If the transplantation of solid organs is one of the most high-technology procedures in modern medicine, then arguably the current system of procuring natural organs from both living and cadaver donors is a relatively low-tech affair. Indeed, Prottas has described the system's role, focusing on the usual sources of cadaver organs and the circumstances under which they became available, as providing "a bridge between human tragedy and high technology."1

Whatever the degree of technology employed, however, there are important ethical issues involved in the retrieval of both organs and tissues, natural or artificial, and the discussion that follows will explore these. To the extent possible, the techniques examined will not be limited to those currently in use, but will also encompass those research approaches that are likely to be clinically validated and employed in the 21st century as a means of resolving the fundamental imbalance between supply and demand.

For readers unfamiliar with the language and literature of bioethics (the moral and value problems of the biomedical and life sciences), it may be useful to quote one of that field's founders, Daniel Callahan, in his endeavor to explain the types of relevant questions one asks:

While bioethics as a field may be understood in different ways and be enriched in different perspectives, at its heart lie some basic human questions. Three of them are paramount. What kind of person ought I be in order to live a moral life and to make good ethical decisions? What are my duties and my obligations to other individuals whose life and well-being may be affected by my actions? What do I owe to the common good, or the public interest, in my life as a member of society?2

When these general questions are placed in the context of organ procurement, a series of ethical/moral principles (or values) become relevant. Childress, who

Organ Procurement and Preservation, edited by Goran B. Klintmalm and Marlon F. Levy. © 1999 Landes Bioscience

has written extensively on this topic, would list those principles or values as " respect for persons, including their autonomous choices and actions; beneficence, including the obligation both to benefit others (positive beneficence) and to maximize good consequences-i.e., to do the greatest good for the greatest number (utility); nonmaleficence, the obligation not to inflict harm; and justice, the principle of fair and equitable distribution of benefits and burdens."3 These principles are often in conflict with each other and must be balanced, in part, by a determination of which principle is the weightiest or most compelling in a given situation. It is also important to note that ethical standards may be far more demanding than the prevailing legal standards, but are never less demanding.

These principles must also be applied against a backdrop of an inadequate number of organs to meet the needs of potential transplant recipients, a number that appears to be relatively static in the United States despite growing lists of persons registered for various types of organ transplants. This disparity and resulting scarcity can be seen in the statistics showing the U.S. national patient waiting list in mid-June 1997 with 52,962 registrations for the various types of solid organ transplants, even though only 19,410 transplants of all kinds were performed in the U.S. during the entire year of 1996.4

Finally, there is a need to clarify the term, donor. Childress has pointed out that because this term has been used to refer both to the source of the decision to donate and to the source of the organs, the latter use is inappropriate unless the two are identical.3 Most often, the source of cadaver organs made no such decision, and it is the family or some other person who is in fact the decision-maker. Our enthusiasm for altruism in the retrieval of organs should not cause us to create confusion by our use of terminology.

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