Let’s Talk About Organ Donation

April 27, 2012 • Posted in Blog

D. Joy Riley, M.D., M.A.

Executive Director

A rare feat in organ transplantation was reported this week.  27-year-old Ray Fearing needed a kidney.  His younger sister, Cera, donated one of hers.  Quickly, though, that kidney started failing.  Although Fearing could no longer use the kidney, his physicians thought that perhaps the kidney could be removed before it shut down altogether, and transplanted to someone else. Fearing and his sister agreed to the procedure, as did the recipient.  So, after 14 days in Ray Fearing’s body, the kidney was removed and re-transplanted — this time, into the body of a 67-year-old surgeon, who needed a kidney, was a match for the organ, and, it was felt, would understand the risks involved.  Now, while Fearing is back on dialysis,

Gomez is taking anti-rejection drugs and is off dialysis. “I finally feel normal,” he said. (CBS News) Organ transplantation has come a long way in the last 50+ years.

Organ transplantation began with a kidney in 1954, but the world took notice when a heart was transplanted in 1967, by South African Dr. Christiaan Barnard.  A year later, the first heart transplant was done in the United States.  Bruce Tucker’s heart was transplanted into Joseph Klett’s chest.  Mr. Klett died about a week later.  That transplant resulted in a lawsuit by Mr. Tucker’s brother, alleging that the transplant team had hastened Bruce Tucker’s death by turning off the ventilator, and that “only minimal attempts to notify the victim’s family and obtain permission for use of his organs” were made.  [Robert M. Veatch, Transplantation Ethics (Washington, D.C.:  Georgetown University Press, 2000), p. 44.]

With the advent of immunosuppressive drugs, and improved organ preservation/transplantation techniques, organ transplantation has become much more common, but not commonplace.  Recent U.S. transplant data follow.

Year        All Organs      Living Donors    Deceased Donors       DCD Donors*

2000        11,931               5,946                 5,985                           117

2009        14,632               6,610                 8,022                           920

*DCD Donor refers to “Donation after Cardiac Death”:  a patient dependent on life-support with no hope of recovery, who desires to be an organ donor, is taken to the operating room, disconnected from that life-support, and (usually) proceeds to cardiac arrest.  After a specified time, the patient is declared dead based on circulatory and respiratory criteria (as opposed to brain death), and organs are removed for transplantation. (Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN / SRTR 2010 Annual Data Report. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; 2011. Available here.)

The federal government, via a collaborative established by the Health and Human Services administration, has set some very specific goals regarding organ transplantation.  The U.S. has been geographically carved into Donation Service Areas (DSAs).  A DSA includes one Organ Procurement Organization (OPO), one or more transplant centers, and one or more donor hospitals.  Each DSA is charged with accomplishing these goals:
  • 75% conversion rates from “eligible donor” to “donor”
  • 3.75 organs transplanted per donor
  • 10% of all donors from DCD sources
  • 20% growth of transplant center volume

The conversion rate in 2008 was 66.41% (http://optn.transplant.hrsa.gov/ar2009/chapter_ii_AR_cd.htm?cp=3).  Per deceased donor, there were 3.01 organs transplanted in 2009. (http://www.srtr.org/annual_reports/2010/212_dc.htm). The national goals have yet to be met, although some DSAs have not only met, they have exceeded these goals.  (Tuttle-Newhall, et al, “Organ Donation and Utilization in the United States:  1998-2007”  Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2009.02565.x/full.)

What does this mean?  This means that hospitals are under pressure of regulation to report to the OPOs when a patient is thought to be near death, whether that person is an inpatient, or has just rolled into the Emergency Room.  The OPO is notified, and someone who has been trained to discuss the procurement of organs arrives to evaluate the patient for organ donation and talk with the family. This means that you and your family need to discuss the important issue of organ donation now, and make your desires known.  If you wish to be an organ donor, tell your family.  Complete advance directives regarding your desires about how you wish to confront issues of medical treatment, and the disposition of your body after your death.  Another possibility:  appoint a durable power of attorney for health care, and have this conversation with him or her.  If you wish to be an organ donor, consider signing the back of your driver’s license.

The converse is just as important.  If you do NOT wish to be an organ donor, tell your family, your durable power of attorney for health care, and your physician.  Write it into your advance directives.  You will be doing everyone involved a favor by apprising them of your decision.  Leon Kass has commented on this choice in his typically elegant manner:

You cannot, it seems to me, talk about supply neutrally without paying some attention to why it is that some people do and other people do not donate. In some cases, expressed fear of decreased care, if one is known to be a potential donor, inhibits some people. There are other people who might express concern for bodily wholeness in death when they go to meet their maker. It seems to me terribly important that we not homogenize this subject and treat in the abstract. (http://bioethics.georgetown.edu/pcbe/transcripts/jan03/session2.html)

Organ transplantation has long been recognized as a potential good, but it is not without its risks.  One worrisome ethical risk is the possibility of descending into utilitarianism, harvesting organs from as many donors as possible in order to do “as much good as possible” for recipients, while ignoring the needs and rights of the former.  While we can celebrate the good that has come from the living organ donation and re-transplantation story of siblings Cera and Ray Fearing, there is much to be learned from the case of Mr. Bruce Tucker.