Ethical Considerations in Cadaver Organ Transplantation

1.With the passage in the Indian Parliament of “The Transplantation of Human Organs Act 1994”  Cadaver Organ Transplantation has legal sanction in India.

2. Before embarking on transplantation of organs harvested from brain dead donors we should examine the ethics of this form of transplantation. Is it in keeping with our ancient religious philosophies?

3. Abortion or the euphemistically termed “Medical termination of pregnancy – MTP” is a good example of the dichotomy between what is legal and what is ethical. While the state sees MTP as a pragmatic solution to an exploding population many doctors refuse to carry out abortions.

The first question relates to brain death. There are two means by which death may be determined: 1) the total cessation of circulatory and pulmonary functions or 2) the total cessation of all brain functions including the brain stem. For the lay person the brain death concept may be clouded by suspicion. He or she would question whether a patient whose heart is beating but whose brain shows no activity is indeed dead.

Today medical evidence is clear that all brain dead persons are dead. In a brain dead individual the heart would stop without support. Even if the heart were supported for an indefinite period of time, the brain would never recover even its most primitive functions. This change of concept may be difficult for us to accept because we have been used to the idea that the most reliable indicator of death is a heart, which stopped and is incapable of being revived.

The second issue is whether this change of concept of death, will open the flood gates of abuse. In other words, would it be likely that in our anxiety to sustain a transplant programme, we would declare death when all criteria for brain death are not unequivocally present. This will not happen for two reasons. First, the law has intrinsic safeguards, which are more stringent than those in the UK and the USA. Second, the environment in our hospital will serve as a check to abuse.

The next concern is the donor family. Will relatives of the brain dead patient be pressurised into agreeing to organ donations? It is necessary that  we set up a mechanism to ensure that relatives are kept informed of the patient’s progress and their rights. We must ensure that the next of kin makes an informed decision in an unpressurised setting. The bereaved family must have every opportunity to opt out of donation. We should also make certain that the relatives  of potential recipients do not approach the potential donor relatives with offers of money or other forms of inducement. Strict confidentiality should be maintained about the identities of the donor and the recipients. The donor relatives should not know the identity of the donor and the recipients. The donor relatives should not know the identity of the recipients who have benefited from the harvested organs. Likewise the recipients should be unaware of donor identity. One person from the transplant team should be designated to explain and seek permission for organ donation from the potential donor relatives once brain death has been declared. The bereaved family needs to understand that “Brain death is death of the person” and that organ donation is the gift of life to another person. Studies from countries where cadaver organ transplantation is being performed, show that the donor families consider the act of organ donation as the highest form of charity, and it has given them solace and lessened the pain of their loss.