Organ donation

In recent decades, major advances have occurred in the field of organ transplantation. Success rates have improved, more patients are now considered eligible for organ grafts, and more and more cities have established transplant centers.

However, the demand for donor organs drastically exceeds the supply. Ironically, in some instances medical innovations have contributed to the shortage. Improvements in surgical technique, in the preservation of organs and in anti-rejection therapy have opened up the live-saving option of organ transplantation to thousands more patients each year. Improvements in the care of patients with advanced chronic illness have also boosted the numbers of potential organ recipients. In the United States, for example, 63,782 patients were on the National Transplant Waiting List on June 30, 1999. Despite this need, only20,961 transplants were performed the previous year, because organs were available from just 9,913 donors.

This critical shortage of donor organs is considered the number-one issue inorgan transplantation, because many more lives could have been saved. In 1998, 4,855 Americans died while awaiting organ transplants. Of those, 2,295 wereawaiting kidney transplants and 1,319 were awaiting livers. Other patients died waiting for donor hearts (767), lungs (486), kidneys and pancreases (93),intestines (45), hearts and lungs (41), and pancreases (9).

During the 1990s, the number of people on U.S. transplant waiting lists tripled, while virtually no increase was recorded in the number of organs available for transplant. It is estimated that between one-third and one-half of people now on waiting lists will die.

According to the United Network of Organ Sharing (UNOS), many myths surroundthe subject of organ donations. For example, many people believe that their medical histories make their organs unusable for transplant purposes, althoughrecent advances make it possible to use many previously unusable organs. Ifone wishes to donate one's organs, it is best to leave this decision to trained professionals who will determine it at the time of death. An organ procurement team will evaluate the eligibility of a potential donor, approach the family to seek consent, and organize the retrieval and distribution of organs.

Although surveys have indicated that a majority of people are willing to donate their organs when they die, most families refuse to grant permission whenapproached. While about 80 percent of Americans support donation, fewer than50 percent agree to organ donation if approached upon the death of a family member. Even if a donor card has been signed, doctors usually seek consent from the family before removing organs for transplant. Sometimes family membersare not ready to give up hope of a relative's recovery, sometimes there is distrust of a complex allocation system, and sometimes the family is simply overwhelmed. Many bereaved families who do consent derive considerable comfort from the fact that several lives can be saved or improved by organs and tissuegrafts from a single donor.

Statistically, men are most likely to donate organs. In 1998, 58% of organ donors were men and 42% were women. Caucasians made up about 76% of the donor pool. The largest demographic group of donors fell in the age range of 18 to 49. UNOS data showed that Midwesterners were most likely to donate.

The cost of removing organs is not be charged to either the family or the estate. Instead, it is charged to the transplant recipient, usually through health insurance or Medicare. In fact, hospitals are implementing Medicare regulations that mandate that referral for organ donation be attempted whenever a potential donor is eligible. Again, the family's consent is key; in many instances, the family is not approached and the goal of the Medicare regulations is to ensure that the family is asked whenever there is a chance that a patient would be eligible to donate. It is estimated that the Medicare regulation,implemented in 1998, is helping hospitals identify 3,000 to 4,000 potential donors annually who would otherwise have been missed. Pennsylvania implementeda similar "routine referral" program in 1995 and immediately saw a noticeable increase in organ donations.

Removal of organs will not disfigure the body nor alter its appearance (a concern of family members thinking of funeral arrangements).

Indicating your wish to donate organs for transplant will not reduce effortsto save your life. Organs will not be removed until all life-saving efforts have failed, and the organ procurement team will not be the same doctors who have tried to save you.

Your age at time of death is not an issue. Even newborns can supply much-needed organs. In fact, 25% of patients awaiting livers are under the age of ten.

If you wish to donate your organs, it is important to advise your family andloved ones of this decision. Including this wish in your will is not enough,because the organs will be unusable by the time your will is read. Many states offer potential organ donors a check-off box on the driver's license, but even when a patient has indicated in writing his or her wish to donate organs,it is customary for health care providers to seek the family's permission aswell.

Organs are especially needed from members of ethnic and racial minorities, because the risk of rejection by the body's immune system is reduced when organs are genetically similar. In addition, some minorities are more vulnerable than the general population to certain heart, lung, kidney, liver, and pancreas conditions that make transplants necessary.

You may also wish to donate your entire body for scientific research, but this is not possible if you are to donate organs. To donate your whole body to science, contact the medical school or research institution of your choice tomake the necessary arrangements.

The scarcity of organs has placed considerable pressure on the organ distribution system. The current system makes organs available locally first, then regionally, then nationally. In the spring of 1998, Donna Shalala, Secretary ofthe Department of Health and Human Services (HHS), proposed that the allocation system be modified. The system was limited by the scarcity of organs andby the time limits for organs to remain viable outside the human body. For example, there is great competition for livers because they will last 12 hours,long enough to be shipped across the country.

Secretary Shalala pointed out that the allocation system gave some patients an unfair geographical advantage. Under the local-regional system for distributing organs, a patient who lived close to an organ donor might receive that organ ahead of the patient who had the greatest medical need for the organ. The United Network for Organ Sharing, the nonprofit corporation that representsall U.S. transplant centers and matches donors and recipients, argued that the "sickest first" policy change proposed by HHS would actually increase death rates. UNOS pointed to statistics showing that the sickest transplant patients often have the poorest chance of survival.

The debate over allocation pitted large medical centers, which tend to attract the sickest patients, against smaller centers that have a more diverse mixof patients, some of them healthier. The Institute of Medicine evaluated thearguments and issued a report in 1999. The institute agreed that the currentsystem does favor healthier recipients over sicker ones but disputed the HHSargument that different waiting times in different regions of the country were burdensome. The institute recommended a new system of allocation that woulddivide the country into regions of at least 9 million people, in an effort to improve the access of sicker patients to scarce organs. It will be up to Congress to make any change in the allocation system. No matter how organs aredistributed, there aren't still aren't enough of them.

Researchers are developing new strategies to try to circumvent the shortage of organs. It is now possible for a healthy parent to donate a partial liver to his or her child. There is preliminary research showing that in some situations, it is not necessary to transplant a whole organ. Sometimes damaged tissue can be repaired by using embryonic stem cells, a process still in the early stages of study. In 1999, scientists made some advances in research to treat Parkinson's disease with fetal cells, and this has encouraged researchers that there may be applications for transplant biotechnology. Some researchersare optimistic about the potential of cloning processes to grow organs as patients need them, while other scientists are looking into the potential of combining stem cell and cloning techniques. Cloning techniques might include using animals to grow needed organs, including skin. Again, this research is still experimental and is not ready to be tested on humans.

In the United States, it is illegal to sell organs. The 1984 National Organ Transplant Act makes it against the law "for any person to knowingly acquire,receive, or otherwise transfer any human organ for valuable consideration foruse in human transplantation if the transfer affects interstate commerce." While mindful of this regulation, the state of Pennsylvania is trying to increase donations by offering an indirect financial incentive to families of organ donors. If a family agrees to organ donation, Pennsylvania pays $300 directly to the family's funeral home to help defray the costs of the funeral.

The shortage of organs for transplant is a global problem that has stimulateda variety of approaches in other countries. Austria and Belgium operate on asystem of "presumed consent." Thus, it is presumed that all citizens will want to donate organs and it is up to individuals to establish that they do notwant to be donors. Bioethicists doubt that this approach will spread becauseit requires intensive public education to ensure that consent is truly given.

In the last 20 years of the twentieth century, organ transplantation has moved from a rare procedure to, by 1994, a surgery that had been performed on a total of 300,000 people around the world. In an effort to keep up with the demand, Israel and India perform kidney transplants at a rate of $10,000 to $30,000 in United States dollars. About $500 to $2,000 of these funds go to the organ "donor." Critics argue that the price of organs in economically depressed countries taints the process of consent. Prices in Argentina run $7,000 fora cornea transplant and up to $80,000 for a liver transplant. By the early 1990s, private, for-profit transplant enterprises had been formed in Turkey, the former Yugoslavia and Russia for the export of organs to countries such asGermany, Italy, France and Cuba. A 1999 report to the Canadian Sociology andAnthropology Association showed that in 1990, Moscow imported to Germany 18,718 thymus glands, 1,172 eyeballs, 3,187 testicles, and over 700 hearts, kidneys, and lungs. The sale of organs for transplant has become so lucrative that there are fears of the involvement of organized crime syndicates in some countries. By the early 1990s, many Western European countries had passed lawsdefining informed consent and controlling the sale and purchase of organs. Bythe mid-1990s, India was under pressure to outlaw the sale of human organs.

After a study of government documents, medical journals and statements by physicians, Human Rights Watch-Asia reported that the main source of organ donation in the People's Republic of China is from prisoners facing execution.

A review of the pressures of the worldwide organ transplant market has convinced some observers of the need for regulated commercial markets. Libertariansargue that control of one's own body is an individual decision and people should be free to sell body parts. Pragmatists argue that payment will stimulate the donation of scarce organs. However, these arguments have little popularsupport in Western countries. The future of organ donation in the United States lies in a national law to fine-tune the allocation system and in medicalresearch to develop alternatives to whole organ transplantation.

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