From the first successful kidney transplant in 1954, organ transplantation has advanced radically to become one of the greatest technological achievements in medicine. As of the early twenty-first century, doctors have successfully transplanted six different organs: the liver, kidney, pancreas, heart, lung, and intestine, as well as several different types of tissue. Simultaneous transplantation of multiple organs is possible as well. The possibility of organ transplant offers hope to thousands of patients suffering from organ failure who may have no other option. However, as the technique improves, the number of people waiting for an organ increases rapidly. More people die on the waiting list each year as the organ shortage escalates. Based on OPTN data as of November 26, 2004, there are 86,876 people on the United Network of Organ Sharing (UNOS) waiting list in need of a transplant and approximately 7,983 individuals died in 2003 while waiting for an organ.
Process and Costs
Cadaveric organ transplant is currently the most popular form of transplantation. However, living donation from both related and non-related donors is widely accepted for kidneys and increasingly more common for liver patients. In the United States, UNOS functions as a centralized system for the allocation of available organs. When an organ becomes available, UNOS is contacted by a local Transplant Coordinator and determines which candidate is the most suitable for the organ, based on clinical factors such as tissue matching, blood type, length of time on the waiting list, immune status, and geographical location. For heart, liver, and intestine transplants, the medical necessity of the potential recipient is also considered (United Network of Organ Sharing Internet site).
As organ transplant becomes a more routine procedure for those suffering from organ failure, it is important to recognize that there continues to be risks involved in this type of surgery. Transplant success has historically hinged on whether or not the recipient's immune system would attack the foreign organ, jeopardizing the effectiveness of the transplant. To limit this, antigen matching between the donor and recipient is a primary concern of UNOS. In the early 1980s, cyclosporine became the first of many drugs to effectively suppress the human immune system to prevent organ rejection. Although not perfect, immunosuppression has become critical to further advancements in transplantation. The intensity of the immunosuppressant treatment can leave recipients susceptible to potentially life-threatening infections.
Immunosuppressant drugs are a lifetime commitment for organ recipients; unfortunately, they are expensive. Kidney recipients spend an average of $10,000 to $14,000 on such medications each year. Congress has struggled with how to pay for this expensive therapy since its conception. Numerous policies have been passed since 1972 to aid in the cost of kidney transplantation as well as immunosuppressant medications for recipients of kidney, liver, and heart transplantations who qualify for Medicare at the time of transplantation and extends for limited time post-transplant. Despite much effort, many transplant recipients still struggle with the increased cost of post-transplant medication critical for their survival. Noncompliance rates due to inadequate finance for organ recipients has been difficult to determine, but may be a common cause of graft failure (Kasiske, Cohen, Lucey, and Neylan 2000). Ethical debates have arisen on this issue. Some believe giving an organ to a patient for whom it is financially impossible to continue treatment is wasting an organ that could save another life. Others argue it is unethical to deny the life-saving procedure to those of lower socioeconomic class.
The allocation of organs has been the source of extensive ethical and political concern. Organs are considered a precious and limited resource because few are available for transplantation, and because of the altruistic nature of the gift of an organ. Many question whether there ought to be standard psychosocial criteria added to the evaluation process to prevent various types of discrimination. Providing prisoners with a transplantable organ has prompted a significant public debate. This was highlighted by the controversy surrounding a prisoner in California who received a heart transplant in January 2001. The debate is centered on the question of who should be given the power to determine whether one individual is more worthy of an organ transplant; beginning this type of preferential treatment is what many ethicists consider a "slippery-slope."
Xenotransplantation is one potential method of attacking the organ shortage. The prefix xeno-means "foreign"; a xenotransplant refers to the process of transplanting a cell or organ from a foreign species. After consideration of factors such as availability, anatomy, and familiarity with the animal, pigs have emerged as the most promising donor option. Genetic engineering offered opportunity to modify the donor animal to more closely resemble the human recipient; coupled with improvements of immunosuppressant therapy, the chance of organ rejection could potentially be significantly decreased (Sachs, Sykes, Robson, and Cooper 2001). At the beginning of the twenty-first century, there had been little success in xenotransplantation, and much debate on the ethics and policy involved with the field. One primary concern with the development of xenotransplantation is the potential for an epidemic caused by previously unknown animal diseases being transferred to humans. Some believe this risk is too dangerous and that xenotransplantation should not be tested.
Another concern that arises with xenotransplantation, a discussion also relevant for certain allotransplant policy, is the commodification of the human body. Organ donation in the United States is considered an altruistic gift. However, policy proposals for financial incentives and some international policies for the buying and selling of organs puts a monetary value on organs. Organs for xenotransplant will be controlled by commercial companies; a recipient will have to purchase an organ. Because these organs will be genetically modified to resemble human organs, commercialization of the organs may have implications for socioeconomic equality. It would also create a rhetoric of human body parts as a purchasable commodity, a concept with which many ethicists have been skeptical (Bach, Ivinson, and Weeramantry 2001).
The benefit of organ transplantation for those suffering from organ failure is virtually undisputed. Unfortunately due to the complexity of the procedure, availability of organs, and the many other variables that factor into an organ transplant, there is still enormous debate surrounding transplantation.
Bach, Fritz A.; Adrian J. Ivinson; and Christopher Weeramantry. (2001). "Ethical and legal issues in technology: Xenotransplantation." American Journal of Law & Medicine 27(2–3): 282–300. Discusses the risks and benefits of technology in general with a focus on xenotransplantation. The authors examine some of the legal, ethical and human rights considerations that this innovation raises.
Fishman, Jay A., and Robert H. Rubin. (1998). "Medical Progress: Infection in Organ-Transplant Recipients." The New England Journal of Medicine 338(24): 1741–1751. Examines the risk of infection for transplant recipients. Provides detailed information regarding the most common infections faced by patients and the points at which various infections arise. Also addresses ways to potentially reduce the risk of infection, through pre-transplant screening of both the donor and the recipients, and treatment of infection with antimicrobial therapy post-transplant.
Kasiske, Bertman L.; David Cohen; Michael R. Lucey; and John F. Neylan. (2000). "Payment for Immunosuppression After Organ Transplant." Journal of the American Medical Association 283(18): 2445–2450. Deals with the problem of payment for immunosuppressant therapy for organ recipients. The government has struggled with this issue and does cover some immunosuppressant medication for eligible donors; the authors discuss the need for expanding this coverage.
Sachs, David H.; Megan Sykes; Simon C. Robson; and David K. C. Cooper. (2001). "Xenotransplantation." Advancements in Technology 79: 129–205. Provides a detailed overview of the field of xenotransplanation. Includes a history and explanation of the science and mechanism of transplanting an organ from an animal into a human, and discusses the possibilities and implications of using xeno-transplantation in the future.
United Network of Organ Sharing. "Who We Are." Available from www.unos.org. A section of the UNOS Internet site that provides a detailed description of the history and membership of the organization.