By Daniella Gimbosh
In 1954, the world saw its first successful organ transplant: a patient in need of a kidney transplant had received one from his identical twin brother (Barker and Markmann, 2013). Since then, there have been revolutionary developments in every field relating to biomedicine and the face of organ transplantation has been completely transformed, with procedures taking vast strides in collaboration with the biotechnology sector. Now, innovative approaches and alternatives to organ transplantation are being developed, such as the rapidly evolving technique of 3D bioprinting which has the potential to replace the traditional transplant approach (Murphy and Atala, 2014).
Although the purpose of organ transplantation serves to save and improve lives, a myriad of ethical pitfalls surrounds this topic. Throughout the years, the utility and equity of organ transplants have been debated fiercely. Different donation systems exist, and “ethical donation is by consent, explicit or presumed, spontaneously offered or secured by request” (Dunstan, 1997). Under an ‘opt-out’ system, all adults are presumed to have given consent to their organs being donated after their death, unless they have explicitly indicated otherwise in a notarized document. Contrastingly, an ‘opt-in’ system requires people to actively give consent prior to their death and register in order to become an organ donor (Rudge, 2018).
The existence of the two contrasting systems in jurisdictions riddles the process of transplantation with ethical dilemmas. On the 20th of May 2020, England implemented a nationwide opt-out system in order to overcome the rampant shortage of available organs for transplantation. The decision was met with harsh backlash from adversaries of the opt-out system. They claimed that it is unethical to assume that anyone who has not opted out wishes to become an organ donor, given that “apathy and/or disorganisation” (Organ Donation Taskforce, 2008) might have prevented them from opting out. Further arguments that have been presented include that the opt-out system leaves room for abuse as death could be rushed in order to provide organs for a patient in need of an emergency transplant (Prabhu, 2018) and that family members of the patient may feel more ambiguity surrounding their loved one’s decision, possibly increasing the risk of family refusal. The inherent ambiguous nature of the organ donation system in terms of ethics is therefore a huge hurdle in the provision of life-saving organs.
The issue of abuse can be introduced with the dystopian concept of ‘donor babies’ or ‘saviour siblings’ – a situation where parents have another child with its only purpose being to provide organs for its sibling (usually with a chronic or fatal disease). This eerie idea is very much a reality, where the ethical concerns are abundantly clear: the exploitation of a child born for the sole purpose of providing organs for their sibling could undoubtedly result in adverse psychological damage and many more welfare and autonomy-related issues (Rubeis and Steger, 2019). Parallels can be drawn with the controversial possibility that people could be forced into providing an organ for a family member or loved one by the patient, their family or even medical staff. Ensuring anonymity and enough support from medical professionals regarding the transplant process could prevent pressured organ donations, but in many aspects this matter is precarious and extremely hard to control.
The selection process for organs has similarly been under scrutiny due to the fact that patients of higher socioeconomic backgrounds could unjustly be prioritised for organ allocation, thanks to financial incentives. Morality needs to be considered even further as racism and ageism may also result in an unethical allocation of organs – many consider it unjust that younger patients may get prioritised over older patients. Moreover, many religions have great ambiguity on the topic of organ donation; although most major religions support the donation of organs, some beliefs do not support interference with the body post-mortem and religions such as Buddhism have certain discrepancies surrounding their views of disfiguring the human body (Karma Lekshe Tsomo, 2006). As such, the enigmatic views of many religious beliefs result in organ donation being viewed as ‘taboo’ and unethical.
Another aspect to consider is the focus on stem cell research in the context of producing organs for transplantation. There are undoubtedly endless possibilities stemming from such research, including the use of induced pluripotent stem cells (iPSCs) for organ provision, which seem far superior to using embryonic stem cells, the latter laden with ethical concerns (De Vos and Assou, 2017). iPSC cells are similar to human embryonic cells but can be generated directly from adult somatic cells and re-programmed into an embryonic stem cell-like state, and therefore could potentially form fully functional organs (Otsuka et al., 2020). The use of such technologies could allow organs to be produced from iPSC cells, which are genetically identical to the recipient, thereby providing a possible solution to the incessant lack of available organs, as well as avoiding the risk of rejection of the organ by the recipient’s body.
Nevertheless – whilst no embryonic tissue is involved with the use of iPSCs – opponents argue that such manipulation of cells is unethical, their justification being that scientists are ‘playing God’ and ‘tampering with nature’. The concept of organ transplantation as a whole is also questioned in terms of how far humans should be allowed to fight for their lives, many arguing that obtaining organs from a healthy person can be considered as ‘cheating death’. Consequently, solving the issues of rejection and scarcity of viable organs proves to be harder than anticipated.
The bioethics of transplantation extend as far as the economic sector, with the commercial dealing of organs in the black market proving to be a daunting prospect. Underground organ tourism is predominantly prevalent in war and disaster-stricken areas, where an abundance of viable organs are available for organ trafficking (Taylor, 2006). The ethical controversies of organ provision for transplants extend further into various other sectors and are substantial. Despite the difficulties of creating an ethically sound and consensual system of donation and transplantation, it is vital that one is created in order to ensure the safety of donors and recipients alike.
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