Transplantation and ethical issues

                                                                  Written by: Štěpán Tichý, M210208


Introduction

In this essay I focus on the topic of transplantation and its potential ethical problems and
issues, which may arise if transplantation is discussed. My aim is to create a short overview of
the ethical issues, which are mainly discussed with transplantation and then try to sum up the
views on the matter with my own opinion on the matter and which view are the most prevalent. I then
follow one of the new trends in the transplantation and sum up my thoughts in conclusion.


1.      Transplantation and its origins

Benedict (2017) writes that history of healthcare and ethics is deeply intertwined with the history
of social change and medical advancements. If we think about our past and the history of how human
body was perceived thorough the years, it becomes clear that a change was always happening.
Humanity went though a time, when ancient Egyptians surgically removed organs and brains out of
their dead leaders to preserve the body tissues. Another time people were burned alive for being
curious and performing cuts to the dead bodies, performing and learning about the human bodies in
secrecy so they could remove the veil of knowledge a little more, while being secretive because
their desire for knowledge was unwelcomed. And now, for the last seventy years we are trying to
decode and ask questions about the morality of our acts.

To specify what a transplantation the definition of organ transplant is needed. It is a surgical
operation, where one human has failing, or damaged organs and the said organ is replaced with a new
functioning one from a healthy person. We perceive organ as something, which has a specific
function in a human body. For example, the liver, heart or kidney are organs. They are made up of
tissues and cells, which work together and have specialized functions.

Another term, which is largely used is grafting. This term means only partially removing tissue and
placing it on or replacing only part of damaged tissue. It then can merge and combine with the
damaged tissue and repair the damage. One of the most spread graft transplants is doing a skin
grafts – replacing burned skin with healthy collected tissue, which is then placed on the damaged
parts of the body and let heal itself to the new body.

Capron (2014) writes about the first kidney transplantation as an “Un-Hippocratic” act, due to
taking a functioning organ and replacing it with alive and functioning organ from a healthy person.
The transplantation happened between two brothers and it is the first permanent transplantation,
which was successful and opened door to a world, which saved many lives and opened a large amount
of ethical questions and problems. Capron states “the criticism was mainly due to the breach of
primum non nocere – above all, do no harm – even for a laudable goal.” And it is understandable
why. The act of transplantation and cutting into a healthy flesh and human has a high risk, but it
also has a high reward.

The risk factor, which is connected to the well being of the patient is one side of the argument,
however much stronger arguments arise one we start to discuss the problematic sides of rules,
exceptions and the how and why questions. It is also very individual due to the differences between
various nations, religions and even states. In one situation a simple procedure is allowed,
however, in other it is not allowed and is being banned. This creates an environment, which is hard
to navigate in. Legal systems around the world view transplantation and its ethical issues
differently, however this paper focuses on ethical issues and views in the United States of America
and the United Kingdom due to the availability of the sources and the most information being
provided and explored.

2.      Distribution and ethical problems in organ donation

The questions, which are arising from the abilities and possibilities of performing organ
transplantations are well summarized in Jensen’s (2011) book The Ethics of Organ Transplantation:
Life and Ethics in Experimental Biomedicine. It brings closer the debate regarding donors and
receivers. He writes regarding donor issues “If someone wishes to give his heart, even if that
should end his life, then should we stand in the way? Should we prevent him from generously giving
to others? Since the person is dying anyway, he can do little else to give of himself. If we simply
drop this bothersome dead donor rule, and turn to consent instead, then we open a deep supply of
organs.” And continues with questioning the current system of someone wanting to give up their live
and donate it to another human being.

Currently we are dealing with consent and its impact on the transplantation. If a person did not
give permission to donate organs, even if they pass away and their organs could be used to save
someone else’s life, it is forbidden to do so. It is connected as Jensen puts it a “freely given
gift, rather than item that is bought and sold”. He then continues to describe the notions of where
organ giving is considered as a marketable solution – in China and Iran, where organs from
condemned criminals are being sold and used as an asset. The differences mentioned above arise in
this approach to the dilemma as well. In most wester countries there is an assumption that the
donor must give a consent or at least some sort of an indication that they want to donate. However,
Spain takes the opposite route and it assumes that everyone is an organ donor and they must
indicate that they do not want to be perceived as an organ donor. This shifts the discussion in a
different way; however, it creates much simpler environment for organ collecting and
transplantation.

There were notions such as in Mexico, that the government could create an open market, which would
buy organs from poor people to help them stabilize their income (Jensen, 2011, p. xix) and this
connects to the fact that the views of organ transplantation are vastly different in every country
and culture. A set of generalized rules is impossible to put together.

The ethical dilemma, which is brought into this discussion is also the question of death. What does
death from clinical definition mean? Are we allowed to view body as a product and can we use it
after death as we want or are there some sort of guidance’s, which should restrict our behaviour
and barrier our approach to the dead flesh vehicles for human’s souls? There are no easy answers.

The ethical dilemmas regarding the receivers of the organs are vast in the same way as they are
described in the previous chapter. Questions and determination of cause of the reason of need for
the new organ – should it matter if the person abused their body in the first place? Should a
person, who caused his own disfunction of the body be treated before a person who is simply unlucky
and part of an accident? Should we give someone a limit for how many transplantations they can go
through? How do we prioritize, is that based on health, status or money? There are infinite
questions regarding the process of choosing the person who requires the transplantation. There are
quite straightforward ones, as listen above and those, which are not so clear such as: should a
person who cannot afford to pay for medication which helps to stimulate their body for better
acceptance of the transplantation be allowed to get the organ, even though there is a lower chance
of it working?

Another issue is covered in an article written by Kierans & Cooper (2011) called Organ donation,
genetics, race and culture: The making of a medical problem and in this article they point out that
these issues are connected to ethnicity and race due to a required systematic match and favour of
organ sharing in ethnically similar groups. And a result is that minorities, or people from South
Asia or Africa wait twice the time for their transplantation than ethnically white people. The
article next points out that this is not an issue of a racism or a issue of one ethnical group
donating more, but an issue of the whole healthcare system, which is set up in the United Kingdom.
However, this also goes with the practice of a little bit of hypocritic, that the article puts on.
On one hand it shows people, that yes, they do not have an issue taking an organ from another
person and on the other hand, they did not register in the organ donor register.

Another question, which was already touched upon is should people, whose lifestyle and their
choices are directly responsible for the need of transplantation be given the needed organ? And
similar is what about a suicidal people, what if they try to commit suicide another time? Should we
use organs from unborn infants? Where is the line of collecting and organ donating?

3.      Money is always a factor

Healthcare and funding and money are very tied together. Without an effective system of payment, no
healthcare system cannot thrive and expand and get better. And so, when one is dealing with a
concept such as transplantation, money always come into the discourse. As mentioned above, in
Mexico, the government proposed that poor people can sell of their kidney to pay debts and it is
not the only country, where these notions were supported. It all is connected to the most basic
notion of supply = demand. And when there are rich people, who do not have problem to be
economically stable, but need an organ, they can find in the less fortunate and wealthy an option.
They can pay for the desired organ – not to mention the possibility on the black market. This ties
to the question “is body a commodity?” there are multiple points of views and ideologies, which
have various opinions. But the fact states that for some, other people bodies are just that a –
commodity. Capron (2014) mentions at the end of his article an interesting conclusion regarding the
situation in China. Thorough the article he discusses how over the last sixty years western
civilisation tries to cure patients without the excessive need of money and restriction and using
organs from willing donors and not from the position of power. Pointing out the activities
performed by World Health Organization (WHO) to stabilise and centralize the organ transplantation
system. This is compared to the fact that China does not want to go similar way and sees minorities
and different religions as opportunities for cheap organs and take the way that human body is a
commodity. It refuses to understand the west-like approach of willing donation without the need of
money. In the end, it is up to them to decide, which way they will go and what exactly they will
decide to go further with the medicine going further and further.


4.      Transplantation of faces

In current day and age, a transplantation is not such a dangerous surgery as it once was. Of
course, we are dealing with transplantations of ears, kidney and things, which have smaller effect
on the human body, however, also transplantations of the heart are possible. They are still
dangerous, but we can mitigate the risks and therefore the success rate is getting bigger and
bigger. So, for this point we can argue, that there are not very many things the modern medicine
cannot do. (of course, this is taken with a grain of salt and must not be taken literally, limits
of science and healthcare are real and cannot be underestimated) With this taken in context
Taylor-Alexander (2014) argues in his publication in the journal International Library of Ethics,
Law, and the New Medicine 126,  that regarding transplantation of faces or as he scientifically
uses correctly the “allotransplantation of composite facial tissue” there are some issues, which
are in the core of ethics and the dilemma around them.

What is happening is that one patient has transplanted face tissues of another person. Very broadly
speaking, having obtained their face. It is a different than simple plastic surgery, as he puts it
“Every day these doctors perform reconstructive operations that involve moving skin, flesh, and
bone around the individual bodies of their patients, often from torso or limbs to their face – they
are experts in autotransplantation.” So, Taylor-Alexander view the change in notion of the
allotransplantation and simple surgical procedure to create a smaller nose. The questions really
start to arise when considering as he puts it “harvesting facial tissue from brain dead donors and
transplanting it to restore the anatomy of craniofacial patients.”, He continues to describe the
procedure “Face transplant surgery involves taking a mixture of composite soft and hard tissue from
a brain dead donor and transplanting it to a recipient who, in the majority of cases to date, has
suffered disfiguration following physical trauma”.

The main difference between kidney transplantation and allotransplantation is that we give a
personality to the face. Our face is how we perceive ourselves. We pride on this and tie everything
to our faces, so therefore if one is after the transplantation of face and the person has a dead
person’s flesh on them – it creates a various psychological traumas and issues. Will the person be
considered now a mixed human? It that flesh his? What is the condition in the way of ageing? What
will the family of the deceased think about it? There are more. Taylor- Alexander ends his
publication with a notion, that he himself is not aware of the correct answer. He writes “When
someone asks me whether I think face transplantation is a good or bad thing, I struggle to find an
answer but try my best to provide a response that captures the complexity of the field” and to me
it shows that this will be felt much later. Once we know the impacts of our decision and
governmental restrictions.

Conclusion

I would like to conclude this with a quote from Jensen (2011) and as he puts it “The elephant in
the room of organ transplantation is the assumption that organ transplantation is a great boon to
society, such that it warrants an unremitting search for new organ sources.” And believe that he
sums this issue up very well. Transplantation is an amazing feat of human healthcare and proof that
humanity understands the human body on deep level. But once we start to discuss the issues and
morality and ethics of the act, we find ourselves in a pit of questions, which are hard to answer.
There have been a lot of studies and opinions shared on this matter, however, the notion I received
from my findings is that the western world is moving forward in creating a system, which puts the
patient and their safety at the first place. The notion of trying to limit or exclude the money and
not to discriminate, yet motivate potential donors is in my opinion beneficial. I had no idea or
previous understanding of this topic and therefore I decided to dive into the problems and compile
them in one place, rather than try to focus on contradicting points of the argument, when I know
there are no things, which are inherently right or wrong, simply there are opinions of people and
people have opinion on everything, even though they do not know anything about the subject.














References

Kierans, C., & Cooper, J. (2011). Organ donation, genetics, race and culture: The making of a
medical problem. Anthropology Today, 27(6), 11–14. http://www.jstor.org/stable/41320231

Capron, A. M. (2014). SIX DECADES OF ORGAN DONATION AND THE CHALLENGES THAT SHIFTING THE UNITED
STATES TO A MARKET SYSTEM WOULD CREATE AROUND THE WORLD. Law and Contemporary Problems, 77(3),
25–69. http://www.jstor.org/stable/24244703

Benedict, J. L. (2017). International Library of Ethics, Law, and the New Medicine 126 (1st ed.,
Vol. 2017). Springer International Publishing.

Taylor-Alexander, S. (2014). On Face Transplantation: Life and Ethics in Experimental Biomedicine
(1st ed., Vol. 2017). Palgrave Macmillan.

Jensen, S. J., (2011). The Ethics of Organ Transplantation: Life and Ethics in Experimental
Biomedicine (1st ed., Vol. 2017). The Catholic University of America Press.