Consideration for a donation--economic aspects

This article considers the economic aspects involved in introducing and putting into operation the model proposed by the author of this article. It rests on the premise that it would be worthwhile to provide money or other economic consideration in order to encourage and hence increase donations of human organs for transplant, whether from living or deceased donors. The model is based on an official central body, which would coordinate receipt of organs from donors, payment to the donors and distribution of the organs to patients, who would not pay anything for receiving the organ and would not even have any contact with the seller-donor. The purpose of this article is to try to examine and prove, that increasing the supply of human organs, whether from living or deceased persons by providing money or some other economic incentive would not only save the lives of persons waiting for organs, but also bring about substantial financial saving to the social community in general and the health system in particular, and thereby make available additional resources for saving lives, shorten the queues and benefit the weaker levels of society. We will show this through examining the various financial costs. This covers both the expense of treating various patients who need transplants on the one hand and the estimated costs to the community, including the patients and their families, on the other hand--as well as the loss of work force to the economy, payment of pensions, care from welfare organizations, etc.

Selling organs and souls: should the state prohibit 'demeaning' practices?

It is sometimes argued that practices such as organ-selling should be prohibited because they are demeaning to the individuals involved. In this article the plausibility of such an argument is questioned. I will examine what it means to demean or be demeaned, and suggest that the mere fact that an individual is demeaning themself does not provide sufficient justification for legal prohibition. On the contrary, such laws might be argued to be demeaning.

Incentives for organ donation: some ethical issues

Objections to commerce in organs has not stopped the spread of such practice around the world. In most countries the gap between supply and demand for organs continues to increase. Kidneys from living donors are considered a valuable addition to the donor pool, and in a more acquisitive world, donor incentives are becoming thinkable, even acceptable. Current incentives for cadaver and living organ donation are reviewed from ethical and legal perspectives. A new principle of reimbursement for the living donor's risk and pain is defined and presented for debate.

Financial Incentives for Cadaveric Organ Donation

One of the main obstacles of organ transplantation all over the world is the insufficient number of available cadaveric organs. Various attempts are considered to increase the consent rate. Financial incentives as a possibility to raise the number of procured organs is a very controversial topic. Arguments for and against financial incentives are presented as well as the different models.

Commodifying life? A pilot study of opinions regarding financial incentives for organ donation

In recent years many policy proposals have been put forward to create financial incentives to encourage families to allow the harvesting of organs from their deceased relatives. While research has focused on whether these policies would actually increase the supply of organs, no research has focused on testing the ethical concerns about such policies. This article presents the findings of a pilot study conducted to determine whether people think that families should end life support of a family member in order to harvest organs if various incentive policies are in place. While the findings do not suggest a direct effect of these inducements, they do indicate that the amount of money received from organ donation is a consideration in making the decision whether to end life support. The implications of this finding for ethical debates and health policy are reviewed.

The role of commercial non-related living kidney transplants

The motivation for dialysis patients to seek early, even pre-emptive, kidney transplantation from living donors is discussed. In most countries both the waiting time and the numbers of patients awaiting kidney transplantation are increasing. Local geopolitics in Jerusalem have produced a unique window to observe present transplant practices which include widespread international marketing of kidneys from paid living donors. These have been subject of media admonitions and total rejection by professional organizations. In a modern world, traditional medical paternalism to both donors and patients should be balanced by rights for individual autonomy. Since patients, donors and medical professionals are already participating in illicit organ trading, is it not time for us to seriously consider the ethical and logistic implications of legalizing financial remuneration for kidney donation?

Cost of organ procurement and transplantation network data collection for a large transplant center

Collection of data on transplant candidates and recipients for the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) is a burden that falls primarily on the transplant centers. We examined the cost of data collection at one large transplant center. The average number of forms per year submitted more than 3 years was 5245. For the 3 years, 2.46 full time equivalents (FTEs) were committed to this data collection. Annual salaries in addition to benefits (calculated at 22% of salary) for these FTEs were US dollars 143026.22. The calculated annual cost per form submitted amounted to US dollars 27.27. Collection of data on transplant candidates and recipients is expensive and the cost of data collection should be understood before the institution of new data collection requirements for the transplant centers.

Applying the four principles

Gillon is correct that the four principles provide a sound and useful way of analysing moral dilemmas. As he observes, the approach using these principles does not provide a unique solution to dilemmas. This can be illustrated by alternatives to Gillon's own analysis of the four case scenarios. In the first scenario, a different set of factual assumptions could yield a different conclusion about what is required by the principle of beneficence. In the second scenario, although Gillon's conclusion is correct, what is open to question is his claim that what society regards as the child's best interest determines what really is in the child's best interest. The third scenario shows how it may be reasonable for the principle of beneficence to take precedence over autonomy in certain circumstances, yet like the first scenario, the ethical conclusion relies on a set of empirical assumptions and predictions of what is likely to occur. The fourth scenario illustrates how one can draw different conclusions based on the importance given to the precautionary principle.

Principlism and communitarianism

The decline in the interest in ethical theory is first outlined, as a background to the author's discussion of principlism. The author's own stance, that of a communitarian philosopher, is then described, before the subject of principlism itself is addressed. Two problems stand in the way of the author's embracing principlism: its individualistic bias and its capacity to block substantive ethical inquiry. The more serious problem the author finds to be its blocking function. Discussing the four scenarios the author finds that the utility of principlism is shown in the two scenarios about Jehovah's Witnesses but that when it comes to selling kidneys for transplantation and germline enhancement, principlism is of little help.

The virtues (and vices) of the four principles

Despite tendencies to compete for a prime place in moral theory, neither virtue ethics nor the four principles approach should claim to be superior to, or logically prior to, the other. Together they provide a more adequate account of the moral life than either can offer on its own. The virtues of principlism are clarity, simplicity and (to some extent) universality. These are well illustrated by Ranaan Gillon's masterly analysis of the cases he has provided. But the vices of this approach are the converse of its virtues: neglect of emotional and personal factors, oversimplification of the issues, and excessive claims to universality. Virtue ethics offers a complementary approach, providing insights into moral character, offering a blend of reason and emotion, and paying attention to the context of decisions. The cases provided can be more adequately understood if we combine the approaches. Both should foster the virtues of humility and magnanimity.

A virtue ethics approach to moral dilemmas in medicine

Most moral dilemmas in medicine are analysed using the four principles with some consideration of consequentialism but these frameworks have limitations. It is not always clear how to judge which consequences are best. When principles conflict it is not always easy to decide which should dominate. They also do not take account of the importance of the emotional element of human experience. Virtue ethics is a framework that focuses on the character of the moral agent rather than the rightness of an action. In considering the relationships, emotional sensitivities, and motivations that are unique to human society it provides a fuller ethical analysis and encourages more flexible and creative solutions than principlism or consequentialism alone. Two different moral dilemmas are analysed using virtue ethics in order to illustrate how it can enhance our approach to ethics in medicine.

Methods and principles in biomedical ethics

The four principles approach to medical ethics plus specification is used in this paper. Specification is defined as a process of reducing the indeterminateness of general norms to give them increased action guiding capacity, while retaining the moral commitments in the original norm. Since questions of method are central to the symposium, the paper begins with four observations about method in moral reasoning and case analysis. Three of the four scenarios are dealt with. It is concluded in the "standard" Jehovah's Witness case that having autonomously chosen the authority of his religious institution, a Jehovah's Witness has a reasonable basis on which to refuse a recommended blood transfusion. The author's view of the child of a Jehovah's Witness scenario is that it is morally required-not merely permitted-to overrule this parental refusal of treatment. It is argued in the selling kidneys for transplantation scenario that a fair system of regulating and monitoring would be better than the present system which the author believes to be a shameful failure.

In praise of unprincipled ethics

In this paper a plea is made for an unprincipled approach to biomedical ethics, unprincipled of course just in the sense that the four principles are neither the start nor the end of the process of ethical reflection. While the four principles constitute a useful "checklist" approach to bioethics for those new to the field, and possibly for ethics committees without substantial ethical expertise approaching new problems, it is an approach which if followed by the bioethics community as a whole would, the author believes, lead to sterility and uniformity of approach of a quite mindbogglingly boring kind. Moreover, much of bioethics is not concerned with identifying the principles or values appropriate to a particular issue, but rather involves analysing the arguments that are so often already in play and which present themselves as offering solutions in one direction or another. Here, as I try to show in discussion of these four scenarios, the principles allow massive scope in interpretation and are, frankly, not wonderful as a means of detecting errors and inconsistencies in argument.

Laparoscopic donor nephrectomy

Background

Living kidney donation represents an important source of organs for patients with end-stage renal failure. Over the past decade, laparoscopic donor nephrectomy has replaced the conventional open procedure in many transplant centres. Using evidence-based methods, this study examines the current status of laparoscopic donor nephrectomy.

Method

A Medline literature search (PubMed database, 1999–2002) and manual cross-referencing were performed to identify all articles relating to laparoscopic donor nephrectomy. Safety and efficacy criteria were analysed systematically for each study. Studies included were categorized using an evidence-based level grading system.

Results

Of 687 publications, 20 studies with level I–II evidence and 12 with level III evidence were analysed. Only one level I study could be identified. Level I and level II evidence suggests superiority of the laparoscopic approach in regard to postoperative analgesic consumption, hospital stay and return to work. Other safety and efficacy criteria, including donor and recipient outcomes, were similar between the two techniques.

Conclusion

Laparoscopic donor nephrectomy has gained community acceptance by physicians and patients over the past decade. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the ‘gold standard’ for donor nephrectomy in the near future.