organ and tissue transplants

7/28/2019 Organ and Tissue Transplants

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ORGAN AND TISSUE TRANSPLANTS: SOME ETHICAL

ISSUES

Paul Flaman

(St. Joseph's College, University of Alberta,

Edmonton, Canada)

Introduction

1. Ethical Issues Regarding the Donor

a) From the Deceased

b) From Living Persons (Adults, Mentally Disabled,

Minors)

c) From Anencephalic Infants

d) From Human Fetuses

2. Ethical Issues Regarding the Recipient

3. Ethical Issues Regarding Allocation of LimitedResources

a) Criteria for Selection

b) Using Animals

c) Artificial Substitutes for Tissues and Organs

d) High Costs, Universality and Justice

4. Ethical Issues Regarding Procurement of Organs

and Tissues

a) Buying and Selling Human Organs and Tissues

b) Media Publicity

c) Types of Consent (Voluntary or Expressed,Family, Presumed, Required Request, Routine

Inquiry)

d) Fears, Confusion and the Need for Education

Conclusion

Some Cases and Questions For Discussion

Introduction

Although the idea of organ transplantation is an

old one, successful transplantation did not occur

until the Twentieth Century. When different blood

types and their respective compatibility or

incompatibility, as well as a method of preserving

blood, were discovered, blood transfusions

became an accepted medical procedure. They

were widely used during the First World War. Dr.

Emmerich Ullmann experimented on dogs with

kidney transplants in the early 1900's. He found

that the transplanted organ functioned longer, the

closer the donor and recipient were genetically

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related. Human skin grafts were attempted in the

late 1920's. It was found that they could be

performed without the problem of rejection

between identical twins. In the early 1940's Dr.

Peter Medawar and his team experimented with

rabbits. They began to understand the immune

system which exists in higher animals and human

beings. Antigens, on the surface of cells, enable

higher organisms to recognize a foreign body. They

stimulate the production of antibodies which are

important in fighting infection. This, however, also

causes the phenomenon of rejection in organ

transplantations.

The more similar the tissues' antigens, of donor

and recipient, the less likely they are to recognize

each other as alien bodies. Tissue typing and

matching is based on this. Rejection remains oneof the main causes of failure in organ

transplantation because it is difficult to find

completely matching tissues. New drugs (e.g.

cyclosporine) greatly ease the rejection problem.

Recipients, except in the case of a transplant

between identical twins, need to take such drugs

for the rest of their lives. In the case of a successful

kidney transplant, however, the costs related to

the transplant and the required drugs are cheaper

than the alternative of renal dialysis. The quality of

life of the recipient is also better.

Today the transplantation of many organs

between well-matched human beings is quite

successful, with the majority of recipients living

five or more years. Kidney, cornea, bone marrow

and skin transplants today, for example, are

considered routine for certain conditions. Heart

and lung or heart-lung transplants, liver and

pancreas (or pancreatic islets) transplants are also

becoming more common. According to Dr. Robert

White, even a human head transplant (perhaps

better referred to as a body transplant) may be

possible. The recipient in this case though would

resemble a quadriplegic because it would be

impossible to connect the 100 to 200 million

severed nerve endings.(Varga, 211-19)

Experiments continue to be done to try to improve

the technology and possibilities regarding

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transplantation. For example, research is being

done regarding human cell cultures, transplants

from human fetuses, including brain tissue, and

from animals to human beings. The latter includes

attempts to genetically design animals with organs

that are less likely to be rejected by human beings.

Some animal products (e.g. insulin and pig heart

valves) are already used regularly. Research also

continues to be done to improve artificial organs

and other artificial aids to human functioning.

Since many people can benefit greatly in terms of

length and quality of life from organ and tissue

transplants, the demand usually exceeds the

supply. The costs related to some organ

transplants are very high as well. Therefore, many

questions are raised today regarding how best to

procure more organs, how to fairly distributelimited resources, and whether all transplants

should be covered by public funds.

The ethical and legal issues related to organ and

tissue procurement and transplantation are often

discussed in light of such principles as autonomy,

benevolence, non-maleficence, free and informed

consent, respecting the dignity, integrity and

equality of human beings, fairness, and the

common good. The Judeo-Christian perspective

affirms the great dignity of each human personcreated in the image of God (cf. Gen 1:26-31). The

various aspects, parts and functions of a human

person participate in this dignity. We are also

social beings who have a responsibility as co-

creators and stewards of God's creation. "In the

donation and transplantation of human organs,

respect is to be given to the rights of the donor,

the recipient and the common good of

society."(CHAC, 44)

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1. Ethical Issues Regarding the Donor

a) From the Deceased

In general it is seen as praiseworthy to will one's

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body or parts of one's body for the benefit of

others after one's death. In 1956 Pope Pius XII

summed up the Catholic view on this:

A person may will to dispose of his [or her] body

and to destine it to ends that are useful, morally

irreproachable and even noble, among them the

desire to aid the sick and suffering. One may make

a decision of this nature with respect to his own

body with full realization of the reverence which is

due it....this decision should not be condemned

but positively justified.(quoted from Ashley and

O'Rourke 1989, 305)

More recently (1985) the Pontifical Academy of

Sciences stated:

Taking into consideration the important advancesmade in surgical techniques and in the means to

increase tolerance to transplants, this group holds

that transplants deserve the support of the

medical profession, of the law, and of people in

general. The donation of organs should, in all

circumstances, respect the last will of the donor,

or the consent of the family present.(MacNeil)

Such a donation can greatly benefit others and

cannot harm the donor who is dead. Not to offer

such a donation can be a sign of indifference tothe welfare of others. To donate, however, is not

considered obligatory. Transplantation is against

some people's consciences for religious or other

reasons.(cf. LRCC, 140-2) Consideration for the

sensibilities of the survivors may also make some

people hesitate to sign over their bodies.

In any case proper respect should always be

shown human cadavers. Although they are by no

means on par with a living human body/person,

they once bore the presence of a living person.

The probably dying potential donor should be

provided the usual care that should be given to

any critically ill or dying person. Because of a

potential conflict of interest, it is widely agreed

that the transplant team should be different from

the team providing care for the potential donor,

who is not to be "deprived of life or of the

essential integrity of their bodily functions.... No

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organs may be removed until the donor's death

has been authenticated by a competent authority

other than the recipient's physician or the

transplant team."(CHAC, 44 and 46) Various parts

of the human body can often be kept in good

condition for transplant purposes after the death,

irreversible cessation of all brain functions, of the

donor.(Jonsen, 235-7)

The Catholic Health Association of Canada (CHAC)

considers transplantations of brain cells

(presuming irreversible cessation of all brain

functions of the donor) in order to restore

functions lost through disease as permissible "as

long as the unique personal identity and abilities of

the recipient are not compromised in any

way."(45)

The German Bishops' Conference and the Council

of the German Evangelical Church consider the

transplant of "reproductive glands" as unethical,

"since it intervenes in the genetic individuality of

the human being."(374) This does not seem to

exclude transplanting all sexual body parts, but the

gonads. Any child that resulted following an ovaryor testicle transplant would have the dead donor

and not the living recipient as its biological mother

or father. This would violate the rights of the child

(see SCDF 1987, 23-26).

The case of the body of a pregnant woman in

Germany, who had been declared brain dead,

being kept alive with the hopes of the child coming

to term was recently given some media attention.

Some criticized this as not giving proper respect to

the woman. Can not this effort, however, be seen

as similar in some ways to organ donation and,

therefore, as commendable? The woman had at

least implicitly offered her body for the child's sake

before her fatal accident. Her family also

requested this.(Associated Press) Cases such as

this also raise the question of "ordinary" and

"extraordinary" means of saving life (see below

under 1.b).

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The use and possible use of cadavers and

"neomorts" (brain-dead individuals maintained on

life support) for a variety of purposes (transplants,

research, training medical students), perhaps even

a considerable time after the person's death, has

provoked ethical and legal debate. Various

concerns include respect for the dead and their

wishes, respecting the family's wishes, benefitting

others and the common good. In light of this,

anyone considering donating their organs and/or

body after their death, highly commendable in

itself, may wish to specify certain limits.(cf. LRCC,

113-17; Gaylin; and CHAC, 43 and 46)

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b) From Living Persons (Adults, Mentally Disabled,

Minors)

Transplants between living persons raise thequestion whether it can ever be ethical to mutilate

one living person to benefit another. Concerning

this many distinguish between parts of the body

that can regenerate (e.g. blood and bone marrow)

and parts that do not regenerate. Regarding the

latter some are paired (e.g. kidneys, corneas and

lungs), whereas others are not (e.g. heart). Before

transplants of organs such as kidneys were

performed, many Catholic theologians considered

this unethical between living persons. They

thought it violated the Principle of Totality whichallowed the sacrifice of one part or function of the

body to preserve the person's own health or life

(i.e. a part could be sacrificed for the sake of the

whole body), but did not allow one person to be

related to another as a means to an end. When

such transplants began in the early 1950's ethicists

gave the problem closer study.

Gerald Kelly (1956) argued that such donations

which have as their purpose helping others could

be justified by the Principle of Fraternal Love or

Charity provided there was only limited harm to

the donor. Some ethicists argued this did not

violate the Principle of Totality provided that

functional integrity of the body was not destroyed,

even though there is some loss to anatomical

(physical) integrity. Donating one of one's kidneys

could be justified for proportionate reasons, since

one can function with one healthy kidney. ("Living

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kidney donors constituted some 15% of the donor

pool in Canada in 1989."[LRCC, 20]) Donating one

of one's functioning eyes, however, can not be

justified, since one's ability to see (functional

integrity) would be seriously impaired.

Basic to medical ethics is the Principle of Free and

Informed Consent. To be properly informed the

potential living donor should be given the best

available knowledge regarding risks to him/herself,

the likelihood of success/failure of the transplant

and of any alternatives. In some cases there is

much pressure to donate (e.g. from family

members if one is a good match). The courts have

rightly refused to compel such donations.

Motivated by charity, which includes a properly

ordered love for others and oneself, one could

decide not to offer an organ.(Ashley and O'Rourke1989, 305-8; CHAC, 31 and 34)

The distinction of ordinary and extraordinary

means is also applicable to transplants. The

Catholic Church teaches that one is obliged to use

ordinary means to preserve life, but not

extraordinary means, that is, means that are very

burdensome (very painful, expensive,

inconvenient, risky, or even very psychologically

burdensome) or do not offer reasonable hope of

benefit, or are disproportionate (cf. SCDF 1980,section IV; Ashley and O'Rourke 1986, Ch. 11.5;

and CHAC, 52-4). Some forms of organ and tissue

transplant from a living donor, especially those

involving invasive surgery, involve considerable

burden to the donor. If means are available that

do not involve such burdens, such as a matching

organ from a deceased donor, these are certainly

to be preferred.

The above principles would allow in some cases

such procedures as "transplanting part of the liver

from a living adult donor into a child recipient,

whereafter the adult donor's liver regenerates

within a month and the child's new partial liver

develops as the child grows"(LRCC, 15), or

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donating one's heart if one were to simultaneously

receive a heart and lung transplant (Garrett et al.,

200).

A competent adult can give free and informed

consent to be or not to be a living donor, but an

incompetent person cannot. Can a guardian

ethically consent for a legally incompetent person,

such as a severely mentally disabled adult or a

minor, to be a living donor? Concerning this issue

some distinguish, for example, between a young

child and a mature minor's ability to comprehend

the implications of donating. Regarding medical

decisions an incompetent person's guardian is to

act for their benefit or best interests, and, as far as

possible, their wishes, if known and reasonable.

Some think children and the mentally disabled

should never be living donors. They are simplybeing used with a violation of their bodily integrity,

risks to their health and life, and no benefit to

themselves. An argument against their being a

living donor of an organ such as a kidney, is that an

alternative such as renal dialysis is often available

until a suitable deceased donor can be found.

Others argue that in some cases the psychological

benefit to the donor (e.g. a child's sibling lives)

could outweigh the risks (e.g. of donating bone

marrow).(LRCC, 48-50) The Catholic Health

Association of Canada (CHAC) says that, "Organ ortissue donation by minors may be permitted in

certain rare situations."(44)

Can it be ethical to have another child for

transplant purposes (e.g. for a bone marrow

transplant)? Conceiving and having a child for this

motive alone would involve treating him/her as a

mere means to another's benefit. This would

violate the great dignity of a person, created in

God's image, who should be loved for his/her own

sake.(cf. CHAC, 45; Garrett et al., 200)

Concerning the whole issue of living donors, the

German Bishops' Conference and the Council of

the German Evangelical Church say:

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...No one is obliged to donate tissue or an organ;

therefore no one can be forced to do so. The

decision to donate one's organs while still alive can

only be made by the individual concerned

personally. Not even parents are allowed to decide

on an organ donation by their child; they are

allowed to give their consent only for a donation

of tissue (e.g., donation of bone-marrow). The

doctor in this case has a special responsibility

because no one can control whether a donation is

truly voluntary.

When a living person donates an organ as a result

of a personal decision, then the organ's transplant

is to be carried out with due attention, and post-

operative medical care of the donors as well as the

recipients must be provided. Further,consideration must be given so that no problems

develop in the relationship between the donor and

the recipients (dependence, excessive gratitude,

guilt feeling).(375)

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c) From Anencephalic Infants

Anencephalic infants are born with a major portion

of the brain absent. If born alive they die within a

few days, although in rare cases some survive for

weeks or months. They can suck and cry and some

argue that their degrees of consciousness or

unconsciousness may vary. According to thewidely accepted criteria of death as irreversible

cessation of all brain functions, they are living

human beings/persons. To increase the likelihood

of procuring viable organs from them, some would

like to redefine death in terms of partial brain

death so that they could be considered dead

(although still breathing spontaneously...), or for

them to be exempt from the total brain death

criteria, or to consider them non-persons. Many

others, however, argue that partial brain death

criteria are invalid in light of our present

knowledge and/or such an arbitrary move would

endanger other classes of living human beings and

lead many more people to refuse to sign organ

donor cards. Although extraordinary means of

prolonging the life of anencephalic infants do not

need to be used, they should be given the normal

care of dying persons.(cf. CHAC, 45-6; LRCC, 95-

106; Garrett et al., 202; Ashley and O'Rourke 1986,

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d) From Human Fetuses

Is it ethical to transplant brain or other tissues

from human fetuses to benefit others (e.g. those

suffering from Parkinson's Disease)? If the fetus

has died of natural causes, the ethical issues would

be similar to other transplants from the deceased.

When the fetus has died or will die as a result of

procured abortion, however, other ethical issues

arise. The Catholic Church considers direct

abortion (the intentional killing of an innocent

human being) to be gravely immoral. Some argue

that to use tissues from a fetus killed by abortion

could be done without approving direct abortion(cf. using tissues or organs from a murder victim).

Such use, however, could "justify" abortion (i.e. to

benefit others) for many women who otherwise

are unsure about having an abortion. A good end

though does not justify an evil means (see Rm 3:8).

The timing of the abortion may be influenced as

well. The widespread usage of electively aborted

fetuses would establish an "institutional and

economic bond between abortion centers and

biomedical science..."(Post, 14; cf. CHAC, 15, re

unethical cooperation)

Some argue that transplanting fetal brain tissue

would require the fetus to be still alive, that is, the

tissue would not be good for transplant purposes

after the fetus has experienced total brain

death.(cf. Duncan, 16-22) Some say that other

means of treating such diseases as Parkinson's can

and should be developed.(cf. Dailey)

Another issue involves consent. Anyone involved

in procured abortion would not qualify as the

fetus' guardian since they hardly have his/her best

interests at heart. The Catholic Health Association

of Canada (CHAC) concludes that,

"Transplantations using organs and tissues from

deliberately aborted fetuses are ethically

objectionable." (45; cf. SCDF 1987, 16-18)

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(45; 1987, 16-18.)

2. Ethical Issues Regarding the Recipient

...nobody [i.e. no potential recipient] has a claim

on organs or tissue of any person, living or dead.

The sick should thus accept the tissue and organs

freely offered by others as a gift.(German

Bishops..., 373)

This position is widely accepted.

Another moral issue involving the recipient is free

and informed consent. A competent person who

could possibly benefit from receiving a transplant

should be adequately informed regarding the

expected benefits, risks, burdens and costs of the

transplant and aftercare, and of other possiblealternatives. So should the guardian(s) of an

incompetent person. A legally incompetent person

who can understand some things that are relevant

to their condition, a proposed transplant, and

decisions that they are capable of making, should

be informed of these in an appropriate way.

Guardians should respect the wishes, if known and

reasonable, of incompetent persons in their care.

No unfair influence should be put on someone to

be a transplant recipient. Potential recipients and

their families can be tempted to pressure,blackmail or bribe a potential living donor to

donate or a health care professional to give them a

privileged position on the waiting list. Such

practices are unethical because they fail to

properly respect the freedom of the donor or they

violate other potential recipients' rights regarding

access (cf. Garrett et al., 206-7) Recipients should

also avoid any unethical cooperation in any abuses

(e.g. the organs or tissues have been procured

immorally/illegally) that are sometimes associated

with transplantation.(cf. CHAC, 15 and 31; Ashley

and O'Rourke 1986, 88 and 90-1; and 4.a below)

A potential transplant recipient and/or their

guardian(s) could also consider their decision in

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light of ordinary and extraordinary means of

preserving life (see above, under 1.b). The

competent adult Jehovah Witness who refuses a

life-saving blood transfusion, for example, because

this is against a tenet of their religion, can be

understood to be refusing means that would be

"very burdensome" for them. Courts, however,

sometimes override the decision of natural

guardians including parents when this is judged

clearly against the best interests of incompetent

persons including a child (e.g. to allow a life-saving

blood transfusion to the child of Jehovah Witness

parents). This issue is more difficult when the child

begins to develop his/her own value system, but is

still considered legally incompetent.(see n. 3

below under "Some Cases...")

Proper safety measures should be followed toprotect transplant recipients from receiving AIDS

and hepatitis viruses, etc.(cf. LRCC, 161; and

Garrett et al., 200)

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3. Ethical Issues Regarding Allocation of Limited

Resources

a) Criteria for Selection

Requests or the demand for human organs and

tissues usually exceed what is available or thesupply. Significant practical and ethical questions

regarding efficiency and fairness arise as to how

best to distribute these limited resources. On what

basis should this person rather than that person be

chosen to receive a given organ? Who should

choose? These decisions are serious as they can

involve who will live and who will die. In section 4

below we will consider some ways of addressing

this problem by attempting to increase the supply

of human organs and tissues. In sections 3.b and c

we will consider some alternative methods of

attempting to meet some of the needs in this area.

In this section, however, we will consider some

criteria for selecting which potential transplant

recipient will receive a given human organ or

tissue.

A widely used and approved criterion of selection

is to give priority to those who have great need

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and who are expected to benefit greatly. For

example, it does not make sense to give a limited

number of available organs to those who will not

benefit or who are expected to only live marginally

longer but suffer much with the transplants, when

others would benefit greatly. While this criterion is

widely accepted as fair, there is much discussion

about how to define and assess "benefit". Many

argue that both expected length of survival and

the possibilities regarding rehabilitation should be

considered.

In spite of the success of transplants, care must be

taken not only that they extend life biologically,

but that they also offer the patient a real chancefor a healthy life. The new organs should add new

years to life, and help to provide a new and better

life.

....as a last resort a choice sometimes has to be

made between a transplant immediately available

but with a very small chance of survival, and a long

term transplant offering a greater possibility of

healing.(German Bishops..., 374-5)

With regard to who will likely benefit more fromreceiving a transplant, medical criteria such as

blood and tissue typing (i.e. who is less likely to

reject the transplant), and the absence of other

life-threatening diseases, are used. Other factors

such as the potential recipient's will to live,

motivation and ability to follow post-operative

directions (e.g. taking immunosuppressants), his or

her family support, and the skill of the transplant

team can also be relevant to the success of a

transplant.(Garrett et al., 213-216)

Potential recipients (i.e. those likely to benefit

from a transplant) are registered on a "first come,

first serve" basis. This, or random methods of

selection (e.g. a lottery) where there is equal

chance, is fair provided that the need and benefit

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are approximately the same among potential

recipients.(cf. Varga, 226; and Ashley and

O'Rourke 1986, 112, and 1989, 308)

Some argue in favor of using criteria such as social

worth, and merit or demerit, to select or prioritize

potential recipients. Concerning "social worth", for

example, is it fair to give priority to a mother of

young children over a single person, or to a

successful doctor over someone who is at present

unemployed? Concerning merit should a retired

person who contributed a lot to the community be

given priority over a young person who has not yet

proven him or herself? Regarding demerit, for

example, should someone who previously abused

alcohol, smoked heavily or ate unhealthily be

denied a liver, lung or heart transplant?(cf.

Altman; Moss and Siegler) Many, however,criticize these and other criteria such as ability to

pay, race, religion, gender, and age, as involving

unfair discrimination. They are said to violate the

equal dignity of all human beings. Criteria such as

"social worth" are also seen by some to be too

difficult and subjective to apply efficiently and

reasonably.(cf. CHAC, 30 and 45; Appleton

International Conference, 6-7; Varga, 226; Garrett

et al., 216; Childress) Childress argues as well that

the criteria for selecting recipients should be open

and subject to public scrutiny.

(. , 226, ' 1986 112,. ,

1989, 308)

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b) Using

Animals

The shortage of various human parts for transplant

purposes has in part motivated research in animal

to human transplants. The use of some animal

parts such as insulin extracted from animal

pancreases, catgut as absorbable sutures, and pig

heart valves, are already "accepted" medical

treatments. Attempts, however, to transplant a

baboon's heart to a human infant (Baby Fae) or a

pig liver to a dying woman, for example, have

aroused considerable controversy.(see LRCC, 18-

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15/32

19; n. 4 below under "Some Cases..."; and Siegel)

Some argue that the present state of transplants

between species does not justify such experiments

which so far do not offer hope of therapeutic

benefit to the human recipients. Defenders of such

experiments argue that they can be justified if no

other alternatives are available and for the

knowledge gained. Some have questioned

whether such transplants involve irresponsible

meddling with nature. Various animal rights

groups have protested the sacrifice of animals

involved in this and other research, which uses

them as "mere means" to human welfare.

Concerning organ transplants from animals to

human beings research is being done with various

immunosuppressive agents with the hope of

finding a combination to overcome the rejection

problem.(Johnston) Attempts are also being madeto genetically engineer and breed new strains of

some animals such as pigs so that their organs can

be transplanted into humans with less risk of

rejection. If successful, the scientists involved hope

that this will overcome the large shortage of

human donor organs.(Reuter; Hanson)

Widely accepted directives for human

experimentation call for both adequate

preliminary animal experimentation to minimize

the risks to human subjects and that the welfare ofanimals used in research be respected.(e.g.

Helsinki Declaration of 1975, p. 1771) Pope John

Paul II in an address to a Congress of the Pontifical

Academy of Sciences said, "...animals are at the

service of man and can hence be the object of

experimentation. Nevertheless, they must be

treated as creatures of God which are destined to

serve man's good, but not to be abused by

him...."(p. 5) The Catholic Health Association of

Canada (CHAC) stipulates that animals involved in

research are to be properly respected and such

research "is to be allowed only when other

methods involving non-living subjects are no

longer helpful. When use of such subjects is

justified, pain relief must be used or suffering

reduced to a minimum."(60)

With respect to tissue transplants between

individuals of different species, Pope Pius XII on

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16/32

May 14, 1956, spoke of the transplant of a cornea,

for example, as moral, if possible and warranted.

He, however, considered the transplant of the

sexual glands of an animal to a human being as

immoral. Thomas O'Donnell interprets the

condemnation of the latter as aimed at transplants

that would "envision an act of attempted

generation."(104-7)

The Sacred Congregation for the Doctrine of the

Faith excludes, among other things, attempts of

fertilization between human and animal gametes

and to gestate human embryos in the uteruses of

animals as contrary to human dignity. It considers

genetic interventions that are therapeutic, for

proportionate reasons, however, as licit.(SCDF

1987, 15-20; cf. CHAC, 60)


considers transplants from living animals to

humans as

...permissible as long as these can fulfill an

essentially beneficial human function in the

recipient. The human dignity of the recipient is not

to be compromised in any way and due respect is

to be paid to the non-human donor in the whole

transplant procedure.(46)

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c) Artificial Substitutes for Tissues and Organs

The shortage of various human parts for transplant

purposes has also in part motivated research in

the development of artificial and synthetic

substitutes for tissues and organs. There are a

number of substances that the human body does

not reject. A number of artificial replacement

technologies including false teeth, artificial limbs

and joints, hearing aids, synthetic lenses,

pacemakers, mechanical and synthetic heart

valves, genetically engineered insulin and growth

)

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17/32

hormone, and renal dialysis, are already routinely

used in treatment. Other technologies such as the

implantable artificial heart are still experimental or

are used temporarily with the hope of keeping the

person alive until a suitable human donor organ is

found.

Artificial replacement technologies are generally

very costly to develop. If they prove to be

successful and are mass produced, their long-term

costs can be significantly reduced. A number of

routinely used replacement technologies such as

long-term renal dialysis, however, remain

expensive. Some ethical questions concerning such

costs will be considered in section 3.d below.

Another issue is that the recipient of some artificial

parts may need to make certain psychologicaladjustments. Consider, for example, the

implantable artificial heart (also a heart transplant

from another animal species) in light of the

"popular belief that the heart is the center of

human emotions, the organ of love."(Varga, 239.

Cf. ibid, 238-41; LRCC, 20-22; and Thomas and

Waluchow, Case 7:3.)


states that artificial substitutes for tissues and

organs are permissible provided they "can fulfill anessentially beneficial human function in the

recipient" and the "human dignity of the recipient"

is not compromised in any way.(46)

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d) High Costs, Universality and Justice

The development and use of technology related to

organ and tissue transplants or artificial

substitutes is expensive. For example, estimates of

the costs of transplant procedures, without

complications, "range from $20,000-$30,000 for a

kidney, $60,000-$80,000 for a heart, and

$120,000-$150,000 for a liver."(Goddard) With

complications the costs can be much higher. Such

costs are beyond the means of many people, if

they are not covered by public funds, medical

insurance or charity. The demand for transplants

has also increased because they have become

quite effective. For example, the one-year survival

rate for all transplants is at least 70-80%; and the

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18/32

five-year survival rate for heart and liver

transplants is 70% and 70-80%

respectively.(Goddard)

Today the issue of whether transplants and other

expensive medical technologies are cost-effective

and whether public funds should cover the costs of

all such procedures for everyone who could

benefit from them is being discussed a lot. It

should be noted, however, that the average cost

per life year gained from a transplant (e.g. kidney)

can be significantly lower than alternative

treatments (e.g. hemodialysis). In addition, the

recipient of a successful transplant often

contributes much more to the economy through

work, spending and paying taxes, than if they

would have died or remained ill.(Goddard)

Other questions include: Could the large sums of

money (or some of it) that is spent on developing

and using transplant technology and artificial

substitutes be better used to improve the health

and quality of life of more people if spent in other

ways (e.g. providing better access to primary

health care, improving education and preventative

health programs, improving the environment by

further reducing pollutants, etc.)? What percent of

health care dollars should be allotted to transplant

programs and related research? Broader questionsinclude: What per cent of public funds should be

spent on the good of health as compared to other

goods? Should government spending and public

health services be limited or reduced, or should

taxes be increased to provide for more people's

needs and/or wants? To what extent should

transplant services and organs be supplied to

people of other countries? There are no easy

answers to such questions of distributive justice

which, among other things, can affect who lives

and who dies. One can also ask how it affects us as

moral agents if we do not help or save all those we

can?(cf. Ashley and O'Rourke 1989, 308-10;

Engelhardt; Garrett et al., 216-19; and Thomas and

Waluchow, 132-4)

Parliament through the Canada Health Act (1985)

has committed Canada to providing "reasonable

access" to "medically necessary" hospital and

70-80%,

70% 70-80% ().

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19/32

health services on a uniform basis. Reasonable

access, however, does not mean absolute access.

The term "medically necessary" is also open to

interpretation.(LRCC, 124-5)

The position of the Catholic Health Association of

Canada (CHAC) is: "Basic health care needs are to

be considered in the allocation of resources for

transplantations, especially when it is a question of

novel procedures involving scarce organs and

expensive, limited medical facilities."(45) With

respect to allocating resources in general it calls

for solidarity with sick persons, careful

stewardship of God's gifts and "active participation

in the formulation of policy for the equitable

distribution of health care funds in society as a

whole", among other things.(22-24)

(1985)

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4. Ethical Issues Regarding Procurement of Organs

and Tissues

a) Buying and Selling Human Organs and Tissues

Some argue in favor of allowing human organs and

tissues to be bought and sold to increase thesupply and to respect people's autonomy. Others

argue against such saying that to treat the human

body and its parts as commodities violates human

dignity.(cf. LRCC, 56-62; and May, 165-7) Human

tissues and organs are in fact being sold in some

places. For example, a French pharmaceutical firm

buys placentas from 110 Canadian hospitals to

manufacture vaccines and other blood products

(Aikenhead), and some living poor people in

countries such as India sell one of their kidneys for

$700 or so. In Bombay, for example, there have

also been some cases of kidnapping where victims

regain consciousness to find that one of their

kidneys was removed while they were

drugged.(Wallace; cf. Rinehart)

Concerning this whole issue some distinguish

between human waste products such as placentas,

body parts that regenerate such as blood, and

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20/32

nonregenerative human organs such as kidneys.

Many distinguish profit making from covering the

donor's expenses. Paying for organs can constitute

unjust moral pressure on the donor. It could

invalidate any free consent or a contract. Some

also fear that the buying and selling of organs and

tissues, if it became widespread, would undermine

the altruism (giving motivated by love) and social

bonding now associated with transplants. It could

also lead to organs going to the highest bidder.

Equity would be violated with ability to pay rather

than medical need determining the distribution of

organs. Some others, however, argue that this

could be controlled by regulating sales, and that

totally forbidding the buying and selling of human

tissues and organs would drive the market

underground. Because of the controversy and

ethical problems surrounding the buying andselling of human body parts, some say that other

alternatives should be pursued to increase the

supply.(cf. LRCC, 78-86; and Garrett et al., 203-4)

A World Health Organization resolution in 1989

that was eventually supported by more than 151

nations in part, "Calls Upon Member States to take

appropriate measures to prevent the purchase and

sale of human organs for transplantation..."(LRCC,

162-3 and 202-3) With respect to blood

transfusions, Pope Pius XII said, "It iscommendable for the donor to refuse

recompense: it is not necessarily a fault to accept

it."(LRCC, 58) Concerning the Christian vision

which sees human life and the body as "a gift of

the Creator, which persons cannot dispose of as

they please", the German Bishops' Conference and

the Council of the German Evangelical Church say,

"This does not exclude compensation for the

expenses incurred by the donation of tissue and

organs, but it does forbid deriving profit from

it."(375; cf. Chilean Bishops' Permanent

Commission, 374). The Catholic Health Association

of Canada (CHAC) holds that the buying and selling

of human organs, tissues and blood "contradicts

the principle of charity which is part of the

necessary justification for such

transplantations."(46)

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21/32

b) Media Publicity

Sometimes an organ or tissue is procured for a

person by publicizing their need through the

media. This could bypass the regular transplant

channels and their selecting recipients for an

available organ on the basis of greatest need and

greatest likelihood of benefit, and first come first

serve (see 3.a above). On the other hand, media

pleas frequently bring in more volunteers than

those required for the case being publicized.

Media publicity also increases public awareness of

the need for transplants and so in the long run

should increase the supply of donated tissues and

organs. Garrett et al. argue that at this stage of

medical history media publicity for a particular

case should be tolerated, but in time it should be

eliminated as much as possible.(212)

)

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(212.

c) Types of Consent (Voluntary or Expressed,

Family,

Presumed, Required Request, Routine Inquiry)

Voluntary or expressed consent involves a person

making known their free offer to donate one or

more of their organs and/or bodily tissue, after

they have died or while alive.(cf. 1.a and b above)

Concerning cadaver donation, a person canexpress their wishes by some form of advanced

directives, such as by filling out the Universal

Donor Card attached to their driver's license. Free

and informed consent is required when the

transplant is from a living donor. Previously

expressed voluntary consent regarding a deceased

donor is the ideal because it involves an act of love

and responsible stewardship over one's body. It

also communicates to others, including one's

family and health care professionals, one's wishes.

In the absence of clearly expressed voluntary

consent, the family or person lawfully responsible

for the body of the deceased may be approached

regarding donation. Proper respect involves due

consideration of the wishes of the deceased and

their loved ones.

Many potential organs and tissues for

transplantation (e.g. of brain-dead accident

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22/32

victims) are lost because the person did not

previously express voluntary consent and their

families were not approached about donating.

Because of this and the shortage of organs and

tissues for transplantation, some have proposed

other models of consent including presumed,

required request and routine inquiry, to hopefully

increase the supply. Although only a minority of

deceased potential donors have signed donor

cards, surveys show that most people favor organ

donation. Some argue that it is ethical to presume

consent on their behalf, unless the person while

alive gave clear indications to the contrary, since a

transplant does not harm the donor after death

and it can benefit others. France, Belgium and

some other countries have various forms of

presumed consent legislation in place. People can

opt out by registering their intention not to be adonor. Questions concerning this approach

include: Should minors and the mentally disabled

be included? To what extent should health care

professionals check to see if the person has

expressed a wish not to donate? Can not this be a

form of exploiting human ignorance and weakness

(cf. people ignorant that they can opt out or too

lackadaisical to do so)?

Required request requires hospitals to develop

protocols to ensure that families of potentialdonors are actually asked to donate. Routine

inquiry requires hospitals to develop protocols to

ensure that families of undeclared potential

donors have the opportunity to donate - people

tend to react more positively when offered a

choice. Some have criticized these approaches as

not allowing professional discretion. Many health

professionals are reluctant to approach families

who have just lost a loved one about

transplantation. This is considered a major barrier

to increasing the supply of organs and tissues.

Most families though do not object to being

approached. Required request or routine inquiry

has been widely endorsed in the United States as a

preferred public policy option when compared to a

free or regulated market of organ and tissue sales

or a presumed consent approach. It is seen as

more respectful of altruism, familial sentiments

and religious interests. It can also help the

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23/32

bereavement process by making something

positive come out of the death. Some significant

increases in organ and tissue donation have been

recorded where this policy is in place. A few

jurisdictions also allow presumed consent

following required inquiry if the family did not

object.

The Law Reform Commission of Canada

recommends maintaining and strengthening the

present express consent model in Canada with

hospitals implementing routine-inquiry protocols.

These, however, are to recognize professional

discretion not to ask in cases where this would

clearly be inappropriate.(LRCC, 39-46, 145-39, and

176-82; cf. Varga, 221-2; Garrett et al., 210-11;

Ashley and O'Rourke 1989, 310; and May, 167-8)

d) Fears, Confusion and the Need for Education

There is a need for education of the general public

and many health care professionals concerning the

whole area of organ and tissue transplants. Many

people are not well informed of the needs, the

shortage of organs and tissues, and the great

potential benefit of many people for transplants.

Many have unfounded fears or reservations or are

confused about some of the issues of being adonor. In a recent United States survey, "the two

most common reasons given for not permitting

organ donation were (1) they might do something

to me before I am really dead; (2) doctors might

hasten my death."(LRCC, note 226) This shows

ignorance of standard policy and procedure

concerning transplants. These include strict criteria

for determining total brain death and the

separation of the ill or dying patient's health care

team and the transplant team.

Although surveys show that most people think

transplantation is a good thing, only a minority

sign an organ donor card. Why? First of all, many

are not fully aware of the advantages of this type

of voluntary expressed consent.(see section 4.c

above) Some people may be unwilling to think

about their own mortality, an inevitable fact, or be

superstitious. For example, they may mistakenly

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24/32

think that signing a donor card will increase their

chance of a fatal accident. Some may have

concerns about the mutilation of their body.

Organs and tissues, however, are carefully

removed and incisions are closed, so that it will

not be apparent to anyone viewing the body that

organs or tissues have been donated.(HOPE, 3)

Also,

Some people wonder what will happen to their

bodies if at death they donate an organ. The truth

is that every earthly body decays. Therefore, the

alternative is between an organ decomposing or

serving to keep an other human being alive. We

Christians believe, as St Paul tells us, that our

corruptible body will be transformed into a

spiritual body for the glory of God (cf. 1 Cor 15:35-

53)(Chilean Bishops' Permanent Conference, 375)

Some people may also not realize that they can

specify limits on an organ donor form regarding

the use of their body (e.g. which organs they may

or may not wish to donate). People should be

encouraged to consider organ and tissue donation

as a "legacy of love", as an incarnate form of

"CHARITY AFTER DEATH."(Wolak, 18)

Health care professionals also need to be educated

about the meaning of organ and tissuedonation.(CHAC, 43) Some have unfounded

reservations about approaching individuals or

families to consider organ and tissue donation. It is

important that some members of the health care

team be trained in approaching potential donors

and their families in a sensitive way. They need to

be able to provide the necessary personal and

social support regarding the grieving process.(cf.

Batten) Some health care professionals also need

to learn that properly respecting the dead human

body is a requirement of our humanness. Along

these lines some medical schools offer services of

remembrance and gratitude before and after

dissecting human cadavers.(Lynch, 1018) Care

needs to be taken, too, regarding the language

one uses about the dead. For example, "harvesting

the dead" connotes "taking" and is repugnant,

whereas "donation" connotes "giving" and is

dignified.(cf. Belk) In order to increase the

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25/32

potential for transplants, some health care

professionals have a special responsibility with

regard to raising the general level of consciousness

of the needs. This should be done in a way that

always properly respects patients' rights of

confidentiality and that does not detract from

communicating other pressing health care issues.

"The public is entitled to be accurately informed

about the medical progress and implications of

transplantation."(CHAC, 47; cf. German Bishops...,

376)

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Conclusion

A number of the many ethical issues concerningorgan and tissue transplants have been treated in

this paper. These issues concern the donor, the

recipient, the allocation of limited resources, and

the means of procuring organs and tissues.

Although there have been some abuses in this

field, and there are some areas of controversy, I

would like to conclude with a positive note.

Organ donation, carried out under proper

conditions, is a beautiful and modern expression of

Christian charity: it gives dignity to the person who

in death becomes a life-support for another; it

shows noble concern for the respect of the life of

others; and it implies a sense of communion with

humanity. The Gospel proclaims that there is no

greater love than to give one's life for another (cf.

Jn 15:13). Jesus welcomes the good done to

another as though it were done to himself (cf.

Matt 25).(Chilean Bishops' Permanent

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26/32

Commission, 375) 375).

Some Cases and Questions For Discussion

1. Don and Dan are identical twins. After Don

suffers kidney failure, Dan is requested by his

brother's wife to donate one of his healthy kidneys

to Don. Does Dan have any obligation to surrender

one of his healthy kidneys to his brother? Under

what condition would you defend Dan's decision

not to surrender his kidney.(From Ashley and

O'Rourke 1986, 172)

2. Is it ethical for a living person with two good

eyes to donate an eye to enable a blind person to

see?

3. Sally was 15 years old and had been a practisingJehovah Witness for several years. She lived with

her sister Jane, who was 18 years old and an

atheist, and mother, who had been a Jehovah

Witness but who renounced this following a legal

separation with her husband. Sally had only seen

her father, who was a devout Jehovah Witness, a

few times since the separation. Sally was involved

in a bad car accident and before lapsing into a

coma was heard to say repeatedly, "I don't want to

die. Please help me." The doctor said Sally would

die without surgery which required a bloodtransfusion. The surgery had a 90% success rate,

with a 5% chance of paraplegia and another 5%

chance of death. Sally's mother insisted that the

operation with a blood transfusion take place to

save her life. Her father strongly objected that this

would violate a sacred principle of Sally, an

avowed Jehovah Witness. Jane pointed out that

Sally was a minor and questioned whether her

commitment to the blood transfusion principle

could have been fully informed and voluntary. Her

parents were her legal guardians. The doctor went

before a judge to seek a resolution. If you were the

judge, what would be your decision?(condensed

from Thomas and Waluchow, 150-4)

4. Baby Fae was born with a severe heart defect

which would cause her death within a few weeks.

Her parents were poor and in a country without

universal medical insurance. Loma Linda Hospital

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27/32

offered to cover the costs of transplanting a heart

from a baboon. The parents signed an elaborate

consent form which was never released. The

doctors did not consider the possibility of a human

donor, thinking the hopes of finding one were

almost nonexistent. It seems that they also did not

seriously consider a new form of corrective

surgery for this type of heart defect with a 40

percent survival rate after several years. Baby Fae

was reported in serious but stable condition for

two weeks following the operation, but died a

week later, apparently of complications related to

rejecting the baboon heart. Did the doctors act in

an ethical manner? Under what conditions, if any,

would a transplant of this nature be

acceptable?(cf. Ashley and O'Rourke 1986, 117;

and Thomas and Waluchow, 119-24)

5. Should public funds cover the related costs of

transplants for all people who can benefit from

them? Should taxes be increased to fund more

publicity of the need and so increase the supply of

organs and tissues for transplants, and to pay for

more transplants, so that more people can live

longer and healthier?

6. Mrs. Simpatico, a nurse, had cared for Joseph,

who was 30 years old, a few weeks before he died.

The hospital has a policy requiring nurses to askthe families of all dead patients for organ

donations. Both she and the family are very upset

about the death. She believes Joseph's young wife

and three children need comfort and not decisions

at this moment, so she does not ask for the organ

donation, even though the hospital has a long

waiting list. When the nursing supervisor discovers

this omission, she reprimands Mrs. Simpatico and

warns her: "One more incident like that and you

will be fired." Is the hospital's policy good? Was it

right for Mrs. Simpatico to make an exception in

this case?(adapted from Garrett et al., 221)

7. Two men on the same service are awaiting a

cornea transplant because of chemical burns on

their eyes. One is an alcoholic street person with

other serious health problems. The other is a

prominent lawyer with a wife and three children. A

donor's eye becomes available, and by coincidence

.

.

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both men's cornea match the donor's. The

physician decides on the basis of "first come, first

served" and transplants the cornea to the

alcoholic. Is it ethical to do this when the alcoholic

has more serious health problems? Is there a

relevance to the patients' social

positions?(adapted from Garrett et al., 221)

8. Anissa is 17 years old when it is discovered she

has leukemia. Her primary hope for survival rests

on a bone marrow transplant, but there are no

likely donors for her unusual genetic

characteristics. Her parents decide to have

another child in the hope that the infant will

provide a tissue match (a 25% chance). Is it

ethically right to conceive a child for the purpose

of generating tissue for transplantation? If the

infant is a tissue match, is it right for the parents todecide for the infant?(adapted from Garrett et al.,

222)

9. In your opinion why do comparatively few

people sign the Universal Donor Card on their

driver's license?(adapted from Ashley and

O'Rourke 1986, 210)

10. After Ben, a 10 year old boy, is declared brain

dead in Alberta Children's Hospital, Dr. Mitchell

asks Ben's parents if they have considered organdonation. They consent because they think it is a

good way to deal with their grief and what Ben

would have wanted. As a result a few other

children are living normal lives: Kirsten of

Edmonton received Ben's heart; Stuart of Airdrie

and Amy of Calgary each received one of Ben's

kidneys; Johnny of Pittsburgh received Ben's liver;

and Steven of Lethbridge received Ben's cornea.

(This case is presented in the video, "Have You

Considered Organ Donation?"[1991, 11 minutes],

the Human Organ Procurement and Exchange

Program [HOPE], University of Alberta Hospitals.)

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.)

References:

Aikenhead, Sherri (1993). "Sale of Human Placentas to French Pharmaceutical Firm Questioned" and

"Hospitals Should Inform Mothers if Placentas Traded - Commissioner," The Edmonton Journal, 3 Mar.

1993, A14, and 4 Mar. 1993, A11, respectively.

Altman, Lawrence K., M.D.(1990). "Should Alcoholics get new Livers?", The Edmonton Journal, 15 Apr.

1990, E6.

Appleton International Conference (1992), "Developing Guidelines to Forgo Life-prolonging Medical

Treatment," The Bioethics Bulletin, University of Alberta, Edmonton, Jan. 1993, 2-7.

Ashley, Benedict M., OP; and Kevin D. O'Rourke, OP (1986). Ethics of Health Care. St. Louis: Catholic

Health Association of the United States.

__________ (1989). Health Care Ethics, Third Edition. St. Louis: Catholic Health Association of the United

States.

Associated Press, "Brain-dead woman suffers miscarriage," The Edmonton Journal, 17 Nov. 1992.

Batten, Helen Levine (1990). "The Social Construction of Altruism in Organ Donation," Ch. 8 in Organ

Donation and Transplantation: Psychological and Behavioral Factors, ed. by James Shanteau and Richard

Jackson Harris. Washington, DC: American Psychological Association.

Belk, Russell W. (1990). "Me and Thee Versus Mine and Thine: How Perceptions of the Body Influence

Organ Donation and Transplantation," Ch. 12 in Organ Donation and Transplantation: Psychological and

Behavioral Factors, ed. by James Shanteau and Richard Jackson Harris. Washington, DC: American

Psychological Association.

Cefalo, Robert C.; and H. Tristam Engelhardt, Jr. (1993). "The Use of Fetal and Anencephalic Tissue for

Transplantation," Eike-Henner Kluge, ed., Readings in Biomedical Ethics: A Canadian Focus. Scarborough:

Prentice Hall Canada Inc., 367-78.

CFRN Television (1987). "A Second Chance" (Video, 50 minutes). Available from HOPE, University of

Alberta Hospitals, Edmonton.

[CHAC] Catholic Health Association of Canada (1991). Health Care Ethics Guide. Ottawa. References are

by page number.

Childress, James (1978). "Rationing of Medical Treatment," Encyclopedia of Bioethics. New York: The

Free Press, 1414-19.

Chilean Bishops' Permanent Commission (1991). "On Organ Transplants," Catholic International, 15-30

April 1991, 374-5.

Dailey, Thomas G. (1993). "Fetal Tissue Transplants: Some Ethical Questions." Edmonton: St. Joseph's

College Catholic Bioethics Centre, Jan. 1993.


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Duncan, Glenn E. (1992). "Grim Harvest," The Catholic World Report, Aug. 1992, 16-22.

Engelhardt, H. Tristram (1987). "Allocating Scarce Medical Resources and the Availability of Organ

Transplantation: Some Moral Presuppositions," Thomas A. Shannon, ed. Bioethics, Third Edition.

Mahwah: Paulist Press, 565-79.

Garrett, Thomas M.; Harold W. Baillie; and Rosellen M. Garrett (1993). Health Care Ethics: Principles and

Problems. Englewood Cliffs: Prentice Hall, Ch. 9.

Gaylin, Willard, M.D. (1987). "Harvesting the Dead," in Bioethics, Third Edition, ed. by Thomas A.

Shannon. Mahwah: Paulist Press, 553-63.

German Bishops' Conference and the Council of the German Evangelical Church (1988). "Christians and

the Ethics of Organ Transplants," Catholic International, 15-30 April 1991, 373-6.

Goddard, Hans (1992). "No Easy Way to Figure Costs of Transplants," The Medical Post, 7 July 1992, 43.

Hanson, Mark J. (1992). "A Pig in a Poke," Hastings Center Report, Nov.-Dec. 1992, 2.

Helsinki Declaration of 1975, Encyclopedia of Bioethics, Vol. 1V. New York: The Free Press, 1978, pp.

1771-3.

[HOPE] Human Organ Procurement and Exchange Program (1993). Organ & Tissue Donation (pamphlet).

Edmonton: University of Alberta Hospitals.

John Paul II, Pope (1982). "Biological Experiments Should Contribute to the Well-Being of Mankind,"

L'Osservatore Romano, English weekly ed., 8 Nov. 1982, pp. 4-5.

Johnston, Cameron (1993). "Transplanting Animal Organs Into Humans Could Soon Become a Reality in

Canada," The Medical Post, 5 Jan. 1993.

Jonsen, Albert R. (1989). "Ethical Issues in Organ Transplantation," Ch. 9 in Medical Ethics, ed. by Robert

M. Veatch. Boston: Jones and Bartlett Publishers, 229-52.

[LRCC] Law Reform Commission of Canada (1992). Procurement and Transfer of Human Tissues and

Organs, Working Paper 66. Ottawa: Canada Communication Group - Publishing.

Lynch, A. (1990). "Respect for the Dead Human Body: A Question of Body, Mind, Spirit, Psyche,"

Transplantation Proceedings, Vol. 22, No. 3 (June), 1990, pp. 1016-18.

MacNeil, Archbishop Joseph N. (1986), excerpt in "Your Religion and Organ Donation" (pamphlet).

Edmonton: Lions Eye Bank.

May, William E. (1977). Human Existence, Medicine and Ethics. Chicago: Franciscan Herald Press, Ch. 7.

Moss, Alvin H.; and Mark Siegler (1993). "Should Alcoholics Compete Equally for Liver Transplantation?",

Eike-Henner Kluge, ed., Readings in Biomedical Ethics: A Canadian Focus. Scarborough: Prentice Hall


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Canada Inc., 85-94.

O'Donnell, Thomas J., S.J. (1976). Medicine and Christian Morality. New York: Alba House.

Post, Stephen G. (1991). "Fetal Tissue Transplant: The Right to Question Progress," America, 12 Jan.

1991, 14-16.

Reuter (1993). "Pigs Born with Human Genes," The Edmonton Journal, 12 Mar. 1993.

Rinehart, Dianne (1993). "Sold for Organs, Risk to Kids Grows," The Edmonton Journal, 22 Jun. 1993,

B14.

[SCDF] Sacred Congregation for the Doctrine of the Faith (1980). Declaration on Euthanasia. Battleford,

Sask.: Marian Press.

__________ (1987). Instruction on Respect for Human Life in its Origin and on the Dignity of

Procreation. Boston: St. Paul Editions.

Siegel, Lee (1992). "Use of Pig Liver Defended," The Press Democrat, 14 Oct. 1992, B4.

Thomas, John E.; and Wilfrid J. Waluchow (1990). Well and Good: Case Studies in Biomedical Ethics,

Revised Edition. Peterborough: Broadview Press.

Varga, Andrew C. (1984). The Main Issues in Bioethics, Revised Edition. Ramsey: Paulist Press, Chs. 11

and 12.

Wallace, Charles P. (1992). "Trafficking on Kidney Street: The Rich get Healthier from Trade in Human

Organs," Science and Medicine, 13 Sept. 1992.

Wolak, Richard, OMI (1990). "Donate Your Organs: Charity After Death: Everyone Should Plan to be an

Organ Donor," Our Family, July/August 1990, 15-18.

Suggested Reading/Viewing:

Ashley, Benedict M., OP; and Kevin D. O'Rourke, OP (1989), Health Care Ethics. St. Louis: Catholic Health

Association of the United States, especially re ethical methodologies, norms of Christian decision in

bioethics, and organ transplantation.

Catholic Health Association of Canada (1991). Health Care Ethics Guide. Ottawa, especially pp. 42-47.

Human Organ Procurement and Exchange Program [HOPE] (1991). "Have You Considered Organ

Donation" (Video, 11 minutes). Edmonton: University of Alberta Hospitals. HOPE also has available other

relevant videos and up-to-date educational literature.

Law Reform Commission of Canada (1992). Procurement and Transfer of Human Tissues and Organs,

Working Paper 66. Ottawa: Canada Communication Group - Publishing.

Thomas, John E.; and Wilfrid J. Waluchow (1990). Well and Good: Case Studies in Biomedical Ethics,


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Revised Edition. Peterborough: Broadview Press, Cases 7:1, 7:3, 8:4, 9:1, 10:1, 10:2, and 12:6.

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