Moral problems of transplantology
Do I need to pay compensation for organ donation?
Transplantology (transplanto – ‘transplanting’) – the idea of being able to replace diseased organs that have lost their function – goes back to mythology. There is a legend about a Chinese doctor who carried out the replacement of diseased organs with healthy ones. In the Christian tradition there is a legend about Cosmas and Damian, who transplanted a leg. But scientific transplantology as a field of application of knowledge and the healthcare industry can be discussed only since the second half of the XX century, when the general development of surgery, the development of the pharmaceutical sector, the improvement of medical technologies made possible transplantation not only as an experimental practice, but in the future as a separate field of high-tech medical care.
Transplantology today causes discussions in connection with the need to find answers to a number of ethically significant questions. The first question is the question of how justified it is from the point of view of social justice to redistribute medical funds in favor of transplantology, which provides necessary assistance, but still for a limited number of people, withdrawing limited resources from the health care system that could help a larger number of patients. To date, such an argument is widespread, which is associated with an indication of the role of transplantology in general in the system of medical knowledge and healthcare. The fact is that transplantology, like resuscitation, is currently a locomotive, within the framework of which the most modern means and methods of treatment are being worked out. And if this area is slowed down, then after that the progress of medicine will be slow in other areas.
The second set of problems is related to the mechanisms for obtaining donor organs. To date, medicine has the opportunity to use donor organs of healthy donors, if we are talking about the possibility of taking a part of an organ, for example, a part of the liver, or one of two paired organs, for example, the kidneys. The world practice of organ harvesting from healthy donors is associated with a focus on a key bioethical principle – the principle of autonomous voluntary consent. In order for this principle to be implemented, the world practice of transplantology, as a rule, requires that the donor and the potential recipient are genetically related, so that this altruistic sacrifice of the organ is not accompanied by any ideas of compensation – material, financial.
However, in recent years, for example, there has been an active discussion in Israeli practice that a healthy donor who has made an altruistic gift to a sick person should receive some compensation not only for risks, but also for inconveniences, and that this compensation could be taken from the insurance of the person who needs a transplant operation. However, such an installation is not global today. In most countries of the world, there is a ban on the purchase and sale of donor organs, humanity is trying to find mechanisms to prevent illegal organ seizures, to prevent the traffic of donor organs, which, unfortunately, takes place, and this practice is quite effective today.
The second option for obtaining donor organs is the use of organs of a deceased person. The development of transplantology is largely connected with the transition to a new understanding of the criterion of death, to the legal consolidation of the so-called brain death. We are talking about the fact that from the moment of death by an independent team of transplantologists according to the established rules, when the correctness of the application of the death criterion in each specific case can be checked, until the moment of organ removal, a limited time must pass. And so, in order to develop transplantology, medicine is forced to organize dying. This should not be understood as the desire of doctors to bring the death of a person who may become a potential donor after death. This should be understood as a requirement in relation to medicine for a clear regulation of the actions of medical personnel on the statement of death, on the removal of donor organs.
In world practice, in the history of the XX century, there were three traditions of organ harvesting from the deceased from a legal and ethical point of view. The first tradition is called routine fence. Currently, it does not exist in any country, since the essence of routine sampling is the removal of organs and fluids from the human body for any purpose, scientific and therapeutic, without obtaining any consent. Routine fence is based on the idea that the human body after death is a public, collective property. And of course, this approach contradicts the key bioethical principle of respect for the autonomy of the patient, any person.
The second tradition of the fence is called the presumption of consent. It is implied that if a person during his lifetime did not express a prohibition that his organs could be removed after death, then such a person is considered as having given consent. Today, in bioethics, the question is debated as to whether such consent, unsolicited, implied, can be ethically justified. There are very tough situations in the world when only the position of the person himself is taken into account, or softer options when doctors ask the position of the patient's relatives.
But from the point of view of the availability of donor organs, the presumption of consent, of course, allows you to get more of those organs necessary to save people's lives than another tradition, the third, the presumption of disagreement. It implies that each person initially does not agree to be a donor, and if he wants to commit this altruistic humanistic act and donate his organs after death to another, then he declares it. Moreover, countries where such a tradition exists, such as the United States, create conditions for a person to declare his position, for example, when obtaining rights, filling out a special questionnaire where he can indicate: "I agree to become an organ donor after I have received injuries incompatible with life."
The fact is that the source of donor organs, as a rule, are young healthy people (if in such terminology we can talk about a person). But due to the tradition of hedonism, when all thoughts of death are often tabooed by modern culture, for a young person to express this position (no matter what it will be: consent or disagreement) it is extremely difficult without preliminary preparation, because a person, agreeing to certain medical manipulations regarding his physicality, as bioethics requires, must be informed.
The development of transplantology, as world statistics show, is not very much related to the legal regulation of organ harvesting after death: there is a presumption of consent or disagreement. The greater effect is not legal regulation, but the special efforts of the state to explain the meaning and possibilities of modern transplantology. For example, through special educational programs, mass media, through participation in specialized advertising campaigns about the donation of media persons.
Since transplantology is experiencing a shortage of donor organs all over the world, to date, the efforts of doctors are aimed at, firstly, prolonging the life of already received organs, at making the received organ more preserved, better quality. Since the medical problem of overcoming the immune barrier has already been solved, it becomes possible, through the introduction of waiting lists, not only on a national but also on a supranational scale, to select a donor–recipient pair quickly enough, to deliver either the recipient to the place where he will receive a donor organ, or to transport a donor organ.
Another area of development of transplantology is associated with the creation of artificial organs, artificial analogues. The third direction is the possibility of using donated animal organs. However, this trend is most associated with discussions about the ethical acceptance of this option due to, for example, religious beliefs. Of all animal species, pigs are the closest in structure and size of organs to the species Homo sapiens. Obviously, the development of xenotransplantology through the use of pig organs is not possible for all regions of the world.
Transplantology as a field also causes discussions in connection with the mechanisms of distribution of the received donor organs. Usually the criteria that are used are as follows. The first criterion is, of course, the compatibility of the donor organ and the potential recipient according to medical indicators. But if several recipients are on the waiting list at once, to whom the received donor organ can be transplanted, then the second criterion comes into force – this is the necessity, vital importance of organ transplantation for a particular patient. If it is not possible to select one recipient according to this criterion, then the third criterion is used – the criterion of the duration of being on the waiting list. Bioethics considers the consistent application of these criteria to be the key to the realization of the principle of fairness in the distribution of donor organs.
Transplantology is a specific science and practice. Not all bioethical principles in it work in full. For example, the traditional bioethical principle of "Do no harm" is completely unrealizable when it comes to taking a donor organ from a living donor. Or in the case when a recipient who has received a donor receives pharmaceutical immunosuppression throughout the rest of his life, which prevents rejection of the donor organ.
Such an important bioethical principle as the principle of truthfulness in terms of completeness of the volume of information is not implemented in transplantology either. Neither the donor nor the recipient have the right to refuse the information, they must receive it in full. And this is not always ethically correct.
About the author:
Elena Bryzgalina – Candidate of Philosophical Sciences, Head of the Department of Philosophy of Education of the Faculty of Philosophy of Moscow State University, specialist in philosophical problems of biology and medicine
Portal "Eternal youth" http://vechnayamolodost.ru
21.06.2016