Ethical issues in organ procurement: A review for intensivists

The scarce supply of transplantable organs is the major factor limiting the growth and success of transplantation. This fact has led policy analysts to focus attention on ways to change the existing public policy drastically regarding organ procurement. Changes that decrease the emphasis on voluntarism and altruism, however, affect these values that are interwoven deeply into American culture. These changes are unlikely to occur. Moreover, people are deeply ambivalent about transplantation. On the one hand, they clearly are enamored by how doctors can restore critically ill patients to a normal life, using technologic advances. On the other hand, they are uncomfortable with the process of organ procurement, fearing that doctors will take their organs too soon or for nefarious reasons. Public opinion polls show that Americans, while supporting organ transplantation, are against policy changes that emphasize maximizing the organ supply more than voluntarism has been able to do. These facts make any radical change in the procurement system unlikely in the near future. Still, there is much that can be done within the current system to improve the organ procurement process. Improving the current system will require a better understanding of why families refuse to donate. Whereas public policy places great stress on the individual as the decision maker for donating, the familial, group nature of the real decision-making process has been all but ignored. For example, research shows that a family's knowledge of the patient's prior wishes is central to their decision. This suggests that public education should stress the importance of telling one's family what one's wishes are concerning donation rather than anonymously checking off an option on a driver's license at a motor vehicle bureau. Research and training regarding how best to inform grieving families about the possibility of donation also are needed. Currently, even among families who agree to donate, there are common complaints about the lack of information regarding brain death, the cost of donation, the effect of donation on funeral arrangements, and health care providers' insensitivity. Poor communication, rather than an informed decision not to donate, may be the cause for the high refusal rates. This suggests that better training in how to discuss organ donation with grieving families may increase consent to donation. It is ironic that in the midst of high-technologic medicine, improved communication may turn out to be the most efficient way to increase procurement and save lives.