- © 2005 Canadian Medical Association or its licensors
New Internet clearinghouses designed to connect patients in need of organ transplants with altruistic strangers are raising ethical dilemmas for Canadian physicians and transplant centres.
Like most transplant centres in the world, Canadian organizations have traditionally shunned live anonymous donations because of the potential health risks to donors, the costs of screening, and concerns that donors might sell an organ or be coerced into donating, thus breaching federal law against organ trafficking.
Now transplant centres are re-examining their policies regarding altruistic and anonymous donation, under the pressure of long waiting lists (more than 4000 Canadians are now waiting for kidneys or livers), the apparently growing number of people willing to donate a kidney or piece of their liver, and the advent of Internet donor matching services. The latter include the nonprofit site livingdonorsonline.org and the for-profit MatchingDonors.com, which charges patients US$295 per month to post profiles and pleas for organs.
Already, the former has resulted in a transplant with a Canadian connection; Welland, Ont. resident Sheryl Wymenga donated her left kidney to a 68-year-old North Dakota man last spring. In the US, MatchingDonors.com made its first match in October when a Colorado man received a kidney from a Tennessee donor. This prompted the United Network for Organ Sharing, the agency that manages the American organ supply, to charge that such a fee-based service undermines the principles of fair distribution of available organs based upon who's sickest and who's been waiting longest.
The parties involved swore affidavits that no financial payment was made for the kidney.
Anonymous donation is also occurring outside the Web. In November, Vancouver doctors performed the first two Canadian transplants of kidneys from living anonymous donors to unrelated patients. Eight additional kidney transplants from such donors are scheduled to be performed, the BC Transplant Society says. In all, 43 BC residents have volunteered their kidneys.
Given that most transplants involve “improving the quality of somebody's life, rather than saving a life,” society must determine whether the benefits of living anonymous donations outweigh the risks, particularly to the donor, says Dr. Christopher Doig, associate professor of critical care medicine and community health sciences at the University of Calgary.
Similarly, the short-term savings that accrue to health care system from getting someone off dialysis (an average $10 000 per year for immunosuppressants as opposed to $50 000 per year for dialysis), must be weighed against the potential costs of life insurance settlements, long-term disability payments, or the costs of subsequent treatment for potential iatrogenic effects such as high blood pressure or subsequent organ failure. Doig adds: “I don't think society as a whole has thought out the broader implications of proceeding with living, anonymous donation.”
Still, the anonymous donations and Internet brokering may be viable alternatives to long waiting lists, says Dr. Ed Cole, director of nephrology for the University Health Network at Toronto's Mount Sinai Hospital. “I'm not sure we all feel this is the ideal solution to the problem but we're not prepared to say, no, we won't consider any of this.” There is concern, for example, over whether the donor is financially compensated. “We certainly do everything we can to ensure that [he or she] is not. But in the end, there's no way you can ever be certain.”
Cole says it may be time for the various levels of government to craft a national program to compensate living organ donors, as well as families of deceased donors. “They are doing a benefit to society and in truth, they're saving the government money.”
Dr. Anthony Jevnikar, past president of the Canadian Society of Transplantation, Corinne Weernink, president of the Canadian Association of Transplantation, say the medical community has accepted the legitimacy of living donations from relatives or friends, and are generally agreed that such donors should be financially compensated for lost wages and other costs while convalescing. “I think anything that we can do to promote living donation and decrease hurdles would be a benefit,” says Jevnikar.
But the ethical issues are far more nuanced in the case of so-called “live unrelated” donors, in part because of the 3-in-10 000 risk of death while on the operating table. It's problematic enough for a physician to reconcile that risk with his oath to “do no harm” when dealing with emotionally-related donors and recipients, let alone those who use the Internet to find each other, says Jevnikar, a professor of medicine and director of kidney transplantation at the London Health Sciences Centre.
The ambiguities have prompted others to explore solutions that use independent oversight to ensure no benefits are being transferred to the so-called altruistic donor, whether through direct financial payment or indirect measures such as educational endowments for other family members.
In Vancouver, Dr. David Landsberg, director of renal transplantation at St. Paul's Hospital, has launched a pilot project to study the long-term psychological impact of altruistic donation that will assess 10 anonymous donors over the next 18 months.
Landsberg argues that a truly altruistic donor should be willing to remain anonymous, and a truly anonymous donation would eliminate concerns about financial reward or coercion. “The only psychological benefit that would come would be knowing that you helped someone that needed it.”
Another potential solution lies in directly coupling anonymous donation with financial incentives.
One school of ethical thought, exemplified by Manchester University law professor John Harris, contends it's wrong to deny people the right to do what they like with their bodies, including selling organs, says Dr. John Dossetor, a member of the Canadian Council on Donation and Transplantation, an advisory body to the nation's deputy health ministers.
Proponents of such a regime argue that creating a “monopolist market” (in which a government agency purchases organs from donors at fixed rates, and then distributes them according to need) eliminates the possibility of wealthy people buying their way off waiting lists, Dossetor adds. “That has some appeal.