Organ donation
Overview
Organ donation is the donation
Donation
A donation is a gift given by physical or legal persons, typically for charitable purposes and/or to benefit a cause. A donation may take various forms, including cash, services, new or used goods including clothing, toys, food, and vehicles...

 of biological tissue
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...

 or an organ
Organ (anatomy)
In biology, an organ is a collection of tissues joined in structural unit to serve a common function. Usually there is a main tissue and sporadic tissues . The main tissue is the one that is unique for the specific organ. For example, main tissue in the heart is the myocardium, while sporadic are...

 of the human body
Human body
The human body is the entire structure of a human organism, and consists of a head, neck, torso, two arms and two legs.By the time the human reaches adulthood, the body consists of close to 100 trillion cells, the basic unit of life...

, from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues
Transplantable organs and tissues
Transplantable organs and tissues may both refer to organs and tissues that are relatively often or routinely transplanted , as well as relatively seldom transplanted organs and tissues and ones on the experimental stage....

 are removed in a surgical procedure
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 following a determination, based on the donor's medical and social history, of which are suitable for transplantation. Such procedures are termed allotransplantation
Allotransplantation
Allotransplantation is the transplantation of cells, tissues, or organs, sourced from a genetically non-identical member of the same species as the recipient. The transplant is called an allograft or allogeneic transplant or homograft...

s, to distinguish them from xenotransplantation
Xenotransplantation
Xenotransplantation , is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenografts or xenotransplants...

, the transfer of animal organs into human bodies.
As recently as the late 1960s and early 1970s, irreversible cardiopulmonary failure was the only standard for determining death for purposes of donation after cardiac death.
Encyclopedia
Organ donation is the donation
Donation
A donation is a gift given by physical or legal persons, typically for charitable purposes and/or to benefit a cause. A donation may take various forms, including cash, services, new or used goods including clothing, toys, food, and vehicles...

 of biological tissue
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...

 or an organ
Organ (anatomy)
In biology, an organ is a collection of tissues joined in structural unit to serve a common function. Usually there is a main tissue and sporadic tissues . The main tissue is the one that is unique for the specific organ. For example, main tissue in the heart is the myocardium, while sporadic are...

 of the human body
Human body
The human body is the entire structure of a human organism, and consists of a head, neck, torso, two arms and two legs.By the time the human reaches adulthood, the body consists of close to 100 trillion cells, the basic unit of life...

, from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues
Transplantable organs and tissues
Transplantable organs and tissues may both refer to organs and tissues that are relatively often or routinely transplanted , as well as relatively seldom transplanted organs and tissues and ones on the experimental stage....

 are removed in a surgical procedure
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 following a determination, based on the donor's medical and social history, of which are suitable for transplantation. Such procedures are termed allotransplantation
Allotransplantation
Allotransplantation is the transplantation of cells, tissues, or organs, sourced from a genetically non-identical member of the same species as the recipient. The transplant is called an allograft or allogeneic transplant or homograft...

s, to distinguish them from xenotransplantation
Xenotransplantation
Xenotransplantation , is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenografts or xenotransplants...

, the transfer of animal organs into human bodies.

Donation after death

As recently as the late 1960s and early 1970s, irreversible cardiopulmonary failure was the only standard for determining death for purposes of donation after cardiac death. This was replaced by brain death
Brain death
Brain death is the irreversible end of all brain activity due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state...

, the irreversible loss of all function, including the brain stem
Brain stem
In vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...

, though donation after cardiac death is a resurgent source for transplantation.

Legislation

The laws of different countries allow potential donors to permit or refuse donation, or give this choice to relatives. The frequency of donations varies among countries.

Opt-in vs. opt-out

There are two main systems for voluntary systems: "opt in" (anyone who has not given consent is not a donor) and "opt out" (anyone who has not refused is a donor). In some systems like in Australia (13.8 donors per million, 309 donors in 2010), family members are required to give consent or refusal, or may veto a potential recovery even if the donor has consented. Opt-out legislative systems dramatically increase effective rates of consent for donation. However, because of cultural and infrastructural factors, public policies and other factors, this does not translate directly into increased rates of donation.

Some countries with an opt-out system like Spain (34 donors per million inhabitants) or Austria (21 donors/million) have high donor rates and some countries with opt-in systems like Germany (16 donors/million) or Greece (six donors/million) have lower rates. However Sweden, which has an opt-out system, has a low rate as well (15 donors/million). The president of the Spanish National Transplant Organisation, has acknowledged Spain's legislative approach is likely not the primary reason for the country's success in increasing the donor rates, starting in the 1990s.

United States

Under the law of the United States
Law of the United States
The law of the United States consists of many levels of codified and uncodified forms of law, of which the most important is the United States Constitution, the foundation of the federal government of the United States...

, the regulation of organ donation is left to states
U.S. state
A U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...

 within the limitations of the Uniform Determination of Death Act
Uniform Determination of Death Act
The Uniform Determination of Death Act is a draft state law that was approved for the United States in 1981 by the National Conference of Commissioners on Uniform State Laws, in cooperation with the American Medical Association, the American Bar Association, and the President's Commission on...

, the National Organ Transplant Act of 1984, and the United Network for Organ Sharing
United Network for Organ Sharing
Located in Richmond, Virginia, the United Network for Organ Sharing is a non-profit, scientific and educational organization that administers the only Organ Procurement and Transplantation Network in the United States, established by the U.S. Congress in 1984.UNOS was awarded the initial OPTN...

 (UNOS). Each state's Uniform Anatomical Gift Act
Uniform Anatomical Gift Act
The Uniform Anatomical Gift Act , and its periodic revisions, is one of the Uniform Acts drafted by the National Conference of Commissioners on Uniform State Laws in the United States with the intention of harmonizing state laws in force in the states.UAGA governs organ donations for the purpose...

 seeks to streamline the process and standardize the rules among the various states. Many states have sought to encourage the donations to be made by allowing the consent to be noted on the driver's license
Driver's license in the United States
In the United States, nearly all driver's licenses are issued by individual states , rather than the federal government. Drivers are normally required to obtain a license from their state of residence, and all states recognize each other's licenses for temporary visitors subject to normal age...

. Donor registries allow for a central information center for an individual's wish to be a donor. It is a pure consent system rather than an extended consent system or a dissent opt-out system.

Europe

Within the European Union
European Union
The European Union is an economic and political union of 27 independent member states which are located primarily in Europe. The EU traces its origins from the European Coal and Steel Community and the European Economic Community , formed by six countries in 1958...

, organ donation is regulated by member states. As of 2010, 24 European countries have some form of presumed consent (opt-out) system, with the most prominent and limited opt-out systems in Spain, Austria, and Belgium yielding high donor rates. In the United Kingdom organ donation is voluntary and no consent is presumed. Individuals who wish to donate their organs after death can use the Organ Donation Register, a national database. The UK has recently discussed whether to switch to an opt-out system in light of the success in other countries and a severe British organ donor shortfall. In 2008, the European Parliament
European Parliament
The European Parliament is the directly elected parliamentary institution of the European Union . Together with the Council of the European Union and the Commission, it exercises the legislative function of the EU and it has been described as one of the most powerful legislatures in the world...

 overwhelmingly voted for an initiative to introduce an EU organ donor card in order to foster organ donation in Europe.

Landstuhl Regional Medical Center
Landstuhl Regional Medical Center
The Landstuhl Regional Medical Center is an overseas military hospital operated by the United States Army and the Department of Defense. LRMC is the largest military hospital outside of the continental United States. It is located near Landstuhl, Germany, and serves as the nearest treatment center...

 (LRMC) has become one of the most active organ donor hospitals in all of Germany, which otherwise has one of the lowest organ donation participation rates in the Eurotransplant
Eurotransplant
The Eurotransplant International Foundation, commonly known simply as Eurotransplant, is an international non-profit organization responsible for encouraging and coordinating organ transplants in its member countries. The headquarters of Eurotransplant are located in Leiden, the Netherlands. The...

 organ network. LRMC, the largest U.S. military hospital outside the United States, is one of the top hospitals for organ donation in the Rhineland-Palatinate
Rhineland-Palatinate
Rhineland-Palatinate is one of the 16 states of the Federal Republic of Germany. It has an area of and about four million inhabitants. The capital is Mainz. English speakers also commonly refer to the state by its German name, Rheinland-Pfalz ....

 state of Germany, even though it has relatively few beds compared to many German hospitals. According to the German organ transplantation organization, Deutsche Stiftung Organtransplantation (DSO), 34 American military service members who died at LRMC (roughly half of the total number who died there) donated a total of 142 organs between 2005 and 2010. In 2010 alone, 10 of the 12 American service members who died at LRMC were donors, donating a total of 45 organs. Of the 205 hospitals in the DSO’s central region—which includes the large cities of Frankfurt
Frankfurt
Frankfurt am Main , commonly known simply as Frankfurt, is the largest city in the German state of Hesse and the fifth-largest city in Germany, with a 2010 population of 688,249. The urban area had an estimated population of 2,300,000 in 2010...

 and Mainz
Mainz
Mainz under the Holy Roman Empire, and previously was a Roman fort city which commanded the west bank of the Rhine and formed part of the northernmost frontier of the Roman Empire...

—only six had more organ donors than LRMC in 2010.

Japan

The rate of organ donation in Japan is significantly lower than in Western countries. This is attributed to cultural reasons, some distrust of western medicine, and a controversial organ transplantation in 1968 that provoked a ban on cadaveric organ donation that would last thirty years. Organ donation in Japan is regulated by a 1997 organ transplant law, which defines "brain death
Brain death
Brain death is the irreversible end of all brain activity due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state...

" and legalized organ procurement from brain dead donors.

India

Organ selling is legally banned in India. Numerous studies have documented that organ vendors have a poor quality of life (QOL) following kidney donation. Live related renal donors have a significant improvement in the QOL following renal donation using the WHO QOL BREF in a study done at the All India Institute of Medical Sciences from 2006 to 2008. The quality of life of the donor was poor when the graft was lost or the recipient died.

Deontological issues

Certain groups, like the Roma (gypsies), oppose organ donation on religious grounds, but most of the world's religions support donation as a charitable act of great benefit to the community. Issues surrounding patient autonomy, living will
Living will
An advance health care directive, also known as living will, personal directive, advance directive, or advance decision, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or...

s, and guardianship make it nearly impossible for involuntary organ donation to occur.

From the standpoint of deontological ethics
Deontological ethics
Deontological ethics or deontology is the normative ethical position that judges the morality of an action based on the action's adherence to a rule or rules. It is sometimes described as "duty" or "obligation" or "rule" -based ethics, because rules "bind you to your duty"...

, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definitions of life
Life
Life is a characteristic that distinguishes objects that have signaling and self-sustaining processes from those that do not, either because such functions have ceased , or else because they lack such functions and are classified as inanimate...

, death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....

, human
Human
Humans are the only living species in the Homo genus...

, and body
Body
With regard to living things, a body is the physical body of an individual. "Body" often is used in connection with appearance, health issues and death...

 is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for procurement is an ongoing problem in clinical bioethics
Bioethics
Bioethics is the study of controversial ethics brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, and philosophy....

.

Further, the use of cloning
Cloning
Cloning in biology is the process of producing similar populations of genetically identical individuals that occurs in nature when organisms such as bacteria, insects or plants reproduce asexually. Cloning in biotechnology refers to processes used to create copies of DNA fragments , cells , or...

 to produce organs with an identical genotype
Genotype
The genotype is the genetic makeup of a cell, an organism, or an individual usually with reference to a specific character under consideration...

 to the recipient has issues all its own. Cloning is still a controversial topic, especially considering the possibility for an entire person to be brought into being with the express purpose of being destroyed for organ procurement. While the benefit of such a cloned organ would be a zero-percent chance of transplant rejection
Transplant rejection
Transplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...

, the ethical issues involved with creating and killing a clone may outweigh these benefits. However, it may be possible in the future to use cloned stem-cells to grow a new organ without creating a new human being.

A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation
Xenotransplantation
Xenotransplantation , is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenografts or xenotransplants...

, or the transfer of animal (usually pig) organs into human bodies, promises to eliminate many of the ethical issues, while creating many of its own. While xenotransplantation
Xenotransplantation
Xenotransplantation , is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenografts or xenotransplants...

 promises to increase the supply of organs considerably, the threat of organ transplant rejection
Transplant rejection
Transplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...

 and the risk of xenozoonosis, coupled with general anathema to the idea, decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.

Teleological issues

On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. In so far as those who donate organs are often impoverished and those who can afford black market organs are typically well-off, it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time — many die while still on a waiting list

Organ donation is fast becoming an important bioethical
Bioethics
Bioethics is the study of controversial ethics brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, and philosophy....

 issue from a social perspective as well. While most first-world nations have a legal system of oversight for organ transplantation, the fact remains that demand far outstrips supply. Consequently, there has arisen a black market trend often referred to as transplant tourism. The issues are weighty and controversial. On the one hand are those who contend that those who can afford to buy organs are exploiting those who are desperate enough to sell their organs. Many suggest this results in a growing inequality of status between the rich and the poor. On the other hand are those who contend that the desperate should be allowed to sell their organs and that preventing them from doing so is merely contributing to their status as impoverished. Further, those in favor of the trade hold that exploitation is morally preferable to death, and in so far as the choice lies between abstract notions of justice on the one hand and a dying person whose life could be saved on the other hand, the organ trade
Organ trade
Organ trade is the trade involving human organs for transplantation. There is a worldwide shortage of organs available for transplantation, possibly a result of regulations forbidding their trafficking.-Legal organ trade:...

 should be legalized. Conversely, surveys conducted among living donors postoperatively and in a period of five years following the procedure have shown extreme regret in a majority of the donors, who said that given the chance to repeat the procedure, they would not. Additionally, many study participants reported a decided worsening of economic condition following the procedure. These studies looked only at people who sold a kidney in countries where organ sales are already legal.

A consequence of the black market for organs has been a number of cases and suspected cases of organ theft
Organ theft
Organ harvesting refers to the removal, preservation and use of human organs and tissue from the bodies of the recently deceased to be used in surgical transplants on the living...

 including murder for the purposes of organ theft. Proponents of a legal market for organs say that the black-market nature of the current trade allows such tragedies and that regulation of the market could prevent them. Opponents say that such a market would encourage criminals by making it easier for them to claim that their stolen organs were legal.

Legalization of the organ trade carries with it its own sense of justice as well. Continuing black-market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade could lead to increased supply, lowering prices so that persons outside the wealthiest segments could afford such organs as well.

Exploitation arguments generally come from two main areas:
  • Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor.
  • Financial exploitation suggests that the donor (especially in the India
    India
    India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...

    n subcontinent and Africa
    Africa
    Africa is the world's second largest and second most populous continent, after Asia. At about 30.2 million km² including adjacent islands, it covers 6% of the Earth's total surface area and 20.4% of the total land area...

    ) are not paid enough. Commonly, accounts from persons who have sold organs in both legal and black market circumstances put the prices at between $150 and $5,000, depending on the local laws, supply of ready donors and scope of the transplant operation. In Chennai, India where one of the largest black markets for organs is known to exist, studies have placed the average sale price at little over $1,000. Many accounts also exist of donors being postoperatively denied their promised pay.
  • The New Cannibalism is a phrase coined by anthropologist Nancy Scheper-Hughes
    Nancy Scheper-Hughes
    Nancy Scheper-Hughes is a professor of Anthropology and director of the program in Medical Anthropology at the University of California at Berkeley. She is known for her writing on the anthropology of the body, hunger, illness, medicine, psychiatry, madness, social suffering, violence and genocide...

     in 1998 for an article written for The New Internationalist
    New Internationalist
    New Internationalist is a magazine from New Internationalist Publications, a co-operative-run publisher based in Oxford, England. It has editorial and sales offices in Toronto, Canada; Adelaide, Australia; Christchurch, New Zealand; and New York, USA....

    . Her argument was that the actual exploitation is an ethical failing, a human exploitation; a perception of the poor as organ sources which may be used to extend the lives of the wealthy.


Economic drivers leading to increased donation are not limited to areas such as India and Africa, but also are emerging in the United States. Increasing funeral expenses combined with decreasing real value of investments such as homes and retirement savings which took place in the 2000s have purportedly led to an increase in citizens taking advantage of arrangements where funeral costs are reduced or eliminated.

Brain death versus cardiac death

Brain death may result in legal death
Legal death
Legal death is a legal pronouncement by a qualified person that further medical care is not appropriate and that a patient should be considered dead under the law. The specific criteria used to pronounce legal death are variable and often depend on certain circumstances in order to pronounce a...

, but still with the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...

 beating, and with mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...

 all other vital organs may be kept completely alive and functional, providing optimal opportunities for organ transplantation.

Most organ donation for organ transplantation is done in the setting of brain death. In some nations (for instance, Belgium
Belgium
Belgium , officially the Kingdom of Belgium, is a federal state in Western Europe. It is a founding member of the European Union and hosts the EU's headquarters, and those of several other major international organisations such as NATO.Belgium is also a member of, or affiliated to, many...

, Poland
Poland
Poland , officially the Republic of Poland , is a country in Central Europe bordered by Germany to the west; the Czech Republic and Slovakia to the south; Ukraine, Belarus and Lithuania to the east; and the Baltic Sea and Kaliningrad Oblast, a Russian exclave, to the north...

, Portugal
Portugal
Portugal , officially the Portuguese Republic is a country situated in southwestern Europe on the Iberian Peninsula. Portugal is the westernmost country of Europe, and is bordered by the Atlantic Ocean to the West and South and by Spain to the North and East. The Atlantic archipelagos of the...

 and France
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...

) everyone is automatically an organ donor, although some jurisdictions (such as Singapore
Singapore
Singapore , officially the Republic of Singapore, is a Southeast Asian city-state off the southern tip of the Malay Peninsula, north of the equator. An island country made up of 63 islands, it is separated from Malaysia by the Straits of Johor to its north and from Indonesia's Riau Islands by the...

, Poland
Poland
Poland , officially the Republic of Poland , is a country in Central Europe bordered by Germany to the west; the Czech Republic and Slovakia to the south; Ukraine, Belarus and Lithuania to the east; and the Baltic Sea and Kaliningrad Oblast, a Russian exclave, to the north...

, France
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...

, or New Zealand
New Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...

) allow opting out of the system. Elsewhere, consent from family members or next-of-kin is required for organ donation. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.
In the United States, where since the 1980s the Uniform Determination of Death Act
Uniform Determination of Death Act
The Uniform Determination of Death Act is a draft state law that was approved for the United States in 1981 by the National Conference of Commissioners on Uniform State Laws, in cooperation with the American Medical Association, the American Bar Association, and the President's Commission on...

 has defined death as the irreversible cessation of the function of either the brain or the heart and lungs, the 21st century has seen an order-of-magnitude increase of donation following cardiac death. In 1995, only one out of 100 dead donors in the nation gave their organs following the declaration of cardiac death. That figure grew to almost 11 percent in 2008, according to the Scientific Registry of Transplant Recipients. That increase has provoked ethical concerns about the interpretation of "irreversible" since "patients may still be alive five or even 10 minutes after cardiac arrest because, theoretically, their hearts could be restarted, [and thus are] clearly not dead because their condition was reversible."

Political issues

There are also controversial issues regarding how organs are allocated to recipients. For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes.

Faith in the medical system is important to the success of organ donation. Brazil switched to an opt-out system and ultimately had to withdraw it because it further alienated patients who already distrusted the country's medical system.

Adequate funding, strong political will to see transplant outcomes improve, and the existence of specialized training, care and facilities also increase donation rates. Expansive legal definitions of death, such as Spain uses, also increase the pool of eligible donors by allowing physicians to declare a patient to be dead at an earlier stage, when the organs are still in good physical condition.

Allowing or forbidding payment for organs affects the availability of organs. Generally, where organs can not be bought or sold, quality and safety are high, but supply is not adequate to the demand. Where organs can be purchased, the supply increase somewhat, but safety declines, as families and living donors have an incentive to conceal unfavorable information.

Healthy humans have two kidneys, a redundancy that enables living donors (inter vivos
Inter vivos
Inter vivos is a legal term referring to a transfer or gift made during one's lifetime, as opposed to a testamentary transfer ....

) to give a kidney to someone who needs it. The most common transplants are to close relatives, but people have given kidneys to other friends. The rarest type of donation is the undirected donation whereby a donor gives a kidney to a stranger. Less than a few hundred of such kidney donations have been performed. In recent years, searching for altruistic donors via the internet has also become a way to find life saving organs. However, internet advertising for organs is a highly controversial practice, as some scholars believe it undermines the traditional list-based allocation system.

The National Transplant Organization of Spain is one of the most successful in the world, but it still can't meet the demand, as 10% of those needing a transplant die while still on the transplant list. Donations from corpses are anonymous, and a network for communication and transport allows fast extraction and transplant across the country. Under Spanish law, every corpse can provide organs unless the deceased person had expressly rejected it. Because family members still can forbid the donation, carefully trained doctors ask the family for permission, making it very similar in practice to the United States system.

In the overwhelming majority of cases, organ donation is not possible for reasons of recipient safety, match failures, or organ condition. Even in Spain, which has the highest organ donation rate in the world, there are only 35.1 actual donors per million people, and there are hundreds of patients on the waiting list. This rate compares to 24.8 per million in Austria, where families are rarely asked to donate organs, and 22.2 per million in France, which—like Spain—has a presumed-consent system.

Prison inmates

In the United States, prisoners are not discriminated against as organ recipients and are equally eligible for organ transplants along with the general population. A 1976 U.S. Supreme Court case ruled that withholding health care from prisoners constituted "cruel and unusual punishment
Cruel and unusual punishment
Cruel and unusual punishment is a phrase describing criminal punishment which is considered unacceptable due to the suffering or humiliation it inflicts on the condemned person...

". United Network for Organ Sharing, the organization that coordinates available organs with recipients, does not factor a patient’s prison status when determining suitability for a transplant.
An organ transplant and followup care can cost the prison system up to one million dollars. If a prisoner qualifies, a state will allow compassionate early release to avoid high costs associated with organ transplants.

Because donor organs are in short supply, there are more people waiting for a transplant than available organs. When a prisoner receives an organ, there is a high probability that someone else will die waiting for the next available organ. A response to this ethical dilemma states that felons who have a history of violent crime, who have violated others’ basic rights, have lost the right to receive an organ transplant, though it is noted that it would be necessary "to reform our justice system to minimize the chance of an innocent person being wrongly convicted of a violent crime and thus being denied an organ transplant"

A South Carolina proposal to shorten prisoners’ sentences in exchange for bone marrow and kidney transplants was proposed as a solution to organ shortages. The idea is criticized by physicians and ethicists because a prisoner is not able to consent to the procedure in a free and non-coercive environment. A program started by Maricopa County Sheriff
Maricopa County Sheriff's Office
The Maricopa County Sheriff's Office is a local law enforcement agency that serves Maricopa County, Arizona. It is the largest sheriff's office in Arizona and provides general-service and specialized law enforcement to unincorporated areas of Maricopa County, serving as the primary law enforcement...

 Joe Arpaio
Joe Arpaio
Joseph M. "Joe" Arpaio is the elected Sheriff of Maricopa County in the U.S. state of Arizona. First voted into office in 1992, Arpaio is responsible for law enforcement in Maricopa County. This includes management of the Maricopa County Sheriff's Office, county jail, courtroom security,...

 encourages inmates of the Arizona state prison system
Arizona Department of Corrections
The Arizona Department of Corrections is in charge of the incarceration of inmates in 10 prisons in the U.S. state of Arizona. As of April 2009, the ADC manages over 40,191 imprisoned inmates and over 7,216 inmates who have been paroled or that are statutorily released. ADC is also in involved in...

 to voluntarily sign up to donate their heart and other organs.

Religious viewpoints

All major religions accept organ donation in at least some form on either utilitarian grounds (i.e., because of its life-saving capabilities) or deontological grounds (e.g., the right of an individual believer to make his or her own decision). Most religions, among them the Roman Catholic Church
Roman Catholic Church
The Catholic Church, also known as the Roman Catholic Church, is the world's largest Christian church, with over a billion members. Led by the Pope, it defines its mission as spreading the gospel of Jesus Christ, administering the sacraments and exercising charity...

, support organ donation on the grounds that it constitutes an act of charity and provides a means of saving a life, although certain bodies, such as the pope's, are not to be used. Some religions impose certain restrictions on the types of organs that may be donated and/or on the means by which organs may be harvested and/or transplanted. For example, Jehovah's Witnesses
Jehovah's Witnesses
Jehovah's Witnesses is a millenarian restorationist Christian denomination with nontrinitarian beliefs distinct from mainstream Christianity. The religion reports worldwide membership of over 7 million adherents involved in evangelism, convention attendance of over 12 million, and annual...

 require that organs be drained of any blood due to their interpretation of the Hebrew Bible
Hebrew Bible
The Hebrew Bible is a term used by biblical scholars outside of Judaism to refer to the Tanakh , a canonical collection of Jewish texts, and the common textual antecedent of the several canonical editions of the Christian Old Testament...

/Christian Old Testament
Old Testament
The Old Testament, of which Christians hold different views, is a Christian term for the religious writings of ancient Israel held sacred and inspired by Christians which overlaps with the 24-book canon of the Masoretic Text of Judaism...

 as prohibiting blood transfusion, and Muslim
Muslim
A Muslim, also spelled Moslem, is an adherent of Islam, a monotheistic, Abrahamic religion based on the Quran, which Muslims consider the verbatim word of God as revealed to prophet Muhammad. "Muslim" is the Arabic term for "submitter" .Muslims believe that God is one and incomparable...

s require that the donor have provided written consent in advance. A few groups disfavor organ transplantation or donation; notably, these include Shinto
Shinto
or Shintoism, also kami-no-michi, is the indigenous spirituality of Japan and the Japanese people. It is a set of practices, to be carried out diligently, to establish a connection between present day Japan and its ancient past. Shinto practices were first recorded and codified in the written...

 and those who follow the customs of the Gypsies.

Orthodox Judaism
Orthodox Judaism
Orthodox Judaism , is the approach to Judaism which adheres to the traditional interpretation and application of the laws and ethics of the Torah as legislated in the Talmudic texts by the Sanhedrin and subsequently developed and applied by the later authorities known as the Gaonim, Rishonim, and...

 considers organ donation obligatory if it will save a life, as long as the donor is considered dead as defined by Jewish law. In both Orthodox Judaism and non-Orthodox Judaism, the majority view holds that organ donation is permitted in the case of irreversible cardiac rhythm cessation. In some cases, rabbinic authorities believe that organ donation may be mandatory, whereas a minority opinion considers any donation of a live organ as forbidden.

Organ shortfall

The demand for organs significantly surpasses the number of donors everywhere in the world. There are more potential recipients on organ donation waiting lists than organ donors. In particular, due to significant advances in dialysis
Dialysis
In medicine, dialysis is a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure...

 techniques, patients suffering from end-stage renal disease (ESRD) can survive longer than ever before. Because these patients don't die as quickly as they used to, and as kidney failure increases with the rising age and prevalence of high blood pressure and diabetes in a society, the need especially for kidneys rises every year.

In the United States, about 108,000 people are on the waiting list, although about a third of those patients are inactive and could not receive a donated organ. Wait times and success rates for organs differ significantly between organs due to demand and procedure difficulty. Three-quarters of patients in need of an organ transplant are waiting for a kidney, and as such kidneys have much longer waiting times. At the Oregon Health and Science University, for example, the median patient who ultimately received an organ waited only three weeks for a heart and three months for a pancreas or liver — but 15 months for a kidney, because demand for kidneys substantially outstrips supply.

In Australia, there are 10.8 transplants per million people, about a third of the Spanish rate. The Lions Eye Institute
Lions Eye Institute
The Lions Eye Institute in Perth, Western Australia, is the largest eye research institute in the southern hemisphere. It is a limited liability company, with not-for-profit and tax-exempt gift recipient status, overseen by a Board of Directors...

, in Western Australia, houses the Lions Eye Bank
Lions Eye Bank
Lions Eye Bank is the name of the various eye banks operated by the Lions Save Sight Foundation , a not for profit foundation within the Lions Clubs International service organisation. The Banks store and prepare donated corneas for transplantation...

. The Bank was established in 1986 and coordinates the collection, processing and distribution of eye tissue for transplantation. The Lions Eye Bank also maintains a waitlist of patients who require corneal graft operations.
About 100 corneas are provided by the Bank for transplant each year, but there is still a waiting list for corneas.

"To an economist, this is a basic supply-and-demand gap with tragic consequences." Approaches to addressing this shortfall include:
  • donor registries and "primary consent" laws, to remove the burden of the donation decision from the legal next-of-kin. Illinois adopted a policy of “mandated choice” in 2006, which requires driver's license registrants to answer the question “Do you want to be an organ donor?” Illinois has a registration rate of 60 percent compared to 38 percent nationally. The added cost of adding a question to the registration form is minimal.
  • monetary incentives for signing up to be a donor. Some economists have advocated going as far as allowing the sale of organs. The New York Times reported that “Gary Becker and Julio Jorge Elias argued in a recent paper that 'monetary incentives would increase the supply of organs for transplant sufficiently to eliminate the very large queues in organ markets, and the suffering and deaths of many of those waiting, without increasing the total cost of transplant surgery by more than 12 percent.'” Iran allows the sale of kidneys, and has no waiting list. The primary argument against this proposal is a moral one; as the article notes, many find such a suggestion repugnant. As the National Kidney Foundation puts it, “Offering direct or indirect economic benefits in exchange for organ donation is inconsistent with our values as a society. Any attempt to assign a monetary value to the human body, or body parts, either arbitrarily, or through market forces, diminishes human dignity.”
  • an opt-out system ("dissent solution"), in which a potential donor or his/her relatives must take specific action to be excluded from organ donation, rather than specific action to be included. This model is used in several European countries, such as Austria, which has a registration rate eight times that of Germany, which uses an opt-in system.
  • social incentive programs, wherein members sign a legal agreement to direct their organs first to other members who are on the transplant waiting list. One example of a private organization using this model is LifeSharers, which is free to join and whose members agree to sign a document giving preferred access to their organs. “"The proposal [for an organ mutual insurance pool] can be easily summarized: An individual would receive priority for any needed transplant if that individual agrees that his or her organs will be available to other members of the insurance pool in the event of his or her death. … The main purpose [of this proposal] is to increase the supply of transplantable organs in order to save or improve more lives."


In hospitals, organ network representatives routinely screen patient records to identify potential donors shortly in advance of their deaths. In many cases, organ-procurement representatives will request screening tests (such as blood typing) or organ-preserving drugs (such as blood pressure drugs
Antihypertensive
The antihypertensives are a class of drugs that are used to treat hypertension . Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from...

) to keep potential donors' organs viable until their suitability for transplants can be determined and family consent (if needed) can be obtained. This practice increases transplant efficiency, as potential donors who are unsuitable due to infection or other causes are removed from consideration before their deaths, and decreases the avoidable loss of organs. It may also benefit families indirectly, as the families of unsuitable donors are not approached to discuss organ donation.

The Center for Ethical Solutions
Center for Ethical Solutions
The Center for Ethical Solutions , founded by Sigrid Fry-Revere, is a 501 non-profit bioethics think tank based in Lovettsville, Virginia whose mission is to find practical solutions to controversial problems in the field of medical ethics...

, an American bioethics think tank, is currently working on a project called "Solving the Organ Shortage," in which it is studying the Iranian kidney procurement system in order to better inform the debate over solving the organ shortfall in the United States.

Distribution

The United States has two agencies that govern organ procurement and distribution within the country. The United Network for Organ Sharing and the Organ Procurement and Transplant Network (OPTN) regulate Organ Procurement Organizations (OPO) with regard to procurement and distribution ethics and standards. OPOs are non-profit organizations charged with the evaluation, procurement and allocation of organs whithin their Designated Service Area (DSA). Once a donor has been evaluated and consent obtained, provisional allocation of organs commences. UNOS developed a computer program that automatically generates donor specific match lists for suitable recipients based on the criteria that the patient was listed with. OPO coordinators enter donor information into the program and run the respective lists. Organ offers to potential recipients are made to transplant centers to make them aware of a potential organ. The surgeon will evaluate the donor information and make a provisional determination of medical suitability to their recipient. Distribution varies slightly between different organs but is essentially very similar. When lists are generated many factors are taken into consideration; these factors include: distance of transplant center from the donor hospital, blood type, medical urgency, wait time, donor size and tissue typing. For heart recipients medical urgency is denoted by a recipients "Status" (Status 1A, 1B and status 2). Lungs are allocated based on a recipients Lung Allocation Score (LAS) that is determined based on urgency and wait time. Livers are allocated using both a status system and MELD/PELD score (Model for End-stage Liver Disease/Pediatric End-stage Liver Disease). Kidney and pancreas lists are based on location, blood type, Human Leukocyte Antigen (HLA) typing and wait time. When a recipient for a kidney or pancreas has no direct antibodies to the donor HLA the match is said to be a 0 ABDR mismatch or zero antigen mismatch. A zero mismatch organ has a low rate of rejection and allows a recipient to be on lower doses of immunosuppressive drug
Immunosuppressive drug
Immunosuppressive drugs or immunosuppressive agents are drugs that inhibit or prevent activity of the immune system. They are used in immunosuppressive therapy to:...

s. Since zero mismatches have such high graft survival these recipients are afforded priority regardless of location and wait time. UNOS has in place a "Payback" system to balance organs that are sent out of a DSA because of a zero mismatch.

Location of a transplant center with respect to a donor hospital is given priority due to the effects of Cold Ischemic Time (CIT). Once the organ is removed from the donor, blood no longer perfuses through the vessels and begins to starve the cells of oxygen (ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...

). Each organ tolerates different ischemic times. Hearts and lungs need to be transplanted within 4–6 hours from recovery, liver about 8–10 hours and pancreas about 15 hours; kidneys are the most resilient to ischemia. Kidneys packaged on ice can be successfully transplanted 24–36 hours after recovery. Developments in kidney preservation have yielded a device that pumps cold preservation solution through the kidneys vessels to prevent Delayed Graft Function (DGF) due to ischemia. Perfusion devices, often called kidney pumps, can extend graft survival to 36–48 hours post recovery for kidneys. Research and development is currently underway for heart and lung preservation devices, in an effort to increase distances procurement teams may travel to recover an organ.

Suicide

People committing suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

 have a higher rate of donating organs than average. One reason is lower negative response or refusal rate by the family and relatives, but the explanation for this remains to be clarified. In addition, donation consent is higher than average from people committing suicide.

Attempted suicide is a common cause of brain death
Brain death
Brain death is the irreversible end of all brain activity due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state...

 (3.8%), mainly among young men. Organ donation is more common in this group compared to other causes of death. Brain death may result in legal death
Legal death
Legal death is a legal pronouncement by a qualified person that further medical care is not appropriate and that a patient should be considered dead under the law. The specific criteria used to pronounce legal death are variable and often depend on certain circumstances in order to pronounce a...

, but still with the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...

 beating, and with mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...

 all other vital organs may be kept completely alive and functional, providing optimal opportunities for organ transplantation.

Scandals

In 2008, California transplant surgeon Hootan Roozrokh was charged with dependent adult abuse for prescribing what prosecutors said were excessive doses of morphine and sedatives to hasten the death of a man with adrenal leukodystrophy
Adrenoleukodystrophy
Adrenoleukodystrophy is a rare, inherited disorder that leads to progressive brain damage, failure of the adrenal glands and eventually death. ALD is a disease in a group of genetic disorders called leukodystrophies, whose chief feature is damage to myelin...

 and irreversible brain damage, in order to procure his organs for transplant. The case brought against Roozrokh was the first criminal case against a transplant surgeon
Transplant surgeon
A transplant surgeon is a surgeon who performs organ transplants....

 in the US, and resulted in his acquittal.

At California's Emanuel Medical Center, neurologist Narges Pazouki, MD, said an organ-procurement organization representative pressed her to declare a patient brain-dead before the appropriate tests had been done. She refused.

In September 1999, eBay blocked an auction for “one functional human kidney” which had reached a highest bid of $5.7 million. Under United States federal laws, eBay was obligated to dismiss the auction for the selling of human organs which is punishable by up to five years in prison and a $50,000 fine.

On June 27, 2008, Indonesian, Sulaiman Damanik, 26, pleaded guilty in a Singapore
Singapore
Singapore , officially the Republic of Singapore, is a Southeast Asian city-state off the southern tip of the Malay Peninsula, north of the equator. An island country made up of 63 islands, it is separated from Malaysia by the Straits of Johor to its north and from Indonesia's Riau Islands by the...

 court for sale of his kidney to CK Tang's
Tangs
Tangs is a company that specialises in the retail market, selling goods to customers. It is based in Singapore, and owns Singapore's oldest store which has become an icon of the Singapore retail market...

 executive chair, Mr. Tang Wee Sung, 55, for 150 million rupiah (US$ 17,000). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of "poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks." Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient's adopted son, and was paid 186 million rupiah (US$ 21,000).

See also

  • Australian Organ Donor Register
    Australian Organ Donor Register
    The Australian Organ Donor Register is an Australian government register, recording individuals who have agreed to donate organs and tissues in the event of their death. The register is administered by Medicare Australia.- Operation :...

  • Organ transplantation in the People's Republic of China
  • Organ transplantation in Israel

External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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