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Ethical Concerns & Organ Donation

Living or deceased donors provide human organs for transplantation as a nearly pure altruistic act. Organs cannot be sold in the United States and technical limitations make it nearly impossible to circumvent the law. Each state has its own organ procurement agency; allocation of organs is coordinated among the states by the United Network for Organ Sharing (UNOS), under contract to the U.S. Department of Health and Human Services. UNOS is governed by a 40-member Board of Directors, and one of its permanent committees focuses on ethics.

  1. Authority to Donate or Decline

    • Organ allocation starts within a state, so donation is controlled primarily by state law. All but four U.S. states and Puerto Rico adopted a Uniform Anatomical Gift Act between 2006 and the middle of 2011, with two of the remaining states' legislatures considering the act. UAGA makes any document of gift --- such as a simple declaration on a driver's license --- or stated wish not to donate legally robust. In practical terms, procurement agencies rarely enforce these statements over the objections of a family facing loss, but they can save precious time in beginning to match a donor with recipients. The greatest ethical concern is to have discussed your wishes with your family before anyone has to act at a difficult time.

    Allocation of Organs

    • UNOS maintains a separate list of recipients waiting for each organ or combination of organs. Recipients' doctors assign numerical ratings according to age, medical condition and other factors relevant to that organ system and the conditions that create the need for transplants. Recipients are prioritized on the lists by an algorithm maintained by UNOS under organ-specific protocols. Organs are first matched within the donor's state or group of states for basic characteristics. The UNOS list comes into play only if no local match is found, to extend the search outward by distance as far as that organ can travel. The lists also contain information about race, since transplants within one race are most likely to be successful. More than half of those waiting for organs are from ethnic minorities that are disproportionately likely to suffer certain organ-damaging illnesses.

    Directed Donation

    • Living donors almost always know who will receive their organs. Such pairs may be direct relatives, or if they are not good enough tissue matches, they may be matched with one or more other pairs so that more patients get organs that are more likely to work better. Each form of these exchanges has its own concerns, but most of them come down to a large component of altruistic wish to help each other and careful consideration of the risks faced. Relatives responsible for the donation of a deceased person's organs may also direct donation to anyone compatible who is already on the waiting list.

    Medical Care of Potential Donors

    • The U.S. Department of Health and Human Services policies under which UNOS functions could not be clearer: "Neither the attending physician of the decedent at death nor the physician who determines the time of the decedent's death may participate in the operative procedure for removing or transplanting an organ from the decedent." This assures that the donor and recipients have entirely separate medical teams. Until a donor is declared dead, that doctor is focused exclusively on saving the donor's life. Transplant surgeons do not work in emergency departments. They are called in to do surgery on a body that is already dead.

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