organ donation

organ donation The donation of human organs and tissues is essential to sustain human transplantation, which is an increasingly important treatment for certain severe medical conditions, and for individuals with irreversible organ failure. Organs currently in demand for transplantation include the heart, kidneys, liver, lungs, intestines, and pancreas; tissues include corneas, heart valves, blood vessels, skin, and bone.

Legally, organ donation can take place from living, genetically-related individuals; from living, unrelated individuals in special circumstances where no unauthorized payment is made to the donor; or from cadavers. Live donation of a single kidney was the first of all (in 1954), but live donation of parts of other organs is a relatively recent innovation in the 1990s. As a source of organs this has a limited impact on availability.

To date the major source of organs and tissues in the West has been from cadaveric donors. Living tissue deteriorates rapidly when it loses its blood supply, and organs need to be cooled and transported for implantation into the recipient within a limited number of hours. Short transfer time, entailing removal of organs from ‘beating heart’ donors, was made possible by the acceptance of ‘brain stem death’ as death. Traditional death, with cessation of breathing and heartbeat, was all that was recognized until the late 1950s. The condition of brain stem death came as a consequence of technological advance, when it became possible to sustain the functions of the major organs with the help of artificial ventilation. There was a need to distinguish between those patients who could recover and those who had suffered brain damage so severe as to be incompatible with life. Mollaret and Goulon (1959) first described brain death in their classic work, ‘Le coma dépassé’ — a state beyond coma.

Brain death criteria were initially discussed by the Ad Hoc Committee of Harvard Medical School (1968). Subsequent recommendations equated brain stem death (or brain death) with traditional death, UK criteria being formally adopted in 1976. The principles of the Harvard criteria have been accepted in many countries and form the basis of the current diagnosis of brain stem death.

The ability to diagnose brain stem death, for an individual maintained on artificial ventilation, in turn maintaining the heart and circulation, allowed organs to remain perfused until a suitable recipient could be identified. Together with the development of drugs to prevent transplant rejection, this meant that transplantation of many organs became a viable medical treatment.

Worldwide, the demand for organs is growing, as the supply of organs and tissues for transplantation has not kept pace with demand. In the UK only approximately 900 individuals become organ donors each year, while over 6000 people are waiting for suitable organs. In the US much the same situation exists, with 70 000 presently on the waiting list and only approximately 5500 cadaveric donors per year. In part, the shortfall in donations reflects an increase in the number of individuals who could benefit from a transplant, but sub-optimal use of the available donor-organ pool; the problems that the acceptance of brain stem death, and the agreement to donate organs and tissues, pose for families also impinge. The often tragic and sudden nature of donors' deaths may be difficult for families to reconcile, especially as donors are previously healthy, relatively young, and robbed of a future. Families are necessarily approached about organ donation when their grief may be all-encompassing, with thinking and concentration a problem. However, if donation is to take place families need to make a number of decisions on behalf of their deceased relative. These decisions may be problematic, as they concern an operation on another's body; yet the time to debate the issues is constrained.

Relatives are asked to accept a non-stereotypical death, brain stem death, as death. The implications of brain stem death transcend the usual experience of the lay individual. The imagery of the brain stem dead is unfamiliar to society's expectations of the dead body, being conceived to be still, pale, and cold. The potential donor maintained on a ventilator may not look dead, and often has no external manifestations of injury, tending to be unscathed, resting, warm, and florid; their chest moves as if they are breathing, and they may even move occasionally if a spinal reflex is activated. Their time of death becomes an arbitrary decision made by the attending physicians, depending upon completion of the required tests. Not only are relatives asked to accept this situation as death, but also they are asked to agree to the removal of the very vital organs that normally would maintain life. They have to contend with accepting the operative mutilation of the body, saying goodbye to a loved one who does not appear to be dead. They have to come to terms with disposing of a body when their loved one's organs are responsible for improving the quality of a recipient's life.

Presently three major legal frameworks govern the donation of organs worldwide. The UK, along with a number of European countries, e.g. Germany and Italy, and Canada, Australia, and New Zealand have ‘opting-in’ systems. This means that the person in lawful possession of the body may authorize the removal of organs and tissues. In practice donation is usually requested from the next-of-kin of the deceased. Many other countries, including e.g. Austria, Belgium, and Singapore, have introduced ‘opt-out’ or ‘presumed consent’ systems that assume individuals have granted permission for their organs to be donated, unless they specify otherwise, in advance of their death. ‘Required request’ or routine enquiry of the next-of-kin of a potential donor, forms part of state law in the US. It provides for hospitals that fail to adopt ‘required request’ polices to be denied support from healthcare funding agencies.

None of the major world religions oppose the donation of organs. However, the Japanese culture which is underpinned by Shinto religion believes that if the ‘itai’, or bodily remains, are harmed then the soul of the dead is believed to be unstable and unhappy and to have the capacity to bring misfortune to the surviving relatives. Therefore, even with the recent acceptance of the brain stem death law Japan, unlike other countries, has chosen to support a system of predominantly living donations.

The shortage of human organs for transplantation has led scientists to explore techniques to facilitate the use of organs from animals (xenotransplantation), particularly the pig.

Magi Sque

Bibliography

New, B.,, Solomon, M.,, Dingwall, R.,, and and McHale, J. (1994). A question of give and take: improving the supply of organs for transplantation. King's Fund Institute, London.
Sque, M. and and Payne, S. A. (1996). Dissonant Loss: the experiences of donor relatives. Social Science and Medicine, 43 (9), 1359–70.

See also brain death; life support; transplantation.