Mark Miller, C.Ss.R., Ph.D.
Because of the uniqueness of each human person, organ donations are not like changing a broken part on a machine. Nonetheless, there is a compatibility of human tissue which allows organ transplants as long as immunosuppressant drugs are available to prevent rejection due to any incompatible differences. The wonder of transplantation along with the accompanying side effects raises a number of ethical issues which are not always easily resolved.
First, there is the question of who gets available organs. The compatibility factor eliminates a certain number of possible recipients. Some people have then suggested that more important persons should have priority. A nuclear physicist, it is proposed, should have priority over a street person. However, when all the factors that go into differentiating human beings are taken into account, we quickly discover that adjudicating the worth of persons by what they do, or their education, or their wealth is inherently wrong because those are all factors external to the dignity of the person. In Canadian society, in accord with Catholic social teaching, we believe in a fundamental equality of all people. Thus, the ethical principle for choosing the correct recipient is usually first come, first served. There is a serious exception to this rule, namely, that the more critically ill person will receive priority, all other factors being equal, because he or she does not have the luxury of extra time.
An interesting question, which is asked in every transplant unit in Canada, is whether there should be equal access for the elderly. Some people in fact are excluded because of age, although the actual age beyond which one will not be considered is often arbitrary. However, other factors are more critical than age alone. Usually, the health condition of the elderly person is the key factor. Older people often face multiple problems and while an organ transplant may solve one difficulty, it may also cause many more because of the pressure put on other organs. Furthermore, there are simply higher risk factors for the elderly in ‘routine’ surgery and anaesthesia. Most transplant teams take a good, long look at the physical, emotional, mental and spiritual factors in a person’s life before considering a transplant.
Second, one of the most difficult questions facing transplant teams arises when it becomes obvious that a person is facing transplantation because he or she abused their bodies to the point where the organ failed. Alcoholics may destroy their livers by drink; smokers put enormous pressure on lungs and hearts; people with diabetes sometimes do not take proper care and end up losing the use of their kidneys. Should these people receive equal access to scarce organ transplants?
There is a great danger in these cases, again, of evaluating the personal worth of individuals. We can say, for example, that an alcoholic has a disease. But our human reactions may also betray a judgemental attitude towards the same person when the expenses of transplantation are concerned. Furthermore, once any of us begins to examine our ‘worthiness’ in accord with the way we have treated our bodies, then we would have to look at the poor diet most of us have, the lack of proper exercise, the missing self-discipline necessary for a healthy lifestyle, and so on. Also, we are just beginning to discover the meaning of genetic propensity for certain conditions like obesity or cancer or possibly even alcoholism. Why one person can eat everything in sight and neither gain weight nor have a cholesterol problem while another is very careful but has problems with both remains something of a mystery.
A more pertinent question can be raised concerning lifestyle, however, if the transplant team realizes that the person in need will not look after himself or herself after receiving a new organ. In other words, if the person is not prepared to follow a careful diet, give up alcohol or smoking, or take the immunosuppressant drugs properly, then should the team take such a person off the transplant list? There are strong arguments in favour of this position. The squandering of a scarce and expensive resource, one that another would use properly, is a major consideration in the assigning of that resource. People, even people who may have abused themselves into their present difficulties, deserve a full and equal chance to live a renewed life through a transplant, but only if they are willing to look after the gift that is given them. Such, I believe, is the traditional, Catholic notion of stewardship.
Third, and finally, we need to consider for a moment a number of issues that arise concerning living organ donations. To this point, we may have assumed that all organs are cadaver organs, that is, donated from those who have just died. Today, however, there are possibilities for people to donate an organ or a part of an organ without dying. It is not unusual, for example, for parents or siblings to donate one of their kidneys or a part of their liver to a loved one whose organs have failed. When the donor is related to the recipient, the threat of rejection is often considerably less. These operations are becoming more common and are often truly a gift of new life. But they are not without problems and I will briefly mention three.
1. The most obvious problem is the risk to the donor. He or she must go through a serious operation with the usual risks and must then live without the organ or part that has been given. Ordinarily, this does not pose a problem for the donor, but it may restrict his or her lifestyle somewhat because they would be a bit more vulnerable with, say, only one kidney.
2. There is also the pressure that may be put on relatives to donate an organ. I do not believe that there can ever be an obligation for a family member to donate a body part to another person. Most family members, it seems, are quite prepared to be generous when a loved one is in need. But there may be many reasons why donating will not be acceptable to a possible donor. One can imagine the pressure, and perhaps the guilt of refusal, for the family member who is compatible. However, I believe that a free gift, not a pressured choice which can lead to all kinds of resentment and recriminations, is the only healthy choice.
3. Lastly, one might raise the question of donating an organ to someone you do not even know! I recall a number of high school students who were prepared to do precisely this after hearing a talk about living donors. They never thought about the eventual possibilities of needing two kidneys should they have a child or a spouse who needed one! Would older people, then, be likely candidates as anonymous living donors? Little is known about what this might mean for older people who may need all their organs precisely because they are getting older. Perhaps this is one of those questions that cannot be answered at the present time. We will have to learn from those generous people who have given an organ to a loved one and are now living with the consequences. Only time will tell us what those consequences really are.