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Weekly UpdatesEXECUTIVE SUMMARY
More than 100,000 individuals are on the waiting list to receive a lifesaving transplant, but many of them will not receive the organ they need. Legislation has been passed to support organ donation--the current organ procurement system in the United States is governed by the Uniform Anatomical Gift Act of 1968 and the National Organ Transplant Act of 1984--but a shortage of donated organs remains. Potential solutions include a legalized organ market, expanded legislation, therapeutic cloning, and xenotransplantation. If no change occurs, the black market in organ procurement will continue to expand. A comprehensive approach consisting of both short-term (increased education and national paired-kidney exchange) and long-term solutions (expanded legislation to fund and promote therapeutic cloning) is presented in this essay.
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On December 23, 1954, Dr. Joseph E. Murray conducted the first successful organ transplant at Peter Bent Brigham Hospital in Boston on identical twin brothers Robert and Richard Herrick. This procedure was the culmination of an extensive research program, including a successful transplant between twin dogs. Richard Herrick lived eight years before the original kidney disease took over his transplanted kidney.
In the last five decades, surgeons have learned how to transplant virtually every vital organ in the human body. Dr. Thomas E. Starzl, a pioneering transplant surgeon at the University of Pittsburgh said: "The growth of transplantation from ground zero to its present state seems like a fairy tale, a fantasy that became reality because of the courage of our patients. The truth is that none of us in the 1950's remotely envisioned the height to which transplantation would rise and the way it has changed the face of medicine. Transplants have had trickle down effects on all aspects of society like acceptance of criteria for brain death, passage of anatomical gift acts and the growth of biomedical ethics" (Altman 2004).
Organ transplantation is one of the most significant breakthroughs in modern medicine, and that success comes with enormous demand. Today in the United States, 79,748 patients await a kidney transplant; 15,771 patients, a liver transplant; 2,807 patients, a heart transplant, and 1,901 patients, a lung transplant (UNOS 2008). The problem is simple: Not enough organs are donated to accommodate transplantation needs, despite decades of public education on the virtues of organ donation and significant legislation supporting this goal. According to the U.S. Department of Health and Human Services, the national donor waiting list has doubled in the past ten years, increasing from 46,961 to 101,953 (as of June 2009), an all-time high. In 2007 alone, 6,479 patients died waiting for a lifesaving organ (UNOS 2008).
With so many lives at stake, Americans are asking whether the United States should sanction a legal market for the buying and selling of organs. Societal norms have evolved over the past 50 years whereby Americans are granted an increasing amount of freedom over what they do with their bodies. Given these perceived increased rights, who is to stop them from selling their organs for the betterment of others? After all, such practices as surrogate pregnancy and selling bodily fluids (blood, sperm, plasma, milk) are legal. Thus, the question raised is, "Where do we draw the line?" Before addressing this issue, the essay discusses the current organ procurement process in the United States and the laws that guide it.
THE CURRENT SYSTEM
For an individual, the organ transplantation system is activated when he or she is placed on a waiting list for an organ transplant. To be placed on a waiting list, the patient must be in end-stage organ failure and have been seen by a transplant physician at a U.S. hospital where organ transplants are performed. Criteria such as the patient's urgency of need, blood type, length of time spent on the waiting list, and overall best match of the organ guide the distribution process. The United Network for Organ Sharing (UNOS) maintains a centralized computer network called UNet. UNet electronically links all transplant hospitals and organ procurement activities. When a deceased organ donor is identified, a transplant coordinator from an organ procurement organization accesses the UNet system and enters necessary medical information about the donor. The system uses this information to match candidates on the waiting list to that donor. The system then generates a ranked list of patients who are suitable to receive the organ or organs (Transplant Living 2008).
This system is governed by two landmark pieces of legislation: the Uniform Anatomical Gift Act (UAGA) of 1968 and the National Organ Transplant Act (NOTA) of 1984. UAGA regulates the procurement of cadaver organs and provides ethical and legal guidelines for organ transplantation. The act draws a clear distinction between living and deceased donors and limits its authority to cadaveric donations. UAGA provides a standardized method of donating organs and other body parts to medicine via one of two methods: An individual may predesignate his or her body for transplantation (often documented by a statement on one's driver's license), or the recipient organization may obtain consent from the closest family member at the time of the donor's death (Goodwin 2006).
Since its original passage, the act has been revised several times. In 1987, it was rewritten to clarify critical areas that were left vague in the original act. For example, under the 1987 revision, physicians have the right to honor a patient's wish to be an organ donor if the deceased's next of kin objects. In practice, however, UAGA is nonbinding without family consent because UNOS requires organ procurement organizations' (OPOs) staff to seek permission from the individual's next of kin (Altinanahtar 2004). The act was amended once again in 2006. The 2006 UAGA establishes standards for donor registries and better enables procurement organizations to gain access to documents of gift in donor registries, medical records, and records of the states' motor vehicle department, which often coordinates donor registration (NCCUSL n.d.).
In October 1984, the U.S. Congress passed the National Organ Transplant Act. It facilitates organ donation and transplantation through federal grants and by the creation of the Organ Procurement and Transplantation Network (OPTN). The act also outlaws the buying or selling of organs and the trade of organs for any source of value. It subjects violators to fines of up to $50,000 and a maximum of five years' incarceration. This act organized all organ procurement organizations into the OPTN to regulate organ distribution. The network is a not-for-profit organization (Goodwin 2006). The legislative intention was to create a transplantation system using standardized medical criteria. Toward that end, NOTA calls for the OPTN to establish a national database of patients, develop a matching process, assist the OPOs in the fair distribution of organs that could not be used locally, create and enforce uniform standards of quality in all areas of the procurement process, and publish data for public access on all areas of the current transplantation process (Altinanahtar 2004).
In light of the current donor procurement system's challenges, surgeons have developed innovative ways to help patients obtain the organs they need. Dr. Robert Montgomery, director of the Johns Hopkins Comprehensive Transplant Center, for example, has pioneered a complex new practice known as paired-kidney exchange that is changing the framework of kidney transplants. The process involves matching a patient who needs a kidney with a compatible stranger; in return, that patient must line up a friend or relative willing to donate an organ to a stranger. The transplants are done simultaneously to ensure no party backs out. The largest kidney swap was performed in April 2008 and resulted in six patients getting their desired organ and six more patients advancing on the waiting list (Bor 2008).
With the recent development of paired-kidney donations and the possibility of a national system being developed, NOTA became subject to serious questions as to what constitutes "source of value." To address those questions, in December 2007, the Charlie W. Norwood Living Organ Donation Act--intended to increase the number of patients receiving kidney transplants by making it easier for paired-kidney exchanges to take place--was passed into law. Congress acted because many transplant centers would not perform exchanges due to administrators' fear of violating NOTA. The Norwood Act ensures that the federal law does not inadvertently prohibit paired donations but rather prohibits the sale of organs from living donors (Satel 2007). It is hoped that this act will allow development of a national system whose purpose is to increase significantly the number of transplants performed. A national organ-pairing system would greatly decrease the waiting list by adding about 2,000 transplants per year (Bor 2008).
During the first kidney swaps, surgeons matched patients and donors using pencil and paper. Today, computer experts and economists are developing programs to optimize matching, employing the same mathematical techniques as those used to determine Major League Baseball schedules, airline departures, and online driving directions to ensure the best match possible (Meckler 2007).
Despite this increased access to organ donation, the waiting list has more than doubled in the past ten years. Thus, it is incumbent on policymakers and researchers in the United States to explore all options toward alleviating this crisis and providing the best medical care possible for its residents. This article presents four potential solutions and the ramifications if no additional action toward increased organ availability is taken.
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