Expanding waiting lists have pushed healthcare professionals to find additional solutions. A variety of potential solutions, including dual transplant, use of organs with anatomical anomalies, and transplantation from hepatitis C-positive patients, are explained below. Dual transplant uses both kidneys from a single donor with impaired renal function. This technique is common in pediatric cases and could be expanded to adults as well. Successful repair of some anatomical anomalies prior to transplant have yielded positive results and could also be considered more widely. Hepatitis C is a virus causing liver disease and risk of liver failure. A few studies have investigated use of infected donor kidneys for hepatitis C-positive recipients with positive results. Recipients without hepatitis C should not receive an infected organ for fear of liver failure. Other possibilities suggested include kidney exchange and donors whose hearts have stopped beating. For more information, please see other articles devoted to these topics on our site. These donor pool expansion methods would be allocated according to a new government protocol, granting first priority to zero-antigen mismatch recipients (a measure of organ compatibility), then to patients with limited life expectancy due to transplant failure, and finally to those who have been on the waiting list longest. Results for many of these extended criteria populations look promising, both to save lives and improve quality of life. Patients should remember that extended criteria organs have higher rates of complication and failure. These risks should be weighed carefully in order to maximize the number of lives saved.

The 1984 National Organ Transplant Act forbids the sale of organs and provides a legal basis that selling parts of one’s body is unethical. Incentives for organ donation could recognize the great deed a donor has done without attaching a specific monetary value. Some “ethical incentives” proposed include a Congressional medal, partial funeral expense reimbursement, medical leave, organ exchange, and long-term donor insurance. To some, the distinction between payment and incentive may be hazy,afterall, each of these incentives has a monetary value. The authors argue that “nonmonetary recognition of donation appeals to our notions of equity and, most important, does not subvert the altruistic social good that must be preserved in a revised system of organ donation.” Maintaining the prohibition of organ sales will limit the exploitation of the poor and uphold the basic ethical principles which keep society functioning.

Dr. Elliot writes a paper describing the British brain death criteria and compares it to other countries’ standards. Most brain death standards, such as the US’, use a ‘whole brain’ approach while the UK system recognizes ‘brain-stem’ death instead. The British define brain-stem death as the “irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe,” all functions attributed to the brain stem. The ‘whole brain’ approach widens the definition to greater brain function. Because both definitions are ultimately dependent on the brain-stem, many of the same tests are used to diagnose both definitions of brain death. Some countries require further confirmatory tests, such as EEG, for whole brain death. Since EEG measures higher brain functioning, it is excluded in the British definition. Disputes over the validity of minimal activity findings in EEG have called its use into question. Both ‘whole brain’ and ‘brain-stem,’ has gained widespread acceptance globally. There is room for greater standardization amongst bodies of criteria. Previous criteria required exclusion of illnesses that could mimic brain death; they apply here as well. Elliot relies heavily on Wijdick’s “Brain Death Worldwide” paper; for more information, please see this entry in our listing.

This paper includes a discussion opener by ethicists Harris and Erin followed by additional articles by Savulescu and Richards on the regulated organ sales debate. Harris and Erin argue that the solution to the organ shortage crisis is an ethical market of organ sales. Their plan would allow a single governing geopolitical area (the UK or EU) to create a single-payer distribution network that would both distribute organs and ensure that no misconduct occurred. Distribution would be assigned according to an established formula of priority. Participants (both vendors and donors) would be resident citizens of the governing area preventing exploitation of citizens from poorer countries. Sellers in this system “would know they had saved a life and would be reasonably compensated for their risk, time, and altruism, which would be undiminished by sale.”Savulescu argues that people should have the right to decide for themselves whether or not to sell a body part. When this right is denied, it constrains anindividual’s autonomy. He feels this is a “double injustice” for those escaping poverty, as if society is saying, “You can’t have what most other people have and we are not going to let you do what you want to have those things.” In contrast, Richards calls for a clarification on the types of arguments against a regulated system for organ sales. She believes that the anti-organ sales camp has failed to distinguish between those who believe that organ sales are immoral and those who anticipate potential harm to be too great when the system is put into practice.

Continuing the discussion for a regulated kidney sales system, Dr. Arthur Matas (Professor of Surgery at University of Minnesota) outlines what the system and its oversights would look like once the 1984 Congressional Ban on organ incentives was lifted. Working within the existing government-regulated organ donor networks, Dr. Matas proposes that regionalized organ procurement organizations (OPOs) would evaluate potential kidney donors, submit the evaluation for regional crossmatch according to the national registry (UNOS) for a matching score, and then offer the organ to the highest ranking candidate in the registry. Upon acceptance, a detailed donor evaluation would be sent to the center. All bills for donor evaluation, surgery, and follow-up would be sent to the OPO, which would then bill the center for its services. Inherent in this system would be certain incentives for the donor. One proposal would offer a fixed sum, term life insurance, long-term health insurance, travel expense and time out of work reimbursements, and/or a tax deduction. Incentives have often been thought of as the morally inferior perspective, though Matas argues, “the moral high ground is to eliminate the ban on financial incentives so that we can increase the number of transplants, significantly decrease or eliminate wait-list deaths, and improve the overall survival rate and quality of life for patients with ESRD [end stage renal disease].” For earlier entries by the same author, see “The Case for Living Kidney Sales: Rationale, Objections, and Concerns.”

In two separate criminal cases, defendants had been convicted of manslaughter in the shooting deaths of victims whose families had donated their organs for transplantation after they had been declared brain dead. The New York Court of Appeals affirmed both lower court decisions, holding that the term “death” as used in state statutes encompasses cessation of functioning of the entire brain even if the heartbeat and breathing are being sustained by artificial means and that, if victims are properly diagnosed as dead, no subsequent medical procedure such as organ removal can be deemed a cause of death.