Full, free and informed consent necessary because it is not in best interests of the live donor. It is not fully compatible with the traditional Hippocratic oath and its fundamental principle “Primum Non Nocere”. To prevent organ sales on pretext of altruistic donation, HOTA89 s2(1)(b) allows only genetically related organ transfers. But why should altruism be limited to the dead? Then again, why should altruism be necessary if there is no problem in the first place? Live donors are indeed an alternative resource to cadaveric donors – but with what incentives?
HOTA89 s1 prohibits payment. There are six reasons forwarded against a market in organs. First, many believe there is something intrinsically wrong with commodifying the human body, and that it would be either impossible or degrading to put a value on human body parts. Indeed, human dignity trumps autonomy – if the human body is uniquely valuable and cannot be owned by others or ourselves, it cannot be bought or sold. Second, commercialisation undermines the principle that organ donation should be altruistic.
Third, this trade would exploit the poor, and the fact that such markets flourish in developing countries is taken to be evidence that only the poor and marginalized would agree to donate their organs for money – only those who see no other way but sell parts of their body, or would rather sell parts of their body than work. Fourth, financial incentives may overbear a person’s will and thus cast doubt upon the voluntariness of their consent. Fifth, some are troubled by the prospect of people assuming some risk to health in return for financial reward.
Finally, a free market in organs would mean that only the rich would be able to afford to buy them, thus disrupting the principle that scarce health care resources should be distributed according to need rather than ability to pay. With regard to the first, Jackson argues that it is not strictly true that it would be impossible to put a value on a human organ, nor that doing so is inevitably degrading – tort law routinely quantifies the loss of various body parts without any assumption that such damages undermine the intrinsic value of the human body.
However, to put a finer point on it, the issue is the valuation of the body with the intention of commodification. Few people set up elaborate schemes to hurt themselves and then procure damages. Indeed such schemes if found out would be illegal. The whole point of the law is to compensate individuals for loss, not to reward them for a commercial exchange. If a free market safeguards against wrongful exploitation and concern is shown for vulnerable people, as well as accounting for considerations of justice and equity – if this can be done then a market in human body products will be shown to be, at the very least, not prima facie unethical.
It has been recommended that the single buyer would take on the responsibility for ensuring equitable distribution of all organs and tissues purchased. This would prevent the rich from using their purchasing power to exploit the market at the expense of the poor. The monopsonist would also have other obligations, such as ensuring correct tissue typing to maximise histocompatibility and so minimise graft rejection, and screening for diseased or otherwise hazardous organs and tissues. Pricing would also be at low levels because it is bound to be – and as it is the only buyer it is also the price setter of what it purchases.
Furthermore, since there is no direct purchasing, rich people cannot prey upon poor people – all stand an equal chance of benefiting. However, the objection is that a donation of a kidney by a living donor is one of the most extraordinary acts of altruism that can be imagined, and this should not be tarnished by making it a commercial transaction. The ethical cornerstone of transplantation is based on the gift of an organ to the recipient whether the donor is alive or dead. To this, cynics such as Erin and Harris argue that there is much hypocrisy about the ethics of buying and selling organs and indeed other body products and services.
This means everyone is paid but the unfortunate and heroic donor, who is supposed to put up with the insult of no reward, to add to the injury of the operation. But who is to put a value on altruism? Certainly Erin and Harris make themselves out to be incapable of it. That aside, the point remains that if a presumed consent system were in place, which ensures autonomy, is backed by religious and moral principles and being effective it would preclude a need for this organs market, whether effective and monopsonistic or otherwise.
Instead of constraining choice, a presumed consent system would enforce autonomy, which is the same reason why the organs market is suggested – it provides choice while solving the problem of scarcity, but as I have shown, so does the presumed consent system. It is superior for the following reasons. A presumed consent system for cadaveric transplants would meets the needs of long waiting lists without commodification and commercialisation thus ensuring greater human dignity, so it would more ethically sound than a market in organs. The procedure would be non-maleficent to the dead donor, and of beneficence to the donee.
Distributive justice would be more abided by – the organ would presumably go to the patient in need, rather than the most able to pay. There is greater welfare on aggregate – instead of just one kidney being transplanted from a live donor requiring a period for recuperation on top of 15% who complain of lasting weakness after the operation, on average 3. 5 organs can be harvested from a cadaveric donor. Rule utilitarianism would also be satisfied – above all do no harm – as no harm is done to the cadaver, whereas harm would be done to the living donor.
Further, according to virtue ethics organ donation is the most virtuous thing to do – this would save lives, and what use are organs in a cadaver if they are destined to rot, or burn? Major religions back organ transplantations – Judeo-Christian and Islamic emphasise charity, whilst Catholic, Buddhist and Hindu emphasise doing good to gain metaphysical favour. So what remains the objection to a presumed consent system? 4 Xenotransplantation If xenotransplantation were successful in humans it would solve all our problems of organ shortage.
However, many practical barriers would have to be overcome, not least of which is the occurrence of natural antibodies in humans against all species except the higher order primates. Thus, without modification of this pre-existing immune response, transplantation of, say, a pig organ into a human would lead to hyperacute rejection of the organ. This could one day be prevented, but numerous other immunological responses to a xenograft have yet to be solved. In addition there is great concern about the possible transfer of infection from the organ donor and in particular transmission of porcine endogenous retroviruses (PERVs).
Given the proven risks and the reality of disease transmission from animals to humans from BSE and CJD in particular, and concern about HIV and Aids in relation to animal-to-human contact, there is an acute awareness of the risk of transplanting animal organs into humans. Indeed until there is some confidence that such retroviruses cannot be transmitted from pig tissues into the human xenotransplantation remains on hold – consider the moratorium imposed by the Council of Europe which has yet to be lifted.
So far, no one has survived beyond 2 months, so no one knows how the cells interact. Furthermore, there are ethical issues related to the production, use, care and disposal of animals. These have direct bearing on ethics and humanity, not just at the level of specific moral concerns but also at the ethical and philosophical levels of our understanding of the nature of human beings over and against the nature of animals, and the particular issue of human and animal rights. The response to this moral objection of ‘playing God’ which bedevils all transplantation is threefold.
First, we already share a great deal of genetic material and DNA with animals. The extra amount is not really significant and will not turn animals into human beings. In response however, we are more concerned that xenotransplantation has effects we have yet to understand or are able to control – consider the diseases which cause human lives to be less than complete because of mutated genes leading to hereditary disorders. The fear is not that animals will turn into human beings, but that the results would be monstrous.
Secondly, faced with such human suffering and the possibility of relief and even cure, to refuse to use helpful medical techniques is not just wasteful but immoral. However, if we had the presumed consent system in place instead, would not the problem be solved, and the issue of great need be irrelevant? Finally, the main argument is that in reality we are constantly interfering with natural functions. The whole of medical practice while it operating in a complementary way to nature does in fact resist the natural processes of disease and dysfunction.
Medicine tries to restore what has broken down and to maximise the amount of health and well-being possible for humanity. To this we could just as well respond, as Fox and McHale have – do we really believe that human life should be extended by all means and at all costs? Are the boundaries of health, or indeed life itself destined for inevitable extension or have we reached appoint where it is time to say that enough is really enough, and that for ethical reasons, including resource allocation, our energies would be better devoted to other health care issues?
Indeed, that move from active treatment to the provision of care and comfort for someone about to die is not always easy or clear, but there is a limit where death cannot be resisted and the attempt itself is degrading and creates more pain and distress for all concerned than benefit. Part of good medical practice is knowing when to stop treatment and let people die with dignity. Xenotransplantation offers a real, though currently distant, hope of providing a source of organs for those who urgently require a transplant.
Before that hope can become a reality, good medical and scientific progress and also careful, publicly acknowledged safeguards and regulation must be in place. The good news is that the various national authorities and the Council of Europe have established such stringent regulations. This is an excellent example of being proactive rather than simply reactive to new scientific advances. This will prevent the horse from bolting rather than trying to close the stable door after the horse has gone. Religious views.
Catholics and Protestants advocate prudence, not only because of the ill-defined nature of this new medical adventure but also because of the risks of contamination it may entail. The question of the identity of humankind generally and of particular individuals is on the table and is especially crucial. The question of xenographs in fact pushes to their utmost limits all the ethical problems posed by transplants – powers and limitations of human beings, identity, sense of solidarity and justice.
Buddhists are not in favour of xenografts and xenotransplantation but regard them as acceptable in certain circumstances – no commercialism, decent living conditions and treatment for the animal, and the procedure should be regarded as a transitional phase, which should be as short as possible. Judaism takes a pragmatic stance, saying that given the importance attached to life, xenotransplants do not pose any religious problem.
It is permissible to save a human life by transplanting animal organs, tissue or cells, especially as there is currently a drastic shortage of human donors – on condition that no unnecessary suffering is caused to the animal. Consideration of physical and psychological impact on recipients of animal organs necessary, but also necessary are further developments in the research field before the full physical impact might be known. Humankind is permitted and even duty-bound to change and improve the world in any way deemed beneficial for humanity.