Dying to donate?
An otherwise healthy man died last week as a consequence of doing the good deed of donating part of his liver for transplant.
Mike Hurewitz, who was 54, died three days after the surgery to give part of his liver to his 57-year-old brother at Mt. Sinai Hospital in New York. His brother, who needed a liver transplant to save his life, survived the transplant.
While many transplant physicians and ethicists (including me) have cautioned aloud that living donor deaths were inevitable as the numbers of such donations increase, Hurewitz's tragedy and another death at the University of North Carolina in 1999 are the only two donor deaths reported over the five years or so of living liver donations.
But as more living donations occur, and as the procedures evolve to include organs that are more difficult to donate, how far should we go in allowing otherwise healthy people to jeopardize their health -- and even their lives -- to help save the lives of others?
The trend to living organ donation
The increasingly common use of living organ donors began with kidney transplants more than a decade ago. In fact, at many transplant centers the majority of kidney transplants are now from living donors. The justification for the increasing use of living donors is the combination of the severe shortage of donated organs, the growing waiting list for recipients, and the relative safety of donating a kidney by otherwise healthy people.
The vast majority of living donors are so-called related donors -- that is, they have a blood, family, or emotional relationship to the organ recipient. This relationship creates both the impetus to donate and the crux of the ethical worries around the donation, since related donors may be willing or feel compelled to overlook the risks of organ donation when their loved one stands to receive so great a benefit.
The problem is that while the medical benefit to the recipient is great, all the risk of the donation falls to the donor. So we must ask whether the benefit to the donor of seeing a loved one's life saved or health improved, along with the benefit of doing a remarkably good deed, is sufficient to balance the risk they are asked to undergo.
The answer may well depend on the level of risk involved, which is substantially greater for donation of a part of the liver, lung or other organs than for donating a kidney.
Making the decision to donate
Once an acceptable risk-benefit balance is established for particular living donations, the primary ethical question is whether the donor is making a voluntary decision.
We can all imagine the pressure family members might feel to come to the aid of a loved one. And even when there is little implicit or explicit pressure, potential donors may be blinded by the hoped-for benefit of their donation, and literally ignore the risk to themselves.
Sometimes we call people heroes when they expose themselves to risk in order to save others, and organ donation can certainly be heroic. But there can be a fine line between heroism and foolhardiness, and the medical profession needs to be sure it can distinguish the two.
So how far should we go with living organ donation?
It is remarkable that medicine has the means to save more lives through transplant techniques that allow living people to give up part of their life-sustaining organs for others. But no matter how impressive the successes of living organ donation, we must redouble efforts and commitment to put safety first.
The transplant community should move down that path by working collectively to learn whatever there is to know from the tragic death of Mr. Hurewitz, and by making clear that whatever benefits living organ donation has to offer, we should never expect potential donors to be dying to donate.
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