Prepared by; Bro. Lipson OFM Cap.
This article is Dedicated to our dear Bro. Jijin Davidson OFM cap
Organ donation and transplantation is one of the major concerns of our human society today. It presents indeed a wonderful medical solution for many patients who would otherwise die due to various types of organ failure. Most transplant programmes depend on cadaveric and living organ donation. However, the number of patients increases day by day all over the world due to the scarcity of the human organs. Organ donation and transplantation create a culture of life and love. Many religious and secular approaches justify organ donation and transplantation because it promotes life. The Catholic Church also favours it, especially in the encyclical Evangelium Vitae, which states that it is an act of virtue of charity. Thus it is clear that the whole process of organ donation and transplantation has a tremendous impact on our society. Living organ donation may have a positive influence on the social context where organ donors and recipients live. But at the same time, living organ donation reveals that donors can be exploited by middlemen and other persons involved in transplantation. Besides, transplantation is a complex technology and it affects socio-economic factors. Another aspect is the psychological dimension. Many reports show that charitable donation gives self-esteem to the donor, while coerced donation creates dissatisfaction to the donors. Consent procedures are easier in living organ donation than with cadaveric donation.
The paper aims at promoting organ donation and transplantation. The first section of the paper discusses the present state of organ donation and transplantation, the second section deals with the ethical issues related to organ donation and transplantation, and the final section is on promotion of organ donation and transplantation on the basis of the virtue of charity. For the ethical justification of living organ donation and transplantation, moral theologians hold the principle of totality and the principle of double effect. The paper tries to state that the approach of the virtue of charity may be considered as a viable ethical model for living organ donation and transplantation. It gives us an insight in the depths of human personhood and the benefits of solidarity in human societies. The main objective of this paper is a medical, legal, and moral theological appraisal of living organ donation and transplantation. In the light of the appraisal, we will propose the approach of the virtue of charity for the moral justification of living organ donation and transplantation.
1. THE PRESENT STATE OF ORGAN DONATION AND TRANSPLANTATION
The present state of organ donation and transplantation deals with different types of transplantation, different types donation, and the medical, moral, and legal problems connected with the practice of organ donation and transplantation.
1.1. DIFFERENT TYPES OF TRANSPLANTATION
Organ transplantation is both a life-extending and a life-saving medical procedure in which a whole or partial organ (or cells in cell therapy) from a deceased or living person is transplanted into another individual, replacing the recipient’s non-functioning organ with the donor’s functioning organ. There are four types of transplantation. They are auto grafts, isographs, homographs, and heterografts. The transplanted organ is often called ‘a graft’.
1.1.1. AUTO GRAFT
An auto graft is the transplanting of an organ or tissue in the same individual from one part of the body into another, such as when a burn victim has healthy skin grafted from one area of the body to the burned area. The morality of auto-grafts, e.g., of the skin, is simply to be judged from the total welfare of the person concerned. This includes, not only the bodily health but such things as psychic self assurance as in the case of cosmetic surgery.
An Isograft is the transplantation of organs or tissues between two genetically identical individuals, such as identical twins. Tissues can be successfully transplanted in identical twins and they would not be rejected since they are theoretically identical to the self; but sometimes they may be rejected because of changes caused by non-genetic factors such as viruses. The first twin kidney transplant was performed in 1954. With this transplantation, immunologic science was given an entirely new insight into the response of tissue from different individuals.
A homograft is the transplantation of an organ from one individual into another within the species which occurs when organs or tissues are donated from a deceased person. This is also known as ‘Allografts’. Kidneys, liver, heart, lung, small bowel, pancreas, and bone marrow are the most frequently transplanted organs. Others include cartilage, corneal tissue, portions of blood vessels, and tendons. The transplanted tissues or organs originate either from a living person or from a cadaver donor (deceased) to a living person.
A heterograft is the transfer of organs between individuals of different species, usually from animals to human beings. For example, a pig liver is transplanted into a human. This transplantation is also called as ‘Xenograft’. Harvesting from animals has always been considered as an option for organ transplantation, since the first attempts in 1906. Transplant physicians are especially interested in xenografts for clinical application because of the shortage of donor organs both from cadavers and from living donors. Moreover, scientists have attempted the transplantation of animal skin to human beings. For the time being, heterografts have not yet been successful in human recipients due to the lack of mechanism strong enough to prevent long lasting rejection.
1.2. DIFFERENT TYPES OF DONATION
Cadaveric and living organs are the two main sources for transplantation. The cadaveric donation includes related and unrelated donations. There are five types of living organ donations.
1.2.1. LIVING RELATED DONATION
It is the donation between genetically related. The basic types of donation were mother to son, brother to brother, father to son, and sister to brother in decreasing order. However, living related donations have certain limitations. The doctors at Christian Medical College Hospital, Vellore point out that certain “voluntary” related living donors are taken into the hospital without their proper consent. They were forced to donate their organs because of the compulsion of other members in their family. In such cases, the doctors simply cited medical reasons to give the donors a way out. It is observed that one can find emotional stress, blackmail and other ramifications among family members.
1.2.2. LIVING UNRELATED DONATION
It is the donation between non-genetic or non-emotional persons. There may be also emotionally related transplantations. Unrelated living paid donations have started in India due to the scarcity of living related donors. Efforts to enlarge the supply of organs included greater interest in the use of living donors. This resulted in an expansion of the kinds of live-donor transplants that surgeons were willing to perform; donors and recipients can be non-biologically related to each other.
1.2.3. CROSS- OVER TRANSPLANTATION
In renal transplantation certain donors cannot donate their organs to a particular recipient because of the ABO incompatibility and other problems with histocompatibility but without any ABO problem with other recipients. For instance, donor A cannot give a kidney to recipient A, but he/she can give it to recipient B. Similarly donor B cannot give kidney to recipient B, but he/she can donate to recipient A.
In this programme, an organ may be transplanted into a patient whose own organ still can help another patient on the waiting list. For example, when a patient needs a double-lung transplant, he/she may receive a combined heart-lung transplant because it is easier technically to include the donor heart with the transplant as opposed to just the lungs. In this situation, the healthy heart of the recipient can be transplanted into another recipient rather than being discarded. So the recipient of the lungs is both a donor (heart) and a recipient (lungs and heart).
1.2.5. INDIRECT LIVING ORGAN DONATION
The close relative of a recipient wants to donate his/her kidney to the donor. But this living related transplantation is not possible due to blood group incompatibility. The recipient is then placed higher on the waiting list, while the organ from the donor is added to the organ pool.
1.3. DONOR OPTIONS
A living donor is any person who voluntarily authorizes the removal of any of his/her human organs for therapeutic purpose. The sources of organs for transplantation are either from cadaver donors (persons who have just died) or from living donors. During, 1960s, organs came either from living donors (for kidneys) or from cadaver donors who were declared dead by the traditional cardiopulmonary criteria (non-heart-beating donors). In India, the preferred donors are the living relatives. If no related donor is available to give the required organ, the next option is a paid donor programme. The third option would be a cadaveric donor organ. In accepting someone as an organ donor the most crucial considerations are the seriousness of recipient’s need, the likelihood of avoiding serious complications for the donor and the quality of the donor’s consent.
1.3.1. LIVING RELATED DONATION
Apart from minor organs like blood, skin, bone and so on major organs like kidney, part of a liver etc. also can be donated by a person while living. Given the severe shortage of donated cadaver organs, relatives, especially parents, may feel compelled to donate. The donor must understand the risks and benefits of donation. Living organ donation is an ethical challenge for medicine because it involves subjecting the donor to some degree of harm. But it also promises significant benefit to organ recipients and, for donors who are eager to give, using them support their personal choices. If doctors also consider the psychological benefit to a donor from saving a loved one, or significantly improving a beloved’s quality of life, or avoiding the guilt of not trying to help, they recognize that donating an organ can be good to the donor. From this perspective, in context of the totality of what is being achieved, taking an organ from a living donor could be better than alternative.
Normal healthy individual can donate one of their kidneys or a part of another organ for transplantation. Because of the limited number of cadaver donors and increasing population of patients developing kidney failure each year, greater use is being made of kidneys from living donors. The best long term results of kidney transplantations are achieved with living donors. Blood group matching and size matching of the donor and recipient are very important. In most instances, living donors are either genetically related to the recipients or emotionally related, such as a spouse or close friend. Parent to child living donor liver donation began in the early 1990s and it has become common in major pediatric centers. Indian doctors are in favors of living related donors and argue that it is best suited to Indian society at the moment.
1.3.2. LIVING UNRELATED DONATION
Unrelated living paid donations have started in India due to the scarcity of living related donors. The unrelated living donor poses somewhat different issues. A donor may take the initiative in seeking out recipients for tissue or may respond to a request by a potential recipient. The motivations of such donors may be altruistic, financial, or obscure. In any case, extremes of self-sacrifice or of avidity for the benefit of others, no less than extremes of endangering others, raise questions about the mental health of the donor. Because unrelated donors raise psychological puzzles and are vulnerable to exploitation, most physicians are unwilling to use unrelated donors.
For several years India has been known as a ‘warehouse for kidneys, or a great organ market’. India is one of the main centres for kidney transplantation in the world because of the low costs and the immediate availability of organs. Rich people in India and those from the Gulf countries marry poor young girls from villages in India. Since the spouse is considered a near relative in Indian transplantation law. One partner can donate his/her kidney to the other partner. But the fact is that after the marriage, these young women are forced to donate one of their kidneys to their husbands whenever such a need arises. After the kidneys are taken, these men divorce their wives. Again, poor people sell their organs for small amounts of money.
1.3.3. CADAVERIC ORGAN DONATIONS
The removal of cadaveric organs for transplantation is not practised to any significant degree at any centre in India. Hindus form a majority in India. The rites to be observed after death include burning the intact body in the presence of the family. It is generally thought permissible for eyes to be removed, but society will not accept the removal of kidneys. It seems that crippled financial state of the health service, together with cultural and religious inhibitions surrounding the mystery of death stand in the way of initiatives towards cadaveric transplantation in the majority of Indian centres.
An ideal cadaver donor would be one who had been previously healthy, but who suffered death from irreversible damage to the brain. It is best when the donor arrives at the hospital while there is still respiration and heart beat. Transplants of organs from human cadavers meet with no objection provided certain precautions are observed. These have been very clearly exposed in the address of Pope Pius XII of May 14, 1956. First of all, a sense of relative dignity of a human corpse should be maintained. The rights and feelings of relatives are to be respected. Normally, permission is to be obtained from the next kin. The donation of organs after death may be encouraged, but intemperate propaganda amounting to moral compulsion should be avoided.
In 1993, the University of Pittsburgh initiated a protocol using non-heart beating cadavers as sources of organs. The protocol was this: if any individual was on a life support system and dying and elected to have the life support system removed, that individual could elect to be an organ donor. Non-heart beating donors fall into two categories: uncontrolled and controlled. Uncontrolled non-heart beating donors are those in whom death is sudden an unexpected without preparatory time to plan for organ removal. Controlled non-heart beating donors are those in whom death is planned event. The patient, with a hopeless prognosis, is going to have life support withdrawn because the patient and the next of kin wish to forgo any measures or interventions that prolong life.
Brain-dead donors are preferred for transplant rather than non-heart beating donors because they almost invariably provide better quality organs. When non-heart beating donors are used transplants are limited to tissues and kidneys, and sometimes the liver. By the time the heart has stopped beating and death is declared through the absence of pulse and respiration, other organs such as the heart and lungs are too damaged for transplant.
Today, many transplantation centres have started taking organ from brain death patients transplanting them into patients. For instance, in Kerala, under the leadership of Society of Organ Retrieval and Transplantation, arrangements are made to share organs from willing donors. There are many hospitals in Kerala, which have the faculty to conduct transplant surgeries. At present inter-hospital transfer of organs is possible in Kerala and in future it will be a great help to a large number of patients in the country.
1.4. MEDICAL ASPECTS OF ORGAN DONATION AND TRANSPLANTATION
Here we discuss only the medical aspect of living organ donation and transplantation because cadaveric donation has no surgical risks. Living organ donation has advantages from an immunological point of view because there is often large degree of similarity between the tissue types of the donor and the recipient. However, we cannot fully avoid the risks to donors and recipients.
Organ transplantation has come far from the day in 1954 when doctors at the Peter Bent Brigham Hospital in Boston performed the first successful kidney transplantation. Great strides in the understanding of the immunological system and its medical manipulation have made the transplantation of major organs a common event. The solid organs are kidney, heart, lung, pancreas, liver; bone marrow is also transplanted. The success rates, in terms of survival of grafts, survival of patient and subsequent quality of life, though variable from organ to organ, are reaching the point where these procedures are considered “accepted and standard therapy” for diseases that destroy major organ function and lead to death. Thus, it is clear that organ transplantation is well established. Its science will progress and, in all probability, will show even greater prospects for success and will prompt even greater boldness. Yet, in spite of all this progress, most people are aware of the difficulties surrounding organ transplants. Problems such as the cost of the procedure and the rate of rejection as well as the side-effects of the drugs used to prevent rejection are frequently discussed in the daily news. But problem that receives the most attention continues to be the shortage of such organs for transplantation. In spite of media blitzes, public education campaigns, and legislation making such donation easier, not nearly enough organs are donated to meet the increasing demand. In 1991, for example, nearly 24,000 patients were awaiting organ transplantation in the United States.
Among the organs available currently for tissue transplantation are kidney, heart, liver, pancreas, the Islet cells of the pancreas, and skin. Since an organ is a living system, it needs to be preserved in a viable condition before transplantation. Transplantation specialists readily admit that there are problems in tissue preservation that they have not yet adequately resolved, keeping cells or tissues at deep-freeze temperatures preserves them because it greatly diminishes their need for oxygen. For this reason, adult human organs like kidneys or hearts cannot be preserved in a viable state by deep freezing techniques. For the present, the best method of preserving the organs involves perfusing them that is, circulating through the blood vessels of the organs a fluid which is rich in certain electrolytes and is kept at a low temperature but above freezing. Another concern regarding organ transplantation has to do with what is called histo-compatibility, the ability of one living organism to accept tissues from another. An organ belonging to one individual is foreign organ relative to another, and if introduced into that person’s body it automatically will be rejected. Without some way of controlling the rejection, a transplanted organ will not be accepted by the recipient’s body. There have been developed several drugs which have the property of what is called “immunosuppression”, that is to say, these drugs suppress the body’s immune reaction which would otherwise reject organ as foreign invader. Another manner of reducing tissue rejection is by obtaining an organ from a person who is genetically close to recipient.
Today one can find more positive attitude towards living organ donation. It is noted that in the case of living organ donor, mortality after surgery is extremely law. For instance, a survey of U.S. kidney transplants shows that there are only five donor deaths in 19,368 live kidney transplants. Patients who decide to undergo transplantation are subject to normal surgical risks. There are also complications of urological and vascular problems, especially with regard to kidney transplantation. Besides, transplantation affects the recipient body’s structure. The main benefit to the recipient is that he/she gets a new lease of life or even a better quality of life.
1.5. LEGAL ASPECTS OF ORGAN DONATION AND TRANSPLANTATION
To understand the practice of living organ donation and transplantation in a wider perspective, we have to depend on its medical developments and legal aspects. Regarding the medical developments, the relative reduction in cadaver-organ donation has led to the necessity for a number of groups and countries to re-evaluate the need for live donation. The potential advantages of living kidney transplantation are improved with long term results. These results of live donation arc impressive with developing techniques. Consequently, out of these medical developments arise many bioethical issues. Hence, the formulations of laws are necessary to govern the area of living donor transplantation. In some countries, where legal or cultural barriers still exist, the development of living-non-related organ transplantation has occurred. Illegal medical practice related to transplantation, and commercialization of human organs has prompted many countries to formulate transplantation laws. The laws enacted to regulate organ transplantation vary with jurisdictions around the world. They generally cater to definitions of death, donor consent, and, often, the prohibition of the commercial trade in organs. The laws in most North American, Asian, and European countries permit organ removal when the patient is pronounced dead. These laws most commonly define death as the irreversible cessation of the entire brain function, although Japanese law allows the individual while living to choose between the cardiac- and brain-based definitions of death according to his or her beliefs. The laws in most countries require donor consent to organ donation. The Uniform Anatomical Gift Act (USA) and the Human Tissue Gift Act (Canada) each require an individual’s express consent to the removal of his or her organs after death.
Transplantation laws can be divided into three groups such as opting-out, opting-in, and required request. 1) According to the opting-out system, every human being will be considered a possible donor after death unless he/she has officially expressed a contrary option. It is also known as presumed consent. 2) By opting-in we mean a process by which people voluntarily sign and submit a will saying that they want to become donors once they are dead. If they do not do this, they will not be legally considered donors. 3) The required request law requires hospitals to ask the family of a deceased patient for a donation of organs and tissue if the deceased is a suitable candidate for organ donation. Some countries have adopted a so called “opt-in” solution. In this case, explicit informed consent by the deceased person before death is required (by carrying an organ donor card, a written statement, a notice in the driver license etc.). Other countries foster a combination of individual consent and proxy consent, the latter being a substitute for the former. This means that family members can ensure the deceased person’s will is observed. In contrast, the “opt-out” solution is based on the idea that everyone counts as potential organ donor and dissenters have to explicitly state their will (e.g., by registering in a data bank, or by personal communication). In both the opt-in and opt-out systems, individuals have the freedom of choice.
Federal law defines the terms of exchange in organ donation. It is against federal law to buy or sell human organs and tissues. Organ and tissue donation requires explicit consent from the donor’s family or a signed donor card. An alternative system exists and is called “presumed consent”. This system reverses the burden of proof regarding family permission. Under it, if a family does not express an objection to organ donation, their permission is presumed. Certainly some nations do not actually procure organs under these laws but insist on obtaining explicit permission from families. Specific laws covering living organ and tissue donors vary greatly between countries. In the United States the chief law addressing organ donation is “The National Organ Transplant Act of 1984 (NOTA). NOTA established the Organ Procurement and Transplantation Net work (OPTN), which is responsible for maintaining a national registry for organ matching, increasing the effectiveness and efficiency of organ sharing and equity in the national system of organ allocation, and increasing the supply of donated organs available for transplantation. A number of international organizations have adopted policies on human organ transplantation that include specific guidelines for living donors, e.g., The World Health Organization (WHO). According to WHO, the human body and its parts cannot be the subject of commercial transactions. Accordingly, giving or receiving payment (including any other compensation or reward) for organs should be prohibited. The World Medical Association’s “Statement on Human Organ and Tissue Donation and Transplantation” states that in the case of living donors, special efforts should be made to ensure that the choice about donation is free of coercion and persons incapable of making informed decisions should be donors in only very limited circumstances. The clauses of the laws are made on the basis of medical, ethical, religious, social and cultural considerations.
In India, the Transplantation of the Human Organ Act of 1994 came into force on February 4, 1995. Some of the states of India had different transplant acts previous to the enactment of this new law. The new law prohibits trade in human organs and addresses the donor’s right, the adequate supply of organs to the needy, the optimization of transplantation costs and the promotion of transplantation procedures. Indian transplantation law allows organ donation from an unrelated person for reasons of affection, attachment, or any other special reasons.
2. ETHICAL ISSUES IN ORGAN DONATION AND TRANSPLANTATION
The practices of organ donation and transplantation raise many ethical questions. Here we discuss, how can we morally justify organ donation and transplantation? What are the ethical issues connected with the donor, the recipient, and xenotransplantation?
2.1. JUSTIFICATION OF ORGAN DONATION AND TRANSPLANTATION
The Catholic Church holds that the virtue of charity is the norm for the justification of cadaveric and living organ donation and transplantation. The other religions also support organ donation and transplantation even if their point of emphasis is slightly different. Let us have a look at the justification of organ donation and transplantation in Christianity and in other religions.
2.1.1. IN CHRISTIANITY
The Catholic Church views organ and tissue donation as an act of charity and love. Pope Pius XII in his address to ophthalmologists in 1956 states that acts of donation cannot be viewed as a duty or as obligatory. Such acts are supererogatory and not obligatory. Moreover, Pope John Paul II justified organ donation and transplantation based on charity in general. He writes in Evangelium Vitae no: 86 that organ donation is an act of love when it is done in an ethical manner. Pope John Paul I who, in addressing the 7th International Congress of the Organ Transplant Society meeting in Rome, September 1978, stated that the whole problem is to act with respect for the person and for one’s neighbours, whether it is a question of donors of organs or beneficiaries, and never to transform man into an object of experiment.
The catechism of the Catholic Church states that it is not morally admissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons. Pope John Paul II in 1991, to a group on Organ Transplants, stated that a person can only donate that of which he can deprive himself without serious danger or harm to his own life or personal identity, and for a just and proportionate reason. It is obvious that vital organs can only be donated after death. In Evangelium Vitae no: 15, Pope stated that when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor. From the above statements it is cleared that unity of the body is present until excision of organs. So if the separation of the body and life cannot be verified or if there is doubt about the separation of the body and life, organ excision is morally prohibited and should not be allowed.
The church holds that “to take tissue from a live foetus for transplantation is unethical.” According to Catholic perspective, donors can donate organs except the brain and reproductive organs. Neither the brain nor the reproductive organs may be procured from human beings or animals for transplant into a human person. The Catholic Church is against paid organ donation. Paid organ donation spoils the spirit of altruism. In paid donation, one does not fully respect the other. Catholic theology insists that the human person is both individual and social. Organ transplantation is morally right, but this is because it contributes to and is keeping with the created and saved dignity of the donor as well as that of the recipient.
2.1.2. IN OTHER RELIGIONS
Organ and tissue donation is viewed as an act of neighbourly love and charity by various religious groups. They encourage all members to support donation as a way of helping others. Buddhists believe that organ and tissue donation is a matter of individual conscience and they place high value on acts of compassion. Rev. Gyomay Masao, president and founder of the Buddhist Temple of Chicago said, “We honor those people who donate their bodies and organs to the advancement of medical science and to save lives.” Jewish thought poses a more serious question because in Judaism there are religious obligations to bury the dead with organs intact. However, this obligation is superseded when a cadaver organ can be removed for the purpose of saving a life of another identified person in need. Similarly, from the Greek Orthodox Church, Stanley S. Harakas writes about the donation of kidney. Organ donation rescues the life of another person as a loving act of mercy. The donor is to be commended if he perceives his sacrifice not as a violation of his bodily integrity, but as a gracious and loving unselfish act. Based on several passages from Quran and Hadith (the Prophet Mohammed’s sayings and examples), the Islamic Code of Medical Ethics upholds: ‘if the living are able to donate, then the dead are even more so; no harm will affect the cadaver if the heart, kidneys, eyes or arteries are taken to be put to good use in the living person. This is indeed charity. Organ donation and transplantation is acceptable also in Hindu tradition. Relatively little information is available about the medical-ethical views of the Sikhs that they also accept organ transplant.
2.2. PAID ORGAN DONATION
One of the main issues related to living organ donation and transplantation is the commercialization of human organs. The human body is becoming a commodity for profitable trade. The problems of organ trafficking and illegal organ trade have raised increased awareness among ethicists as well as international organizations. Those who criticize a free market of organs fear that this will seriously increase social injustice.
The main types of arguments in favour of commercialization can be grouped around four moral principles: a) Justice: it is unjust to let people die due to organ scarcity, b) Liberty: personal autonomy implies that one has the right to dispose of one’s body as one pleases, c) Beneficence and Utility: commercialization would lead to a win-win situation, both donors and recipients would likewise benefit from it, and d) Efficiency: a free market will make the system more efficient and solve the problem of demand. Though there are arguments in favour of the commercialization of human organs, there are at the same time other arguments against this practice. These tendencies and arguments can be criticized on the basis of nearly the same principles. So it is feared that a) the practice of paying money for organs will increase injustice because only the wealthy will then be able to afford an organ transplantation treatment, b) the autonomy of the poor will in fact be limited due to their lower social status and financial constraints, c) commercial donation will discourage altruistic donors and, consequently, the number of altruistic donations will seriously decrease, and d) the commodification of the human body ignores the existential meaning of the body for personal identity and self-understanding.
Recipients, too face problems in commercialization. Many recipients seek paid kidney transplants because of the scarcity of cadaveric organs. The problem is that recipients have no opportunity for the choice of the donor, and the cost is very high. In many cases, the purchased kidneys are rejected and patients face death because of other risks in transplantation. This creates a “feelings of guilt and remorse” both for the recipients and relatives. Moreover, there is also a serious problem of transmitting diseases from purchased kidneys, and many say that it is medically unsafe.
The paid donation can corrupt the medical profession. Medical judgments are made by market agencies. Commercialization also has an impact on the local community. The fixed price for body parts in market goes against the autonomy and the dignity of the human person, and this is also against religious and secular values. Commercialization affects the international community too. When one recipient knows that he/she cannot purchase a kidney in his/her country because of the transplantation laws, he/she may travel to other countries where he/she can purchase one. By doing this recipients violate legal and ethical standards in his/her own country. Clearly, there are differences in the ethical standards of different countries. R. C. Fox observes that commodification of the human body is the most serious argument against commerce.
The Catholic Church is against paid organ donation. Parts of the body are not to be treated as commodities. Trade in human body parts is unacceptable, as in any other disrespectful use of organs or tissues of a living or deceased person. At the World Congress of Transplantation Society, Pope John Paul II said “any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as ‘object’ is to violate the dignity of the human person.”
2.3. ETHICAL ISSUES CONNECTED WITH DONOR
An organ for transplantation must be taken from either a recently dead cadaver, or a living human donor, or a compatible animal. Taking organs from a cadaver violates certain traditional religious and social attitudes which require us to show respect for the dead by not mutilating the corpse. Taking an organ from a living donor violates the medical dictum, “Do no harm,” because it puts the donor at some risk of serious harm from anaesthesia, intra-operative complications and post-surgical complications. The procedure itself is also certain to harm the donor with disfigurement. Many people would agree that life preservation or significant life enhancement can justify overriding the moral imperatives that would otherwise prohibit disremembering corpses and harming healthy individuals. However, even though we may decide that, because of the significant good it achieves and the small risk of harm, organ transplantation can be morally acceptable practice. But we still have to answer many weighty ethical questions about removing organs. When is a human being dead? What other criteria must be met before organs can be taken from a corpse? Must family consent be obtained? Can cadaver organs be purchased from family of the deceased like other inherited property? When can a living donation be accepted? Etc. Thus here we discuss the ethical issues related to the living and the cadaveric donor.
2.3.1. THE LIVING DONOR
In many countries, donating living organs is seen as an important alternative to cadaveric donation. Depending on legal regulations and cultural attitudes, the frequency of living organ donation ranges from 20% to 90% of all organ donations. Close family members, spouses, friends, or sometimes even strangers are considered as possible living organ donors. While living organ donation largely benefits the recipients, the donors’ risks include severe health problems or even death. While living donors were initially limited to blood relatives to reduce the risk of immune rejection, improved immunotherapy has expanded the pool of potential donors far outside of those related by blood, to those who are emotionally related to each other. This has resulted in expanding the notion of ‘relatedness’ to include people related by marriage as well as those who are not traditionally considered relatives- friends, co-workers, members of the same community, such as so called Good Samaritans. The main ethical concerns related to living organ donation include functional integrity and the consent of the donor.
22.214.171.124. FUNCTIONAL INTEGRITY
The donor does have the responsibility of maintaining the functional integrity of his/her body, if not anatomical. The donor certainly cannot give an unpaired organ, such as heart, which will most certainly result in death. This would be equivalent to suicide. Hence in the case of paired organs, he/she may give one kidney providing the other kidney is healthy and able to maintain adequate kidney function for him/her. Although there has been loss of anatomical integrity, functional integrity has been retained. We have to understand the difference between anatomical integrity and functional integrity. The former refers to the material or physical integrity of the human body and the latter to the systematic efficiency of the human body.
From the medical perspective, the principle of totality would mean ‘all the parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body.’ Theologians have seen the principle of totality related to functional integrity. B.M Ashley and K. D. O’Rourke present their own formulation of the principle of totality and call it the principle of ‘Totality and Integrity.’ It reads as follows: ‘except to save life itself, the fundamental functional capacities which constitute the human person should not be destroyed, but preserved, developed, and used for the good of the whole person and of the community.’ On the one side this principle grants priority for some human values over others. On the other side, it breaks the ‘fundamental integrity’ of human person for certain kind of worth, except in the most extreme choice between life and death.
Pope Pius XII, in his allocution of September 13, 1952, to Histo-pathologists, after having stated that man has not an unlimited power over his body, affirmed: ‘In virtue of the principle of totality, of his right to employ the services of the organism, as a whole, he can give individual parts to destruction or mutilation when and to the extent that it is necessary for the good of his being as a whole.’ Here the intention of the Pope was to exclude indiscriminate mutilation for the sake of experimentation. He particularly wanted to reprove the idea that an individual person is only a part of the society and hence his bodily integrity is to be wholly subordinated to the good of the entire society.
One of the major ethical issues in the organ transplantation was the ethical decision concerning the removal of a healthy organ from a normal person for the benefit of someone else. For the first time in surgical history, a normal, healthy person was to be subjected to a major surgical operation for the benefit of someone else. This problem was resolved by arguing for the primacy of love or charity over the value of the physical integrity of the body. The donation of an organ, when it does not involve loss of an important function or does not gravely endanger the personal fulfilment that comes from the sacrifice for the sake of others. Organ transplants from the living donors could be justified, not by the principle of totality, but by the so-called principle of charity. This was not a very accurate way of speaking since charity or love is the comprehensive value that determines the entire moral activity, not merely a few isolated cases. So, gradually, it became clear that the principle of totality would have to be expanded to include, not only somatic good of the human organism but his spiritual well being as well. Thus, for instance, the donation of an organ for transplantation would be motivated by sacrifice for another which would result in the spiritual fulfilment of the donor.
126.96.36.199. INFORMED CONSENT OF THE DONOR
Autonomous donor consent is a basic consideration in taking an organ from a donor because it would be an assault and battery to take an organ from someone without his or her consent. Furthermore, in the light of the clear harms that will be done, without the person declaring that the donation would be an overall good there is usually no reason to presume that it is. Since respect for autonomy is one of the most crucial moral imperatives, cooperating with someone’s autonomous choice to give provides a primary reason for accepting her or him as an organ donor. So donor consent, informed and un-coerced, must always be had coercion can occur in many ways, but special attention and care need to be given to environmental and parental coercion, to the coercion subtly associated with any commercial exchange. Organ donation on the part of those incapable of informed consent is unethical, unless it can be successfully established that the death of the threatened recipient would visit grave psychological harm on the prospective donor. Hence conscientious surgeons will refuse to take an organ from a mentally weak person. He will be reluctant to take one from an adolescent or a prisoner since the freedom of choice may not be sufficiently perfect in them. The donor and his family should be fully informed about all the risks involved and the benefit that may be reasonably expected for the receiver. Pressure from the relatives through the prospect of guilt or censure must be noted.
One special difficulty may arise when the prospective donor is a brother, sister, close relative of the recipient, and is reluctant to undergo the procedure. Because of the pressure placed on such a potential donor, it is questionable whether a truly free consent can be given. He or she may know the medical consequences and risks involved in the donation and may be very fearful of going through with it. If the donor individual is married, it may well be that the spouse objects to the donation. Consequently, every effort must be made to make sure that undue pressure is not placed on the potential donor. This requires that the family situation be carefully weighed by those involved in the organ transplantation process before a donor is solicited.
In short, informed consent of the person donating the organ and benefit to the life or health of the person receiving the transplant are required. Blessed Pope John Paul II says that organ donation is a free and conscious decision either on the part of the donor, or of someone who legitimately represents the donor. It is also a decision of giving without any remuneration. Really, donation concerns the well being of another person.
2.3.2. CADAVERIC ORGAN DONATION
The ethical considerations surrounding transplants vary depending on whether the source of the transplanted organ is a cadaver or a living donor. Where the use of cadavers is concerned, no substantial objection has emerged from various philosophical or religious traditions. Most ethical concern about transplants from cadavers has centred on three issues: the need for appropriate consent, the determination of certain death when vital organs are involved, and the insistence that the benefit to the recipients be in proportion to the hazards of the procedure. Here we mainly discuss the ethical issues include the concept of brain death, and consent.
188.8.131.52. BRAIN DEATH
People can donate organs after their death too. A person is dead when he has irreversibly lost all capacity to integrate and coordinate the physical and mental functions of the body. The one immutable medical criterion for organ donation has been brain death, or more exactly, the determination of death by brain-death criteria.
With the need for cadaver donors has come a redefinition of death itself. Within the medical world itself, there has been a widespread ethical concern about the determination of death for the cadaver donor, and most medical centres have formulated careful guidelines to redefine death in accord with new medical standards. In the past conventional definitions of death had depended on cessation of heart action, but such a definition has threatened to encumber transplant technology by “unnecessarily” ruining the relevant organ. When the heart and the circulation of blood stop, the kidney or other organs can be badly damaged. Under the leadership of Beecher at Harvard Medical School a new concept of brain death has been carefully defined. Utilizing specific signs and tests, physicians can declare death before the heart has stopped beating, and the circulatory system can be maintained until the time the organ is removed from the body. Brain-dead donors, with the assistance of a ventilator, have oxygen circulating in their blood, which maintains the usefulness of organs for transplant.
Death is a biological event based on the permanent cessation of brain or cardio circulatory function. However, there are also social, legal, and cultural factors impacting on its determination. In medicine and law, the separation between being alive and dead cannot be ambiguous. It marks the point in time after which consequences occur, including no legal or medical requirement to provide resuscitation or life support technologies, loss of personhood and most individual rights, the opportunity for organ donation and autopsy proceedings, execution of the decedent’s legal will, estate and property transfer, payment of life insurance, final disposition of the body by burial or cremation, and of course religious or social ceremonies to mark the end of a life. At present brain death is legally and ethically been accepted for the procurement of vital organs for transplantation.
184.108.40.206. CONSENT OF THE DONOR OR THE LEGAL GUARDIAN
In cases of morally acceptable organ donation it is necessary to have obtained prior release from the donor if a signed statement indicating that the donor is willing to give his organs after the death is ideal. On the legal level, the Uniform Anatomical Gift Act, which has passed in all fifty states, does provide for such a pre-death determination to be made. A number of states offer applicants for a driver’s license the opportunity to indicate their determination to be organ donors. Such a declaration is then entered on the back of the driver’s license. If a donor release a document is not available, then necessary consent must be obtained from the next of kin.
In fact, the problems of the heart transplantation are largely the problems of the donor and his family. The position of the relatives of a possible donor is very difficult. They are likely to be in a state of shock because of the accident or illness that has created a potential donor. The donor may be treated as a source of supply rather than as a patient. He may be moved to a hospital more convenient for the operation. The relatives are being asked to anticipate or even to participate in the death of the donor because the donor must be dead and he surgeon wants his heart as fresh as possible. Until recently it was nearly always aimed at discovering when one ought to cease defence of life. Now it is asked to determine when one may profit from death. Heart transplants can involve divided loyalty on the part of the physician. Accident victims can be immediately treated as potential heart donors rather than as present stroke victims.
The deceased are treated with proper dignity, i.e., not treated as mere things and that proper consent is obtained either before death or by legal custodian. The Catholic Church says that organs and tissues may be removed from a deceased person who has bequeathed them verbally or in writing or in the absence of such clear expression of the deceased person’s will, with permission of the family. Even in the face of a clear expression by deceased of intent to donate organs at death Catholic facilities should always take into account the wishes of those grieving the person’s death and seek to ensure that sufficient time and information have been given them to comprehend the situation before proceeding.
2.4. EHTICAL ISSUES CONNECTED WITH THE RECIPIENT
Problems associated with the recipient are, in a sense, less acute since it is the recipient who is going to benefit by the process. One decision that needs to be made is whether the intended transplantation procedure truly offers some benefit to the individual. The process of transplantation is not without risk itself and the benefits and risk must be weighed in this situation. The proper informed consent needs to be obtained from the recipient as well. There should be a proportionate relation between physical risk to the donor and good for the recipient. The risk I donation as “an act of charity is proportionate to the good resulting for the recipient. CCC no. 2296 states:
Organ transplants confirm with the moral law and can be meritorious if the physical or psychological dangers and risks incurred by the donor are proportionate to the good sought for the recipient. It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.
A relatively sticky problem arises when there are multiple recipients for a single organ. The medical facts must first be determined. Which potential recipient, for example, has the greatest chance of accepting the organ by virtue of tissue compatibility? The issue of recipient selection from a group has been discussed widely. Should social criteria be a factor? Should age, need, or some other fact be involved in the determination of which recipient gets the organ? Would it be proper for a young and otherwise healthy man or woman who has great promise for the future to be preferred over an older individual who is a chronic alcoholic and has relatively little to offer society? Should a mayor of a city, governor of a state, a general, ambassador, or bishop be preferred over someone who is relatively a social nonentity?
Pragmatic reasons cannot be allowed to dominate. As a consequence, some have suggested a lottery method so that the selection among the candidates who are medically and approximately equal would be equitable. Only clinical factors such as urgency, need and ability to benefit should be taken into account. The general principle that surgery cannot be carried out without the consent of the person to be operated upon is equally applicable to organ transplantation as well. Recipients also should give their consent for the operation. The physician should inform the donor and the recipient in an honest, appropriate, and comprehensive manner of the possible risks of organ donation and transplantation.
Along with the measures taken to increase the number of human donor organs, the 1990s brought a surge of renewed interest in Xenotransplantation. It is the grafting of animal organs, tissues, and cell into human beings. The special characteristics of non-human tissue (e.g., bone marrow from baboons because of their HIV resistance) and the promise of increased organ supply makes the option of using tissue and organs from animals appealing. Preliminary experiments on animals and adequate precautions must be adopted before proceeding with such transplantation. The question of possible ‘brutalization,’ i.e., the fear of the receiver losing human characteristics, has been raised, but in the operation so far carried out, such fears have not been raised. However, the transplantation of sexual glands from the animals to man would seem to be immoral. As sex hormones have a very strong influence on the whole organism and personality, the animal glands are likely to produce undesirable changes of personality.
Xenotransplantation research seeks to address three major problems: (1) the immunological rejection of animal tissue and organs is a complex biological response of the human body and can result in non-function of the xenograft. In addition, (2) the physiological and anatomical compatibility of animal organs has to be ensured in order to guarantee organ function over an acceptable period of time. Moreover, (3) the risk of transferring animal pathogens (such as viruses, bacteria, or fungi) from graft to host must be minimized. However, Xenotransplantation is permissible provided the procedure will not impair the integrity of the recipient nor impose inordinate risks on the recipient or others. With regard to animal-human hybridization, the Church says that “the introduction of parts of the human genome into animal tissue or vice versa must not involve extensive animal-human hybridization, inheritable changes to a human being, or the formation of an organism possessing some human and some animal material which may be capable of further development as an embryo.”
3. PROMOTION OF ORGAN DONATION AND TRANSPLANTATION
We have seen in the last section the ethical issues related to organ donation and transplantation. The virtue of charity is an important element in promoting organ donation. This kind of value education can be imparted both by religious groups and by secular agencies. Man is a social being destined to live, not as a hermit, but as a member of society. In order to perfect his nature man stands in need of his fellow men. He requires their cooperation to provide for his physical, intellectual and spiritual needs. He can render such assistance in very many ways, one of which might be to sacrifice his own body for the sake of another. To overcome the shortage of cadaveric organs, many transplant units around the world have started using organs from living donors. Living organ donations and transplantations save and improve the lives of patients and as such, may be considered the highest form of loving and giving or caring for another. Organ donation is a form of self-sacrifice in the sense that it is the self-giving of a person to another person from his/her own body. This sort of self-sacrifice is the ultimate gift one can offer for another. Donating one’s own organs to others is a clear sign of acceptance and recognition of others, and a profound way of practicing charity.
There are many positive aspects in living organ donation and transplantation. The main advantage to the recipient is that he/she gets a new life. The living donor based on charity helps the recipient who is in a critical stage. Due to the scarcity of human organs, living donors supply organs like kidneys for transplantation. This is really due to the social concern of the living donors. In this perspective, donation is a mark of social solidarity with the community. Donating an organ leads to a positive self-assessment. A donor saves the life of another person which, in turn, gives a sense of fulfilment to the donor himself/herself. Another merit is that living organ donors get psychological and spiritual satisfaction. Many argue that though a donor faces risks, he/she also receives spiritual good. Psychological studies indicate that living organ donation increases the self-esteem of the donors.
3.1. FOUR TRADITIONAL PRINCIPLES OF MEDICAL ETHICS
Within the medical tradition and ethical reflections, surrounding its practices, four principles have been appeared and have to been isolated over all time. They are: 1) Principle of Justice, 2) Principle of Beneficence, 3) Principle of Non-maleficence and 4) Principle of Autonomy. Each these principles has the status of moral duty. So they cannot be essentially linked to the feelings of charity, friendliness and mercy. Tom Beauchamp and James Childress suggest these four principles.
3.1.1. THE PRINCIPLE OF AUTONOMY
The concept of autonomy in moral philosophy and bioethics recognizes the human capacity for self-determination, and puts forward a principle that the autonomy of persons ought to be respected. This means the will of the patient is the law. The reasons were a)the good offered by the physician is no longer universal; b) the growing maturity of the patient population; c) medicine is inexact science both in diagnosis and therapy; d) the secularization that has brought out the fact that the general norms such as ‘the preservation of life at any cost is relativized. The most important bioethical rule to fall under the principle of respect for autonomy is the requirement for the informed consent of patients before health professionals intervene in their bodies. Health professionals must disclose to a patient the various possible courses of treatment for his/her condition and their likely outcomes. They must let the patient understands this information; they must let make the patient make the decision for himself/herself, so that he/she directs his/her medical care in the light of his/her own values and preferences.
3.1.2. THE PRINCIPLE OF NON-MALEFICENCE
This principle demands in the first place “Do no harm.” The requirement is that health professionals not intentionally harm their patients. This principle encodes the ancient medical dictum, primum non nocere (do no harm). Because there are many different kinds of harm, the principle of non-maleficence supports many different rules, such as: “Do not intentionally kill a patient,” and “do not intentionally cause a patient unnecessary pain or suffering.” This principle could, for example, require that treatment of a patient cease when it becomes a burden to him/her., even if that cessation hastens his/her death. This principle also plays an important role in research ethics, for it prohibits experimentation that is likely to harm subjects, even when they consent to it. It cannot be universally applicable, because it is not simple possible in every case to avoid pain in every treatment to avoid all harm.
3.1.3. THE PRINCIPLE OF BENEFICENCE
Beneficence denotes the practice of good deeds. In contemporary ethics, the principle of beneficence usually signifies an obligation to benefit others or to their good. It is a principle of major importance in bioethics and has been prominent in the codes of physicians since antiquity. This principle states that ‘one performed the action or observed the custom or rule that will bring the greatest possible good to the greatest number of people.’ According to W. Frankena, he divides it up into four aspects. They are: a) one may not inflict evil or injury; b) one must prevent evil or pain; c) one must as much as possible to eliminate the evil; d) do everything that promotes the good. The principle of beneficence requires health professionals to advocate on behalf of their patients in order to ensure that they receive appropriate care. It also mandates paternalistic intervention when, because of age, disability, or disease, a patient lacks the capacities for autonomous choice.
3.1.4. THE PRINCIPLE OF JUSTICE
It is based on distributive justice. The principle of justice means ‘similar cases must be treated similarly.’ From the philosophical point of view three criteria are proposed. They are: a) Wages or Merit: Aristotle argues that the criterion of wages is virtue. Here justice means the good in harmony with virtue; b) Similarity of conditions: it leans on democratic models; c) Need: it is one of Marxist origin which states that “from each according to his /her means, to each according to his/her needs.”
The distributive version of this principle is especially relevant in bioethical issues having to do with the morality of institutions, where it requires that the benefits and burdens of the institution be shared fairly. The principle might require, for example, that the state provide a certain level of healthcare to all of its citizens. It also plays a significant role in evaluating the ethical dimension of a scheme for rationing scarce resources (such as origins for transplant or beds in an intensive care unit).
Beauchamp and Childress intend that each of these principles be taken as only prima facie binding. The directives that flow from them are to be followed only when they do not clash with those arising from a different principle. Otherwise, a suitable resolution of the conflicting directives must be crafted.
3.2. THE PRINCIPLE OF TOTALITY
The Catholic Church has used the principle of totality for the justification of living organ donation and transplantation. The principle of totality means, “the parts of the physical entity, as parts, are ordained to the good of the physical whole.” From the medical perspective, the principle of totality would mean “all parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body.”
Theologians have often had recourse to the principle of totality to try to discover how far a man may sacrifice himself for his own good and for the good of the community. This principle asserts that the part exists for the whole and that, consequently, the good of the part remains subordinate to the good of the whole; that the whole is determining factor for the part and can dispose of it, in its own interest.
From the very beginning, this principle has been applied most obviously on the level of the physical organism, in which all the parts are substantially united to the whole. The official statement of the Church regarding the application of the principle of totality to medical problems can be seen mainly in the period of Pope Pius XII. According to him, “a part of the body has no meaning outside its reference to the whole that as a part is to be thought of only in relation to the whole.” In keeping with the medical knowledge of his time, Pius XI made a restrictive application of this principle to excision of organs when no other provision can be made for the good of the whole body. Pope was opposed to one erroneous interpretation of the principle of totality for justifying morally the removal of organs from one living human being for the benefit of another. Pope insisted, the human person is not simply a part of society or humanity in the same as an arm or kidney is part of one physical organism. The God given destiny of a human person, no matter how unimportant in the eyes of others- and the destiny of his/her bodily parts- is not primarily to be disposable for the sake of others.
The first thing to note is that the Pope speaks of the good of the whole. While it is true that Pius XII used the term “organism,” theologians today agree in understanding the good of the whole to mean not only the good of the physical organism but also the good of the whole person. Traditionally the principle of totality was restricted to the somatic aspect of life: “Any treatment, including mutilation, is licit if it is necessary for the saving or the well-being of the whole individual from organism.” The first major breakthrough came when the question of organ transplants living donors arose. Those who thought this legitimate held that it could be justified, not by the principle of totality, but by the so-called principle of charity. It became clear that the principle of totality would have to be expanded to include, not only the somatic good of the human organism but his moral and spiritual wholeness of the person – a wholeness that arises , pursued and achieved by charitable donation to others. Thus, there is the subordination of the physical perfection of the donor to his own perfection of grace and charity.
3.3. VIRTUE OF CHARITY: AN ADEQUATE ETHICAL MODEL FOR ORGAN DONATION AND TRANSPLANTATION
Many theologians justified living organ donation and transplantation from the perspective of charity. Besides, we see that the writings of Pope Pius XII and John Paul II justify organ donation and transplantation in general on the ground of charity. For instance, Pius XII’s address to ophthalmologists in 1956 argues that acts of donation cannot be viewed as a duty or as obligatory. Such acts are supererogatory and not obligatory. Hence, concern for the common good and love of neighbour symbolize genuine self-giving for others. The Catholic Church holds “organ donation as the Christian’s holiest sacrament and it is clear that most of transplantation continues to depend on benevolent donation.” In short one may rightly observe that in the Catholic Church organ donation is justified by the virtue of charity. Furthermore, we note that other religions also justify living organ donation on the ground of charity or love. Most Christian churches support the personal decisions of organ donation as an act of love, charity, and ministry to others. As Christ gave His life for us, our useable organs at our death can be a gift of life to others. There is no specific doctrinal mandate to be an organ donor, but just as the gift of physical property is a personal decision so is the decision of organ donation.
Since organ donation was a relatively new concept and not very well understood, people tried to make sense of it by comparing it to more familiar concepts and phenomena. They anchored the concept in acts such as giving a gift or giving charity. The words they used to describe it were in themselves indications of the ideas they borrowed to understand this new concept. The following were twelve representations which participants used to describe organ donation. Organ donation is seen as Giving a Gift; Giving Charity; Doing One’s Duty; Giving New Life; Recycling Spare Parts; An Insurance Policy; Living on in Another Person; Desecrated the Human Body; Butchery; Destroyed a Person’s Immortality; Destroyed a Person’s Identity; or An Attempt to Play God.
The virtue of charity gives adequate emphasis to the autonomy of the donor and the recipient. The donor should give genuine consent. The intention or motive behind donation is a free and autonomous choice. The intention of the donor is directed by gift-giving to the recipients. This is appreciated because it has to do with helping another person. Most arguments for and against organ donation and transplantation fall into two major categories: those dealing with expressed love to one’s neighbor and those dealing with treatment of the body. The ethical approach of charity changes the emphasis on the physical nature of the human person into the promotion of the total good of the human person. The total personal good of the person is an important element in this approach. Although the command to “love your neighbor” was quoted by Jesus (Matthew 5:43), Paul (Romans 13:9) and James (James 2:8), it may be traced back to Leviticus 19:18. This passage justifies its use in the ethics of organ donation and transplantation. The Hebrew word translated love in Leviticus is used in the Old Testament to describe the love one should have for a neighbor, as well as the love one should express toward God (Deuteronomy 6:5) and strangers (Deuteronomy 10:19). People are to express this love toward God and one another because of who God is, and because we are created in his image. Jesus extends the scope of who may be one’s neighbor in the parable of the Good Samaritan (Luke 10:25-37) and in Matthew 5:43-44. The overarching principle is that we are obligated as Christians to love everyone. Jesus’ life and words exhort all people to love brother, sister, neighbor, enemy and stranger. One way to express this love is through the convenient provisions of modern technology that make organ donation and transplantation possible.
The virtue of charity gives emphasis to the relevance of the social dimension, which is important for living organ donation and transplantation. In the case of living organ donation, this approach points to a social dimension where donors and the recipients are part of the society. The social aspect is also one of the elements that assist in making decisions in living organ donation and transplantation. The value of solidarity encourages the donors and recipients, and others who participate in transplantation, to make responsible decisions. Moreover, in the present situation where we are facing a crisis of organ shortage, helping patients who are in a critical stage, really shows the social character of the human person.
The virtue of charity surpasses principlism, especially in its application to living organ donation and transplantation. The virtue of charity can, therefore, be called our ethical model for living organ donation and transplantation. The virtue of charity can be seen in different forms in religious and secular levels. In the virtue of charity, one is in no way obliged to donate one’s organs and if anybody does so, it is purely a virtuous act. Charity allows the living donor to make a proper personal decision, which is a combination of self-sacrifice and self-concern. The promotion of donation based on the virtue of charity will be an important element in increasing living organ donation. Autonomy of the donor is clearly maintained in charity. Without the virtue of charity, living organ donation may be a mere selling of body parts.
Today we experience a real scarcity of human organs even though organ transplantation facilities are widely available. In this context, both living and cadaveric organ donation and transplantation should be promoted. Today, many transplantation centres have started taking organ from brain death patients transplanting them into patients. For instance, in Kerala, under the leadership of Society of Organ Retrieval and Transplantation, arrangements are made to share organs from willing donors.
The credit for bringing on the organ donation revolution in Kerala goes to Fr. Davis Chirammel, a Catholic priest. After donating one of his kidneys to a poor patient in 2009, he put forward the idea of kidney bank and cross donation of kidneys to help hundreds of patient awaiting transplants. He set up the Kidney Federation of India to oversee the donation process and give financial help to patients in need of dialysis. It has successfully eliminated the racketeers who operate between donors and beneficiaries.
Kerala network for organ sharing, an online registry run under the Deceased Donor Organ Transplantation Programme, selects patients based on specific guidelines. Once brain death is confirmed and the relatives give consent for organ donation, it is from this registry that the needy are selected. The matching tests are done and those who fit in are selected. Apart from individuals and organizations, the media, too, has played its role. In 2011, Malayalam film maker Rajesh Pillai came out with a movie called ‘Traffic,’ a thriller about a race against time to deliver a beating heart harvested from a brain death patient. A constable drives from Kochi to Palakkad, a distance nearly 150km, through crowded roads in two hours to deliver it to a patient awaiting transplant. The film was block buster in many ways. It set cash registers ringing, has broken the myths surrounding cadaver organ transplants and has inspired many people to promote organ donation and transplantation. The Malayala Manorama newspaper, in association with the state government, rolled out an organ donation campaign “Mritasanjeevani,” which encouraged its readers to sign for donating their organs. Kerala Chief Minister Oommen Chandy has said procedures for donation would be made easier. He commended that “organ donation is a great sacrifice. Without empathy, one cannot do such a noble deed.”
Evangelium Vitae (no: 101) speaks about the proclamation and promotion of life: “The Gospel of life is given to us as a good to be shared with all people; so that all men and women may have fellowship with us and with the Trinity.” Organ donation and transplantation highlights the relational and social dimensions of human life. Through organ donation and transplantation also one proclaims the gospel of life. More clearly, patients in a critical stage of kidney or other organ failure have to either undergo transplantation or face death. In these people one has to see the real face of the other. We cannot force anyone to donate, but people should be motivated to make free and voluntary donations. In this condition, the spirit of charity relevant both from religious and secular points of view can work properly with regard to the promotion of organ donation and transplantation.
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