Editorial: Organ donation - An Enduring Gift

Michael McCabe
Issue 12, April 2004

Christopher had been crossing the road on a drizzly wet Wellington day when he was hit by two cars. He
suffered multiple injuries and was placed on life support in Intensive Care.

While it was well known that 16-year old Christopher had no love affair with schooling it soon became clear that he was much loved by his family and friends, judging by the numbers in the waiting room at Intensive Care. After a week on life-support and after a diagnosis of brain-death the decision was made to withdraw ventilation and allow him to die. The night before this happened the attending-physician asked Christopher's mother and sister if they would allow his kidneys and corneas to be donated for transplant. The family agreed and the following day Christopher's two kidneys and two corneas were transplanted into four patients at Wellington Hospital.

To make a decision to nurture the life of another and to do so in the most painful of circumstances is nothing short of heroic. And yet that is what Christopher's family did. In the depths of profound grief they offered life-giving hope to four patients who themselves were suffering from the effects of chronic pain and illness. In their pain they gave of themselves in order to heal the pain others were suffering. In the years that followed their generosity helped to bring healing and hope not only to themselves but equally to the families and friends of the patients who received the gift of new life from Christopher.

In his Address to the 18th International Congress of the Transplantation Society in August 2000, Pope John Paul II praises such selfless giving and the donation of a loved ones organs as heroic because it involves not just a matter of giving away something that belongs to us but of giving something of ourselves. He considers transplants as a wonderful advance in medical technology in recent years because they help to promote and enhance the primary goal of all medicine, namely, the service of human life. In Evangelium Vitae [n.86] he says that when they are performed in an ethically acceptable manner the gift of donated organs not only offers health and life to another but also nurtures a genuine culture of life to the sick who sometimes have no other hope.

It is estimated that around 400 people are currently on the transplant waiting list in New Zealand with the majority of these patients waiting for a kidney transplant. A principal source of transplant organs, such as kidneys, heart, liver and corneas comes from patients who have been placed on artificial respiration in Intensive Care Units and who were subsequently diagnosed with brain-stem death. Currently some 1400 patients per year die in New Zealand's 23 Intensive Care Units though not all such patients are suitable candidates for organ donation. New Zealand has one of the lowest organ donation rates in the world.

By abstracting from the individual case we can see some of the deeper ethical and moral considerations in the process of organ donation and transplantation. These include establishing brain death, obtaining informed consent, and, resource allocation issues including the choice of the recipients for the donated organs.

While the plight of those who are on the waiting list for organ transplant has been well publicized in recent times, the effects of this publicity are as yet unknown. The New Zealand Government's Health Select Committee has recently released a set of recommendations on organ donation. These include:

Additional education for health professionals involved in organ donation
Establishing and funding a national organ and tissue donation agency
Ensuring that all persons involved in organ and tissue donation and retrieval have appropriate expertise.
Developing consistent protocols for discussing organ and tissue donation with families

Recent history highlights the importance of informed consent and accordingly healthcare delivery now places great emphasis on the need for, and processes around, gaining informed consent. The complexities of the situations surrounding organ donation and organ transplantation further highlight the need for individuals and families to be properly informed so that they can then consent or decline in a free and conscientious manner. Where an individual has not previously expressed a wish to be an organ donor the process of consent becomes even more complex since it necessarily involves a patient's family. In some cases it will involve those who have enduring power of attorney, that is, the legal and moral power to speak on the patient's behalf.

The process of informed consent must be free of coercion. This means that families, after being fully informed on organ donation are free to decline permission for donation. It also requires great sensitivity on the part of the clinician charged with obtaining the consent to donate, principally because this process takes place against the backdrop of anticipatory grief and shock. Given the depth of this grief and shock and the highly technological nature of an Intensive Care Unit it is also understandable when families override a loved one's wishes to be an organ donor. That reality underscores the need for family members to communicate their wishes to their loved ones long before any emergency arises.

We need also to be sensitive to the position of the healthcare professionals in this situation. As they have worked to save the patient's life they have been deeply involved with his or her family. Perhaps they should have the option to bring in other trained professionals such as chaplains and social workers to raise the question of organ donation with the family. This would also facilitate a clear separation between the physician being involved in two discussions, namely, to withdraw clinically futile treatment, and, to obtain consent for organ donation. This would offer greater flexibility for the physician, particularly where there is family conflict over the withdrawal of treatment.

The subject of organ donation and organ transplantation is implicitly linked with resource allocation, and hence with the principle of justice. Pope John Paul II says that from a moral standpoint, an obvious principle of justice requires that the criteria for donated organs should in no way be 'discriminatory' [that is, based on age, sex, race, religion, social standing, etc.] or 'utilitarian' factors [that is, based on work capacity, social usefulness, etc.] Instead, in determining who should have precedence in receiving an organ, judgements should be made on the basis of immunological and clinical factors. Any other criterion would prove wholly arbitrary and subjective, and would fail to recognize the intrinsic value of each human person as such, a value that is independent of any external circumstances. [i]

In this edition of The Nathaniel Report we feature the personal stories of Father Brian Quin, recipient of a kidney transplant, and his donor, and brother, Alan. Their stories highlight the heroic dimensions and profound gift associated with the donation and receiving of human organs. On a somewhat different theme the feature article on stem cells anticipates and comments on the proposed development of regulations around research on human embryos in New Zealand. The linking thread in the two topics is the promotion and nurturing of the integral dignity of the human person. Human embryos and human organs must never be reduced to the status of commodities.

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[i] Pope John Paul II: Address to the 18th International Congress of the Transplantation Society

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Rev Michael McCabe, PhD
Director
The Nathaniel Centre