- Aysegül Demerhan Erdemir,
Uludag Üniversity, Medical Faculty
Department of Medical Ethics
Organ transplantation that is applied in Turkey and in many countries of the world, today, is a subject of interest to many scientific fields, such as medicine, law etc. The physicians of this modern period who have studied human health since Hippocrates (460-377 B.C), have made applied transplants to protect human life, and have applied some rules and codes for the application of these methods. Medical ethics teaches both the legal problems of organ transplantation to the candidates of medicine and trains them in this respect (I). Some codes are present in Turkey, today.
We see many periods of organ transplantation in history. The first thoughts about organ transplantation go back to antiquity. For example, folklore beliefs about the passing of strength and health from powerful men to weak men were common among people in antiquity. The concept of organ transplantation is also present in mythology. Greek mythology mentioned that a magician called Mede gave youth and strength to an old man by way of blood transplantation. Some parts of the body were transplanted to the face in order to repair defects in ancient India. The blood of gladiators was given to epileptic patients in ancient Rome.Thus, the hot blood was obtained from the wounded gladiator. People used these methods in later centuries, and in the 19th century the blood of a magician was used for patients after he was executed in Göttingen in 1859(2,3).
Pedanius Dioscorides (First century A.D.) mentioned that the blood of animals had been used for human health in ancient Rome. Thus, the blood of tortoises was used for corns, the blood of rabbits and bats for eye aches, the blood of hens for earaches and the blood of rats for warts. Moreover, the excrement of ill animals was given to the patient. The flesh of freshly slaughtered animals, such as hens was applied to the wound. Aulus Cornelius Celsus (3-64 A.D), a Roman physician, mentioned that the flesh of animals was also applied to the kidney of a man with a renal disease(4,5). The spleen of goats was applied to the spleen of ill men, which was then dried on a stove. So, it was believed that the spleen of ill men would get better. Moreover, rope that was made from the fur of rabbits, was wrapped around the patient, in the hope that he would get better. One of the organs of fish was wrapped around pregnant women, and it was believed that the birth would be easy. Moreover, the eyes of river crabs were applied to the eyes of patients before the sun rose, and it was believed that the eyes would be cured. Patients were wrapped in the skin of animals and it was believed that the patient would be powerful. To wrap the patients in the skin of animals was also seen in the Middle Ages. Seven month old babies were wrapped in the skin of animals in order that they would be powerful (6,7).
It was believed that the method of the external application of the organ of animals to the human body cured disease in the ancient ages, and this method was seen as one of the therapeutic methods of ancient folklore. Moreover, parts of plants were applied to ill organs in those ages. It was also believed that strength would be transplanted from man to man. For example, the clothes of a strong man were put on a weak man, and so the transplantation of strength was applied. The shirt of a powerful man was put on a woman after childbirth in order that she would gain strength(8,9).
Some organ transplants were conducted in ancient ages. Gaspare Tagliacozzi made some studies in Bologna University in 1597. This scholar transplanted a part of his arm to a patient who had lost his nose. In the same period, studies about blood transfusion also began. These studies that were made on animals were applied to humans by Danys in 1667. The first organ and tissue transplants are thought to have been in 1771 when Hunter removed the testes of cocks and put them again in the abdomen. So, he observed that this organ grew in this part and functioned. Moreover, he transplanted the testes from cocks to hens and observed the same result (10,11).
Baronio applied skin autotransplantation on sheep in 1804. Heizinger, a Frenchman tried cornea transplantation. Paul Bert studied the problem of homograft tolerance and investigated the subject of parabiosis(12,13). Blood transfusion developed at the beginning of the 20th century, after Landsteiner discovered blood groups in 1900. Blood transfusions were applied in the First and Second World Wars and the discovery of the Rh factor allowed this application to develop. Ulmann applied renal transplantation to dogs in 1902(14,15). Many others developed the technique in kidneys (16,17). Voronay investigated homeotransplantation of cadaver kidneys in 1936, Hamburger in 1946 and in 1953, and Lawler in 1950, applied these experiments to patients on the death bed (18,19). Murray applied the first experiment to twins in 1954. Hume investigated people with different antigens, and the first success was achieved in 1962. Renal transplantation was applied from animals to humans in 1964. Reemsta and other scholars used this transplantation from chimpanzees to men and they had a successful period of 9 months. Renal Isotransplantation was applied to monozygotic twins by Merrill in 1966 (20,21,22).
Heart transplants were applied
to animals by Alexis Carrell in 1905. Neptün and
Demikler made experiments on dogs in later years. Hardy
transplanted the heart of a chimpanzee to a man. Christian Barnard,
transplanted the heart from man to man in Cape Town in Southern
Africa in 1965 for the first time. Since then heart transplants
have expanded. Nowadays transplants of organs and tissues such
as kidney, heart, liver, lung, pancreas, stomach, small intestine,
spleen, larynx, ovary, bone, vein, nerve, parathyroid, ear, and
eye are also made. Liver transplants were applied to animals in
1956, and these applications were made on people in 1964(23,24),
and in pancreas(25,26).
Medical students who studied anatomical models before the modern medical school (1827) was founded, made anatomical experiments on corpses after this time. The first official permission for cadaver studies was given in 1842 in Turkey. Popular beliefs prevented these experiments before this date in Turkey. Today, Turkish medicine is highly developed and many studies are made on organ transplantation. The codes in regard to organ transplantation dated 1979 and 1982 are valuable from the point of view of the application of organ transplantation (27,28,29).
We can take renal transplantation as an example. Kidney transplantation has been a treatment for renal diseases for 25 years, and this condition gives positive results from the point of view of socio-economic conditions. The first kidney transplantation was conducted in 1967 in Turkey. The application of kidney transplantation began at the Hacettepe University Hospital Hospital Transplantation Unit in 1975, along with a revolutionary break-through in the understanding and the practice of transplantation. After this date, transplantation has been done on a regular basis in many centers throughout Turkey. Moreover, a cadaver kidney that was brought from a European Transplantation Foundation in 1978 provided the first cadaver transplantation. Furthermore, the Turkish Transplantation and Burn Foundation was founded in Ankara in 1980. This foundation helps organ transplantation, encourages education, and establishes therapeutic buildings. The dialysis Center of Organ Transplantation and Burn Foundation was opened in Ankara in 1982 (30,31,32,33).
A special law regarding Organ Transplantation did not exist in Turkey before 1979, and many operations could not be made. The code of Organ and Tissue Procurement and Transplantation number 2238 in 1979 has some rules about these operations. An amendment was also made in favor of organ and tissue retrieval from cadavers in 1982. Organ and tissue retrieval is divided into two parts:
b) Organ and tissue retrieval from a dead body (cadavers).
Some articles of this code in 1979 should have shown more advanced characteristics from the point of view of medical ethics and law. In this code, some subjects should have some detailed rules. These subjects are descriptions of death, social, psychological and moral conditions of the donor and the recipient, the problem of permission, the duties of physicians, and the conditions of organ and tissue recipients from cadavers (dead bodies).
An article about the general rules of this code in 1979 points out that organ and tissue procurement will be made with therapeutic, scientific and diagnostic aims. But, this code was passed only for diagnostic and therapeutic purposes. Therefore, if organ transplantation is conducted as a medical experiment, a separate article about this subject must be found in this law.
Furthermore, article 2 of this law explains organs and tissues whose transplantation cannot be performed. But every organ has a different characteristic from the point of view of medicine. Therefore, characteristics of every organ and tissue must be stressed in this code (34,35,36).
The positive side of this law is the prohibition about the organ and tissue recipient for benefit and money. This is because in my opinion providing benefit is contrary to the rights of personality and this condition is an ethical quackery (37). Moreover, article 5 of this code points out that the donor must be 18 years, and a desire of an insane person about organ giving is not legal. This condition is also a positive point. If the recipient is alive, the consent of both recipient and donor are necessary. The written consent of the donor is very important. This condition is stressed in this code (38).
The donor loses something and the
recipient gains something. They must be familiarised with this
subject from the point of view of social, moral, and psychological
aspects. That is, the physician must educate them in this respect.
The recipient must be informed of the results of the operation,
because the physician can be responsible for all kinds of complications
after the transplantation. Furthermore, a physician must inform
the spouse of the donor. This condition is very important from
the point of view of social problems. If the donor is dead, the
death must be determined according to objective findings. According
to the 1979 code, medical death must be determined, and this determination
must be made according to the scientific level in the country.
But the determination of death must be made according to objective
medical findings, and the types of deaths must be explained. Thus,
the personality ends with death (Article 27 of Civil Law). So,
the rights of personality also end with death. Therefore, the
determination of death is very important from the point of view
of the Penal Code and Civil Law.
Some points from medical ethics
A person does not suddenly die. After the heart stops beating, the cortical cells of the brain die irreversibly in 4-6 minutes. Liver, pancreas, and kidneys die in 30 minutes. The skin, hair, bone, cartilage etc. live several days, even several weeks. This means that the above organs should be transplanted during these time limits, namely before they are dead. It is practically impossible to do this procedure unless the donor and recipient are present in the operating room with two sets of surgical teams. Because only living organs and tissues can be transplanted, we have to maintain cardio-pulmonary function in order to keep the organs alive until the end of the transplantation procedure.
Furthermore, the definition of death, the determination of the time of death, and the burying of the corpse are important conditions from the point of view of embalming and autopsy. The signs of classical death are: a) Absence of heart beat and peripheral pulses. b) Absence of respiration. c) Absence of corneal reflexes. d) Absence of response to external stimuli. e) Dilated pupils. f) Presence of a bluish color of the lips. All these conditions are the early signs of classical death. Later signs of death are as follows: 1) Algor mortis (decrease in body temperature). 2) Rigor mortis (rigidity of the body) 3) Livor mortis (purplish discoloration of skin).
The term brain death came into the medical literature during the last two decades. It simply means that the brain is dead while other parts of the body are alive. If cardiopulmonary resuscitation is successfully done within 4-6 minutes after heart and lung functions have stopped, the person will come back to the life; if CPR is done later than 4-6 minutes, cortical neurons die and they can not regenerate as other body cells. The brain stem is the center of the respiration and circulation, as well as other parts of the autonomic nervous system. In brain death, the entire brain, including the brain stem is dead; however, the functions of other organs, namely the whole function of the body except the brain may be re-started with CPR or a heart-lung machine.
Clinical signs of brain death are irreversible cessation of all functions of the brain, deepest possible come, absence of all voluntary and non-voluntary movements, fixed pupils and apnea. In brain death, the patient's respiration and heart beat stop as soon as the respirator is turned off. Otherwise, the patient may live up to 4-6 weeks. The best proof is a flat EEG (Electroencephalogram) for at least 24 hours. In an autopsy, the destruction of the entire brain, including the brain stem, is observed.
Determination of death is important for inheritance, life insurance, taxes, marital status, and organ transplantation. In 1981 the President's Commission of the USA made the following definition: Irreversible cessation of all functions of the entire brain, including the brain stem, means dead. A determination of death must be made in accordance with accepted medical standards. Islamic law points out that the personality of man ends with death, and so all the responsibilities of a dead man will end. According to the Islamic beliefs, the organs of dead man can be transplanted to living man. Thus, Diyanet Isleri Baskanligi Din Isleri Yüksek Kurulu (Religions Affairs' Directory) stated that the organs of a dead man would be transplanted in 1980. But some families do not want men to touch the corpses of their own relatives since they regard them as sacred. They believe in some other moral values. Our society has some traditions and beliefs about dead men and these traditions cannot change in a short time (39,40,41).
Some educational efforts are very necessary for in increase in the number of cadaver organ transplants in Turkey. a) Collective education (Press, TRT, Schools, Social Meetings, Organ Donation Campaigns). b) Professional education (The education of the physicians, health personnel, and administrative personnel of public foundations). c) The education of people by cultured religious advisors. Today, the traditions of some people, and the lack of education can prevent organ donation from a cadaver (42,43). Furthermore, we can see some artificial organ transplants being applied.
It is known that organ transplantation from the dead body to an alive man can be applied according to the verbal or written testament of a person. If a testament is not present, the relatives of dead man can give permission. If a person's life is ended as a result of an accident or natural disasters, and if none of the above relatives is present at the time of the death, his or her healthy organs may be taken without will or consent after death is determined, as described in article II. In emergency cases where another person's life depends on the dead person's organs by transplantation, this operation can be applied. The last paragraph was added in 1983.
Brain transplantation from human to human can be applied in the future. Some experiments are made on animals in this respect. But, in the brain transplantation, some problems in regard to the personality can be seen. Some subjects, such as law, and ethics can prevent the surgeon. Because in these kinds of transplantations the change in personality may occur (44). If organ transplants are useful operations are applied according to legal rules, the science of medical ethics that will also approve these kinds of applications (45,46).
modern operations have been applied due to modern codes and so,
many organ transplants have been made in Turkey. This shows how
one Asian country has faced organ transplants in contrast to the
East of Asia in Japan, as Morioka wrote (47).
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