Organ Donation: Demand and Supply

Abstract

With its widening indications, the need for organ transplantation is growing globally. Currently, there is a crisis of organ shortage and a dire need to adopt ways and means to overcome it to save lives and improve the quality of life of patients with end-stage organ failure. In this regard, on the one hand, efforts should be made to eliminate the barriers to organ donation, such as people’s ignorance about organ donation and ethical and religious concerns. On the other hand, strategies should be implemented to enhance organ donation, which in the case of deceased donors, include accelerating the donation process, instituting a policy of presumed or mandated consent, and utilizing extended criteria for donors. In the case of living donors, these include accepting the paired donation and removing disincentives to donation. Organ donation can also be boosted by allowing restricted compensation or reward. Using social media platforms to educate people, facilitate contacts, and match with unspecified donors is also worthwhile. In the future, xenotransplantation is also showing some promise.

1. Introduction

The availability of donor organs is a fundamental prerequisite for running a transplantation program. While the need for organ transplantation and its scope continues to expand, unfortunately, there continues to be a significant demand-supply gap in respect of potential donors, impeding the full exploitation of transplantation to save lives or improve the quality of life of patients with end-stage organ failure [1, 2, 3]. The problem can be traced back to myriad global causes, though some afflict particular countries due to their peculiar sociodemographic characteristics. Generally, lack of awareness, ethical concerns, religious dogma, and logistical problems are the major barriers to organ donation [4]. Overcoming them would require devising multifaceted strategies aiming at expanding all possible sources of donors. Living donations need particular emphasis since the pool of deceased donors is limited and cannot expand beyond a certain point due to inherited constraints [5, 6]. Furthermore, in addition to in-vogue strategies, some forward-thinking initiatives will be required for a substantial improvement in the situation.

1.1 Issues in organ donation

These may be universal or linked to the donor type. They broadly can be either deceased or living. The former is further classified as DBD (donation after brain death) or DCD (donation after cardiac death), while the latter is specified or unspecified [7]. The specified donors, in turn, can be directed (to a genetically related, emotionally related, or unrelated recipient) or undirected (through an exchange program); the unspecified donors are for anonymous recipients.

Some commonly encountered obstacles to organ donation are:

1.1.1 Awareness about organ donation

Even though transplantation has been around for many years, surprisingly most people in the general population, and also, in the medical community do not have adequate information about organ donation and transplantation [8, 9]. Even in developed societies, ignorance still reigns supreme, making it one of the most significant obstacles to organ donation [10].

This level of ignorance breeds skepticism toward the whole concept of transplantation. For instance, people might believe that professionals might be overly eager to remove donor organs to benefit potential recipients, even if this comes at the expense of the donors’ interests—not knowing it is the donor or the donor’s family who are the main stakeholders and have the final say in the matter [11]. These concerns can be alleviated only by educating people and informing them of every step of the organ donation process so they can make an informed decision about the donation [5, 12]. An independent donor advocacy team is also a step toward removing any misgivings regarding donor safety and rights [13]. All such measures can go a long way in ending the stigma associated with the practice of transplantation.

The dissemination of information regarding donation opportunities can significantly increase the proportion of potential donors [12, 14, 15]. For instance, Facebook’s initiative to educate people about organ donation has led to a noticeable increase in the number of people in the United States who have signed up to become organ donors [16]. Another observation is that when people are provided with additional information about brain death, it makes them more willing to accept it, which speeds up the process of organ donation as a direct result [17].

1.1.2 Ethical issues

Organ donation may be hampered by several ethical issues which are directly linked to the process. Such concerns may arise when it comes to the following:

• Consent of donors

• Definition of death

• Nondirected living donation

• Donation of organs by patients of euthanasia

• Practice of rewarding or incentivizing organ donation.

• Online campaigns to encourage organ donation

• Xenotransplantation-related issues, such as animal rights, human dignity, risk of stem-cell technology, and genetic editing.

1.1.3 Consenting to organ donation

Consent that satisfies ethical standards should, in theory, be given of one’s own free will and motivated solely by altruism; it should never be given in response to any form of pressure or coercion, nor should it be persuaded by the promise of monetary gain. However, in actual practice, it is difficult to determine objectively to what extent these standards are or could be followed [18]. As a consequence of this, there will always be some degree of uncertainty present. This inescapable shortfall in the process negatively impacts the populace’s perception of transplantation as a whole.

Major ethical concerns about organ donation by living-related donors focus on the possibility of undue influence and emotional pressure and coercion by the recipients or their relatives to the point where the donor may be harmed.

Giving one’s consent in the event of donation after death can take many different forms, but none is immune to ethical questions. In the opt-in option, those eligible to donate their organs do so voluntarily in life so that their organs can be harvested after they pass away. In some countries, the family is still allowed to decline the donation—referred to as the “soft option,” as opposed to the “hard option,” in which the family does not have this choice [19]. In the opt-out system, consent is treated as a default option, and if there is no declaration to the contrary from the deceased person, the consent is presumed to have been given. Though the opt-out option has been adopted by many countries, the ethical question of whether or not presumed consent accurately reflects the wishes of the deceased and violates donor autonomy continues to be debated [20]. Furthermore, it creates an even greater potential for abuse of power by medical professionals [21]. Not the least, there is yet no clear evidence that the opt-out option has increased the donation rate to any extent [21, 22].

A modification to the opt-out is the mandated consent, which means that all adults eligible for organ donation must register their intention to donate or not during life [22]. In this way, the wishes of the deceased individual would be honored posthumously regardless of the position held by the family. However, ethical concerns remain regarding individuals who either do not register or whose families are denied access to their medical records [23].

Organ conscription is a relatively new concept that refers to harvesting all healthy organs after death for transplantation regardless of the recipient’s consent [24].

Living donors are free of the above issues but pose physical, psychological, and social challenges and there is always an element of doubt about their interpersonal relations and the motive behind the donation [6, 8].

1.1.4 Controversies about brain death

Even though death, as determined by neurological criteria, has been a legal definition of death for quite some time, the legitimacy of brain death determination has been called into question ever since its initial implementation, and various clinical scenarios continue to appear which give rise to medical, legal, and ethical controversies [25]. Furthermore, the inconsistencies within personal and institutional practices in establishing brain death, combined with the differences in legislation in various countries, raise the possibility of error in the diagnosis, thus adding to public discontentment [4, 26].

On the other hand, many religious and cultural communities still recognize death based on circulatory criteria, that is, irreversible cessation of heartbeat, and not neurological criteria [27]. Nevertheless, the issue is under continuing debate in these circles [28].

1.1.5 Non-directed living donation

There is an ongoing debate on the question of whether or not the practice of non-directed living donation is ethically justifiable [7, 29]. It is because it leaves a lacuna for illicit financial dealings or any other illegitimate arrangement between the donor and recipient [18].

1.1.6 Organ donation by euthanasia patients

Donating organs after a person has committed suicide with assistance is a relatively new concept that has raised new ethical questions [30]. Further, patients in this situation have the option of giving their permission to have their organs removed from their bodies while they are still alive. Not only does this remove concerns about obtaining consent after death, but it also makes it possible to retrieve organs while they are still healthy [31]. However, the possibility of pressuring potential donors into deciding on assisted suicide earlier than they otherwise would have is an ethical dilemma that needs to be solved for this practice to be considered morally acceptable [30, 31].

1.1.7 Rewards and incentives for organ donation

Notwithstanding its tremendous potential to boost organ donation, it is considered unethical to commercialize human organs or to make them as items of exchange or trade because the use of human body as an object violates an individual’s dignity. Therefore, in the majority of nations, organ donation is only possible from “altruistic” donors; this means that no monetary or other forms of material value can be exchanged for a donor organ [29]. However, after much debate and exchange of arguments for and against paying donors, most authorities now agree that the expenses incurred by the donor in going through the process of organ donation can be reimbursed as these could be substantial [5, 12]. However, such payments should not be to the extent to become a financial incentive or disincentive to becoming a donor. Some other permissible ways of compensation could be exemptions from paying taxes, giving registered donors allocation priority, covering funeral costs, and making payments for unforeseen expanses [12, 32, 33].

1.1.8 Online platforms for organ donors

Finding living kidney organ donors online is made possible in the United States and the United Kingdom by the availability of online platforms containing registered altruistic living donors [12]. Though the facility dramatically simplifies the living donation process and lessens the strain on the waiting lists, it is shrouded in controversy since it is impossible to conclusively rule out the possibility of rewarding donations despite the undertakings made by the stakeholders to the contrary [34].

1.1.9 Religious issues

There is not a single religion in the world that is entirely against organ donation as all belief systems share common values of altruism, reverence for the sacredness of the human body, and respect for human dignity. Therefore, the majority accept organ donation as long as there is the donor’s consent, no significant risks are involved, and actual deaths are verified in the case of deceased donors [27].

However, some Muslim jurists, Christian scholars, and Jewish rabbis are against it, particularly concerning deceased donors, primarily because of the debates surrounding the concept of what constitutes death [35]. Even though a minority holds it, this viewpoint may significantly influence organ donation in predominately religious communities [36].

In order to counter the fallouts of such negative religious trends, it is of the utmost importance to actively engage religious leaders and organizations in the drive for organ donation [27]. For instance, a person of faith might be included right at the beginning during the family counseling process after a donor has been declared brain dead.

1.1.10 Logistic issues

Setting up a deceased donor program on a national level is administratively quite demanding. In addition to political will and extensive infrastructure, there is also a need for a committed organization with dedicated leadership, a trained human source, and networking with intensive care units (ICUs). It is, therefore, quite understandable that while the developed countries have well-established deceased donor programs, patients in developing and undeveloped countries, except a few, are deprived of this important donor source [37, 38].

1.2 Developments in Prevailing practices

Deceased donors, which primarily involve donation after brain death (DBD), continue to be the primary sources of donor organs in countries where the program has been established on a national level. Donations after circulatory death (DCD) supplement the deceased donor source but at the cost of inferior outcomes [3, 39]. Despite their inclusion, however, the number of deceased donors has not increased enough to meet the demand; in fact it has reached a plateau in most countries [6].

1.2.1 Improving the efficiency of the deceased donor program

By identifying potential donors early in intensive care units, the necessary medical and legal procedures, including family counseling, can be completed early, thereby protecting the organs from the pathophysiological changes in the body that come with brain death [24]. Appropriate training and persuasion of the ICU staff and transplant coordinators can also help in timely referrals and their conversion to actual donors [31].

Including expanded-criteria-donors (ECD) could also help increase the deceased donor pool [22]. Similarly, drug intoxication as the cause of death should no longer be considered a contraindication to organ donation, and kidney transplants from HIV-positive donors to HIV-positive recipients are also permissible [40].

1.2.2 Improvements in living donation

In the case of living-donors, their scope can also be increased by expanding their eligibility criteria. For instance, if otherwise fit, people aged up to 70 or having obesity or vascular malformation can also be accepted as donors [5, 41]. Living-unrelated donors are another area that deserves greater attention. Despite not sharing a genetic connection with the recipient, the graft outcome is similar to that obtained from living-related donors [42]. These donors might have emotional ties with the recipients or be strangers, getting motivated for donation by knowing the potential recipient’s need through an intermediary person, the media, or public solicitation. Such a donation may be directed or undirected in exchange for priority of donor’s family member listed for the deceased donor [3].

The paired donor exchange in which two donors exchange kidneys among their respective recipients because of their blood or tissue incompatibility with the original donor is yet another way of increasing the living donor donation rate [43]. In practical terms, the exchange works by assisting donor/patient pairs with incompatible blood types to find another donor/patient pair with whom they are compatible with exchanging kidneys. There are currently paired kidney programs operating in the United Kingdom (UK), a few other European countries, and as a pilot project in the United States [3].

Domino transplantation provides yet another source of donor organs [44]. In this method, one donor makes a contribution to the recipient of an incompatible couple. The second donor, known as the domino-donor, then makes a contribution to either another couple or the waiting list. In contrast to kidney-exchange donation, which necessitates the mutual compatibility of both the recipient and donor couples, domino-paired donation does not require such compatibility between the parties. Another form of domino-donation involves donating the kidney or liver of an individual who has already received a transplant to another person on a waiting list for one of those organs.

1.3 New approaches

As a result of the ongoing disparity between organ supply and demand, Investigations are being conducted into various alternative options, such as xenotransplantation and artificial organs which can help in reducing the burden of potential recipients. For example, artificial extracorporeal liver support devices capable of performing hemodialysis, therapeutic plasma exchange (TPE), and albumin dialysis have been developed in recent years. TPE has been shown to improve patients’ chances of surviving acute liver failure in clinical trials, and these trials show that the devices are safe and well tolerated by patients [45]. In addition, a total artificial heart (TAH), also known as mechanical circulatory support that restores total pulmonary and systemic flow, is an alternative option for people currently waiting for a donor’s heart [46]. Similarly, wearable artificial kidneys are also under clinical trials presently [47].

The practice of xenotransplantation, also known as the transplantation of pig organs into humans, has been brought one step closer to becoming a reality because of recent developments in techniques of gene editing which allow breeding pigs free of xenoantigens and porcine endogenous retroviruses—the two main causes of failure of previous attempts in this direction [48].

However, even though these alternative methods hold promise, they present several challenges and concerns about the source of organs, animal rights, human dignity, and potential organ transplant potential carcinogenicity of stem-cell research, as well as improperly employing genetic techniques. Thus, research in this direction requires tight regulation.

2. Conclusion

Organ donation is a multifaceted field that, in addition to medical and scientific concerns, involves the interaction of social, religious, ethical, and legal domains. Therefore, it is necessary to take a multipronged approach to meet the ever-increasing demand of patients who are candidates for organ transplantation. However, checks and balances should always be in place to ensure that donors are safe and their rights are protected.