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Organ Transplant Community Grapples With Ethical Pitfalls

When do efforts to solicit donor organs cross the line?

WEDNESDAY, Aug. 3, 2005 (HealthDay News) -- When a 31-year-old public relations executive suddenly fell ill last month in need of a complete liver transplant, well-meaning colleagues issued a press release drawing attention to her plight.

But did their plea on behalf of co-worker Shari Kurzrok, who remains hospitalized at New York University Medical Center, violate ethical boundaries or spur others to cross the line?

"I think it's fair to say that there were some activities undertaken that went a little too far," conceded Kym White, managing director of Ogilvy Public Relations Worldwide in New York, which issued the press release and helped arrange a small print advertisement seeking a liver donor with Type A or Type O blood.

White said some of the activities in which people have engaged were inappropriate, although she insists the campaign was borne of good intentions.

As the demand for donor organs in the United States continues to outstrip supply, more people are using the Internet and advertising to find donor organs. And as the safety of transplantation surgery improves, more living donors are coming forward to offer one of their kidneys or a lobe of a liver or lung.

All of this raises new ethical quandaries, according to the writers of three companion articles in the Aug. 4 issue of the New England Journal of Medicine. Who decides, for example, whether a living donor is psychologically and physically fit to donate a kidney? And how will the nation's organ transplant system ensure the fair distribution of organs to those most in need -- not simply the most vocal?

In a prepared statement, the United Network for Organ Sharing (UNOS), a private group that contracts with the federal government to administer the nation's Organ Procurement and Transplantation Network (OPTN), said it is committed to providing comprehensive information about the risks and benefits of being a living donor. In addition, it said, the OPTN has established criteria for living donor transplant programs.

Meanwhile, a proposal regarding deceased donor solicitations will go before the OPTN/UNOS board of directors this November, UNOS said in the statement.

Kurzrok's case exemplifies a practice known as "direct donation." Instead of waiting for the nation's organ transplant system to identify and procure a liver, family and friends of the Great Neck, N.Y., native took it upon themselves to help find a donor.

"Direct donation of organs from deceased donors is very problematic," said Dr. Robert Steinbrook, national correspondent for the New England Journal of Medicine.

The reason? He quoted Dr. Francis L. Delmonico, a Boston transplantation surgeon who serves as president of UNOS's executive committee: Such solicitations "can undermine the allocation system and prevent the best medical use of the organ."

Steinbrook's commentary recalls the case of a 32-year-old Houston man with liver cancer who received a directed liver last year after advertising in newspapers, on a Web site and on two highway billboards but who died eight months after the transplant.

"His controversial campaign might have encouraged a donation that would not have occurred otherwise, or diverted a liver from someone with a greater chance for long-term survival," Steinbrook recounted.

At the same time, direct donations from living donors, especially kidney donors, will continue to be an important source of organs, he said.

Across the nation, about 89,000 people were on waiting lists to receive an organ transplant as of last month and, of that group, 62,500 patients were awaiting kidney transplants, Steinbrook said. Yet only a quarter of them are expected to receive a transplant with the next year.

Living donation is helping to fill the gap between supply and demand. In 2004, just over 27,000 organ transplantations were performed, including 6,991 that involved living donors, UNOS said. Since 1988, the number of living donors has more than tripled.

The expanded use of living donors also has given rise to controversial methods of solicitation, such as the 2004 start-up of MatchingDonors.com, a venue for linking patients with potential living donors.

"What MatchingDonors is interested in doing is allowing people in need of organ transplants to find a way to find a live organ donor," explained Dr. Jeremiah Lowney, the Web site's medical director. "We're helping to try and decrease the number of people on the (waiting) list."

But like a dating service, MatchingDonors has no mechanism for ensuring the accuracy of information submitted by potential donors and recipients, noted Dr. Robert D. Truog, a professor of medical ethics and anesthesia at Harvard Medical School and author of one of the journal articles. "Given the life-or-death consequences of the procedure, organ donation should not be governed by the ethics of caveat emptor," he observed.

Great caution should be taken is assessing the benefits and risks to the living donor, urged pediatric nephrologist Dr. Julie R. Ingelfinger, the New England Journal of Medicine's deputy editor. A living donation may be appropriate if someone is willing to part with an organ and is deemed an appropriate candidate by a team of professionals, including a psychiatrist trained in transplant medicine, she said.

But suppose a 23-year-old woman who is about to get married and hopes to have children insists on donating a kidney, even though she suffers from familial nephritis, a genetic disease causing progressive kidney failure.

"I think when it's not medically safe, I think physicians are bound to do no harm," she said.

More information

The U.S. Health Resources and Services Administration can tell you more about organ donation.

SOURCES: Robert Steinbrook, M.D., national correspondent, and Julie R. Ingelfinger, M.D., deputy editor, New England Journal of Medicine, Boston; Kym White, managing director, Ogilvy Public Relations Worldwide, New York City; Dr. Jeremiah Lowney, medical director, MatchingDonors.com, Canton, Mass.; Aug. 4, 2005, New England Journal of Medicine
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