Human organ and tissue transplantation
Report by the Secretariat
Current issues in transplantation
Access
5. The persistent and widening gap between patients' need for organs and the number available for transplantation has become a major concern to many Member States. The supply of cadaveric organs is limited by an inadequately informed and educated public, inefficient or non-existent organizations for procuring transplant material, and cultural and religious barriers in some countries.
6. Access to transplantation is limited in low- and many medium-income countries, where the rate of transplants remains far below that of richer nations. Even between countries which have similar levels of health resources, patients' access to transplantation also varies. Moreover, for patients who have kidney failure, access to transplantation is reduced when funds are spent on other forms of treatment that are less cost-effective.
7. Access to transplantation entails more than the surgery itself, because success is measured by longer survival of the patient and a long-term improvement in the quality of life. Successful transplantation of organs and living tissues depends on continued medical follow-up and the patient's compliance with a regimen of immunosuppressive drugs. Yet the expense of immunosuppressive therapy or treatment of the resulting complications can be catastrophic for individuals, even in rich countries.
Quality and safety
8. Despite advances in the field, transplant recipients may face several avoidable risks. Donors may be inappropriately selected and tested. Sterilization methods, when applicable (as with some tissues), can be inadequate. Each of these steps can lead to the transmission from the donor to the recipient of infectious agents, from prions (in dura mater and corneas, causing sporadic Creutzfeldt- Jakob disease) to viruses such as West Nile virus, as in recently reported cases, and malignancies. The international circulation of tissue for transplantation raises new difficulties in cross-border disease control. Further, there is the risk that material for transplantation may be of poor quality. Contamination by bacteria or fungi, for instance, can result from inadequate practices in procurement, processing, storage or delivery, and lead to graft failure and severe consequences for recipients, as has been reported recently in various developed countries.
9. The removal of a kidney or a fraction of the liver or lung from a living donor is not risk-free. Several studies have reported severe long-term consequences of uninephrectomy, in particular for paid donors, in countries with weak health systems. Kidney donation by well-selected living donors with good health coverage carries negligible risk, although recently it has emerged that some former kidney donors in the United States of America are on transplant waiting lists. The outcomes of living organ donation need further assessment in each context, through donor registries and the like.
Ethical challenges
10. The growing reliance on living donors (including those who are genetically as well as emotionally unrelated to the recipient) is one of several challenges to the premises of the Guiding Principles. Globally, in 2000, nearly half of all transplanted kidneys came from living donors, a proportion that increases to more than 80% in low- and medium-income countries. Yet ensuring that living donors are acting knowingly and voluntarily, even in the absence of financial incentives, is complex. Factors such as undue influence, family pressure and the difficulty of establishing a donor's actual physical and mental capacity to give voluntary consent have to be taken into account in establishing living donor programmes. Donors must be chosen carefully in order to avoid outcomes that are unsatisfactory, not just medically but also psychologically.
11. Despite the strong tradition that organs and tissues should be regarded as gifts, some members of the transplant community and policy-makers in several countries have expressed interest in allowing financial incentives for provision of human body material in the hope of increasing access to transplantation. Indeed, although payment is illegal in almost all countries, there are numerous reports that living "donors" of transplanted kidneys are remunerated directly or indirectly in many countries. Yet paying for human organs and tissues commodifies the human body and entails the risk of using it as a tool. Paid donors are known to have been exploited in several countries. Further complications arise when tissues that were donated without compensation are collected, processed, stored and distributed (activities with costs that need to be recovered) and thus become items for which payments are made by the time they are transplanted.