Since the early days of transplantation, ethical issues have arisen and been addressed. In the beginning there were ethical issues with regard to experimentation and new treatments being used on patients. As patient and graft survival improved, it then became unethical not to transplant.

Nations and regions vary in their current state of medical development. In less developed countries, the ethical concept of justice requires that priority must be given to general medical and health programmes. Expensive transplants can help only a few individuals.

Countries also vary in their legal, political, religious and social readiness to undertake human transplantation. Some societies have well-established criteria for ‘brain death’, others do not recognise a neurological diagnosis of death, therefore despite having the medical knowledge, cadaveric transplantation is not possible.

There is no universally accepted agreement on:

• the use of living donors
• animal donors (xenotransplantation)
• payment for organs
• indications for recipient listing
• donor suitability
• allocation of organs.

The ethical systems of even the most developed of countries are continually challenged by Transplantation. Economic considerations must be weighed against ‘the public good’. Even when consensus has been reached, there are always new or special cases which arouse controversy. Countries may learn from the experiences of others.

Use of Living Related Donors

• First live related kidney transplant between identical twins in the 1950s
• Permission was then extended to non-identical twins, subsequently to biologically related then to non-genetically related family members.
• The advantage of living donor graft survival must be weighed again the physical and psychological risks to the donor.

In most countries the ethical basis for live donation has been firmly established in law and confirmed by biological outcome. Waiting times are rising and immediacy is particularly advantageous for children. Despite improved results with cadaver donor transplants, the scarcity of human organs and the difficulty in providing cadaver organs urgently mean that the role of live donation as an ethical alternative can only increase.

Live Related Transplantation
In live transplantation, the risks and benefits are not equal since the donor bears most of the risk but the recipient receives most of the benefit. C Elliott believed that a distinction should be made between “allowing” a person to risk harm to himself and “encouraging” it: ‘Substantial payment to organ donors arguably crosses the line between allowing and encouraging’.

Conclusions

• Should we be determined to maintain life at any cost?
• This attitude can cause distress and suffering to patients, so when do we stop?
• Who do we transplant and with which organs?
• Do we consider the ageing process and our ultimate mortality enough?