The organ business

Are we morally obligated to extend every life that we have the technological or medical ability to extend? The claim that we are underlies Ronald Munson’s book. He provides a fairly comprehensive survey of the ethical issues involved in organ transplantation in a lively style, relying on current, historical or fictional cases to illustrate many of the ethical and policy issues. He also integrates relevant medical and scientific information into the discussion.

Munson’s background makes him the right person to write this book. He is a professor of philosophy of science and medicine at the University of Missouri–St. Louis, has served as a medical ethicist on a National Institutes of Health study and a human subjects review committee and has written three novels. Yet his book is not definitive. We need to think more broadly and deeply about some of the issues he raises.

Munson makes three major claims: that we ought to increase the organ supply, that donors and recipients should be protected from exploitation, and that telling stories about individuals is morally helpful in assessing the complex issues associated with transplantation. The logic that underlies his first claim is familiar and easy to understand. Organ transplantation saves lives, even though it is a complicated practice that leaves chronic disease in its wake even in the best of circumstances. Thousands of people die every year because of the scarcity of available organs. Thus, we have a “prima facie obligation to shape policies and practices to save their lives.”

So distressing to Munson are the looming deaths of those with organ failure that he favors nearly every innovation intended to increase the organ supply, including the sale of organs. The following fictional case represents Munson’s ideal scenario for organ sale. Alice Cushman’s daughter, Karen, needs a kidney transplant. Karen’s father is dead and her mother’s kidneys turn out to be too scarred to be usable. Meanwhile, Betty Burke’s son, Chris, needs a bone marrow transplant. His insurance will pay only 70 percent of the $300,000 treatment, so his mother must raise the remaining $60,000 herself. Luckily, Betty and Alice meet in the hospital waiting room and devise a plan in which Betty pretends to be a long lost cousin and donates her kidney to Karen for the $60,000 she needs for her son.

Munson considers this an ideal case. His argument is that selling one’s nonvital organs to achieve a chosen benefit is merely an extension of allowing individuals to make decisions about the course of their lives and the risks they are willing to take. We allow people to race motorcycles and climb mountains for recreation, so we ought to allow them to take similar risks for more noble purposes such as securing needed medical care for a loved one. According to Munson, there is no moral difference between giving a kidney to one’s child and selling it if the money gained is used to secure other necessary health care for that child. “Except that money changes hands, the consent, risks, and motivation in [the Cushman-Burke] transaction are the same as in the trading and in the donation.” Munson also supports the sale of organs for other reasons, although he doesn’t make an extended argument for this position.

Munson grants that there may be risks associated with the sale of organs, including exploitation of the poor, decline in the quality of organs, decline of altruism in society, and the detrimental effects of commodifying the human body. However, he finds these insufficient deterrents when balanced against the “gain of saving thousands of lives.” He dismisses similar objections against policies of accepting donations by children, use of anencephalic newborns as donors, and use of animal and mechanical organs. After all, what “repels [opponents of these policies] may result in saving or prolonging the life of a sister, a mother, . . . a child.”

Although the logic that underlies Munson’s arguments is well accepted, it bears further scrutiny. The fact that people die because they can’t obtain an organ does not in itself prove that we have a duty to increase the organ supply. A significant increase in organs available for transplantation would have mixed results. Its positive consequences would be that more people would receive transplants, some of whom have the potential to respond very well to a transplant. In addition, some difficult allocation decisions could be avoided. For instance, we wouldn’t have to decide whether smokers should compete equally for lung transplants with nonsmokers, since there would be enough for both groups.

But increasing the organ supply would also mean that many individuals who are now considered questionable candidates would be accepted at transplant centers, and their care would be more expensive and their outcomes less satisfactory than current cases. In addition, the cost of significantly increasing the number of transplants is potentially extremely high; scarcity is now the only factor that controls the cost of these medical procedures, which range in price from $100,000 to $400,000. These costs would further burden the strained resources of private and public insurance agencies, thereby decreasing the amount of money spent on other goods (medical and social).

We should not begin the discussion by assuming that maximizing the length of life for those with organ failure is the best way to address health concerns. In fact, if our goal is to save as many people as possible, we will likely conclude that organ transplantation is not the best method. Public health initiatives would be much more effective.

Furthermore, holding up the extension of one life or 5,000 lives as the conclusive justification for any procurement policy suggests that those extended lives trump every other good in society. We know this isn’t true. Other important social values are worth protecting, even at the expense of foreseen but unintended loss of life. We are forced to acknowledge this when people go off to fight wars. We tacitly accept it when we allow people to carry guns or when budget constraints prevent us from hanging a traffic light at a busy intersection.

Munson’s second claim is that we should protect both recipients and donors from exploitation. Munson explores the case of Baby Fae, who received a baboon heart in 1984. Munson’s treatment of this case (like his discussion of Mickey Mantle in his first two chapters) is well researched and balanced. He concludes that sometimes professional ambition and even humanitarian zeal can cause well-intentioned physicians to pressure patients or their families to accept experimental treatments. That is why it is important to have government regulations and an external review of risky proposals. Munson adds that we should prove treatments safe and effective before offering them to children, unless a particular promising treatment can be tested only on children.

It would be difficult to disagree with Munson’s conclusion. We certainly ought to protect children from a researcher’s ambition. However, there is not much difference between Baby Fae’s mother and people considering standard transplantation for vital organs (heart, lung and liver) for themselves or loved ones. Many will be so frightened by the prospect of death that they will be unable to understand the risks and benefits of a proposed transplant—so they are hardly accepting the risks freely. When the results are poor, transplants can impoverish an entire family and lock some family members into caregiver roles. Professionals try to educate patients about the rigors and risks of transplantation, but know that much of what they say is not absorbed. Thus, the need to protect children involved in research is only one instance of the widespread and seemingly intractable problem of obtaining informed consent.

Avoiding the exploitation of living donors is also extremely difficult. Living donors are counseled about the risks of donation, but often this is done after they have decided to donate based on glowing reports in the media about the practice, and the spoken or unspoken understanding that donating an organ will make them heroes in their families. This past January Mike Hurewitz, a healthy 57 year old, donated 60 percent of his liver to his younger brother, Adam, at Mount Sinai Hospital in New York. Adam is now recovering and may enjoy several more years of life. Mike died of postoperative complications. Immediately following the report of this story, healthy siblings at other transplant centers backed out of scheduled surgeries. The very fact that news of this donor death changed their minds suggests that they hadn’t initially comprehended the risk, even if their surgeons had stressed it.

Desperate people are hard to educate and easy to exploit. Perhaps the best defense against such exploitation is balanced information and education about transplantation before individuals find themselves in desperate straits. The practice of organ procurement organizations encouraging high school students to sign their organ donor cards—a practice mandated by law in some states—does not qualify as balanced education.

Munson’s final claim is that we need to examine individual transplant cases because doing so keeps us connected to real people and the complex circumstances of their lives. Munson’s historical cases add this complexity to his analysis. His chapters on Mickey Mantle and Baby Fae are the best in the book. Imagining particular individuals and scenarios reminds us to remain humble and serious when we ask questions about the worth of transplantation and its social and economic costs.

However, some stories close off important conversations rather than enrich them. We are already familiar with these stories, found in television movies or feel-good segments about organ donors or recipients on the local news. Such stories amount to a kind of emotional blackmail; we can’t ask the most important question—is transplantation, in general, worth its costs?—because that would be like saying that Robby, Mickey or Karen ought to have died. Munson’s fictional stories tend to echo these one-dimensional accounts.

We must tell stories about both the good and bad sides of transplantation. One of my stories is about Tom, a lung transplant recipient who was one of my patients when I was a nurse in an intensive care unit. He lived nearly a year after his lung transplant, but never was well enough to leave the hospital. He had some good days, but he experienced a great deal of pain, anxiety and limited mobility. He also intermittently suffered from “ICU psychosis,” imagining that his nurses were purposely throwing his intravenous tubing on the floor and stepping on it. When his father would visit the unit, he would never enter his son’s hospital room, but would stand grieving his son’s slow death from outside the glass walls.

We can also tell the story of Mike Hurewitz and his untimely death, or of Barbara Tarrant, R.N., who donated a kidney to her grown son in Greenville, North Carolina, last year. She suffered a massive stroke the day after surgery, and is now confined to a nursing home, paralyzed on her left side, able to speak only a few words at a time, most of them meaningless. We could also find stories about people like Molly, whose insurance company pays for transplants but says it can’t afford to include the benefit of psychiatric medications that keep suicidal thoughts at bay.

Stories are a convenient and effective vehicle to educate the public about transplantation, but no single story by itself provides a conclusion. Perhaps it makes sense that philosophers, ethicists and scientists finally turn away from personal stories and ask questions about numbers. How many transplant recipients live five years? How many have complications?

Munson’s message, finally, is fairly traditional, differing from the mainstream only in his extreme enthusiasm for organ transplantation. His imaginative approach fails to tap the rich complexities and moral dilemmas of this practice. The most crucial question Munson doesn’t ask may be, “What do we think death is, and to what lengths should we go to delay it?” Munson seems to impart godlike qualities to modern medicine and science, as the title of his book suggests. He begins by referring to a transplant recipient as a “modern Lazarus.” He seems to imagine that there are no human goods more valuable than the continuation of physical life, and nothing to hope for beyond earthly existence.

Christian readers, among others, may find this worldview ultimately unsatisfying, and in the end unable to free us from considering the meaning of our mortality. After all, everyone brought back from “death,” whether by Jesus or by modern medicine, will eventually die again.