Transplantation ethics

Organ donation and transplantation, in all forms and phases, engage clinically with anaesthesia and critical care. Although undoubtedly a major medical achievement, and of significant benefit to the recipient and some consolation to bereaved families, cadaveric donation poses a series of ethical challenges that warrant addressing by the profession if public confidence is to be maintained. The original bedrock of donation, brainstem death, was formulated at a time of medical paternalism and can be viewed today as conceptually vulnerable, anachronistic and a barrier to changing donation practice. Subsequent recruitment strategies, although understandable from a utilitarian perspective, appear insensitive to ethical principles, the law and a public expectation of transparency and professional accountability. Extending a definition of death to include anencephaly and vegetative states, elective ventilation, a return to donation after cardiac death and presumed consent are the major examples of approaches which have created significant professional divisions and highlighted a need for public consultation. Alternative solutions from stem cell technology and xenotransplantation will not realistically supplant the need for cadaveric organs within the next decade, creating an imperative for a new ethical and legal framework for donation that commands public confidence. Abandoning previous concepts of death and potentially the ‘dead-donor’ rule will predictably be problematical, but persisting in manipulation of the diagnosis of death to facilitate organ retrieval at maximal viability carries the risk of further undermining trust in organ donation and in the wider medical profession. Those members of the profession engaged in or affected by organ donation carry a responsibility to promote resolution of these complex problems.