Background and Rationale of the Study

Although the idea of organ transplantation is an old one, successful

transplantation did not occur until the Twentieth Century. When different blood types and
their respective compatibility or incompatibility, as well as a method of preserving blood,
were discovered, blood transfusions became an accepted medical procedure. They
were widely used during the First World War. Dr. Emmerich Ullmann experimented on
dogs with kidney transplants in the early 1900's. He found that the transplanted organ
functioned longer; the closer the donor and recipient were genetically related. Human
skin grafts were attempted in the late 1920's. It was found that they could be performed
without the problem of rejection between identical twins. In the early 1940's Dr. Peter
Medawar and his team experimented with rabbits. They began to understand the
immune system which exists in higher animals and human beings. Antigens, on the
surface of cells, enable higher organisms to recognize a foreign body. They stimulate
the production of antibodies which are important in fighting infection. This, however, also
causes the phenomenon of rejection in organ transplantations.
The more similar the tissues' antigens, of donor and recipient, the less likely they
are to recognize each other as alien bodies. Tissue typing and matching is based on
this. Rejection remains one of the main causes of failure in organ transplantation
because it is difficult to find completely matching tissues. New drugs (e.g. cyclosporine)
greatly ease the rejection problem. Recipients, except in the case of a transplant
between identical twins, need to take such drugs for the rest of their lives. In the case of
a successful kidney transplant, however, the costs related to the transplant and the

required drugs are cheaper than the alternative of renal dialysis. The quality of life of the
recipient is also better.
Today the transplantation of many organs between well-matched human beings
is quite successful, with the majority of recipients living five or more years. Kidney,
cornea, bone marrow and skin transplants today, for example, are considered routine
for certain conditions. Heart and lung or heart-lung transplants, liver and pancreas (or
pancreatic islets) transplants are also becoming more common. According to Dr. Robert
White, even a human head transplant (perhaps better referred to as a body transplant)
may be possible. The recipient in this case though would resemble a quadriplegic
because it would be impossible to connect the 100 to 200 million severed nerve
endings. (Varga, 211-19)
Experiments continue to be done to try to improve the technology and
possibilities regarding transplantation. For example, research is being done regarding
human cell cultures, transplants from human fetuses, including brain tissue, and from
animals to human beings. The latter includes attempts to genetically design animals
with organs that are less likely to be rejected by human beings. Some animal products
(e.g. insulin and pig heart valves) are already used regularly. Research also continues
to be done to improve artificial organs and other artificial aids to human functioning.
Since many people can benefit greatly in terms of length and quality of life from organ
and tissue transplants, the demand usually exceeds the supply. The costs related to
some organ transplants are very high as well. Therefore, many questions are raised
today regarding how best to procure more organs, how to fairly distribute limited
resources, and whether all transplants should be covered by public funds.

The ethical and legal issues related to organ and tissue procurement and
transplantation are often discussed in light of such principles as autonomy,
benevolence, non-maleficence, free and informed consent, respecting the dignity,
integrity and equality of human beings, fairness, and the common good. The JudeoChristian perspective affirms the great dignity of each human person created in the
image of God (cf. Gen 1:26-31). The various aspects, parts and functions of a human
person participate in this dignity. We are also social beings who have a responsibility as
co-creators and stewards of God's creation. "In the donation and transplantation of
human organs, respect is to be given to the rights of the donor, the recipient and the
common good of society."(CHAC, 44).

1. Ethical Issues Regarding the Donor

a) From the Deceased
In general it is seen as praiseworthy to will one's body or parts of one's body for the
benefit of others after one's death. In 1956 Pope Pius XII summed up the Catholic view
on this:
A person may will to dispose of his [or her] body and to destine it to ends that are
useful, morally irreproachable and even noble, among them the desire to aid the sick
and suffering. One may make a decision of this nature with respect to his own body with
full realization of the reverence which is due it....this decision should not be condemned
but positively justified.(quoted from Ashley and O'Rourke 1989, 305). More recently
(1985) the Pontifical Academy of Sciences stated:

Taking into consideration the important advances made in surgical techniques and in
the means to increase tolerance to transplants, this group holds that transplants
deserve the support of the medical profession, of the law, and of people in general. The
donation of organs should, in all circumstances, respect the last will of the donor, or the
consent of the family present. (MacNeil)
Such a donation can greatly benefit others and cannot harm the donor who is dead. Not
to offer such a donation can be a sign of indifference to the welfare of others. To donate,
however, is not considered obligatory. Transplantation is against some people's
consciences for religious or other reasons. (cf. LRCC, 140-2) Consideration for the
sensibilities of the survivors may also make some people hesitate to sign over their
bodies.
In any case proper respect should always be shown human cadavers. Although
they are by no means on par with a living human body/person, they once bore the
presence of a living person. The probably dying potential donor should be provided the
usual care that should be given to any critically ill or dying person. Because of a
potential conflict of interest, it is widely agreed that the transplant team should be
different from the team providing care for the potential donor, who is not to be "deprived
of life or of the essential integrity of their bodily functions.... No organs may be removed
until the donor's death has been authenticated by a competent authority other than the
recipient's physician or the transplant team."(CHAC, 44 and 46) Various parts of the
human body can often be kept in good condition for transplant purposes after the death,
irreversible cessation of all brain functions, of the donor.(Jonsen, 235-7)

The Catholic Health Association of Canada (CHAC) considers transplantations of

brain cells (presuming irreversible cessation of all brain functions of the donor) in order
to restore functions lost through disease as permissible "as long as the unique personal
identity and abilities of the recipient are not compromised in any way."
The German Bishops' Conference and the Council of the German Evangelical Church
consider the transplant of "reproductive glands" as unethical, "since it intervenes in the
genetic individuality of the human being." This does not seem to exclude transplanting
all sexual body parts, but the gonads. Any child that resulted following an ovary or
testicle transplant would have the dead donor and not the living recipient as its
biological mother or father. This would violate the rights of the child (see SCDF 1987,
23-26).
The case of the body of a pregnant woman in Germany, who had been declared brain
dead, being kept alive with the hopes of the child coming to term was recently given
some media attention. Some criticized this as not giving proper respect to the woman.
Can not this effort, however, be seen as similar in some ways to organ donation and,
therefore, as commendable? The woman had at least implicitly offered her body for the
child's sake before her fatal accident. Her family also requested this.(Associated Press)
Cases such as this also raise the question of "ordinary" and "extraordinary" means of
saving life (see below under 1.b).
The use and possible use of cadavers and "neomorts" (brain-dead individuals
maintained on life support) for a variety of purposes (transplants, research, training
medical students), perhaps even a considerable time after the person's death, has
provoked ethical and legal debate. Various concerns include respect for the dead and

their wishes, respecting the family's wishes, benefitting others and the common good. In
light of this, anyone considering donating their organs and/or body after their death,
highly commendable in itself, may wish to specify certain limits. (cf. LRCC, 113-17;
Gaylin; and CHAC, 43 and 46)

b) From Living Persons (Adults, Mentally Disabled, Minors)

Transplants between living persons raise the question whether it can ever be ethical to
mutilate one living person to benefit another. Concerning this many distinguish between
parts of the body that can regenerate (e.g. blood and bone marrow) and parts that do
not regenerate. Regarding the latter some are paired (e.g. kidneys, corneas and lungs),
whereas others are not (e.g. heart). Before transplants of organs such as kidneys were
performed, many Catholic theologians considered this unethical between living persons.
They thought it violated the Principle of Totality which allowed the sacrifice of one part or
function of the body to preserve the person's own health or life (i.e. a part could be
sacrificed for the sake of the whole body), but did not allow one person to be related to
another as a means to an end. When such transplants began in the early 1950's
ethicists gave the problem closer study.
Gerald Kelly (1956) argued that such donations which have as their purpose
helping others could be justified by the Principle of Fraternal Love or Charity provided
there was only limited harm to the donor. Some ethicists argued this did not violate the
Principle of Totality provided that functional integrity of the body was not destroyed,
even though there is some loss to anatomical (physical) integrity. Donating one of one's
kidneys could be justified for proportionate reasons, since one can function with one

healthy kidney. ("Living kidney donors constituted some 15% of the donor pool in
Canada in 1989."[LRCC, 20]) Donating one of one's functioning eyes, however, cannot
be justified, since one's ability to see (functional integrity) would be seriously impaired.
Basic to medical ethics is the Principle of Free and Informed Consent. To be properly
informed the potential living donor should be given the best available knowledge
regarding risks to him/herself, the likelihood of success/failure of the transplant and of
any alternatives. In some cases there is much pressure to donate (e.g. from family
members if one is a good match). The courts have rightly refused to compel such
donations. Motivated by charity, which includes a properly ordered love for others and
oneself, one could decide not to offer an organ. (Ashley and O'Rourke 1989, 305-8;
CHAC, 31 and 34)
The distinction of ordinary and extraordinary means is also applicable to
transplants. The Catholic Church teaches that one is obliged to use ordinary means to
preserve life, but not extraordinary means, that is, means that are very burdensome
(very painful, expensive, inconvenient, risky, or even very psychologically burdensome)
or do not offer reasonable hope of benefit, or are disproportionate (cf. SCDF 1980,
section IV; Ashley and O'Rourke 1986, Ch. 11.5; and CHAC, 52-4). Some forms of
organ and tissue transplant from a living donor, especially those involving invasive
surgery, involve considerable burden to the donor. If means are available that do not
involve such burdens, such as a matching organ from a deceased donor, these are
certainly to be preferred.
The above principles would allow in some cases such procedures as
"transplanting part of the liver from a living adult donor into a child recipient, whereafter

the adult donor's liver regenerates within a month and the child's new partial liver
develops as the child grows"(LRCC, 15), or donating one's heart if one were to
simultaneously receive a heart and lung transplant (Garrett et al., 200).
A competent adult can give free and informed consent to be or not to be a living
donor, but an incompetent person cannot. Can a guardian ethically consent for a legally
incompetent person, such as a severely mentally disabled adult or a minor, to be a living
donor? Concerning this issue some distinguish, for example, between a young child and
a mature minor's ability to comprehend the implications of donating. Regarding medical
decisions an incompetent person's guardian is to act for their benefit or best interests
and, as far as possible, their wishes, if known and reasonable. Some think children and
the mentally disabled should never be living donors. They are simply being used with a
violation of their bodily integrity, risks to their health and life, and no benefit to
themselves. An argument against their being a living donor of an organ such as a
kidney is that an alternative such as renal dialysis is often available until a suitable
deceased donor can be found. Others argue that in some cases the psychological
benefit to the donor (e.g. a child's sibling lives) could outweigh the risks (e.g. of donating
bone marrow). (LRCC, 48-50) The Catholic Health Association of Canada (CHAC) says
that, "Organ or tissue donation by minors may be permitted in certain rare situations."
Can it be ethical to have another child for transplant purposes (e.g. for a bone marrow
transplant)? Conceiving and having a child for this motive alone would involve treating
him/her as a mere means to another's benefit. This would violate the great dignity of a
person, created in God's image, who should be loved for his/her own sake.(cf. CHAC,
45; Garrett et al., 200)

Concerning the whole issue of living donors, the German Bishops' Conference and the
Council of the German Evangelical Church say:
...No one is obliged to donate tissue or an organ; therefore no one can be forced to do
so. The decision to donate one's organs while still alive can only be made by the
individual concerned personally. Not even parents are allowed to decide on an organ
donation by their child; they are allowed to give their consent only for a donation of
tissue (e.g., donation of bone-marrow). The doctor in this case has a special
responsibility because no one can control whether a donation is truly voluntary.
When a living person donates an organ as a result of a personal decision, then the
organ's transplant is to be carried out with due attention, and post-operative medical
care of the donors as well as the recipients must be provided. Further, consideration
must be given so that no problems develop in the relationship between the donor and
the recipients (dependence, excessive gratitude, guilt feeling).(375)
c) From Anencephalic Infants
Anencephalic infants are born with a major portion of the brain absent. If born alive they
die within a few days, although in rare cases some survive for weeks or months. They
can suck and cry and some argue that their degrees of consciousness or
unconsciousness may vary. According to the widely accepted criteria of death as
irreversible cessation of all brain functions, they are living human beings/persons. To
increase the likelihood of procuring viable organs from them, some would like to
redefine death in terms of partial brain death so that they could be considered dead
(although still breathing spontaneously...), or for them to be exempt from the total brain
death criteria, or to consider them non-persons. Many others, however, argue that

partial brain death criteria are invalid in light of our present knowledge and/or such an
arbitrary move would endanger other classes of living human beings and lead many
more people to refuse to sign organ donor cards. Although extraordinary means of
prolonging the life of anencephalic infants do not need to be used, they should be given
the normal care of dying persons.(cf. CHAC, 45-6; LRCC, 95-106; Garrett et al., 202;
Ashley and O'Rourke 1986, Ch. 11.2, and 1989, 311-12)
d) From Human Fetuses
Is it ethical to transplant brain or other tissues from human fetuses to benefit others (e.g.
those suffering from Parkinson's Disease)? If the fetus has died of natural causes, the
ethical issues would be similar to other transplants from the deceased. When the fetus
has died or will die as a result of procured abortion, however, other ethical issues arise.
The Catholic Church considers direct abortion (the intentional killing of an innocent
human being) to be gravely immoral. Some argue that to use tissues from a fetus killed
by abortion could be done without approving direct abortion (cf. using tissues or organs
from a murder victim). Such use, however, could "justify" abortion (i.e. to benefit others)
for many women who otherwise are unsure about having an abortion. A good end
though does not justify an evil means (see Rm 3:8). The timing of the abortion may be
influenced as well. The widespread usage of electively aborted fetuses would establish
an "institutional and economic bond between abortion centers and biomedical
science..."(Post, 14; cf. CHAC, 15, re unethical cooperation)
Some argue that transplanting fetal brain tissue would require the fetus to be still alive,
that is, the tissue would not be good for transplant purposes after the fetus has

experienced total brain death.(cf. Duncan, 16-22) Some say that other means of treating
such diseases as Parkinson's can and should be developed.(cf. Dailey)
Another issue involves consent. Anyone involved in procured abortion would not qualify
as the fetus' guardian since they hardly have his/her best interests at heart. The
Catholic Health Association of Canada (CHAC) concludes that, "Transplantations using
organs and tissues from deliberately aborted fetuses are ethically objectionable." (45; cf.
SCDF 1987, 16-18)

2. Ethical Issues Regarding the Recipient

...nobody [i.e. no potential recipient] has a claim on organs or tissue of any person,
living or dead. The sick should thus accept the tissue and organs freely offered by
others as a gift. (German Bishops..., 373)
This position is widely accepted.
Another moral issue involving the recipient is free and informed consent. A competent
person who could possibly benefit from receiving a transplant should be adequately
informed regarding the expected benefits, risks, burdens and costs of the transplant and
aftercare, and of other possible alternatives. So should the guardian(s) of an
incompetent person. A legally incompetent person who can understand some things that
are relevant to their condition, a proposed transplant, and decisions that they are
capable of making, should be informed of these in an appropriate way. Guardians
should respect the wishes, if known and reasonable, of incompetent persons in their
care. No unfair influence should be put on someone to be a transplant recipient.
Potential recipients and their families can be tempted to pressure, blackmail or bribe a

potential living donor to donate or a health care professional to give them a privileged
position on the waiting list. Such practices are unethical because they fail to properly
respect the freedom of the donor or they violate other potential recipients' rights
regarding access (cf. Garrett et al., 206-7) Recipients should also avoid any unethical
cooperation in any abuses (e.g. the organs or tissues have been procured
immorally/illegally) that are sometimes associated with transplantation.(cf. CHAC, 15
and 31; Ashley and O'Rourke 1986, 88 and 90-1; and 4.a below)
A potential transplant recipient and/or their guardian(s) could also consider their
decision in light of ordinary and extraordinary means of preserving life (see above,
under 1.b). The competent adult Jehovah Witness who refuses a life-saving blood
transfusion, for example, because this is against a tenet of their religion, can be
understood to be refusing means that would be "very burdensome" for them. Courts,
however, sometimes override the decision of natural guardians including parents when
this is judged clearly against the best interests of incompetent persons including a child
(e.g. to allow a life-saving blood transfusion to the child of Jehovah Witness parents).
This issue is more difficult when the child begins to develop his/her own value system,
but is still considered legally incompetent.(see n. 3 below under "Some Cases...")
Proper safety measures should be followed to protect transplant recipients from
receiving AIDS and hepatitis viruses, etc.(cf. LRCC, 161; and Garrett et al., 200)
3. Ethical Issues Regarding Allocation of Limited Resources
a) Criteria for Selection
Requests or the demand for human organs and tissues usually exceed what is available
or the supply. Significant practical and ethical questions regarding efficiency and

fairness arise as to how best to distribute these limited resources. On what basis should
this person rather than that person be chosen to receive a given organ? Who should
choose? These decisions are serious as they can involve who will live and who will die.
In section 4 below we will consider some ways of addressing this problem by attempting
to increase the supply of human organs and tissues. In sections 3.b and c we will
consider some alternative methods of attempting to meet some of the needs in this
area. In this section, however, we will consider some criteria for selecting which
potential transplant recipient will receive a given human organ or tissue.
A widely used and approved criterion of selection is to give priority to those who have
great need and who are expected to benefit greatly. For example, it does not make
sense to give a limited number of available organs to those who will not benefit or who
are expected to only live marginally longer but suffer much with the transplants, when
others would benefit greatly. While this criterion is widely accepted as fair, there is much
discussion about how to define and assess "benefit". Many argue that both expected
length of survival and the possibilities regarding rehabilitation should be considered.
In spite of the success of transplants, care must be taken not only that they extend life
biologically, but that they also offer the patient a real chance for a healthy life. The new
organs should add new years to life, and help to provide a new and better life.
....as a last resort a choice sometimes has to be made between a transplant
immediately available but with a very small chance of survival, and a long term
transplant offering a greater possibility of healing.(German Bishops..., 374-5)
With regard to who will likely benefit more from receiving a transplant, medical criteria
such as blood and tissue typing (i.e. who is less likely to reject the transplant), and the

absence of other life-threatening diseases, are used. Other factors such as the potential
recipient's will to live, motivation and ability to follow post-operative directions (e.g.
taking immunosuppressants), his or her family support, and the skill of the transplant
team can also be relevant to the success of a transplant.(Garrett et al., 213-216)
Potential recipients (i.e. those likely to benefit from a transplant) are registered on a
"first come, first serve" basis. This, or random methods of selection (e.g. a lottery) where
there is equal chance, is fair provided that the need and benefit are approximately the
same among potential recipients.(cf. Varga, 226; and Ashley and O'Rourke 1986, 112,
and 1989, 308)
Some argue in favor of using criteria such as social worth, and merit or demerit, to
select or prioritize potential recipients. Concerning "social worth", for example, is it fair
to give priority to a mother of young children over a single person, or to a successful
doctor over someone who is at present unemployed? Concerning merit should a retired
person who contributed a lot to the community be given priority over a young person
who has not yet proven him or herself? Regarding demerit, for example, should
someone who previously abused alcohol, smoked heavily or ate unhealthily be denied a
liver, lung or heart transplant?(cf. Altman; Moss and Siegler) Many, however, criticize
these and other criteria such as ability to pay, race, religion, gender, and age, as
involving unfair discrimination. They are said to violate the equal dignity of all human
beings. Criteria such as "social worth" are also seen by some to be too difficult and
subjective to apply efficiently and reasonably.(cf. CHAC, 30 and 45; Appleton
International Conference, 6-7; Varga, 226; Garrett et al., 216; Childress) Childress

argues as well that the criteria for selecting recipients should be open and subject to
public scrutiny.
b) Using Animals
The shortage of various human parts for transplant purposes has in part motivated
research in animal to human transplants. The use of some animal parts such as insulin
extracted from animal pancreases, catgut as absorbable sutures, and pig heart valves,
are already "accepted" medical treatments. Attempts, however, to transplant a baboon's
heart to a human infant (Baby Fae) or a pig liver to a dying woman, for example, have
aroused considerable controversy.(see LRCC, 18-19; n. 4 below under "Some
Cases..."; and Siegel) Some argue that the present state of transplants between
species does not justify such experiments which so far do not offer hope of therapeutic
benefit to the human recipients. Defenders of such experiments argue that they can be
justified if no other alternatives are available and for the knowledge gained. Some have
questioned whether such transplants involve irresponsible meddling with nature.
Various animal rights groups have protested the sacrifice of animals involved in this and
other research, which uses them as "mere means" to human welfare. Concerning organ
transplants from animals to human beings research is being done with various
immunosuppressive agents with the hope of finding a combination to overcome the
rejection problem.(Johnston) Attempts are also being made to genetically engineer and
breed new strains of some animals such as pigs so that their organs can be
transplanted into humans with less risk of rejection. If successful, the scientists involved
hope that this will overcome the large shortage of human donor organs.(Reuter;
Hanson)

Widely accepted directives for human experimentation call for both adequate
preliminary animal experimentation to minimize the risks to human subjects and that the
welfare of animals used in research be respected.(e.g. Helsinki Declaration of 1975, p.
1771) Pope John Paul II in an address to a Congress of the Pontifical Academy of
Sciences said, "...animals are at the service of man and can hence be the object of
experimentation. Nevertheless, they must be treated as creatures of God which are
destined to serve man's good, but not to be abused by him...."(p. 5) The Catholic Health
Association of Canada (CHAC) stipulates that animals involved in research are to be
properly respected and such research "is to be allowed only when other methods
involving non-living subjects are no longer helpful. When use of such subjects is
justified, pain relief must be used or suffering reduced to a minimum."(60)
With respect to tissue transplants between individuals of different species, Pope Pius
XII on May 14, 1956, spoke of the transplant of a cornea, for example, as moral, if
possible and warranted. He, however, considered the transplant of the sexual glands of
an animal to a human being as immoral. Thomas O'Donnell interprets the condemnation
of the latter as aimed at transplants that would "envision an act of attempted
generation."(104-7)
The Sacred Congregation for the Doctrine of the Faith excludes, among other things,
attempts of fertilization between human and animal gametes and to gestate human
embryos in the uteruses of animals as contrary to human dignity. It considers genetic
interventions that are therapeutic, for proportionate reasons, however, as licit.(SCDF
1987, 15-20; cf. CHAC, 60)

The Catholic Health Association of Canada (CHAC) considers transplants from living
animals to humans as
...permissible as long as these can fulfill an essentially beneficial human function in the
recipient. The human dignity of the recipient is not to be compromised in any way and
due respect is to be paid to the non-human donor in the whole transplant procedure.(46)
c) Artificial Substitutes for Tissues and Organs
The shortage of various human parts for transplant purposes has also in part motivated
research in the development of artificial and synthetic substitutes for tissues and
organs. There are a number of substances that the human body does not reject. A
number of artificial replacement technologies including false teeth, artificial limbs and
joints, hearing aids, synthetic lenses, pacemakers, mechanical and synthetic heart
valves, genetically engineered insulin and growth hormone, and renal dialysis, are
already routinely used in treatment. Other technologies such as the implantable artificial
heart are still experimental or are used temporarily with the hope of keeping the person
alive until a suitable human donor organ is found.
Artificial replacement technologies are generally very costly to develop. If they prove to
be successful and are mass produced, their long-term costs can be significantly
reduced. A number of routinely used replacement technologies such as long-term renal
dialysis, however, remain expensive. Some ethical questions concerning such costs will
be considered in section 3.d below.
Another issue is that the recipient of some artificial parts may need to make certain
psychological adjustments. Consider, for example, the implantable artificial heart (also a
heart transplant from another animal species) in light of the "popular belief that the heart

is the center of human emotions, the organ of love."(Varga, 239. Cf. ibid, 238-41; LRCC,
20-22; and Thomas and Waluchow, Case 7:3.)
The Catholic Health Association of Canada (CHAC) states that artificial substitutes for
tissues and organs are permissible provided they "can fulfill an essentially beneficial
human function in the recipient" and the "human dignity of the recipient" is not
compromised in any way.(46)
d) High Costs, Universality and Justice
The development and use of technology related to organ and tissue transplants or
artificial substitutes is expensive. For example, estimates of the costs of transplant
procedures, without complications, "range from $20,000-$30,000 for a kidney, $60,000$80,000 for a heart, and $120,000-$150,000 for a liver."(Goddard) With complications
the costs can be much higher. Such costs are beyond the means of many people, if
they are not covered by public funds, medical insurance or charity. The demand for
transplants has also increased because they have become quite effective. For example,
the one-year survival rate for all transplants is at least 70-80%; and the five-year
survival rate for heart and liver transplants is 70% and 70-80% respectively.(Goddard)
Today the issue of whether transplants and other expensive medical technologies are
cost-effective and whether public funds should cover the costs of all such procedures
for everyone who could benefit from them is being discussed a lot. It should be noted,
however, that the average cost per life year gained from a transplant (e.g. kidney) can
be significantly lower than alternative treatments (e.g. hemodialysis). In addition, the
recipient of a successful transplant often contributes much more to the economy

through work, spending and paying taxes, than if they would have died or remained ill.
(Goddard)
Other questions include: Could the large sums of money (or some of it) that is spent on
developing and using transplant technology and artificial substitutes be better used to
improve the health and quality of life of more people if spent in other ways (e.g.
providing better access to primary health care, improving education and preventative
health programs, improving the environment by further reducing pollutants, etc.)? What
percent of health care dollars should be allotted to transplant programs and related
research? Broader questions include: What per cent of public funds should be spent on
the good of health as compared to other goods? Should government spending and
public health services be limited or reduced, or should taxes be increased to provide for
more people's needs and/or wants? To what extent should transplant services and
organs be supplied to people of other countries? There are no easy answers to such
questions of distributive justice which, among other things, can affect who lives and who
dies. One can also ask how it affects us as moral agents if we do not help or save all
those we can?(cf. Ashley and O'Rourke 1989, 308-10; Engelhardt; Garrett et al., 21619; and Thomas and Waluchow, 132-4)
Parliament through the Canada Health Act (1985) has committed Canada to providing
"reasonable access" to "medically necessary" hospital and health services on a uniform
basis. Reasonable access, however, does not mean absolute access. The term
"medically necessary" is also open to interpretation.(LRCC, 124-5)
The position of the Catholic Health Association of Canada (CHAC) is: "Basic health care
needs are to be considered in the allocation of resources for transplantations, especially

when it is a question of novel procedures involving scarce organs and expensive,

limited medical facilities."(45) With respect to allocating resources in general it calls for
solidarity with sick persons, careful stewardship of God's gifts and "active participation
in the formulation of policy for the equitable distribution of health care funds in society
as a whole", among other things.(22-24)
4. Ethical Issues Regarding Procurement of Organs and Tissues
a) Buying and Selling Human Organs and Tissues
Some argue in favor of allowing human organs and tissues to be bought and sold to
increase the supply and to respect people's autonomy. Others argue against such
saying that to treat the human body and its parts as commodities violates human
dignity.(cf. LRCC, 56-62; and May, 165-7) Human tissues and organs are in fact being
sold in some places. For example, a French pharmaceutical firm buys placentas from
110 Canadian hospitals to manufacture vaccines and other blood products (Aikenhead),
and some living poor people in countries such as India sell one of their kidneys for $700
or so. In Bombay, for example, there have also been some cases of kidnapping where
victims regain consciousness to find that one of their kidneys was removed while they
were drugged.(Wallace; cf. Rinehart)
Concerning this whole issue some distinguish between human waste products such as
placentas, body parts that regenerate such as blood, and nonregenerative human
organs such as kidneys. Many distinguish profit making from covering the donor's
expenses. Paying for organs can constitute unjust moral pressure on the donor. It could
invalidate any free consent or a contract. Some also fear that the buying and selling of
organs and tissues, if it became widespread, would undermine the altruism (giving

motivated by love) and social bonding now associated with transplants. It could also
lead to organs going to the highest bidder. Equity would be violated with ability to pay
rather than medical need determining the distribution of organs. Some others, however,
argue that this could be controlled by regulating sales, and that totally forbidding the
buying and selling of human tissues and organs would drive the market underground.
Because of the controversy and ethical problems surrounding the buying and selling of
human body parts, some say that other alternatives should be pursued to increase the
supply.(cf. LRCC, 78-86; and Garrett et al., 203-4)
A World Health Organization resolution in 1989 that was eventually supported by more
than 151 nations in part, "Calls Upon Member States to take appropriate measures to
prevent the purchase and sale of human organs for transplantation..."(LRCC, 162-3 and
202-3) With respect to blood transfusions, Pope Pius XII said, "It is commendable for
the donor to refuse recompense: it is not necessarily a fault to accept it."(LRCC, 58)
Concerning the Christian vision which sees human life and the body as "a gift of the
Creator, which persons cannot dispose of as they please", the German Bishops'
Conference and the Council of the German Evangelical Church say, "This does not
exclude compensation for the expenses incurred by the donation of tissue and organs,
but it does forbid deriving profit from it."(375; cf. Chilean Bishops' Permanent
Commission, 374). The Catholic Health Association of Canada (CHAC) holds that the
buying and selling of human organs, tissues and blood "contradicts the principle of
charity which is part of the necessary justification for such transplantations."(46)
b) Media Publicity

Sometimes an organ or tissue is procured for a person by publicizing their need through
the media. This could bypass the regular transplant channels and their selecting
recipients for an available organ on the basis of greatest need and greatest likelihood of
benefit, and first come first serve (see 3.a above). On the other hand, media pleas
frequently bring in more volunteers than those required for the case being publicized.
Media publicity also increases public awareness of the need for transplants and so in
the long run should increase the supply of donated tissues and organs. Garrett et al.
argue that at this stage of medical history media publicity for a particular case should be
tolerated, but in time it should be eliminated as much as possible.(212)
c) Types of Consent (Voluntary or Expressed, Family,
Presumed, Required Request, Routine Inquiry)
Voluntary or expressed consent involves a person making known their free offer to
donate one or more of their organs and/or bodily tissue, after they have died or while
alive.(cf. 1.a and b above) Concerning cadaver donation, a person can express their
wishes by some form of advanced directives, such as by filling out the Universal Donor
Card attached to their driver's license. Free and informed consent is required when the
transplant is from a living donor. Previously expressed voluntary consent regarding a
deceased donor is the ideal because it involves an act of love and responsible
stewardship over one's body. It also communicates to others, including one's family and
health care professionals, one's wishes. In the absence of clearly expressed voluntary
consent, the family or person lawfully responsible for the body of the deceased may be
approached regarding donation. Proper respect involves due consideration of the
wishes of the deceased and their loved ones.

Many potential organs and tissues for transplantation (e.g. of brain-dead accident
victims) are lost because the person did not previously express voluntary consent and
their families were not approached about donating. Because of this and the shortage of
organs and tissues for transplantation, some have proposed other models of consent
including presumed, required request and routine inquiry, to hopefully increase the
supply. Although only a minority of deceased potential donors have signed donor cards,
surveys show that most people favor organ donation. Some argue that it is ethical to
presume consent on their behalf, unless the person while alive gave clear indications to
the contrary, since a transplant does not harm the donor after death and it can benefit
others. France, Belgium and some other countries have various forms of presumed
consent legislation in place. People can opt out by registering their intention not to be a
donor. Questions concerning this approach include: Should minors and the mentally
disabled be included? To what extent should health care professionals check to see if
the person has expressed a wish not to donate? Can not this be a form of exploiting
human ignorance and weakness (cf. people ignorant that they can opt out or too
lackadaisical to do so)?
Required request requires hospitals to develop protocols to ensure that families of
potential donors are actually asked to donate. Routine inquiry requires hospitals to
develop protocols to ensure that families of undeclared potential donors have the
opportunity to donate - people tend to react more positively when offered a choice.
Some have criticized these approaches as not allowing professional discretion. Many
health professionals are reluctant to approach families who have just lost a loved one
about transplantation. This is considered a major barrier to increasing the supply of

organs and tissues. Most families though do not object to being approached. Required
request or routine inquiry has been widely endorsed in the United States as a preferred
public policy option when compared to a free or regulated market of organ and tissue
sales or a presumed consent approach. It is seen as more respectful of altruism, familial
sentiments and religious interests. It can also help the bereavement process by making
something positive come out of the death. Some significant increases in organ and
tissue donation have been recorded where this policy is in place. A few jurisdictions also
allow presumed consent following required inquiry if the family did not object.
The Law Reform Commission of Canada recommends maintaining and strengthening
the present express consent model in Canada with hospitals implementing routineinquiry protocols. These, however, are to recognize professional discretion not to ask in
cases where this would clearly be inappropriate.(LRCC, 39-46, 145-39, and 176-82; cf.
Varga, 221-2; Garrett et al., 210-11; Ashley and O'Rourke 1989, 310; and May, 167-8)
d) Fears, Confusion and the Need for Education
There is a need for education of the general public and many health care professionals
concerning the whole area of organ and tissue transplants. Many people are not well
informed of the needs, the shortage of organs and tissues, and the great potential
benefit of many people for transplants. Many have unfounded fears or reservations or
are confused about some of the issues of being a donor. In a recent United States
survey, "the two most common reasons given for not permitting organ donation were (1)
they might do something to me before I am really dead; (2) doctors might hasten my
death."(LRCC, note 226) This shows ignorance of standard policy and procedure

concerning transplants. These include strict criteria for determining total brain death and
the separation of the ill or dying patient's health care team and the transplant team.
Although surveys show that most people think transplantation is a good thing, only a
minority sign an organ donor card. Why? First of all, many are not fully aware of the
advantages of this type of voluntary expressed consent.(see section 4.c above) Some
people may be unwilling to think about their own mortality, an inevitable fact, or be
superstitious. For example, they may mistakenly think that signing a donor card will
increase their chance of a fatal accident. Some may have concerns about the mutilation
of their body. Organs and tissues, however, are carefully removed and incisions are
closed, so that it will not be apparent to anyone viewing the body that organs or tissues
have been donated.(HOPE, 3) Also,
Some people wonder what will happen to their bodies if at death they donate an organ.
The truth is that every earthly body decays. Therefore, the alternative is between an
organ decomposing or serving to keep an other human being alive. We Christians
believe, as St Paul tells us, that our corruptible body will be transformed into a spiritual
body for the glory of God (cf. 1 Cor 15:35-53)(Chilean Bishops' Permanent Conference,
375)
Some people may also not realize that they can specify limits on an organ donor form
regarding the use of their body (e.g. which organs they may or may not wish to donate).
People should be encouraged to consider organ and tissue donation as a "legacy of
love", as an incarnate form of "CHARITY AFTER DEATH."(Wolak, 18)
Health care professionals also need to be educated about the meaning of organ
and tissue donation.(CHAC, 43) Some have unfounded reservations about approaching

individuals or families to consider organ and tissue donation. It is important that some
members of the health care team be trained in approaching potential donors and their
families in a sensitive way. They need to be able to provide the necessary personal and
social support regarding the grieving process.(cf. Batten) Some health care
professionals also need to learn that properly respecting the dead human body is a
requirement of our humanness. Along these lines some medical schools offer services
of remembrance and gratitude before and after dissecting human cadavers.(Lynch,
1018) Care needs to be taken, too, regarding the language one uses about the dead.
For example, "harvesting the dead" connotes "taking" and is repugnant, whereas
"donation" connotes "giving" and is dignified.(cf. Belk) In order to increase the potential
for transplants, some health care professionals have a special responsibility with regard
to raising the general level of consciousness of the needs. This should be done in a way
that always properly respects patients' rights of confidentiality and that does not detract
from communicating other pressing health care issues. "The public is entitled to be
accurately

informed

about

the

medical

progress

and

implications

of

transplantation."(CHAC, 47; cf. German Bishops..., 376)

Conclusion
A number of the many ethical issues concerning organ and tissue transplants have
been treated in this paper. These issues concern the donor, the recipient, the allocation
of limited resources, and the means of procuring organs and tissues. Although there
have been some abuses in this field, and there are some areas of controversy, I would
like to conclude with a positive note.

Organ donation, carried out under proper conditions, is a beautiful and modern
expression of Christian charity: it gives dignity to the person who in death becomes a
life-support for another; it shows noble concern for the respect of the life of others; and it
implies a sense of communion with humanity. The Gospel proclaims that there is no
greater love than to give one's life for another (cf. Jn 15:13). Jesus welcomes the good
done to another as though it were done to himself (cf. Matt 25).(Chilean Bishops'
Permanent Commission, 375)