Public pleas for organs fuel ethical qualms
■ Experts at a transplant ethics conference weigh the pros and cons of allowing strangers to donate to patients who plead their cases on the Internet.
In 2004, MatchingDonors.com helped arrange an organ transplant between a donor and recipient who met through its Web site, sparking a heated debate about public solicitation of donors.
The conversation at the Frontiers of Ethics in Transplantation conference, held last month in Chicago, showed that the controversy still hasn't abated, even as more transplant centers soften their stance on these types of donations.
Douglas W. Hanto, MD, PhD, said at the conference that patients who publicly solicit strangers to donate are jumping ahead in the organ waiting line.
"The publicity and personal stories are misleading," said Dr. Hanto, chief of the division of transplantation at Beth Israel Deaconess Medical Center in Boston. "They suggest that a patient has unique needs and imply the recipient is for some reason exempt from criteria that apply to others on the waiting list. But all patients have personal stories of suffering."
MatchingDonors.com charges potential organ recipients $295 to list their profiles, but will waive the fee for people who cannot afford it. Dr. Hanto said public solicitations give an unfair advantage to well-to-do, well-educated, good-looking patients. "I had a patient who viewed herself as an unattractive black woman," he said. "She told our psychologist, 'If I put my profile on MatchingDonors.com, why would anyone want to donate to me?' "
Living donors should be able to direct their donations, said conference panelist Dan W. Brock, PhD. "The usual view is that a kidney is a private resource," said Dr. Brock, director of the Harvard Medical School Division of Medical Ethics. "It's my kidney in some kind of property sense. It's even tighter than that -- it's an identity relation. 'I am my body.' "
Dr. Brock said it is within donors' "ethical discretion" to give their kidneys to whomever they please, even if the recipients are low in the organ queue. He added that if allowing publicly solicited donations led to an overall decrease in the donor pool then that might be a good reason to frown on the practice, but there is no evidence that they have had much effect on the organ pool as a whole.
A total of 74 transplants have been arranged through MatchingDonors.com, but the controversy also extends to cases where patients have solicited donors through personal Web sites and ads on billboards and local radio.
Different thoughts on living, cadaver donations
In 2004, the Health Resources and Services Administration directed the Organ Procurement and Transplantation Network to develop guidelines on public solicitation of donated organs from living and deceased donors. The OPTN's board of directors concluded that living and deceased donations were different.
Publicly soliciting directed donation of deceased organs "would have a negative impact on the equitable allocation system of deceased organs" and is "inappropriate," the agency said in a policy statement published in the January 2006 American Journal of Transplantation.
On living donation, however, the agency said it "cannot regulate or restrict the ways relationships are developed in our society." So, it was left up to transplant centers to ensure the donor does not expect pay, is informed of the medical risks and is mentally stable.
In October 2006, the American Society of Transplant Surgeons adopted similar policy, saying that publicly solicited living donor transplants are ethical "as long as the motivation is based in altruism and there are well-defined safeguards regarding informed consent and evaluation in the transplant centers performing them that insure safety for the donor, the recipient, the transplant center, and the community."
A survey of 132 U.S. kidney transplant centers published in the October 2007 American Journal of Transplantation found that only 30% were willing to accept donors who were publicly solicited.
But things seem to be changing quickly, said Jeremiah J. Lowney, DO, MatchingDonors.com co-founder and medical adviser. "Transplant centers were quite apprehensive initially when we first got started," Dr. Lowney said. But many centers have since changed their tune, including Chicago's Northwestern Memorial Hospital and Rush University Medical Center, and Johns Hopkins Hospital in Baltimore.
"It's completely up to the transplant center to determine whether any surgery takes place," Dr. Lowney said. "We're just interested in getting people talking."
Even Dr. Hanto, when faced with a 28-year-old patient who found a donor through the Web matching site, ultimately agreed "after much deliberation" to do the transplant.
"Yes, we'll do it," Dr. Hanto said of Beth Israel's policies on public solicitation of living donors. "We only wouldn't do it if it wasn't suitable for other reasons."