consented to collectively. For some members of these cultural groups, anonymity protocol preventing contact between donors and recipients on the grounds that organ donation should be unidirectional and unconditional may not be a suitable moral framework. The ethical model of organ donation as an altruistic gift is not transferrable because gift-exchange depends on three obligations – to give, to receive, and to reciprocate (Mauss 1990).

Divergent beliefs and ideas about the body and identity, therefore, have ethical implications for the reception of organ transplantation in different social contexts and the manner in which it is promoted by health-care providers in multicultural environments. Cultural and religious differences also implicate the ways health-care professionals approach people in clinical settings when making requests to the families of donoreligible patients. Assumptions by health-care providers about different groups’ willingness to donate based on ethnic or religious afﬁliation and reports of historically low donation rates among speciﬁc demographics should not automatically preclude offering the option of deceased donation. Not only is the right to refusal integral to acceptable informed consent; it cannot be expected that individuals will always subscribe to the views of the group to which they belong.

Donation After Cardiac Death And Bioethics

Various proposals have been suggested to supplement the donor pool from deceased donors who are certiﬁed brain dead by neurological criteria in the ICU. These proposals include using older donors, paired kidney exchange, live donation from prisoners, proposals to introduce presumed consent, and suggestions for ﬁnancial reimbursement and compensation for both living and deceased donation. More recently, transplantation specialists have reconsidered criteria around the determination of death by allowing organ donation from non-heart-beating organ donors (i.e., donation after circulatory determination of death (DCDD)). The deﬁnition of DCDD is older than brain death and refers to the absence of the circulation of blood and other signs of life. The notion was widely recognized around a decade ago after a national conference in the United States of America on the topic.

DCDD is now legal in a number of countries (e.g., United Kingdom, United States, Canada, Australia, and New Zealand), but it is controversial and has implications for the way we think about digniﬁed death and about informed consent. In short, DCDD raises alarm bells for some commentators regarding two guiding ethical principles. The ﬁrst is the dead donor rule, which means patients must be dead before their organs can be retrieved. The second principle is that the care of living patients must never be adversely affected in the interests of favoring an organ recipient. Critics of DCDD want to know how long it takes after the heart stops for a person to be declared dead so that the organs can be removed, to ensure they remain viable. Problems arise because there is no consensus regarding the criteria to determine death. The legal time is around 2 min, but physicians suggest anywhere between 5 and 10 min is needed between cessation of a patients’ cardiopulmonary function and the declaration of death. The ethical issue this raises for palliative care, and particularly for patients themselves, is whether physicians will wait until death is completely certain before attempting to retrieve organs for transplantation, and thereby risk degradation of those organs, or whether they will prioritize the needs of the transplant recipient over care for the donor. If they wait, they respect the dignity of the donor; if they do not wait, they potentially maximize a better outcome for the recipient. On the other hand, if the patient decides in favor of DCDD, some bioethicists say there is reason to believe they will experience a renewed sense of autonomy at the prospect of their donative act.

Living Organ Donation

Living organ donation is increasingly promoted in jurisdictions where deceased donation rates are low. It provides better transplant outcomes than deceased donation and can reduce the time a transplant recipient spends on a waiting list for a deceased donor organ, as well as increasing the possibility of convenient scheduling of the transplantation procedure for the donor and recipient. These factors, along with more effective immunosuppressant medication and less invasive surgeries, have resulted in a signiﬁcant expansion of the number of living organ donors in recent decades. Although living kidney donation has always been the preferred therapeutic option in places such as Japan, it is now an established practice in many other places.

Types Of Living Organ Donation

The transplantation literature categorizes living organ donation into two different types: living directed donation and living non-directed donation. Donation is directed when the living donor speciﬁcally identiﬁes the organ recipient. Donation is non-directed when the recipient is selected by a transplant program from a waiting list of persons medically compatible with the living donor. Living directed donors are further classiﬁed as related or unrelated to the recipient. In living related donation, the donation is directed to a relative who is genetically related to the living donor. A living related donor can be a child, sibling, or parent. Because living donation between related donors and genetically identical recipients (such as identical twins) minimizes possible organ rejection, the transplant outcomes of these procedures and survival rates are often superior. Living directed donation also includes donation to recipients who are biologically unrelated, but emotionally or socially related to the donor. In living unrelated donation, the recipient can be a spouse or common-law partner, friend, colleague, or an acquaintance in the donor’s community.

Living non-directed donation refers to living donors who are not related to the recipient genetically or emotionally. In countries prohibiting organ sale, these donors are sometimes referred to as “anonymous,” “altruistic,” or “Good Samaritan” donors, because they give an organ to someone they do not know. In transplantation ethics, altruism has been narrowly deﬁned to refer to voluntary donation motivated by the absence of external reward, monetary exchange, and commercialization (Epstein and Danovitch 2009). The name “Good Samaritan” refers to the second commandment of the New Testament Bible, “You shall love your neighbor as yourself,” and is based on the ethical ideal of altruism as unconditional and selﬂess love of all human beings. “Good Samaritan” kidney donation received media attention in 2006 when 15 adults from an Australian-founded group called the “Jesus Christians” decided to donate a kidney altruistically (CNN 2014). The terms “altruistic,” “Good Samaritan,” and “anonymous” donor are not equivalent. Not all anonymous donors are religiously motivated, and some transplantation analysts prefer the term non-directed donor, because they believe both non-directed and directed donors act altruistically. However, some analysts argue that the intangible effects of altruistic donation such as eternal reward (in the context of Good Samaritanism) or psychological wellness or self-esteem (for non-religiously motivated donations) tend to suggest that non-directed donation is hardly ever completely altruistic. With the development of internet websites connecting potential donors with recipients, altruistic (stranger) donors may use criteria to request directed donation. Across the globe, unpaid non-directed donors are few in number. Living non-directed donors are not permitted in some jurisdictions, or in some transplant centers, due to medical professionals’ suspicion of their motives or concerns regarding the possibility of organ commerce.

Living Organ Donation And Bioethics

Health-care professionals have deliberated the moral justiﬁcation of living organ donation to save the life of another person since the beginning of the era of organ transplantation. Risk to living donors raises ethical concerns within the medical community about violating the principle of non-maleﬁcence and the moral injunction to “do no harm.” Although the advent of laparoscopic nephrectomy (minimally invasive keyhole surgery to remove a kidney, pioneered in 1995) improved positive outcomes for living kidney donors, medical risks remain (Segev et al. 2010). Mortality and morbidity rates for live donation of a section of a liver, a more recent medical procedure, carry even higher risk to the donor (Gordon 2013).

At the level of policy and practice, the ethical dilemma medical professionals confront is how to weigh the risks to the donor, a healthy individual, who is consenting to self-harm by undergoing surgery he or she does not need, alongside the beneﬁts to the transplant recipient, who receives life-saving therapy or vastly improved quality of life. Living donation is permitted on the basis that donors may receive the psychological reward of feeling good for alleviating the suffering of another person or reducing the time they spend on the waiting list for a suitable deceased donor organ. Empirical studies indicate an additional beneﬁt for living donors may be increased self-esteem.

The quality of a living organ donor’s consent is an essential consideration for health-care professionals in determining whether or not a person is a suitable candidate for living donation. Determining informed consent is a mandated component of the psychosocial evaluation of living organ donors and is based on the principle of respect for individual autonomy. Without a donor’s consent and declaration that they are acting voluntarily, in the interests of the recipient, an organ cannot be taken from them.

A primary concern for health-care professionals is that living donation challenges the traditional criteria of informed consent used to determine an individual’s decision-making and voluntariness. In the case of directed donation, it raises ethical challenges regarding the autonomy and moral agency of some prospective donors, such as children, adolescents, and mentally incompetent persons, who may be perceived as assenting to donate to a family member but who may not be able to make decisions independently (Crouch and Elliott 1999). At the same time, the conventional model of deliberative reasoning which health-care professionals use to assess a donor’s autonomy may not ﬁt the decision-making process that characterizes directed donation between family members, intimates, and loved ones. Empirical research shows that these donors make instantaneous decisions about donation without reﬂecting on their actions because it feels “natural” or the “right thing to do.” A key concern for health-care professionals is how to ensure prospective donors are free from external pressures or coercion from other family members or medical practitioners to donate, as well as being free from internal pressures, such as feelings of obligation due to role expectation or guilt if they do not actively help. In communitarian-oriented societies, such as Asia and Africa, where autonomy is not conceived in an individualistic manner, concerns that donors in familial contexts may feel pressure to donate may not always be true. In such societies, autonomous decisions may precede or occur in consultation with recognized authorities.

In addition to assurances that living directed donors’ offer to donate is voluntary and intentional, ethical concerns are raised regarding the motivations of living non-directed donors, given that there are no physical beneﬁts, few psychological beneﬁts, and no emotional ties to the recipient. Health-care professionals must not only judge whether the offer to donate a kidney by living non-directed donors is a genuine expression of normal altruism and free from coercion; they must also ensure that donors are not seeking payment. Given the scarcity of deceased donor organs and improved survival rates from living donors, a number of commentators have advocated government-controlled, regulated systems to encourage living donation, on the basis that an “ethical market” (Erin and Harris 2003) can uphold the principles of beneﬁcence, non-maleﬁcence, autonomy, and justice for donors and recipients worldwide. A powerful opposing view is that undue inducements in the context of unpaid organ donation shade into unjust inducement of poor and vulnerable persons in the context of transplant tourism.

Transplant tourism is a form of “medical tourism,” in which afﬂuent potential recipients travel across international borders to obtain organs and health care associated with transplantation, at a lower cost than in the patient’s home country. The practice relies on live organ donors who may be operated on without knowledge that their organ is being removed or sell their organs under conditions that are almost always exploitative and harmful to the donor’s welfare. A common geographical pattern is for potential recipients to move from the global north to medical facilities in developing countries and receive organs sourced from providers who have been trafﬁcked from the global south or “third-” world countries to the transplant tourism destination (Shimazono 2007).

Organ donation has been on the agenda since the emergence of bioethics in the late 1960s, but it is not just an issue of domestic importance. Global bioethics scholars have increasingly asked why organ transplantation attracts so much attention and why we continue to spend enormous amounts of energy and resources on trying to supplement the donor pool when there are other more pressing concerns to be addressed, such as worldwide health inequalities relating to rising rates of diabetes, obesity, and end-stage renal failure. On a global scale, bioethical concern about the shortage of deceased donor organs in developing countries, and the global movement of organs for transplantation, has resulted in international cooperation between professional and nongovernmental organizations, such as WHO and UNESCO, to eradicate illegal organ trade and trafﬁcking. As part of The Declaration of Istanbul on Organ Trafﬁcking and Transplant Tourism (2008), which prohibits global organ trading, country signatories are required to develop national self-sufﬁciency in organ donation. It is incumbent upon signatories to the Istanbul Declaration to protect vulnerable populations in resource-poor countries from exploitation, by implementing programs to prevent organ failure and meet patients’ needs within their own jurisdictions. Thinking about bioethics from an interdisciplinary perspective enables us to take these factors into account, as well as helping to inform understanding of the professional patient relationship and institutional practice.

Bibliography :

Benjamin, M. (2001). Pragmatism and the determination of death. In T. A. Mappes & D. DeGrazia (Eds.), Biomedical ethics (5th ed., pp. 316–324). New York: McGraw Hill.
(2014). Would you give your kidney to a stranger? http://www.cnn.com/2006/HEALTH/06/01/living.donors. index.html. Retrieved Oct 2014.
Crouch, R., & Elliot, C. (1999). Moral agency and the family: The case of live related organ transplantation. Cambridge Quarterly of Health Care Ethics, 8, 275–287.
Epstein, M., & Danovitch, G. (2009). Is altruistic-directed living unrelated organ donation a legal ﬁction? Nephrology, Dialysis and Transplantation, 24, 357–360.
Erin, C. A., & Harris, J. (2003). An ethical market in human organs. Journal of Medical Ethics, 29, 137–138.
(2014). http://eur-lex.europa.eu/LexUriServ/ LexUriServ.do?uri=OJ:L:2004:102:0048:0058:EN:PDF. Retrieved Aug 2014.
Gordon, E. (2013). Ethical considerations in live donor transplantation: should complications be tolerated? Current Opinion in Organ Transplantation, 18, 235–240.
Lewis, G., & Pickering, N. (2003). Māori spiritual beliefs and attitudes towards organ donation. New Zealand Bioethics Journal, 4(1), 31–35.
Lock, M. (2002). Twice dead: Organ transplant and the reinvention of death. Berkeley: University of California Press.
Lock, M., & Crowley-Matoka, M. (2008). Situating the practice of organ donation in familial, cultural, and political context. Transplantation Reviews, 22, 154–157.
Mauss, M. (1990). The gift: The form and reason for exchange in archaic societies (trans: Halls, W.E.). New York: WW Norton.
Munson, R. (2002). Raising the dead: Organ transplants, ethics and society. New York: Oxford University Press.
Rix, B. A. (1999). Brain death, ethics and politics in Denmark. In S. J. Younger, R. M. Arnold, & R. Schapiro (Eds.), The deﬁnition of death: Contemporary controversies (pp. 227–238). Baltimore: Johns Hopkins University Press.
Segev, D. L., Muzaale, A. D., Caffo, B. S., Mehta, S. H., Singer, A. L., & Taranto, S. E. (2010). Perioperative mortality and long-term survival following live kidney donation. JAMA, 303(10), 959–966.
Shimazono, Y. (2007). The state of the international organ trade: A provisional picture based on integration of available information. Bulletin of the World Health Organization, 85(12), 955–962.
The Declaration of Istanbul on Organ Trafﬁcking and Transplant Tourism. (2008). The Transplantation Society & International Society of Nephrology. http://www.declarationoﬁstanbul.org. Retrieved Feb 2011.
Veatch, R. M. (2000). Transplantation ethics. Washington, DC: Georgetown University Press.
Munson, R. (2007). Organ transplantation. In B. Steinbock (Ed.), The Oxford handbook of bioethics (pp. 211–239). New York: Oxford University Press.
Sharp, L. (2006). Strange harvest: Organ transplants, denatured bodies, and the transformed self. Berkeley: University of California Press.
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World J Transplant
v.5(2); 2015 Jun 24

Philosophy of organ donation: Review of ethical facets

Correspondence to: Aparna R Dalal, MD, Assistant Professor in Anesthesiology, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, NY 10029, United States. [email protected]

Telephone: +1-216-2722545 Fax: +1-206-4864610

Transplantation ethics is a philosophy that incorporates systematizing, defending and advocating concepts of right and wrong conduct related to organ donation. As the demand for organs increases, it is essential to ensure that new and innovative laws, policies and strategies of increasing organ supply are bioethical and are founded on the principles of altruism and utilitarianism. In the field of organ transplantation, role of altruism and medical ethics values are significant to the welfare of the society. This article reviews several fundamental ethical principles, prevailing organ donation consent laws, incentives and policies related to the field of transplantation. The Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death outline criteria for death and organ retrieval. Presumed consent laws prevalent mostly in European countries maintain that the default choice of an individual would be to donate organs unless opted otherwise. Explicit consent laws require organ donation to be proactively affirmed with state registries. The Declaration of Istanbul outlines principles against organ trafficking and transplant tourism. World Health Organization’s Guiding Principles on Human Cell, Tissue and Organ Transplantation aim at ensuring transparency in organ procurement and allocation. The ethics of financial incentives and non-financial incentives such as incorporation of non-medical criteria in organ priority allocation have also been reviewed in detail.

Core tip: Transplantation ethics is philosophy that involves systematizing, defending and recommending concepts of right and wrong conduct related to organ donation. As the demand for organs increases, it is essential for the society to ensure that new and innovative laws, policies and strategies of increasing organ supply are bioethical. In the field of organ transplantation, role of altruism and medical ethics values are significant to the welfare of the society. This article reviews the fundamental ethical principles to prevailing organ donation consent laws, incentives and policies.

Organ donation is founded on the pillars of altruism. When the moral value of an individual’s actions are focused mainly on the beneficial impact to other individuals, without regard to the consequences on the individual herself, the individual’s actions are regarded as “Altruistic”. Auguste Comte[ 1 ] coined the word “Altruism” (French, altruisme, from autrui: “other people”, and also derived from Latin alter: “other”). He was the French founder of positivism and described his views in Catéchisme Positiviste[ 2 ], where living for others was “Altruism”. Altruism can be classified into two types-obligatory and supererogatory. Obligatory altruism is defined as a moral duty to help others. Supererogatory altruism is defined as morally good, but it is not morally required-going “above and beyond” one’s duty. The act that maximizes good consequences for all of society is known as utilitarianism[ 3 ].

Altruistic behavior and happiness are reciprocal in nature. In fact, neuroscientists have found neural bases for altruism[ 4 ]. With functional magnetic resonance imaging, it has been shown that the subgenual cortex/septal region, which is intimately related to social bonding and attachment, gets activated when volunteers made altruistic charitable donations[ 4 ].

The opposite of altruism is egoism[ 5 ]. Egoism is the sense of self-importance. Psychological egoists claim that each person has his/her own welfare on their priority agenda. Some form of self-interest, such as intrinsic satisfaction, ultimately motivates all acts of sharing, helping or sacrificing. Other motivating criteria are expectation of reciprocation, and/or the desire to gain respect or reputation, or by the notion of a reward in life after death.

MORAL OBLIGATIONS

Ethically, doctors are professionally responsible to adhere to medicine’s unique moral obligations. The Hippocratic tradition is the origin of several tenets of medical ethics. One of them is the commitment to nonjudgmental regard. Health professionals are professionally responsible to render care to patients without being affected by any judgment as to the patient’s worthiness[ 6 ].

Another medical ethical tenet is Primum non nocere or “first, do no harm”. This principle is clearly embodied in the Hippocratic oath for physicians. This principle of non-maleficence is the most serious ethical concern in living donor transplants, due to the potential of doing medical harm to the donor. Many donors experience significant pain and short-term disability. The risk of surgical complications in living donor surgery is 5% to 10% risk and the risk of death is 0.5% to 1%[ 7 ].

A doctor has a duty of beneficence that constitutes a professional obligation to benefit patients, placing their good before his or her own. Fiduciary responsibility encompasses use of knowledge, powers, and privileges for the good of patients[ 6 ]. This is the essence of medicine’s fiduciary responsibility and commitment to beneficence.

DEATH AND ORGAN RETRIEVAL

Prior to the establishment of brain death criteria in 1968, the main source of grafts was donation after cardiac death (DCD)[ 8 ]. Thereafter, donation after brain death (DBD) soon became as the leading source of organs mostly due to the improved graft quality and potential for multiple organs. However, due to organ shortage, there was a renewed interest in cardiac/circulatory death. The potential for Donation after Circulatory Determination of Death programs is enormous. It is a very effective way to increase the grafts pool in both, adult as well as pediatric population[ 9 ]. A critical pathway for deceased donation, both DBD and DCD, was developed in 2011[ 10 ].

In 2012, a statement on Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death was structured[ 11 ]. Determination of death can be made after the cessation of circulation and respiratory function for 2 min. Underlying ethical principles considered were: (1) acts that promote the opportunity to donate viable organs respect the patient’s potential interest in becoming an organ donor; (2) the legitimacy of surrogate decision making for critically ill patients whose wishes are unknown extends to decisions regarding organ donation; (3) if real or perceived conflicts arise between the goals of providing optimal end-of-life care and the goals of procuring organs, delivery of quality end-of-life care should take priority. The dead donor rule emphasizes that the recovery of donated organs shall not cause the donor’s death.

PRESUMED CONSENT

World Health Organization (WHO) defines presumed consent as a system that permits material to be removed from the body of a deceased person for transplantation and, in some countries, for anatomical study or research, unless the person had expressed his or her opposition before death by filing an objection with an identified office or an informed party reports that the deceased definitely voiced an objection to donation[ 12 ].

Implicit consent[ 13 ] is consent without some specific move denoting consent, and inaction is itself a sign of consent. An example would be when the chairperson of a board meeting announces a motion carried unless there are any objections. It is important to emphasize that implicit consent is still real or actual. Those attending the meeting are aware that their silence will be inferred as consent, unless they specifically object[ 14 ].

Many ethicists believe that actual consent is not essential for organ donation[ 15 ]. The default position should be that one would want to donate organs as it is for the good of the society[ 16 ]. They also believe that it is immoral for an individual to decline consent for donation of his or her organs[ 13 ].

Presumed consent was first introduced in Spain by law in 1979. Spain has the highest deceased donation rate per million populations (35.3 p.m.p. in 2011)[ 17 ]. However, Organizacion Nacional de Trasplantes (ONT), Spain’s governing transplantation organization, confers this success to its “Spanish Model” rather than its legislation[ 18 , 19 ]. Success factors of the Spanish Model include its legal approach and a comprehensive program of education, communication, public relations, hospital reimbursement, and quality improvement[ 20 , 21 ]. Intensive care unit doctors or anesthesiologists work part-time as in-hospital transplant coordinators[ 22 ]. The hospital pays them bonus salaries for organ donations they undertake[ 23 ]. The Spanish ONT explicitly denies that this factor alone causes the success seen in Spain[ 24 , 25 ]. This model differs significantly from that in the United States where transplant coordinators are part of the Organ Procurement Organizations (OPO).

In Spain, there is no national non-donor registry[ 21 ]. Approximately nineteen of twenty-five nations with presumed consent laws have some provision for individuals to express their desire to be an organ donor[ 22 ]. However, health professionals in only four of these nations (Belgium, France, Poland and Sweden) acknowledged that they do not override a deceased’s expressed wish if the family objects[ 22 ]. A de facto family veto is significant to the choice between consent processes in cases where opt-in and opt-out schemes have a different after-effects on families subsequently vetoing organ removal[ 26 , 27 ]. If the family vetoes, then the opt-out case becomes much weaker.

Some ethicists feel that a duty to donate or feeling of obligation to the society aids transition from presumed consent to conscription for organ donation[ 28 ]. In the conscription model, every individual is under compulsion to donate organs[ 29 ]. The individual’s body and organs are owned by the State. However, such a model may not be compatible with democracy, as it is recipe for totalitarianism[ 30 ]. Totalitarianism is usually portrayed by the coincidence of authoritarianism, i.e ., state decision-making and ideology are not framed by the ordinary citizens, i.e ., a pervasive scheme of values are announced and promoted by institutional means to control and direct all aspects of life[ 31 ].

Though presumed consent laws have been accepted in Spain and other European nations, they have been consistently rejected in the United States. Presumed consent has been considered in the United States, but not beyond initial considerations. The Ethics Committee of the United Network for Organ Sharing (UNOS) developed a white paper on presumed consent in 1993[ 32 ] and repeated those findings in 2005. It noted there was no clarity whether a large proportion of the population was primed for this type of system. At least three states, Delaware, Colorado, and New York, have considered modifying their laws to presumed consent stances (Nytimes.com 2010), but these efforts quickly fizzled out.

EXPLICIT CONSENT

WHO defines explicit consent is defined as a system in which “cells, tissues or organs may be removed from a deceased person if the person had expressly consented to such removal during his or her lifetime”[ 12 ].

Explicit consent policies require an individual to “opt-in” by proactively stating their wishes to be a donor such as signing a donor card or clearly accepting a donor status on a driver’s license. Any person 16 years age and above, may consent, in writing with a signature at any time. Verbal consent is also permissible in the presence of a least two witnesses during the person’s last illness. The consent has to specify that the person’s organs can be used post-mortem for therapeutic purposes, medical and scientific education or research[ 33 ].

Explicit consent is recorded as advanced directives on state registries, by the issue of donor cards, and on the driving license. If one does not explicitly consent to donate on the form, the default setting is that one has not consented at all. Many people, however, do not record their decision to donate. Unfortunately, many organs are buried rather than donated. This is because potential donors and their families believe that the organ distribution system is unfair and potential donors may receive less aggressive medical care[ 34 ]. In the United States, African Americans, Catholics and Hispanics are less likely to be registered as organ donors[ 35 ].

Issues with registering explicit consent at the Department of Motor Vehicles (DMV) include inertia and people’s predictable bias towards choosing options that require least effort where they are just trying to complete the license application process[ 36 ]. Most people find the DMV to be either stressful or simply an unpleasant place to be. After waiting for a long time to be seen, it is easy to become tired, eager to leave, anxious, frustrated, and even angry[ 37 ]. Some, rationally or not, may fear that they might bring about their own death through a motor vehicle accident by deciding to donate at the DMV. Individuals are isolated from connections to family members and other trusted and beloved people whom they would want to be present when making an important decision regarding their death[ 38 ]. Even when people do opt in by checking off “donor” on their driver’s license, OPOs will often follow the negative wishes of the family of the deceased, overriding a recorded decision to donate[ 36 , 39 ].

However, by the end of 2013, with increasing awareness and education, 117.1 million people in the United States enrolled in state donor registries. This represents 48% of all United State residents age 18 and over[ 40 ].

Donate Life Statistics state that 76% of Australians have pointed out that they are willing to become organ and tissue donors[ 41 ]. In 2013, the Australian donor rate was 16.9 donors per million people[ 41 ]. The Australian organ donation outcome in 2013 was 10% higher than in 2012[ 42 ]. If the family is aware that the deceased was likely to consent to organ donation, then they are more likely to donate. Ninety-three percent of Australians stated that they would certainly endorse their loved one’s wishes if they knew what the wishes were[ 41 ].

ORGAN TRADE

In the United States, Anatomical Gift Act and the National Organ Transplant Act of 1984, prohibit the buying and selling of organs[ 43 , 44 ]. Unfortunately, illegal organ trade and transplant tourism still persist in many other countries despite many laws made and enforced against it[ 45 ]. The organ vendors are promised paltry sums of money, and they are frequently deceived out of some of the procurement fee. The surgery for organ procurement and the post-transplant care is often substandard[ 46 , 47 ]. Paid vendors experience social stigma for having sold a part of their body as well as emotional and physical damage[ 46 , 47 ].

If a person owns her body, then she has the right to autonomy, i.e ., to sell her body parts. Limits on autonomy are placed to protect individuals from themselves. A good example would be that we do not allow individuals to be slaves so that the moral dignity of the individual is preserved[ 48 ]. Additionally, it be possible that the individual is acting involuntarily or is being coerced due to circumstances that are unfair[ 49 ]. Respect for autonomy[ 50 ] permits one to question an individual’s decision when it is against the individual’s best interest. An individual may make a decision that is contrary to his or her own interest due to miscalculation, coercion, undue influence or simply misinformation. Though the organ vendor harms himself, and this harm is not inflicted on others, we as a human society, place ourselves in a substandard position, if we allow vulnerable persons to sell their body organs on the grounds of commodification[ 49 ].

Transplant tourism results in corruption, coercion and crowding out[ 51 ]. It enhances corruption by allowing the sale of organs to go forward in that it may “dehumanize society by viewing human beings and their parts as mere commodities”[ 52 ]. Crowding Out occurs by allowing the sale of organs which will cause individuals who would have donated organs to instead sell them, thus reducing the number of donated organs, or it will cause individuals to refuse to donate at all, leading to an overall reduction in procured organs[ 53 ]. Organ brokers or recipients often coerce poor sellers, who have no other reasonable economic alternative, to sell their organs[ 54 ].

In May 2008, The Transplantation Society and the International Society of Nephrology convened an international summit meeting on organ trafficking and transplant tourism in Istanbul. More than 150 professionals from 78 countries attended this meeting. The text of the Declaration of Istanbul (DoI) on Organ Trafficking and Transplant Tourism was published simultaneously in “Transplantation”, and “The Lancet”. In 2010, the World Health Assembly updated WHO’s guiding principles on human cell, tissue and organ transplantation to add principles aimed at vigilance and safety in transplantation and at ensuring transparency in organ procurement and allocation[ 55 ].

Several professional and governmental bodies voluntarily adhere to the principles of the DoI and WHO. The DoI and WHO guidelines have also been incorporated into national laws and regulations[ 56 ]. In 2008, the Government of India amended and fortified its Transplantation of Human Organs Act[ 57 ]. In Philippines, Anti-Human Trafficking Law was launched in June 2009[ 58 ]. Pakistan and Egypt also passed similar laws in 2010[ 59 , 60 ]. Latin American Society of Nephrology[ 61 ], and the Society of Transplantation of Latin America and Caribbean, have endorsed the DoI[ 61 , 62 ]. In 2012, Brazil specifically mentioned the DoI in its national regulations[ 63 ]. UNOS policy based on the DoI requires all non-United States citizen transplant waiting-list registrants to specify whether the United States is their primary place of residence or whether they have come to the United States for the purpose of transplantation or any other reason[ 64 ].

PRISONERS AS ORGAN DONORS OR RECIPIENTS

The United States Constitution’s Eight Amendment states that inmates have a right to healthcare. Some argue that prisoners are less deserving for consideration as transplant recipients. Many contend that it is a poor use of a limited resource, since a prisoner, whose life is saved by transplant, may re-enter a life of crime. Should a prisoner’s right to transplant depend on the nature of the crime or the terms of his/her incarceration-such as white-collar crimes against capital crimes, or first time offenders vs repeat offenders?

Donation benefits both prisoner as well as society by compensating for crimes against society. It would give the prisoner an opportunity to prove to himself and others that he can do something worthwhile. On the other hand, prison environment may prohibit free and voluntary consent. Reduction of sentence for organ donation could be misused as a form of coercion. It may be more acceptable if the decision to donate was made before the prisoners conviction and that the organs to go the recipient via UNOS matchlist. But then, would the recipient agree to accept the organs if he/she was aware that the donor was a prisoner on a death row sentence? In April 2011, MSNBC news conducted a survey in which almost 80% of 86736 voters responded “yes” to the question, “Should death row inmates be allowed to donate their organs?”[ 65 ]. Patients would appreciate it, e.g ., Patients on Dukes Lung Transplant List were asked whether they would accept lungs from a death row inmate if the organ was good, and 75% replied in the affirmative[ 65 ].

FINANCIAL INCENTIVES

The UNOS Ethics Committee defines financial incentives as any material gain or valuable consideration obtained by those directly consenting to the process of organ procurement, whether it be the organ donor himself (in advance of his demise), the donor’s estate, or the donor’s family[ 66 ].

Financial Incentives can be direct or indirect. Regulated organ sale, tax credits, etc ., are some of the direct financial incentives. Reimbursement for funeral expense, life and disability insurance are some indirect financial incentives[ 67 ]. For living donors, incentives could include: tax credit, long-term health care, tuition or job training; employment; or payment[ 68 ]. The convention on human rights and biomedicine of the Council of Europe has favored compensation for donor expenses incurred[ 69 ]. This has also been supported by the World Medical Association[ 70 ] and the WHO[ 12 ]. Several United States states have passed legislations that provide paid leave to organ and bone marrow donors. The laws also offer tax benefits for live and deceased organ donations and to employers of donors. However, a study stated that these provisions did not significantly impact the quantity of organs donated[ 71 ].

Some believe that financial incentives will increase the supply of organs. A form of “donor insurance”, has been suggested. In this method, a person agrees in advance to organ donation after his or her death. Payment is made to his beneficiaries or his estate after the donation[ 66 ]. Financial incentives are also rationalized based on whether they pertain to obligatory or supererogatory altruism. To charge money for one’s organ would be wrong if an altruistic kidney donation were morally obligatory. On the other hand, if altruistic donation were supererogatory, then to charge money for one’s organ would not be wrong. Rather, demanding money would be non-supererogatory. It would be categorized as perhaps not good, but not wrong, and morally permissible[ 72 ].

Decreased emotional gain for the donor family, decreased respect for the sanctity of the human body and life itself, and a loss of the personal touch that currently exists in the altruistic donation process are some of the reasons cited for opposing the provision of financial incentives. There is also a fear of creation of organ markets where the poor would be harvested for the rich. Financial approaches to organ donation may start “the ultimate slide down the slippery slope” - i.e ., the human body actually becoming a commodity to be bought, sold and exchanged for in a manner similar to any other good or service[ 66 ].

Financial incentives are officially permissible in Iran. A controlled living unrelated kidney donors (LURDs) transplant program has been initiated. If the patient has no living related donor, she is referred to The Kidney Foundation of Iran to find a suitable LURD. The Iranian Society of Organ Transplantation monitors this program to ensure that there is no broker introducing donors to recipients, nor there is any transplant tourism[ 73 ]. In Iran, this program has been effective in reducing the kidney transplant waitlist[ 74 ]. The kidney donors register in the Dialysis and Transplant Patients Association. After the donation, they are rewarded with the equivalent of $ 1200 United States dollars and 1 year of medical insurance by the government[ 75 ].

In Philippines, from 2002 to 2008, a regulated system of incentives for living organ donors was implemented[ 76 ]. The program offered a sizable “gratuity package”. Transparency, ethics, monitoring of transplant facilities and maintaining a donor registry was mandated. Unfortunately, the intended outcomes differed from reality. The black market was not eliminated and organ brokers or middlemen continued to be involved[ 77 ].

In 2010, China launched a financial incentives compensation policy in five pilot provinces and cities. Two forms were considered for financial compensation. The “thank you” form expresses gratitude on behalf of the Red Cross Society of China for subscription to organ donation. The “help” form is social welfare support for underprivileged families[ 78 ]. This initiative has been criticized due to involvement of an extremely vulnerable group. Additionally, there was no public campaign to endorse social change making this new initiative ethically objectionable[ 79 ].

In 2012, The Working Group on Incentives for Living Donation developed guidelines for development of a regulated system of incentives for living and deceased donation. These guidelines state that each country should have a regulatory and legal framework for implementing incentives and the entire process must be transparent and overseen by international and governmental authorities[ 68 ].

NON-FINANCIAL INCENTIVES

The Israeli Organ Transplant Law is a novel approach to increase supply of organ to meet the escalating demands. Historically, Israel’s organ donation rate was very low. Jewish law condemns violation of the dead. This has been interpreted that Judaism prohibits organ donation. Rabbinic issues surrounded the concept of brain death. Thus, many patients died waiting for organs. But in the Talmud, saving a life supersedes almost everything. Many commandments may be overstepped if saving a life is the goal. Therefore, it could be argued that organ donation actually fulfills a very high religious virtue[ 80 ].

So Israel decided to implement a new approach and became the first country in the world to incorporate “nonmedical” criteria into the priority system based on medical criteria. In 2008 two new laws relevant to organ transplantation were introduced. The Brain-Respiratory Death Law defines the precise circumstances and mechanisms to determine brain death. The Organ Transplantation Law bans reimbursing transplant tourism involving organ trade. Registered donors are given priority for organs, should they ever need one. Disincentives for living donation are removed by providing insurance reimbursement and social supportive services[ 81 ].

First priority is granted to candidates whose first-degree relatives donated organs after death. It is also granted to candidates who have been themselves have registered as kidney or liver-lobe donors. Second priority is granted to candidates who have registered as organ donors at least 3 years prior of being listed. Third priority to candidates whose first-degree relatives have registered as organ donors at least 3 years prior to their listing[ 82 ]. A Parliamentary amendment was recently made to this clause that has broadened the prioritization to any living donor. Prior kidney, liver lobe or lung lobe donors, who now need an organ, are granted first priority in the allocation of these organs[ 83 ].

This law is based on the ethical principle of reciprocal altruism[ 84 ] where by those in the society who are willing to help others will in turn be helped. This effectively works as an incentive for many to become registered donors[ 82 ]. It also derives some features from UNOS policy, which allows living donors of organs priority to receive a transplant from a deceased donor should they ever need one[ 85 ]. The Singapore’s Human Organ Transplant Act grants priority to a person who did not register any objection in respect of organ donation vs organ allocation over a person who has opted out from organ donation[ 86 ].

This law has been criticized on ethical grounds, as one’s chances of obtaining priority points may potentially increase with greater number of first-degree relatives and may be disadvantageous to those with fewer siblings. Additionally, it introduces the potential for individuals to register solely to assure priority points in the future, while advising their families to decline donation in the event of their death[ 87 ].

When this law was implemented, an organ donation public awareness campaign was also launched. Television, radio, billboard and newspaper advertisements were introduced promoting the new priority system. The perception that Jewish law forbids donation was countered. Shopping centers and coffee houses were overwhelmed with information regarding organ donation. This resulted in an overwhelming response from the Israeli population. Seventy thousand Israelis registered for organ donation cards within the first 10 wk of the campaign[ 80 ]. In 2011, the Israeli organ donation rate increased from 7.8 to 11.4 donors per million populations[ 81 ]. Israeli transplant tourism to China to receive organs has now ceased[ 88 ].

The gap between organ demand and supply is forever widening. It is essential to review ethical facets of every new law, strategy or policy initiated to increase the organ donation. Ethical reflections of organ donation quandaries promote and advance this field in a bioethical manner that ultimately benefits humanity and the well-being of the society.

Conflict-of-interest: None.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Peer-review started: August 21, 2014

First decision: September 16, 2014

Article in press: March 18, 2015

P- Reviewer: Gordon CR, Zielinski T S- Editor: Gong XM L- Editor: A E- Editor: Wu HL

COMMENTS

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