Ethical conflicts in new strategies

With the advances in medicine the number of patients in need of an organ transplantation is ever increasing. Organ procurement stemming from explantations of brain-dead organ donors and living persons is by no means sufficient to meet the increasing demand. Therefore, new strategies are warranted until this unique and limited remedy becomes superfluous through new physical or chemical means of treatment or xenotransplantation. Cadaveric organ donation precludes obtaining consent of the donor to safeguard self-determination. This process poses difficulties, because only few countries could organize a nationwide living will determination. Presumed consent, which is the way out, is very much under discussion, but the legal requirements with regard to consent expression definitely influence the rate of organ procurement. Once organs are explanted the question is how to distribute them justly and supranational organizations taking care of this naturally enhance efficiency, simply because in a larger donor pool immunological matching is better and subsequently the chance of better utilization is higher. The use of other than medical criteria for organ allocations is under dispute; however, practically it has become apparent that massive imbalances could threaten the whole system by demotivating centres taking the trouble and expense to explant organs. Living donation, which is mostly performed between related persons, poses problems with regard to family structure or subsequent developments of the function of the transplanted organ. However, a particularly important and difficult task is providing full information to a living donor with regard to possible complications and the risk that he or she is taking. As an additional source cardiac arrests and situations of pre-clinical or clinically monitored dying of suitable persons have been thought of. Some experience has been collected with these so-called non-heart-beating donors. The one major problem seems to be the conversion of resuscitation efforts and the intention to save and treat these patients. On the other hand, on termination of these efforts measures for salvage and protection of the explanting organs could prematurely impede the whole therapeutic approach. As far as the explanted organs, the kidneys, are concerned, it seems to be difficult to guarantee the same quality as for the brain-dead organ donor source, who has been observed and diagnosed for hours and even days. Also, in principle the well-established brain-dead donor model might be rediscussed in the light of the non-heart-beating donor concept, which seems to be incompatible with the concept of brain death. Many legal and ethical as well as political implications have to be carefully considered on the introduction of new strategies of organ ex- and transplantation.