UNOS: Don't solicit for cadaveric donation
■ A transplant ethicist says the agency missed its chance to limit directed organ donations only to family members.
By Andis Robeznieks — Posted Dec. 20, 2004
From simple classified ads declaring "I need a kidney," to sophisticated Web sites suggesting "You only need one," solicitations for organ donations are capturing the public's attention; but the United Network for Organ Sharing is worried that they may also be compromising the public's faith in the organ allocation system.
That's why, at its meeting last month, the UNOS board adopted a position statement opposing efforts to solicit and direct cadaveric organ donations from strangers to specific individuals. The board cited concerns about fairness and subverting a system designed to allocate organs on the basis of need and usefulness.
"We put a lot of stock in the allocation system," said UNOS ethics committee chair Mark D. Fox, MD, PhD. "No, it's not perfect, but it's equitable, and we're all striving to get it right."
The statement noted that UNOS "opposes any attempt by an individual transplant candidate (or his/her representatives) to solicit organ donation from a deceased donor ahead of other waiting candidates in a manner that subverts the established principles and objectives of equitable organ allocations."
It also encouraged people considering public appeals to promote the general need for organs and not to direct a donation to a specific individual.
"Organ allocation isn't a popularity contest," said Dr. Fox, a physician ethicist at the University of Oklahoma College of Medicine in Tulsa.
Dr. Fox, an internist and pediatrician, said well-intentioned friends and relatives who solicit on behalf of a patient on the organ waiting list fail to view the big picture.
"They say 'Our friend wouldn't be alive if we hadn't done this,' and I can understand that point of view," he said. "But our focus is on the 87,000 people on the waiting list, and their focus is on one person."
Dr. Fox said the position statement is meant to guide organizations in the UNOS network.
He said that, although UNOS opposes advertising for directed cadaveric donations, the ads are constitutionally protected free speech, so UNOS has no power to ban them.
Although the First Amendment may permit advertising for organs, Sheldon Zink, PhD, director of the University of Pennsylvania's Program for Transplant Policy and Ethics, said UNOS missed a chance to say directed donations should only be allowed between family members.
"I don't think it resolved anything," she said. "I thought [the statement] was extremely soft, and I was surprised that the board didn't rise to the occasion with something more."
Robert Sade, MD, a member of the AMA Council on Ethical and Judicial Affairs and a former member of the UNOS ethics committee, said the AMA doesn't have an official position on public solicitation or directed donation. He added that the UNOS statement does include a "problematic" assumption: That public solicitation for directed donations has a negative impact on the supply of organs.
"As far as I know, no one has looked at this," Dr. Sade said. "It's plausible that directed donations have no effect. And, if donors would have donated anyway, then there's an equity problem."
But, if directed donations are increasing the supply of organs, he said some may view that positively despite the apparent inequities it may create.
Dr. Zink, however, said these apparent inequities are also capturing public attention. She said she has noticed a growing backlash against people like Todd Krampitz of Houston, whose successful advertising campaign for a new liver this summer has spawned many imitators.
"At first, he was this nice guy who needed a liver, but then they turned on him and now say he jumped in line," she said.
Dr. Fox said these are issues the ethics panel has considered. He added that there is talk of limiting live organ donations to those between people who have an established relationship, but defining what that means is difficult.
He said these relations could include family members, co-workers or members of the same church. But then he said questions could arise about churches with large congregations where the donor and recipient don't even know each other.
"What kind of relationship matters? Fellow Democrat or NASCAR fan?" he asked. "That's something we're struggling with."
Dr. Fox said his "worst nightmare" would be counter-advertising with billboards saying to potential donors: "Don't give Andy your liver."