Ethical Issues in Organ Transplantation in India

- Dr. A. K. Tharien
Christian Fellowship Hospital,
Oddanchatram, Tamil Nadu, 624619, INDIA

Eubios Journal of Asian and International Bioethics 6 (1996), 168-9.

The last few decades have witnessed revolutionary changes in medical science. Organ transplantation is indeed a great breakthrough in medical history, like the discovery of anesthesia and antibiotics. Ancient Indian and Chinese medical literature includes some description of organ transplantation, but the technical basis of modern organ transplantation was initiated by Alexis Carrel, a French Surgeon experimenting in animals in 1902. The human kidney was transplanted in 1946, Liver in 1963 and heart in 1967. This was followed by many other organs including lung, pancreas and intestines. WHO has now approved organ transplantation as a well established therapy.

Technical barriers like vascular anastamosis and immunological rejection problems have been overcome. Many socially conscious citizens came forward to donate their internal organs in the true spirit of humanity to save precious lives.

Criteria of Death

Viability and suitability of some organs depend on the time that has lapsed after the organic death of the subject. So there is a tendency to remove the organ from the dead donors as early as possible. Law once regarded death as "extinction of life" as manifested by the absence of heart beat and respiration. The medical community was faced with the dilemma of not being able to 'harvest organs' from patients who seemed to have lost all brain functions but continued to be kept alive by life support systems which artificially maintains respiration and circulation.

A Harvard Medical School committee made a historic proposal in 1968, recommending the criteria of death based on brain activity. In 1976 the Royal College of the UK published a comprehensive code for determination of 'Brain Death'. Now most countries, including India in 1994, redefine death as cessation of brain stem activity and organs can legally be removed after brain death.

The Procedure

There are two ways to obtain consent for removal of organs from dead individuals: (1) Presumed consent, in the absence of objection from the deceased when he was alive or from family members; (2) Informed consent, based on the express consent of the deceased or the family members.

As the demand for organ is greater than availability, there is the dilemma of who should get priority. Is it the most sick one who have greatest or the relatively healthier ones, whose chances of survival and benefit are better. In 1994, 3000 patients died in USA while waiting for an organ. There is also the influence of money, race and religion creeping into the distributing system.

Commercialization of Human Organs

Recently in India commercialization of organs has been a blot on the ethical foundation of the medical profession. There was then no comprehensive law controlling organ transplantation. There was an organized network involving hospitals, doctors, touts and agents doing unethical trading in human organs through the "organ racket".

Some nursing homes acted as frontal outfits. Rich buyers from India and abroad have been buying kidneys and other organs from poor slum dwellers and rural folks without proper information and consent of the concerned persons. The choice before the poverty stricken people is whether to sell one kidney and live or to keep both kidneys and die of starvation! Unfortunately some of the donors did not survive to receive the monetary remuneration promised. The law that the donor should be a relative or spouse was also circumvented through certain dubious means such as "kidney marriage" by rich Gulf country men, marrying a girl before the operation and divorcing her soon after surgery. Another method was transboundary smuggling of organs by live carriers where trade can take place in a foreign country where laws are not so strict. There were other criminal ways of stealing kidneys on the pretext of performing other operations like appendectomy or kidney stones.

Human organs like kidney, liver, heart or fragments of body like skin, semen, egg, genes, embryo and even fetuses are sold over the counter as a commercial enterprise. Andrew Kimbrell's book "The Human Body Shop" reveals the following: *Unregulated fetal tissue brokers in the US reap close to a million dollars a year in fetal organ sales. * Researchers have successfully transplanted fetal organs into laboratory animals creating "humanized" mice. * Babies are bought and sold through surrogate mother contracts. * Frozen embryos are often in legal limbo as the courts decide whether they are people or property. * Numerous patents on human genes have been awarded (see paper by Takagi).

To attempt to overcome the uncontrollable trade in organs the Indian parliament passed a bill in 1994, in keeping with the WHO guiding principles, prohibiting commercial dealings. There are restrictions for removal and retrieval of human organs and also regulations of hospitals involved to ensure transparency by all concerned. Law prohibits removal and transplantation of organs for any purpose other than therapeutic. Surgery can only be done after explaining the effect and risks both to the donor as well as the recipient. For violation of rules the act prescribes a minimum imprisonment of two years extendible to seven years and a fine of Rs.10,000/- to Rs.20,000 for the middle man.

Discussion and Conclusions

Hindus, Muslims and Christians generally support organ donation as this is an act of giving. Judaism prohibits deriving benefits from mutilating or delaying the burial of a corpse but this prohibition can be overridden to save a life for organ transplants. In Japan there is much debate about using brain dead donors, and still no law.

To overcome the scarcity of organs attempts have been made to use organs from other species like Chimpanzee kidneys, baboon heart, liver and kidney. There is also a risk of transmission of unknown infection from animals to humans triggering human epidemics. Organs from transgenic pigs after altering the immune potential are being tried to avoid rejection.

Organ transplantation has raised many ethical, moral, religious and legal issues. Biotechnology has made great advances. As in other technological endeavors, absence of accountability and a regulating system have virtually reduced the human body to a lucrative, commercial enterprise. The medical profession must set ethical guidelines. Organ transplantation is a very expensive procedure. Besides the cost of surgery the transplant patient has to spend an enormous amount for immune suppressive drugs throughout their life. Sheila Sherlock in the book, Disease of Liver warns, before a liver transplant is considered the patient and the family must be told of the physical consequences.

The question is also raised whether it is justifiable to spend enormous amounts of money and energy to prolonging the like span of a few, when in developing countries like India thousands are denied even the basic primary health needs which cost very little. Also it is a cruel act to extend longevity of like without improving the quality of life, I would welcome some answers to these questions from readers.

Organ transplanation in Israel - Grunfeld
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