Public Solicitation of Organ Donors
【关键词】 Solicitation,
During the past half-century, organ donation has been fertile territory for both extraordinary compassion and complex ethical questions. As transplantation has become safer and outcomes have improved, the rules for donation and the fair allocation of organs have struggled to keep pace.
In 2004, there were about 27,000 solid-organ transplantations in the United States ― nearly 1600 more than there had been in 2003. Yet the demand for organs remains far greater than the supply. As of July 2005, there were about 89,000 people on waiting lists. For the largest group ― the 62,500 patients awaiting kidneys ― the expectation is that only about a quarter of them will receive a transplant within the next year. Greater public awareness of the organ shortage could lead to more donations, but doubts about the safety of donation by living persons and the integrity of the allocation process can jeopardize public trust. In January 2002, a donor died after giving a portion of his liver to his brother at Mount Sinai Medical Center in New York. Subsequently, the number of liver transplantations involving living donors in the United States ― which had increased from 395 in 2000 to 518 in 2001 ― decreased to 362 in 2002 and about 320 each in 2003 and 2004.
During the past year, a passionate controversy has developed about the public solicitation of organs, which takes place over the Internet, on billboards, and through other advertising. This is a complex matter, as discussed by Truog in this issue of the Journal (pages 444 446). Until recently, it was exceedingly rare for a kidney to be transplanted from a donor who was unknown to the recipient or whose blood or tissue was not compatible with the recipient's. Solicitation arouses concern about the potential for financial exploitation, the inequitable allocation of organs, and the subversion of the standards for donation. Federal regulations authorize directed donation, which is defined as "the allocation of an organ to a recipient named by those authorized to make the donation." Thus, soliciting organs from a living or dead donor is not unlawful, although the National Organ Transplant Act of 1984 prohibits the transfer "of any human organ for valuable consideration for use in a human transplantation if the transfer affects interstate commerce." Reasonable payments are permitted for the costs of organ procurement and storage and for the expenses incurred by living donors ― in travel, housing, and lost wages.
In August 2004, a 32-year-old Houston man with liver cancer received a directed liver donation from a deceased donor after he advertised in newspapers, on a Web site (www.toddneedsaliver.com), and on two highway billboards, and his story had been widely publicized. He died in April 2005, eight months after the transplantation. His controversial campaign might have encouraged a donation that would not have occurred otherwise ― or diverted a liver from someone with a greater chance for long-term survival.
Further controversy surrounds MatchingDonors.com. On its Web site, the organization, which is based in the Boston area, describes itself as "a venue where patients and potential donors can meet and communicate, and hopefully expedite a donor agreeing to give a patient a much needed organ." It states that the organization "is a nonprofit corporation and 100% of the money paid for patient memberships is applied to running this site." Potential recipients pay a one-time fee of $595 or a monthly fee of $295 to be listed, but about 70 percent of the 65 patients with active profiles are being listed without charge, according to Dr. Jeremiah Lowney, the organization's medical director and cofounder. There is no inherent reason why it should matter whether a living donor meets his or her intended recipient at work or a place of worship, online, or in some other way. But the involvement of a commercial entity has been criticized.
Since MatchingDonors.com was launched in February 2004, it has paired about 30 living organ donors and recipients. As of July 1, 2005, 12 transplantations had taken place, all of them of kidneys. There was wide media coverage of the first of these transplantations, which occurred at a Denver hospital in October 2004. The recipient, who had been seeking a kidney for five years, said that he had not paid for the kidney but had reimbursed the donor about $5,000 for expenses. The week after the transplantation, the donor was jailed in Tennessee for failure to pay child support. In March 2005, he took ― and was said to have failed ― a televised polygraph test, during which he was asked if he had profited from the transplantation.1
Although the public solicitation of organs has been a factor in very few transplantations, the transplantation of kidneys from living donors is increasingly common. The United Network for Organ Sharing, a private, nonprofit organization based in Richmond, Virginia, operates the Organ Procurement and Transplantation Network (OPTN) under contract with the federal government. The networks share the same board of directors and are collectively known as OPTN/UNOS. At a public hearing held in Chicago in June, Dr. Francis L. Delmonico, a Boston transplantation surgeon who is president of OPTN/UNOS, noted that "anyone can be a live kidney donor who is medically and psychosocially suitable. It is no longer the case that one has to be HLA-matched. The outcome for a friend, spouse, or anonymous donor is just as good as that from a parent or child." Transplantation of a kidney from a living donor, however, remains a major surgical procedure with attendant risks and complications, as discussed by Ingelfinger in this issue of the Journal (pages 447 449). In addition, until recently, the presence of preformed antibodies against HLA antigens or incompatibility with respect to ABO blood type has generally ruled out intended donors.2
Since 2000, there have been more living kidney donors than cadaveric donors in the United States, although kidneys from cadavers ― because both kidneys are usually available ― still account for about 60 percent of kidney transplants (see line graph). Nearly two thirds of living donors are related to their recipients by blood (see pie chart). Those without a blood relationship are most commonly spouses or others who have a previous personal relationship with the recipient that is unrelated to the person's need for a transplant. In 2004, 85 people received a kidney through anonymous donation, in which a volunteer approached a transplantation center with no knowledge of a specific recipient. In the same year, 30 people received a kidney through paired exchange, in which two donors provided a kidney to each other's intended recipients because both had been found to be incompatible with the recipient to whom they had wished to donate.
Kidney Transplantations in the United States, 1988 2004.
Data are from the Organ Procurement and Transplantation Network.
Relationships between Living Kidney Donors and Transplant Recipients in the United States, 2004.
Data are from the Organ Procurement and Transplantation Network.
The OPTN receives the majority of its funding from a one-time computer registration fee of $459, which is assessed when a transplantation center accepts a candidate for a transplant from a deceased donor or when a person who had not been on the waiting list receives a transplant from a living donor. Historically, consistent with its federal charge, the OPTN has focused on transplants from deceased donors. Donation by living persons was less common and usually involved people who knew each other. Such donation has primarily been the responsibility of individual transplantation centers.
Now, the OPTN is taking an active role in transplantation from living donors. In October 2004, the Department of Health and Human Services directed it to develop voluntary-allocation guidelines for organ donations from living donors that are made to an anonymous pool, not to specific patients, and other voluntary policies and guidelines as "it believes necessary and appropriate to promote the safety and efficacy of living donor transplantation for the donor and the recipient."3 The responsibilities include the development of guidelines about the public solicitation of organ donors. In November 2004, OPTN/UNOS announced its opposition to the solicitation of organs from deceased donors who had no personal or family bond with the patient.4 According to Delmonico, such solicitations "can undermine the allocation system and prevent the best medical use of the organ."
In June 2005, OPTN/UNOS announced that it "will not participate in efforts to solicit living donors for specific transplant candidates."5 Specifically, it will not create a Web site similar to MatchingDonors.com. OPTN/UNOS will, however, "provide comprehensive resource information to support prospective live donors, including medical criteria for who can donate and individual transplant institutions' protocols for live unrelated donation."5
OPTN is establishing quality criteria and guidelines for living-donor kidney and liver programs. Programs must have staff with the requisite training and expertise to evaluate donors fully, to ensure that donations are voluntary, and to perform living-donor surgery. In addition, better data about the outcomes of living donors should be forthcoming. The OPTN is also working toward requiring that transplantation centers report within 72 hours the death of a living donor or the donor's need for organ transplantation. Finally, OPTN/UNOS will develop a nationwide mechanism for allocating organs from living donors who have not directed their donation to specific persons.5 The principles will be similar to those for allocating organs from cadaveric donors. Eventually, there might be a registry for altruistic kidney and liver donors, such as the National Marrow Donor Program, which lists volunteer marrow donors.
The controversy over the public solicitation of organs has forced the transplantation community to address a difficult issue and to reexamine its approach to living donors. As long as there is a profound organ shortage, the challenge of trying to help patients in need of transplants while upholding the integrity of the overall allocation system will not go away.
Source Information
Dr. Steinbrook is a national correspondent for the Journal.
References
Hartman T. Donor fails lie detector test on organ transplant. Rocky Mountain News. March 11, 2005:6A.
Delmonico FL. Exchanging kidneys -- advances in living-donor transplantation. N Engl J Med 2004;350:1812-1814.
Letter from Dr. James F. Burdick, director, Division of Transplantation, Healthcare Systems Bureau, Health Resources and Services Administration, Department of Health and Human Services, to Walter K. Graham, Executive Director, United Network for Organ Sharing, October 29, 2004.
OPTN/UNOS board opposes solicitation for deceased organ donation. Press release of the United Network for Organ Sharing, November 19, 2004. (Accessed July 14, 2005, at http://www.unos.org/news/newsDetail.asp?id=374.)
OPTN/UNOS board addresses information needs of potential living donors. Press release of the United Network for Organ Sharing, June 24, 2005. (Accessed July 14, 2005, at http://www.unos.org/news/newsDetail.asp?id=456.)
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