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Chapter Six Bioethics, Organ Donation, and Transplantation On May 23, 2004, the New York Times published a story that described the sale of a kidney in an international organ trafficking ring that operated in Israel, South Africa, and Brazil.1 Mr. Alberty Jose da Silva, a thirty-eight-year-old slum resident living in Recife, Brazil, was flown to South Africa, where he sold his kidney for six thousand dollars to an Israeli broker, who transplanted it into a forty-eight-year-old woman from Brooklyn, who paid just over sixty thousand dollars for the organ. The kidney transfer was one of more than one hundred suspect transplants performed in less than two years at St. Augustine’s, a hospital in Durban, South Africa. Though the sale and the purchase of human organs is illegal in most countries, the Brooklyn woman’s husband was confident that there was nothing wrong with what he and his wife had done: “I felt helpless , because she was going to die,” he said. “Helping her get that kidney was the best thing that I have ever done for anyone in my entire life.” In this chapter, which deals with the bioethics of organ transplantation , I begin with a brief history of organ transplantation to set the stage for our moral analysis. I then move to the ethical framework that is used to justify the practice of organ donation and exchange: organ donation is an act of self-giving that should be motivated by charity. Next, I discuss the moral issues raised by proposals to procure organs from aborted and disabled donors. May organs be procured from aborted fetuses, anencephalic infants, and unconscious patients in the vegetative state? I then move to the issue raised by our opening vignette of this chapter. Given the lack of available organs from these and more noncontroversial sourc170 1. Larry Rohter, “The Organ Trade: A Global Black Market: Tracking the Sale of a Kidney on a Path of Poverty and Hope,” New York Times, May 23, 2004, at http://query .nytimes.com/gst/fullpage.html?res=9C0CE0DD163EF930A15756C0A9629C8B63&fta= y&scp=1&sq=organ%20trade%20global%20black%20market&st=cse. Bioethics, Organ Donation, Transplantation 171 es, several bioethicists have raised the issue of financial compensation for organ donation to encourage higher “donation” rates. How should we evaluate this proposal and other suggestions that legitimate the sale and purchase of human organs? After this, I move to questions of allocation: Who should receive the limited numbers of organs that are donated every year? What criteria should be used to triage potential organ recipients? Finally, I end with a critical survey of the debate surrounding the definition of death and the neurological criteria that equate brain death with death, concluding that the available evidence indicates that brain-dead patients are not dead. Organ Transplantation A Historical Framework The first successful kidney transplant from one living human being to another, at the Peter Brent Brigham Hospital in Boston on December 23, 1954, was the breakthrough that established the field of human organ transplantation on firm scientific foundations.2 The medical team led by Dr. Joseph E. Murray removed a kidney from Ronald Herrick and implanted it into his identical twin brother Richard, the victim of a fatal kidney disease. Richard recovered quickly and went on to live nine more years until he died of a heart attack. Transplants of a lung, a liver, and a heart followed within the next decade, though these were not successful in the long term because surgeons were not able to overcome the immune barrier: the donated organs were eventually rejected and destroyed by the recipient’s immune system. The next major breakthrough in transplant medicine involved the discovery of drugs that could suppress the immune system, thus preventing the rejection of a donated organ. The first such immunosuppressant was 6-mercaptopurine, discovered by Robert Schwarts and Walter Dameshek at Tufts University in 1959.3 However, it was the discovery, in 1978, of the drug cyclosporine A that catalyzed the rapid growth of transplantation in the 1980s.4 More recent discoveries, including the development of the 2. J. P. Merrill, J. E. Murray, J. H. Harrison, and W. Guild, “Successful Homotransplantation of Human Kidney between Identical Twins,” JAMA 160 (1956): 277–282. 3. R. Schwartz, A. Eisner, and W. Dameshek, “The Effect of 6-Mercaptopurine on Primary and Secondary Immune Responses,” J Clin Invest 38 (1959): 1394–1403. 4. R. Y. Calne et al., “Cyclosporine A Initially as the Only Immunosuppressant in 34 [3...

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