Organs and Stem Cells: Policy Lessons and Cautionary Tales

Just when it appears that the debate about human embryonic stem cell research is dying down, another purported scientific breakthrough or scandal, commission report, or proposed state or federal law comes along to rekindle what seemed to be a fading ember. In this column, I briefly examine what we might learn from experiences with another controversial area in science and medicine—organ transplantation. There are some important lessons, both positive and negative, for the still-evolving policy environment of stem cell research.

Those working in the early years of organ transplant faced many questions that have recognizable parallels in the stem cell research debate: (1) where would organs come from (read embryos for stem cells); (2) how would our understanding of human life and its definitions be affected by the desire to perform transplants (read moral status issues of human embryos); and (3) what policies were needed and how would society responsibly oversee this new and controversial area of research and medicine (with obvious parallels to the stem cell debate)? These and other questions arose in the context of a public that was at turns shocked, amazed, and concerned by news of the ability to take a beating heart from the body of one person and successfully transplant it into the chest of another, prompting reactions ranging from existential angst to repugnance.¹

Definitions of Life and Death

When advances in technology allowed solid organs to be transplanted, the organ transplant community quickly found itself facing a range of ethical, legal, and policy issues. Since circulation is critical to the survival and eventual use of organs after death, the traditional definition of death as whole body death presented practical and philosophical barriers. The understanding of death needed to be revised, with input from medical, social, and moral perspectives. The medical profession took the lead in crafting a new definition of death by brain criteria, but it relied on a consensus process drawing on a wide range of stakeholders. Although not without controversy, then or now, the process yielded a definition that was universally adopted as a matter of policy.

The lesson? Leadership and consensus-building among relevant stakeholders can go a long way toward addressing public concerns. The challenge for the stem cell context is that it will take more than stated agreement among a group or groups of experts in science and ethics to create a meaningful consensus about the moral status of early stage embryos. But if the experiences with organ transplant from deceased donors hold any relevance, dealing with this core issue of stem cell research will be among the most important policy contributions. Efforts like those of the International Society for Stem Cell Research, consensus bodies such as The Hinxton Group, and recent Institute of Medicine studies addressing oversight of stem cell research² are all examples that echo the experience in organ transplant.

Ownership and Allocation of Organs

Once a mechanism for removing organs from dead donors was identified and agreed upon, the organ transplant community faced difficult questions about who controlled use and disposition of organs outside the body. Were they property to be treated as part of the deceased's estate, giving heirs the usual rights of ownership and disposition? Could organs be bought and sold like other forms of property? After much discussion and debate, policies were created that (1) endorsed the view that organs from deceased donors ought to be viewed as a community resource;³ (2) made it a crime to exchange solid organs for any "valuable consideration";⁴ and (3) turned oversight of the procurement and allocation of donated organs over to a newly created pseudogovern-mental body (the United Network for Organ Sharing). This construct has served the transplant community, transplant recipients, and society reasonably well. The basic principles informing these policies—that organs are a community resource that should be allocated equitably and should not be bought and sold—have held up remarkably well over the twenty-plus years of transplant policy experience.

Over that history, work in transplant science and medicine has led to remarkable successes, creating an insatiable demand for more organs...