Organ donation ethics

Is it permissable to donate your organs based on race? Does it matter if it is to a specific person instead?

Such are the quandries in organ transplantation, detailed in this article in the NEJM (I know it is old, I've been meaning to blog on this, but been busy).

In the first case, a man's family stipulated that, based on his racist beliefs, only whites could receive his organs. The organ allocation system complied, but it caused such an uproar that the state, Florida, passed a law banning the practice.

In the second case, a Jewish man decided to donate one of his kidneys to a Jewish child who needed a transplant, despite the fact that he did not know her. He apparently would not have donated his organ if she had not been Jewish.

Is Florida right to ban the practice of discrimination. Should the Jewish man's kidney have been accepted?

I think the second case is easy: while I find the man's insistence on only donating to a Jewish recipient unseemly, I can't see rejecting the organ. While the recipient will get the organ because she is Jewish, I don't see anyone else who is harmed. Everyone else waiting for a kidney is still on the list and someone else may get a transplant that would have gone to the girl since she is off the list. Additionally, as long as directed donation is acceptable banning donation based on race/ethnicity/religion will just encourage people not to disclose why they chose a given recipient. In addition, it seems like a bit of a slippery slope. Say this man knew the girl who needed the transplant because they went to the same synagogue, would that be unfair (since a Christian girl wouldn't have the same opportunity?).

I should note that there is some controversy about the whole idea of living people deciding to donate their organs to specific non-relatives: the procedure is not risk free and favors patients who can effectively appeal for donation to a large audience. This gives an advantage to the well-off, who are disproportionately white. My feeling is that we can accept some unfairness to minorities for the overall greater good that living related donation to non-relatives allows. Indeed, some minorities may get kidneys by virtue of others already having organs via living related donation. I don't think anyone seriously opposes the donation of kidneys among relatives on ethical grounds.

The first case is a bit tougher, but I think Florida is right to ban racially directed donation. One big difference is that living donors can direct their organs as they choose, whereas cadaveric donor's (i.e. dead ones) are allocated based on a complex system that takes into account genetic matching, acuity of need and length of waiting. Is this difference fair? Maybe, maybe not but it makes sense. Alive, I'd give a kidney for my child or sibling without a second thought, but haven't given one to a stranger as of yet. I will, though, happily donate to whoever needs it once I'm dead (if appropriate). If living donors (at least those who weren't related or even know the recipient personally) couldn't specify who their organs went to, we'd probably see a big drop in donations, although I suspect the number of living donations to strangers is low. Of course, one could argue that the inability to direct donation by race may keep racists from being (cadaveric) organ donors (ed- perhaps we could have a new donation campaign directed at racists "Donate 'em now while they'll still go to another whitey").

In addition, stipulating his organs can only go to white recipients does affirmatively discriminate against non-white patients who would have otherwise gotten the organs.

I also think the state of Florida and society need to strongly oppose outright racism, which is what donating only to another white person is. I'd feel the same way if the man had specificied only a Jewish/Catholic/born-again/etc. recipient. Of course, the living donor case comes perilously close to this line.

One other interesting thing in the article is the following

With directed donation to loved ones or friends, worries arise about the intense pressure that can be put on people to donate, leadingthose who are reluctant to do so to feel coerced. In these cases, transplantation programs are typically willing to identify a plausible medical excuse, so that the person can bow out gracefully

So if your brother "couldn't" donate a kidney to you, maybe he just didn't wan't to.

I should also note that Dr. Truog, author of the article, was head of the ICU at Boston Children's when I was there and while I didn't work with him much, made a very good impression. Unlike some "medical ethicists" who just go to meetings and listen to each other pontificate, he really takes care of patients and cares about real-life ethical issues.

UPDATE: much more on organ donation, here, from Galen's Log, someone actually involved