Bioethics in India: Proceedings of the International Bioethics Workshop in Madras: Biomanagement of Biogeoresources, 16-19 Jan. 1997, University of Madras; Editors: Jayapaul Azariah, Hilda Azariah, & Darryl R.J. Macer, Copyright Eubios Ethics Institute 1997.

32. Ethics in Allocation of Organs for Transplantation in Humans

D.S. Sheriff
VMKV Medical College, Salem 636 308


Organ transplantation is a life-saving procedure. Its procurement, donation and acceptance carries a moral dimension apart from its medical criteria. Commercialization of organ donation has been the focus of medical community as to bring a balance between medicine and societal demands. The donation from cadaver to living donors including the donation of organs from animals brings into play medical, ethical and social problems.

The conferences of European Society for Organ Transplantation and the European Renal Association held at Ottawa and Munich discussed the danger of commercialization of organ donation especially in India and certain countries of the Middle and Far East related to the question of living kidney and cadaver donors. Among the many strategies discussed with respect to commerce in organs is the possibility of offering "incentives" to encourage the public donate their organs. It was specifically emphasized that this does not speak of purchase of organs. Instead stratagems such as relieving a family of the cost of their deceased relative's funeral in return for the donation of his or her organs, reducing the amount of money they lose in the form of death duty, or providing pension to a widow who authorizes the use of her deceased husband's organs for transplantation are all forms of commerce. "Incentives" of this kind would undermine two important and basic ethical principles, namely that donation should be voluntary and the decision autonomous.

Allocation Of Organs

When the number of organs available for transplantation is insufficient, available organs have to be allocated on the basis of certain criteria. But who is to decide as to who must get the organ even if one has the authority and competence to do the allocation? Many people regard it axiomatic that doctors should decide which patient is to receive an organ and which not, after all, transplantation is said to be essentially a medical procedure. This view is justified as far as medical criteria and findings permit a prediction as to whether a patient is likely to benefit from an organ transplantation or not. Purely medical considerations are relevant to such a decision, and where resources are in short supply the most accurate measurement possible of the probable effects of transplantation on the potential recipient cannot be dispensed with. It would be pointless to perform transplantation on patients who were unable to benefit from them.

The real problems arise when the allocation of organs to patients who could all benefit from a transplantation but for whom not enough organs are available. Here, medical criteria alone are inadequate. Value judgments must be made, and this presupposes the existence of a system of values. Doctors possess such a system, the most important principles of which are, traditionally, to save life, to relieve suffering and to restore health. These principles however, are not in themselves represent adequate basis for organ allocation, as they can come into conflict with each other, for example, where allocation to one patient would most effectively save life, to another it would effectively relieve suffering and to a third it would restore health. In this situation it is difficult for doctors to decide which of these principles should take precedence. Even if doctors were able to agree amongst themselves on such questions, it is doubtful whether the public (which, after all donates the organs and requires them) would agree with such order of precedence or would regard the maximization of medical criteria as being the most important aim of transplantation. Non-medical criteria, such as justice and mercy, equal opportunity, social acceptability, and self-determination, are also important for organ allocation.

In determining the value of a medical assessment, non-medical criteria must also be taken into account, and the various moral considerations related to each other. Decisions of this type have nothing to with medical science; there is therefore no sound reason for leaving them to doctors. It is preferable that doctors be able to devote themselves to their patients with undivided loyalty, an ideal that is incompatible with the task of allocating organs on the basis of a set of overriding principles. The doctors whose paramount commitment is to the welfare of their patients would in fact in many cases be virtually obliged to make wrong allocation decisions. In a society that must make the fundamental decision on what moral considerations should take precedence. Which patient should be given preferences? The one who is most seriously ill or the one in whom a transplantation promises to be most successful? The allocation of organs is thus a moral, rather than a medical question.

Allocations are made at three different levels

The macro level: organ allocation falls within the realm of politics. It is here that basic decisions on the allocation of resources are made, both in terms of competition between the health services and other areas of public expenditure and in terms of competition between different areas within the health system (e.g. transplantation versus prevention). At this level, allocation of resources is not made according to medical criteria but it is certainly an area of decision-making in which the public should be involved. Where it has managed to make itself heard, public opinion has proved very valuable.

The intermediate level: this refers to institutional allocations, for which a number of centres and programs within the same discipline are in competition.

The micro level: this is the realm of individual doctors and their individual patients. All doctors strive to ensure that available organs are allocated to their own patients - according to principles to whose formulation the doctors have contributed with medical information, but whose validity will be determined at higher allocation level.

Allocation decisions can be made on the basis of a number of considerations

The principle of saving Life, according to which an organ should be given to the person in greatest need of it, should not always be paramount. It is however, readily accepted by doctors, as it is in accord with the medical principles that help should be given first to those who need it most.

Generally the conflict with the principle of saving life is the principle of medical utility, according to which the organ should go to the person in whom the chances of success are greatest. Here, the greatest profit represents the greatest good. The principle of loyalty leads surgeons to perform repeat transplantation even in cases where the prognosis is extremely poor and the re-transplantation cannot be justified in social terms. The principle of random selection is generally hold in poor esteem by doctors. It is value-free and has a certain impersonal fairness. Consideration of waiting times satisfies the call for justice. However, it disregards the questions of urgency and would need to be expanded to incorporate this principle.

Ability to pay can also, in a subtle way, be an allocation criterion. It should, however, play no part, especially where the transplantation program is financed out of public funds and the organs to be transplanted are donated by the population at large. To regard the "social value" of the recipient as a criterion cannot be acceptable.

The need of the transplantation program can also influence allocation decisions. Here the utility principle is applied not to the likely medical result, but to the needs of the program itself. Such needs, however, should not be considered only in association with one or more of the other principles; they are never sufficient in their own right an criteria for determining the allocation of an organ.

Finally, allocation decisions may be made on the basis of the needs of the public policy.

Allocation of Kidneys

Potential kidney transplantation recipients face a special ethical problem being "caught in the dialysis trap". When the question of kidney transplantation arises, doctors providing dialysis may find themselves in a conflict between their own interests and those of their patients. Occasionally certain private profit-oriented institutions favour dialysis to transplantation when compared to institutions which are not profit-oriented. Keeping such possibilities in mind, all patients with terminal renal failure should be informed of all ethically acceptable forms of treatment including kidney transplantation.

Allocation of Hearts

The patients waiting for heart transplantation is quite likely to die while on the waiting list. The ethical dilemma here in that patients with good chance of recovery are condemned to death on the waiting list if organs are allocated to those who most urgently need them. It is therefore pertinent in this field that the call is most commonly heard for organs to be given to those patients in whom the chances of success are greatest; it is said that given the scarcity it cannot be morally justifiable to perform heart transplantation on moribund patients.

Allocation of Livers

The criteria for allocation of livers are: the waiting time principle; the utility principle, and the principle of saving life. The patient who needs the liver most urgently who gets it. In the case of a patient with fulminant liver failure both the third and the second principles apply in that the patient who most urgently needs the organ is also the one who most likely to benefit from it. Thus, where the probability of success is below a certain, as yet unspecified level, transplantation need not to be performed. The general consensus regarding use of living donors to provide organs for transplantation suggests that "The donation of an organ by a living adult who is genetically related to the recipient is ethically acceptable provided both the donor and the recipient (or, where the latter is not capable of consenting, his or her representative) have been given detailed information and have voluntarily given their consent." "The donation of an organ by a living person is also ethically acceptable where the donor is the spouse of, or some other person emotionally related to, the recipient."

Though these resolutions hold good for kidney transplantation, transplantation of other organs like liver, pancreas and small intestine has created new moral and medical problems. Developments of such procedures require further research. Some believe that ethical considerations forbid further research and some way ethical considerations impose the obligations to follow up new developments in research and therapy. From the point of view of ethical responsibility, the crucial question is whether it is permissible to damage one individual in order to help another. The answer to this question must consider the benefit to the recipient, the risk to the donor, the benefit to the donor (including an assessment of the risk-benefit ratio), the possibility of free choice on the part of the donor (who should decide on donation voluntarily and only after being comprehensively informed) and the benefit to society as a whole.

Transplantation of Fetal Tissues

Experience with pancreatic cells of human fetuses have proved to be immunogenic. The use of tissue from aborted fetuses creates ethical problems such as: The use of fetal tissue and elective abortion are inseparable. If abortion is immoral, so too in the use of fetal tissue. Though it is a fragile area, there is a suggestion that there may not be a moral link between an abortion and the use of resulting tissue unless the abortion was performed explicitly in order to obtain the tissue . This area remains a very highly controversial one. Therefore the question of transplantation of fetal tissue involves the whole of society.

Transplantation of animal organs into humans

The shortage of human organs necessitated the use of animal organs for transplantation purposes. The animal organs are mostly transplanted as a temporary measure to sustain life until a suitable human organ becomes available. Concordant transplantation (e.g. between humans and monkeys) in which type of rejection that occurs is the same as that within a species, and discordant transplantation (e.g. between cats and dogs) in which hyperacute rejection reactions occur. Rejection vary according to whether the transplant is a vascularized organ (e.g. liver, heart), a non-vascularized organ (e.g. skin, bone) or consists of individual cells. But with more experimental work to be done to rule of many pitfalls including transmission of deadly viruses, synthesis of different proteins (animal livers) and other situations, still the ethical question that one envisages is one of moral value - the life of an animal to the human suffering.


1. Ethics, Justice and Commerce in organ replacement therapy. Proceedings of the first joint meeting of European Society for organ transplantation and the European Renal Association. 1990; Munich, Germany.

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